Using Data to Explain Chiropractic Outcomes
INTERVIEW
Interview with Christine Goertz, DC, PhD
The American Chiropractor
Christine Goertz, D.C., Ph.D., is President of Christine Goertz LLC, and Chief Operating Officer of the Spine Institute for Quality (Spine IQ). She also has an adjunct faculty position at the Department of Orthopaedic Surgery, Duke University Medical Center. Dr. Goertz received her Doctor of Chiropractic (D.C.) degree from Northwestern Health Sciences University in 1991 and her Ph.D. in Health Services Research, Policy and Administration from the School of Public Health at the University of Minnesota in 1999. She has extensive experience in the administration of Federal grants, both as a PI and as a program official at the National Institutes of Health (NIH). Dr. Goertz has received nearly $32M in federal funding as either principal investigator or co-principal investigator, primarily from NIH and the Department of Defense. From 2007-2018 she was Vice Chancellor of Research and Health Policy at Palmer College of Chiropractic where her primary area of focus was the investigation of chiropractic care for spine-related disorders. Dr. Goertz currently chairs the American’ Chiropractic Associations Committee on Quality and Accountability (QC AA) and serves on the Board of Governors for the Patient Centered Outcomes Research Institute (PCORI), where she was recently appointed to a 3-year term as Vice Chair by the Comptroller General of the United States. In an interview with The American Chiropractor (TAC), Dr. Christine Goertz (CG) explains how we can use Spine IQ to demnstrate outcomes for chiropractic, and shares what her experience was like along her journey.
TAC: What led you to research?
CG: I started working on my PhD in health services research and health policy the year after I graduated from Northwestern Health Sciences University in 1991.1 was motivated to seek a career in research because I felt like there was so much I still didn’t know about which treatments worked best on which patients and when trying to talk to policy-makers about chiropractic. These important stakeholders were asking really good questions about mechanisms of action, efficacy, safety, and cost that I couldn’t answer when I looked at the very few studies available at that time.
TAC: Can you tell us about Spine IQ?
CG: The mission of the Spine Institute for Quality (Spine IQ), an independent non-profit 50 lc3, is to define quality, demonstrate value, and build trust in conservative spine care delivery using multidisciplinary models, performance measurement, and research to increase the patient-centered value of spine care delivered by doctors of chiropractic through three key initiatives: 1) the Spine IQ multidisciplinary clinical data registry for conservative spine care, in partnership with registry vendor Quality Value Health (QVH) Inc.; 2) the Spine IQ four-step quality designation program for doctors of chiropractic, which is in the final stages of development; and 3) the conduct of health services research designed to evaluate key questions regarding the effectiveness, safety, and cost of conservative spine care delivery. For more information, please visit our website at SpineIQ.org.
TAC: Do you work and function out of donations? How does Spine IQ fund itself?
CG: Spine IQ is very fortunate to have key funding partners that include Logan University and the American Chiropractic Association. We are also grateful to Palmer College of Chiropractic and the NCMIC Foundation for their significant early financial support of Spine IQ’s efforts. We continue to look for partners who are willing to invest in our work—to #TransformSpineCare delivery using evidence-based, data-driven approaches.
TAC: Do you think that the experience portrayed in the research is an accurate representation of the experience of chiropractors in the field?
CG: Randomized clinical trials are necessary in order to answer questions regarding the effectiveness, cost, and safety of chiropractic care. At the same time, we also need to be collecting data in chiropractic offices in order to evaluate outcomes in the real world. This is one of the driving forces behind Spine IQ. We intend to use our clinical data registry as a mechanism for collecting data that allows us to help DCs evaluate their own clinical performance, but also to conduct rigorous research using pragmatic study designs that can answer policy-relevant questions about DC spine care delivery.
TAC: In your analysis of the effects of chiropractic on low back pain, and neck pain, how do you deal with the fact that different chiropractors use different techniques, and soft tissue strategy?
This is a really important question. There are over a hundred chiropractic techniques but only two have demonstrated better outcomes than a sham or usual medical care in large randomized clinical trials - low velocity, variable amplitude (flexion distraction) and high velocity low amplitude (HVLA) adjusting. So far the way that I have dealt with this issue in my clinical trials has been to focus on the two techniques that already have an evidence base. Obviously much more work needs to be done to rigorously evaluate the others. It is important to keep in mind that "Absence of evidence is not evidence of absence". However, in our evidence-based world, it is also reasonable to expect that the treatments used by all clinicians have been studied. I believe that the best way to build the necessary evidence base for chiropractic techniques is through the use of large clinical data registries. This approach allows us to collect real-world data so that we can evaluate outcomes across techniques in order to see which deliver the best results. This is one of the reasons that I founded the Spine IQ, so that we could begin to collect technique data and analyze it using rigorous scientific methods. This effort will become increasingly important as insurers begin to classify some chiropractic techniques as “experimental” given the lack of data available in the scientific literature.
TAC: Does Spine IQ offer a plug-in that I can do with any software or are there certain service providers that work more integrated with it?
CG: There are currently three ways to enter data into the new Spine IQ clinical data registry during our Beta-testing phase. The first is direct data entry. The second is by downloading a file called consolidated clinical document architecture (CCDA) from your electronic health record. The third is to use one of our templates to gather patient data that can then be uploaded to the registry. Stay tuned as we are also working with a number of chiropractic electronic health record vendors to develop a direct pipeline from your electronic health records into the registry.
TAC: Did you ever work as a practicing chiropractor in the field or have you always been in the classroom or in research?
CG: When I graduated from chiropractic college, I stayed at Northwestern Health Sciences University for more than a year as a research fellow, seeing patients and working as a research assistant. After I left to concentrate on my PhD work, I did practice relief in the Minneapolis area for another few years. Since then, my primary focus has been on research and health policy.
TAC: Have you noticed a difference in the way males practice versus females?
CG: My personal experience has been that at least smaller women have to practice a little bit differently because of the size differential between them and the patients they treat.
I graduated from chiropractic school at 5’ 2” and weighed just over 100 pounds. When I got into my first adjusting class, I really struggled with doing a side-posture adjustment. One day, we had a substitute teacher. At some point, I said to him, “Maybe I can't do this. Maybe I’m just not big enough.” He offered to watch me adjust a fellow student. Afterward, he asked why I was standing so far away from the adjusting table during the treatment. I realized that my regular instructor was over six feet tall, and when he treated a patient, he stood several inches away from the table. It was a turning point for me, and by the time I graduated, I was able to easily adjust people who weighed 250 pounds.
TAC: How have you seen the role of the female chiropractor changed over the years? For women specifically, what kind of advice do you think would be valuable to them going out into the field today?
CG: I think the chiropractic profession needs to do a better job of embracing diversity in many different ways, including providing better mentoring and leadership opportunities for women. Last year, I wrote what I called the #DCMeToo blog post for the American Chiropractic Association and was really overwhelmed by the response that I got, especially from younger female doctors. My advice to women (and men too, for that matter) is to find a mentor, get involved with professional organizations that support causes you believe in, be willing to work hard, and stand up for yourself and others when it is necessary.
TAC: Anything further to add?
CG: Many people have heard me say this before, but I really believe that there has never been a more exciting time to be a doctor of chiropractic. Given the global burden of musculoskeletal disorders, the opioid crisis, and a new wave of interest in non-drug therapies, DCs are well positioned to significantly impact the quality of spine care delivery in the United States. However, we have to recognize that significant barriers exist. I have been working on multidisciplinary health policy initiatives for almost 30 years, and I can tell you that even today those in charge of creating and implementing current health care delivery models often either 1) do not think about chiropractic; 2) have reservations regarding the quality and consistency of chiropractic care delivery; or 3) do not know how to include DCs within an integrated healthcare system. Unfortunately, many DCs do not know how to communicate the value of the patient care that they provide to important stakeholder groups using language that these groups are able to understand. The rapid movement toward data-driven, value-based care creates an unprecedented opportunity to level the playing field. However, it requires new ways of thinking about DC performance and payment that I hope, for the sake of the patients we serve, we are all able to embrace.
You may contact Dr. Goertz at [email protected]
