Self-reported use of family physician, chiropractor and physiotherapy services among adult Canadians with chronic back disorders: an observational study

Chronic back disorders (CBD) are a prevalent and costly public health issue; however, little is known about the patterns of community-based health care use among Canadians with these common and potentially disabling conditions. Compared to 289 other diseases and conditions, low back pain is the leading cause of morbidity worldwide when considering years lived with disability [1]. In Canada, 22% of adults report having back problems lasting 6 months or more [2] and health care expenditures are estimated between $6 and $12 billion annually [3]. Back disorders are costly to individuals and strain health care resources due to high rates of primary physician care visits, [4, 5] specialist consultations, diagnostic procedures [6, 7], and prescribed medications such as opioids [8]. Limited access to appropriate primary care is thought to be a contributing factor to this “medical disaster” [9].

Although family physicians are typically the first clinical contact for people with low back disorders [5], they may not be the most appropriate health care provider to assess and treat these conditions [10, 11]. Conversely, physiotherapists have been shown to have high levels of competency in the assessment, diagnosis, and management of low back disorders and are extensively trained in non-pharmacological pain management approaches [12, 13]. Furthermore, adding clinical services that physiotherapists and chiropractors are trained to offer (such as exercise prescription and manual therapy) to usual general medical practitioner care for low back disorders are more cost-effective than usual medical care alone [14]. Unfortunately, access to community-based (i.e. outside of hospitals) or privately delivered physiotherapy and chiropractor services may be limited to those who have additional health insurance or are able to pay, with investigation and treatment for people with CBD who cannot afford these services falling, often inappropriately, to publicly-funded medical care [15‐17]. Although people in Canada can access physiotherapy and chiropractic services directly without a physician referral, several barriers may result in those with CBD seeking care first (or only) with a family physician whose care is fully funded by the public system. For example, lack of awareness of how or when to access these non-physician services, as well as the misconception that a physician referral is required to receive reimbursement from insurance companies outside of the publicly funded system.

Despite back disorders being the most common pain problem in the general population [18] and one of the most common reasons for seeking health care [5, 15]; little is known regarding the comparative use of family physician, chiropractic, and physiotherapy services in Canada. Elucidating these differences may help to identify potential gaps in access to care and may assist in the development of strategies to optimize equitable access. The objectives of this research were to: 1) investigate patterns of use of family physician, chiropractor, and physiotherapy services; and 2) profile the sociodemographic and other factors associated with use of different health care providers among adult Canadians with CBD.

The prevalence of self-reported use of each of the health care provider groups can be found in Fig. 1. The majority of respondents with CBD sought care only with a family physician (53.8%), with only 2.5 and 1% seeking care only with a chiropractor or physiotherapist respectively. Respondents reported seeking care with the following combination of providers: chiropractor/family physician (20.9%); physiotherapist/family physician (16.2%); physiotherapist/chiropractor (0.3%); family physician/chiropractor/physiotherapist (5.0%).

The results of the descriptive analysis for each health care provider group are presented in Table 2. Due to Statistics Canada’s strict confidentiality and vetting guidelines, we were unable to report certain low prevalence values (i.e. ethnicity other than Caucasian, strongly and moderately influenced MIZ among physiotherapist use group).

Table 3 presents our multivariate models for each health care provider group along with the unadjusted (bivariate) logistic regression results for each variable included in the model. Bolded values were statistically significant at p < 0.05 level.

The following summarizes the multivariate analysis findings with only variables that were significant in the final models listed. Factors associated with use of a family physician ‘only’ were: older age (i.e. > 34 years); female; lower educational attainment; lower income; immigrant status; current smoker; having comorbidities other than CBD; less pain limiting function; less self-rated stress; lower overall self-rated health. Factors associated with ‘any’ use of a chiropractor included: higher educational attainment; higher income; Caucasian (versus non-Caucasian); non-smoker; having less than 3 co-morbidities; moderate pain-limited function; higher self-rated stress; better overall self-rated health. Factors associated with ‘any’ use of a physiotherapist included: younger age (< 50 years); female; higher educational attainment; higher income; urban residence; other ethnicity (versus Caucasian); non-smoker; more physically active; more pain-limited function. The vast majority of the odds ratios presented in the final adjusted models are statistically significant (Table 3). Despite the statistical significance of the results, most of the associations are of moderate strength (OR = 1.4–1.9 or their complement as an inverse association, 0.71–0.50). A few of the odds ratios are above 2 (< 0.5) (e.g. older age, higher income quintiles, number of co-morbidities), which is generally thought to be considered a stronger association in epidemiologic studies.

Prior research investigating health care use among adult Canadians with CBD using the 2000–2001 CCHS [4] found some similar patterns to the present study, with some exceptions which may arise from different methodological approaches and data availability. Notably, the prior work did not use the restricted data files for the CCHS available through Statistics Canada, thus was limited in the type and level of variables that could be investigated (e.g. residence not included, income was only a dichotomous variable). Also, no multivariate analysis was performed to control for possible confounding. For example, we found an income gradient of greater use of physiotherapy and chiropractor services among those with progressively higher incomes and an inverse relationship of income levels with family physician usage. These findings regarding socioeconomic status are similar to research comparing family physician and chiropractic service usage in Saskatchewan [22] and Toronto, Ontario [23]. The vast majority of chiropractors and approximately half of physiotherapy providers in Canada work in the private sector [24], thus being able to access these services for CBD will be largely dependent on having additional health insurance, which an estimated one third of Canadians do not have [25]. Paradoxically, possessing private health insurance for uninsured health costs is highly associated with income [26], yet Canadians with lower incomes are more likely to have CBD [2]. Similarly, rural residents of Canada are nearly 30% more likely than urban dwellers to experience CBD [2], with limited access to appropriate health care proposed as a contributing factor to higher prevalence rates [27‐29]. Poor access to publicly funded physiotherapy services and lack of multidisciplinary team support in rural settings have been identified as issues by Canadian physicians [30]. We found lower use of physiotherapy services among rural and remote respondents with no difference between rural and urban respondents in use of either family physician or chiropractor services; this is counter to what others have found in relation to chiropractic services [22]. Our findings may reflect people with CBD who either are more likely to travel to receive physician or chiropractic services in urban centres, or increased service delivery and/or providers in rural and remote settings.

A recently published ‘call to action’ on the global problem of low back pain highlighted the risks of overmedicalization of low back pain with excessive medical investigations and low value health care approaches that increase the risk of long-term back-related disability [31]. Ensuring equitable access to affordable health care for those who need it was among the several recommendations arising from this expert panel. The relatively high proportion of respondents in this study who reported seeking care ‘only’ with a family physician (fully publicly funded within the Canada) suggests that many people with CBD are receiving a predominantly medical approach to care. Enhancing access to non-pharmacological treatment options, such as physiotherapy or chiropractic care, for people with CBD is an important public health issue in Canada, particularly in light of the current opiod crisis. The first and last recommendations of the 2017 Canadian Guideline for Opiods for Chronic Non-cancer Pain [32] include referral to multidisciplinary non-physician care providers; however, given the access barriers to these services, these guidelines become challenging to follow in many clinical settings. Several models of care that include physiotherapists or chiropractors within primary care settings have shown benefit [33‐36], and others that are attempting to overcome access barriers are being investigated [37, 38].

This study is one of the few known analyses that provides a national picture of self-reported health care use among people with CBD that accounts for multiple socio-demographic, and health characteristics; however, there are several limitations to consider. The main limitation is that due to the design of the CCHS, we were unable to determine the reason why respondents sought care. Although only half of those who experience low back pain are thought to consult a health care provider, most of those who consult have experienced symptoms for a longer period of time [39]. Thus our focus on CBD would take into account those with more prolonged symptoms who may be more likely to seek care. To focus on community-based health care provider use, our analysis did not include people who were hospitalized in the past year. However, this likely removed some respondents who also sought care with health care providers outside of the hospital. We did not include ‘any’ use family physician services in this analysis in order to focus predominantly on ‘only’ use of predominantly publically funded services. The small sample sizes of physiotherapy or chiropractor service use ‘only’ precluded us from profiling these as mutually exclusive groups. As such, there is overlap in participants who reported seeking care with each of these provider groups. The usage patterns of people with CBD (Fig. 1); however, suggests that, aside from family physicians, multiple provider usage is more common than seeking care with a single provider. Our dependent variable was a minimum of a single visit in the past year. Examination of patterns of use with multiple visits over time may yield different results. This study is based on data that is several years old; however, our as of yet unpublished analysis of newer survey data (i.e. 2014 for physiotherapist use only among general population) suggests similar gaps in access among rural and lower income populations. Furthermore, we are not aware of any significant policy or funding changes that have been implemented in Canada that would suggest the current patters of use would be substantially different. Self-reported health care utilization is not likely to be as accurate as administrative data; however, there is no available administrative data source in Canada to comparatively examine these health care provider groups. Finally, the cross-sectional design does not permit conclusions regarding the direction of the observed associations.

This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations. The identified gaps in access to care among certain population groups demonstrates that there is not equitable access to care among Canadians with CBD. Enhancing access to potentially beneficial non-physician services for people with CBD requires rethinking the way front-line back care is delivered in Canada, including pressure on insurers and policy makers to cover and enable greater access to non-pharmacological management treatment options that have demonstrated value [34, 40].