ON Spinal Chat

An Evidence-based Framework for Chiropractic Care

Episode Summary

In 2020, the Ontario Chiropractic Association (OCA) formed the Evidence-based Framework Advisory Council with a mandate to help develop a shared understanding or framework around what exactly evidence-based practice means for chiropractic care. In this episode, we check in with Caroline Brereton, OCA's CEO, to hear about the Evidence-based Framework Advisory Council (EBFAC), its goals, the process it’s following, how it will help OCA members support better patient care and advance the profession. Caroline chats about the EBFAC’s progress, what to look for in the near future and what its long-term goals entail.

Episode Notes

In 2020, the Ontario Chiropractic Association (OCA) formed the Evidence-based Framework Advisory Council with a mandate to help develop a shared understanding or framework around what exactly evidence-based practice means for chiropractic care.  In this episode, we check in with Caroline Brereton, OCA's CEO, to hear about the Evidence-based Framework Advisory Council (EBFAC), its goals, the process it’s following, how it will help OCA members support better patient care and advance the profession. Caroline chats about the EBFAC’s progress, what to look for in the near future and what its long-term goals entail.

Topics Covered:

Key Links to References/Resources Discussed:

About Caroline Brereton:

Caroline is CEO of the Ontario Chiropractic Association and oversees the Evidence-based Framework Advisory Council (EBFAC). 

Through working for 18 years on acute care’s front-line to now leading the fourth largest chiropractic association in the world by membership, she has lived varied perspectives of our health care system.

Her passion for quality patient care in Ontario began in 1992 with her work as a registered nurse caring for elderly patients with complex needs at Queensway General Hospital, in Toronto’s west end.

As Caroline's career evolved, she moved to Trillium Health Centre (now Trillium Health Partners) in 1998, where she held several senior level positions, from Director, Medical Health Systems, to Vice President, People, Corporate and Clinical Support Services. At Trillium, she applied a new leadership philosophy and accountability framework to initiate customer service models that improved patients’ experience and outcomes.  Caroline was also honoured to lead the implementation of the University of Toronto’s Mississauga Medical Academy and the Shared Service West Organization transformation, on behalf of four organizations.

In addition to her nursing and midwifery credentials, Ms. Brereton has an MBA from Queen’s University and is a graduate of the Rotman School of Management Advanced Health Leadership Program.

Since joining the Ontario Chiropractic Association (OCA) as CEO in June 2018, she has focused on building relationships with all partners that impact chiropractors and their patients in Ontario. Caroline is committed to ensuring the OCA is making a difference for its members and supporting others in their accountabilities to the profession.

In her previous tenure as Chief Executive Officer of the Mississauga Halton Community Care Access Centre (CCAC) and Vice Chair of the Ontario Association of Community Care Access Centres (OACCAC) Board of Directors, she collaborated with multiple partners to help drive our system’s transformation to integrated, patient-centred care.

Caroline was inspired by the initiatives  CCAC's  interconnected teams implemented to improve patients’ experience and outcomes. These initiatives ranged from a primary care advisor model that achieved a 76 per cent engagement rate with primary care providers across the region to our seamless transitions hospital partnership that reduced the number of patients returning to hospital within 30-days after discharge by 52 per cent.

Delivering home and community care every day gave her and the CCAC a front-line advantage. It showed what works and what is vital to our health care system. These experiences opened Caroline's eyes to our system’s potential. 

Caroline is excited by the possibility of creating a world-class, fully integrated health system in Ontario and potentially across Canada.  Like many health care leaders, Caroline is also constantly thinking about ‘how’ to best achieve this for Ontarians.

She believes all health care partners must share their insights and work together, hand in glove, to shape a system that overcomes long-term challenges and continuously raises the bar for quality of care. 

In addition to her OCA role, Caroline is also a Board member of the Regional Geriatric Program of Toronto.

Episode Transcription

An Evidence-based Framework for Chiropractic Care



Welcome to ON Spinal Chat, where we explore what O-C-A is doing, or supporting, to help enhance your patient care, grow your practice, or advance the chiropractic profession.

If you ask Ontario chiropractors, other healthcare professionals, or patients to define evidence-based chiropractic care, you'll hear a range of answers. 

These mixed perceptions can be confusing. They also raise a range of questions, from the role and impact of patient preference in evidence-based care delivery, to what are the barriers to successfully integrating research evidence into clinical practice. 

That's why the Ontario Chiropractic Association formed the Evidence-based Framework Advisory Council with a mandate to help develop a shared understanding or framework around what exactly evidence-based practice means for chiropractic care.

I'm Leslie from the O-C-A, and today I'm speaking with Caroline Brereton, our C-E-O, to check in on the Evidence-based Framework Advisory Council, or the EFAC, as it's often called, its goals, the process it's following, and how it will help our members support better patient care and advance the profession. 

Having worked on acute care's frontline for 18 years before holding senior positions in Ontario's public health system and joining the O-C-A in 2018, Caroline brings a unique perspective to this work. 

We'll chat about the EFAC's progress, what to look for in the near future, and what its long-term goals entail. And be sure to check the show notes for the list of topics and links discussed in this podcast.



First off, why did the O-C-A develop the Evidence-based Framework Advisory Council?


The language of evidence-based practice is one that is commonly used in modern clinical care and is something that the profession has embraced over the last number of years. 

However, it's multidimensional, and we started this project to help our members, our patients, and our stakeholders understand what chiropractic care means within the context of evidence-based practice.


Out of curiosity, why now? What motivated the O-C-A to move forward on this at this point in time, which I know was before the pandemic started.


The profession has matured a lot in recent years with a growing interest in the research agenda, a growing investment in that area. And we know that the research conducted to date shows us that chiropractors can have a really important role to play in the musculoskeletal health of patients, and much of that evidence points to the role chiropractors play in low back pain. 

However, chiropractors are spine, muscle, joint, and related nervous system experts. And so, there is much more to the care that chiropractors deliver than low back pain, although low back pain is really significant. Other disability-related to spine, muscle, joints, and the related nervous system issues is a leading cause of disability globally. And there's an increased emphasis on ensuring musculoskeletal health around the world. 

So, we wanted to make sure that the comprehensive care that chiropractors deliver is expressed through the evidence-based framework, and that we understand how to communicate that to patients and key stakeholders.


What are the key goals of the Evidence-based Framework Advisory Council?


The first very important goal given our role with respect to the profession is to be able to communicate the comprehensive care that chiropractors deliver. 

There are a wide variety of ways in which chiropractors can contribute to neuromuscular skeletal health for our patients. And so, we want to be able to develop that comprehensive and inclusive definition, so that we can communicate effectively with patients and stakeholders what it is that our chiropractors do.

There are many conditions that chiropractors treat that are MSK conditions and neuro MSK conditions. And then there are treatments for which chiropractors treat the side effects of those conditions. There are many competencies that chiropractors have, which we don't talk about very often.


And how will the Evidence-based Framework Advisory Council change this scenario?


With the work that we are doing, we expect to have language that allows us to talk about the breadth of work that chiropractors can do. 

And so, that becomes an important next step after we've completed our deep dive into the elements of the evidence-based framework, is to generate those communication tools that will allow us to have patients and residents of Ontario and elsewhere understand the breadth of care the chiropractors can deliver.

The second key goal is to gain a clearer understanding of research priorities moving forward. 

As a significant contributor to the research agenda in Canada, we are frequently asked for input, which is wonderful. Outside of the processes led by the wonderful organization, the Canadian Chiropractic Research Foundation, and the Canadian Chiropractic Guideline Initiative, we have opportunities where we are asked directly to fund additional research, and we want to have an informed voice in the shaping of the research agenda. 

We want to know what's important to patients, to our clinicians, and to the health system as a whole, so that we can really increase the contributions that chiropractors make to the overall care of patients. 

So, our second goal is a clearer understanding of the research priorities for our input into the research agenda.

And the third piece is to strengthen the role that the O-C-A can play in knowledge translation for the members in Ontario. 

We have members who have graduated over a long period of time, many members reflecting different phases of their careers. And keeping up with the research agenda, keeping up with the changing expectations of patients, understanding what supports are in place for clinicians in private practice, those are not insignificant in terms of the support that's needed to stay in touch with that. 

And we have an important role as an association to support our members in staying connected to that work.


I understand we're not doing this work in a vacuum. Could you describe who's involved on the Advisory Council, as well as how they're tapping into other work that's been done to date?


The Advisory Council is comprised of members of the O-C-A from Ontario who have diverse clinical backgrounds and are involved in chiropractic care in different ways. 

We have clinicians who see patients of all backgrounds, of all demographics. We have members of the Council who are involved in education, are involved in research, and at different stages of their careers. 

Outside of the work and the input from Council members, we have research supports for Council. And in doing that work, we tap into and are accessing the leading research papers that are available to us on the subject of evidence-based practice. And we have a patient, as well, represented on our Council.

And then, in examining the evidence pillar of the evidence-based framework, we are turning to experts outside of the Council membership who have contributed significant work in various areas of expertise for chiropractors. So, whether that is with respect to migraines, for example, or maintenance care, we're tapping into others who have done research to learn from those as well.

An important part of our process is to consult with key stakeholders involved in the chiropractic profession, to get their perspectives as well, as we refine the outputs from the Evidence-based Council. So, as you would imagine, those are other associations, educational institutions, those involved in research, have all been invited to participate.


What process is the Advisory Council following to implement this work and develop the key deliverables?


I mentioned, we have a diversity of practice styles on Council demographics within the practice age groups, locations, gender, and roles within the chiropractic ecosystem. So, there is incredible diversity within Council. 

We've started this process by focusing on, what do we have in common that we can work towards that's in the best interests of patients and therefore in the best interests of the profession. 

I believe that the process we have followed is a model for conversations about other big questions that we have for the profession. Let's start to see what we have in common that brings the best outcomes for patients and keeps the patient front and center in what we do. 

And so, I want to acknowledge that the way in which Council with all its diversity approach, their work is certainly one that I think has yielded lots of positive outcomes for us to work within Ontario.


And what's the response been to date?


We've been met enthusiastically with respect to the work. There's been a very positive reception to the importance of doing this work and doing it well for the profession. 

There's been willing input shared that helps us refine our work, and an openness to collaboration when we finalized our work and when we have a sense of how we'd like to move forward with the pieces of work that are within our accountability. 

There is an openness to learning, to listening to what other voices have to say, and that's been wonderful.


I want to loop back to one of your first points on the benefit in terms of getting a clear understanding of the research priorities to fund. You've talked about the research agenda. Can you describe what that is in a little more detail for our members?


The research agenda in Canada has been really advanced over the recent years with the strengthening of the Canadian Chiropractic Research Foundation, and an important part of how C-C-R-F is pursuing its work is with engagement of key stakeholders. 

So, for example, the provincial associations are actively engaged in providing feedback. In order for us to provide feedback, it's important for us to understand what's on our members' minds. 

What is it our members see as priorities? What are they seeing in their practice that perhaps is not fully explained by high-quality research now and that with a focus on it could be very important for us to learn from. 

So, the research agenda is an emerging process by which the clinicians at the grassroots delivering care to patients, their voices are heard at the tables where decisions are being made about the funding of research priorities.

In addition, the research agenda appropriately is driven by understanding what are the needs of patients in a particular jurisdiction. Late last year, we had the Global Alliance for Musculoskeletal Health release a really important document talking about the burden of disability globally, with respect to musculoskeletal problems. And we know that that's reflected here in Canada as well.

And then, there are different demographics within our population in Ontario, for example, who experience different issues based on the kind of work that they do, the resources they have, how well their voices are represented in the publicly funded health care system, or in the private health care system. 

So, we do know that a topic for us moving forward will be, how do we ensure that diverse communities in Ontario understand the care that they can receive from chiropractors, and how those patients can benefit from chiropractic care. And we have some work to do to understand that. 

The research agenda, I think, is multifaceted, and this work will help inform us in a number of ways to shape that agenda moving forward.


Does our online patient and family advisory council, called the Partnership for Better Health, have a role in this work?


Absolutely. That's a growing online forum for patients who have been working with chiropractors, or who perhaps want to work with chiropractors, want to learn a little bit more. 

We can certainly leverage the voice of that community to influence the priorities for the research agenda moving forward. So, it's a very important input.


And I believe that's something that's unique to the O-C-A.


As far as we're aware, it's a first of its kind certainly in Ontario. 

The voice of patients we know has been instrumental in shaping the priorities for the healthcare system in the past, and we anticipate that will continue moving forward. So, a very important initiative undertaken by the O-C-A, and we'll continue to see that grow in its importance.


Now, I understand that O-C-A has been investing in research for the past few years. When we've got this work done, and being able to identify these priorities that you've outlined, how is it going to impact O-C-A's support of research, and down the line, how will our members benefit?


We see an opportunity for the O-C-A to continue and increase our investment in research because we understand that to advance the profession in Ontario, we have to be able to answer some important questions about how chiropractic care can contribute to solving some of the significant challenges that our health system faces and that patients face. So, research helps us answer those questions.

And, as we learn more about why it is that chiropractic care works, there will be increasing opportunities for chiropractors to play an important role. There will be increasing numbers of patients in Ontario suffering from degenerative diseases, such as arthritis, and advancing with respect to the chiropractic profession will help us identify how chiropractors can increase their contribution. And that's just one example.

So, there's real value for our members in the O-C-A continuing and increasing its contribution to the research agenda, because it is essential to our other work of advocacy for the role of chiropractors in the health care system.


Absolutely. Is there an example that you want to cite in terms of which patient group might actually benefit from this research? Or is it too early?


That's a good question. I think some of it is early. Sometimes there's a misunderstanding about one of the core competencies that our chiropractors have, which is the adjustment and the role that it can play with patients' health care. 

So, using research to explain, what is an adjustment? How does it impact the health of a patient? How does it impact their clinical condition? How is that treatment modified for patients as they age, or as they have other co-morbidities, is something that will benefit patients to continue through care plans at different times in their life cycle. 

So, because we haven't contributed some of the major questions yet, based on where the work is at, and that would be something that's done in collaboration with others, it's a bit early to answer that question.

But, I'll circle back to the diverse communities that we serve in Ontario. There are many communities who come from a different view of how to engage with the publicly funded health care system. 

How do we communicate what chiropractic care is about, in a way that meets their patient expectations for the plan of care and how outcomes will be evaluated? Some of it is taking what we know right now, in terms of the science and the clinical outcomes, and integrating that with what we've less well examined and understood, which is patient preferences for how their care is delivered.


What's been done on patient preferences to date in terms of research and studies?


When we started our deep dive into the patient preference pillar of the evidence-based framework, we recognized that not much has been done and that while some has been done, it's work that needs to be built upon. So, we turned to others who have had the same realization in more recent years. And so for example, Health Quality Ontario, a leader in the development of guidelines for many conditions treated within the publicly funded health care system, started to recognize that patient compliance with the guidelines they were producing needed to consider how patients wanted care to be delivered, including things like how they wanted clinicians to interact with them, how they wanted clinicians to communicate with them, who they wanted to have involved in their care. Health Quality Ontario had a number of years ago, launched a patient engagement strategy to make sure that the voice of patients is reflected in the guidelines that they produce.

There are other places such as the Canadian Patient Safety Institute and others who focus on patient safety around the world, who have also identified how important the voice of the patient is in ensuring the best outcomes of care. And so, we certainly have looked towards existing leaders with respect to that. But, not as much work has been done specific to the chiropractic profession, and we do see that as a significant opportunity moving forward.


We've talked about the whole research agenda, and you mentioned accelerating. So, with this work, do you see how this might change the speed that we can address this work?


Well, certainly in conversation with leadership at C-C-R-F, we know that they are doing significant partnership development work so that they can grow the investment pool that's available for distribution to our researchers. And, what's been shared and what we know is, many who are interested in funding research are keenly interested in that research being rooted in what do patients want, what is the voice of patients, and how do we meet the needs of diverse patients and communities. And that certainly resonates with us.

So, when we are identifying research questions that address all elements of the evidence-based framework, the best available evidence, the patient preference, and clinician expertise, that's going to resonate with funders, and I think will bring partners to the table for C-C-R-F and for others that will allow us to accelerate that research.


Great. Thank you. I want to go back to knowledge translation. Could you outline how you see the Evidence-based Framework Advisory Council's supporting knowledge translation, and how that may affect our members?


Part of the work that we're doing within this project is to look at what current thinking is and leading practices are, with respect to knowledge translation for any regulated health professional group. 

We have to think about what has been researched in the past and think about the fact that chiropractors generally practice in private practices in the community without the infrastructure that much of the knowledge translation research has been placed within. 

If you think about knowledge translation activities for professionals who work in acute care settings, or organized community care, or long-term care, those organizations provide infrastructure that's easily accessible to the professionals in that group to access new learning. There's easily available, mentorship resources, multiple levels of expertise that's available for novice practitioners, for example. 

So, we have to think about what we currently know about knowledge translation and how that applies in settings that are sole practitioners, or small practices, or multidisciplinary practices, but perhaps with only one chiropractor and other professionals within that group.

When looking at the current research with respect to knowledge translation, how does that apply to the chiropractic profession specifically? And then, do the different generations of practitioners want to receive things differently? 

And we believe that is the case, that it is not a one size fits all. 

And we are looking at what that continuum of support for knowledge translation needs to be for the profession in Ontario. Tapping into our Council members on that, we will be tapping into focus groups with different members who will likely bring us different perspectives. 

And, I think we'll learn from that the different ways in which our members want to continue to learn about the more recent research that's evolved, how to stay connected with it, and how to integrate it into practice.


Thank you. Now, I know we've talked a lot about how the whole EBFAC is going to enhance the chiropractic profession. But at a high level, what do you see if you had to pin it down to the top three ways?


The first one I would reflect on is, it will give us the ability to communicate with important key stakeholders, which include our patients, our potential patients, about the comprehensiveness of care that chiropractors can deliver. Therefore, how they can meet patient needs and what patients can expect from that care.

I think the second way is, it will definitely help us to accelerate what we see as the important research questions to move the profession forward, and be able to position the profession to meet the needs of emerging gaps in our healthcare system.

I think another way that this work will help us, is actually related to helping our members have successful practices. When we can talk about how the application of the best available evidence increases patient satisfaction with their care, their satisfaction with the interaction they've had with the clinician, therefore the positive way in which a patient will speak about the interaction they've had, the care they've received, the outcomes they've achieved, that helps our members.

Another way specific to what the O-C-A can do, is with our O-C-A Aspire, electronic patient record and practice management solution, can start to build into our electronic patient record, guidelines and processes of care that are based on the evidence and that are at the fingertips of our practitioners. 

That's something that we will work towards as the profession generates more guidelines. As we answer more of the research questions, how do we build that into our OCS buyer solution, which can be a foundation for not only an efficient practice but a practice that is able to integrate evidence-based care in a more seamless way into their day-to-day practice.


Just for clarity then, members who are using O-C-A's Aspire will have access to these features?


That would be our goal. The way we have designed our electronic health record is that when a diagnosis is made, care plans can be automatically populated with the best available evidence, and also customized to the patient preference. 

It's not cookie-cutter medicine, because that's not what evidence-based care is. But, it makes it easier for our members to have the best available evidence available to them for the care plan, and to spend their time communicating with the patient and speaking with the patient about how to customize that care plan delivery in a more efficient way.


I'd like to know a little more on how the EBFAC will improve patient care. You've just outlined one way. Are there other ways that you see this work improving and enhancing patient care?


I think what's exciting for members of the Council and for the team members at the O-C-A, is that we believe that no matter what their experience years have been in the profession, this work will excite members to engage in the conversation around evidence-based care. 

To understand the value of constantly looking to improve how we deliver care and how that can improve their goals for their practice, their goals for their patients. 

I see that anytime we can encourage a health care practitioner to pursue ongoing learning, to think about how to engage the patients in their care in a more personalized way, that can only benefit the profession and patients as well.


Now, you've got a patient on the Council. How is this being reinforced by the feedback you're getting from the patient in terms of the value that this could provide to patients?


The voice of our patient member on the Council has been really important in a number of ways. 

First, and I think we all probably know this but we forget it, is to make sure that when we have our deliverables and when we communicate, especially with patients, we do it in language that patients can understand. 

So, I'll use something that'll be familiar to our members, which is, what is an adjustment? Depending on who your patient is, they will want more or less detail about, well, what is this adjustment? What does it mean? How does it work? And so, our patient has been very helpful in getting us to think about being able to communicate what we do in a way that our patients can understand. That's the first thing.

The second way that our patient has been really helpful, is to share with us the experience of patients navigating the journey to look for a chiropractor. And, what are the things that patients encounter when looking for a chiropractor that makes it challenging or easier for them to say, ah, this is the person for me. 

This work will therefore be helpful when we can work with our members in providing insight into how they communicate on their websites, within our own website, being able to identify who are chiropractors in a particular person's area that has an expertise in a particular clinical condition or a particular area of focus.

And the third way is that our patient has reminded us that patients have many clinicians in their circle of care and that patients want communication to be happening between those who are in their circle of care. 

And I think that's very important, that whether or not our members are working in the publicly-funded system, and the majority or not, that doesn't mean that there isn't a desire on behalf of the patients to have their circle of care knowledgeable of what's going on and that we don't have a responsibility to share important information with other clinicians in that circle of care.


So, once we have a comprehensive and inclusive definition for chiropractic care and all the other preliminary work in place, what are the next steps?


Our goal with this work is to do some research, do an assessment of where is our knowledge-based right now with respect to evidence-based chiropractic care. What does the application of the evidence-based framework mean for the profession? And, what are the questions that remain not answered that we would want to answer moving forward? 

And the O-C-A is not the organization to do that in isolation.

The first step is to make sure that as many people as possible, who are involved in the chiropractic ecosystem, as I call it, have visibility to our work and can use that work to build upon. We are seeking for our work to be published in a prominent journal so that key stakeholders can see the work, can ask questions about the work and can build upon the work because this is evolving work, it's not static work.

As with anything that involves patient care, many people have to come together in the system for the patient. And so, we see that there are opportunities for us to collaborate with some of the stakeholders I already mentioned. Those who are fostering the research agenda. Those involved in teaching and education, associations like ourselves, who support continuing education for our members. 

We see a role for the Association in a more wholesome way, leveraging, for example, our Partnership for Better Health, to more fully engage with patients on this topic. To continue to understand the different segments of the population who use chiropractic care, or who are seeking resources to help them with care, to understand what they're expecting, and to be able to communicate to key stakeholders and to our members as well.

So, we see the first step as making sure as much of our work is visible to key stakeholders. 

The contributions of the members of the Evidence-based Framework Advisory Council are significant. They have given a significant amount of time and commitment to this work, and we believe that it is fully deserving of as much attention as we can bring to it. 

Our next steps following publication will be moving into sustainability. Partnerships will be part of that. But also, how do we evolve the work that we do as an association to make sure that this work continues to be a focus, and we continue to invest our resources in the next steps for this work.


Now, if members have any questions after listening to this podcast, where can they go?


Well, certainly, feel free to reach out to myself or any member of the team. Our contact information is available on our website. 

Also, feel free to reach out to our Board of Directors. Our Board is championed by incredibly committed members from within the profession in Ontario. And they value the feedback they get from the members and are also absolutely committed to bringing that feedback back to the organization and to the Board table and making sure that we can use that input to move the profession forward here in Ontario.


Thank you, Caroline, for updating us on the Evidence-based Framework Advisory Council's work, and your insights on its progress towards establishing a comprehensive and inclusive understanding and definition for evidence-based chiropractic care. 

Thanks also for highlighting the related impact of O-C-A's other initiatives, like O-C-A Aspire, our electronic health record and practice management solution, as well as the Partnership for Better Health, our online Patient and Family Advisory Council.


We'll be back next month with another podcast, which may focus on the current status of this pandemic, with insights on supports and member feedback on what's working for them. I hope you'll join us.