In July 2004, the Veterans Health Administration (VHA) Directive 2004-035 established the provision of chiropractic services on station within VHA . This directive was issued in response to a Congressional mandate (Public Law 107-135), advocated by Veterans Service Organizations and chiropractic professional associations. The directive specifies that chiropractic services are for management of neuromusculoskeletal conditions and are included in the standard Medical Benefits Package for all enrolled veterans. Furthermore, these services are to be delivered on station at a minimum of one facility in each Veterans Integrated Service Network, by full-or part-time hiring or contracting with licensed chiropractic physicians (chiropractors).
By late 2004, VHA had identified 26 facilities at which to introduce these services and the first chiropractic clinics were established. In fiscal year 2005, more than 4,000 veterans received on-station chiropractic services in VHA. By fiscal year 2008, the program had expanded to 36 clinics and more than 12,000 veterans received services. During this period, the number of clinics increased by 38 percent and the number of veterans seen at these clinics tripled.
To date, no national-level data have been presented regarding the characteristics of VHA chiropractors and related clinical structures. Previous work has described chiropractors and their patients in private practice in the United States and Canada [2-5]. This research has shown significant variation among providers regarding professional training, practice parameters, academic experience, and scholarly activity.
Chiropractors typically manage spinal pain or other musculoskeletal complaints. In private practice settings, the average chiropractic patient is aged 40 to 50, slightly more than half are female, and less than 10 percent are referred by medical physicians . In VHA, almost half the patient population is aged 60 and only about 7 percent are female . By directive, all patients seen in chiropractic clinics must be referred by medical providers. Thus, VHA chiropractic patients are likely to represent a substantially different demographic than those seen in private chiropractic practice. Moreover, since the introduction of chiropractic services was centrally mandated yet locally implemented, natural variation is expected in clinical structures.
This study describes characteristics of the chiropractors serving in VHA, as well as other elements of chiropractic service delivery in VHA.
Study Design and Participants
The project was designed as a descriptive observational survey. The study population included all chiropractors in the VHA system, excluding one who is an author of this article. At the beginning of this study, all other chiropractors on record with the VHA Department of Patient Care Services were contacted and invited to participate. Chiropractors who became VHA providers after the study began were not included. The Department of Veterans Affairs (VA) Connecticut Healthcare System and Palmer College of Chiropractic Institutional Review Boards approved the study.
Participants were asked to complete a survey assessing provider demographics, aspects of their training, and clinical practice characteristics. Participants were also asked to provide information about patient demographics, conditions, evaluation and management, and clinical care.
Data Collection and Management
The survey of provider characteristics is modeled after previous surveys of chiropractors in private practice, notably the work of Nyiendo et al.  and Hurwitz et al. . Because of the small number of chiropractors in VHA, we chose not to pilot the survey in our sample to avoid potentially biasing some respondents. *
Subjects completed the survey anonymously. Participants were provided access codes to the Web-based survey, and only the Web developer had access to the codes. …