Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia.

0.2 MB·English

by  Wardle, Jon L

Wardleetal.Chiropractic&ManualTherapies2013,21:5
http://www.chiromt.com/content/21/1/5 CHIROPRACTIC & MANUAL THERAPIES
RESEARCH Open Access
Referrals to chiropractors and osteopaths: a
survey of general practitioners in rural and
regional New South Wales, Australia
Jon L Wardle1,2*, Davi W Sibbritt1,2 and Jon Adams1,2
Abstract
Background: Chiropractic and osteopathy form a significant part of the healthcare settingin rural and regional
Australia, with national registration of practitioners, public subsidies for services and highutilisation by the
Australian public. However, despite their significant role inrural and regionalAustralia, therehas been little
exploration of theinterfacebetween chiropractic and osteopathy and conventional primary health care
practitioners in this area. The study aim was to examine thereferral practices and factors that underliereferral to
chiropractors and osteopaths byrural and regional Australian general practitioners (GPs), by drawing on a sample of
GPs inrural and regionalNew South Wales.
Methods: A 27-item questionnaire was sent to all 1486 GPs currentlypractisingin rural and regional Divisions of
General Practicein NewSouthWales, Australia.
Results: A total of 585GPs responded to the questionnaire, with 49 questionnaires returned as“nolonger at this
address”(response rate: 40.7%). The majorityof GPs (64.1%) referred to a chiropractor or osteopath at least a few
times per year while 21.7% stated that theywould not refer to a chiropractoror osteopath under any
circumstances. Patients asking theGP about CAM (OR=3.59; CI: 1.12, 11.55),GP’suse ofCAM practitioners as a major
source of information (OR=4.39; 95% CI:2.04,9.41), lackof other treatment options (OR=2.41; 95% CI: 1.18, 5.12),
access to a widevariety of medical specialists (OR=12.5; 95% CI:2.4, 50.0), GP’sbelief in theefficacy of chiropractic
and osteopathy services (OR=3.39; 95% CI:2.19, 5.25) and experiencingpositive results from patients using these
services previously (OR=1.67; CI: 1.02, 2.75) were allindependently predictive ofincreased referral to chiropractic
and osteopathy services amongst therural GPs.
Conclusions: There is a significant interface between chiropractic and osteopathy and Australian rural and regional
general practice inNew South Wales. Althoughthereis generally high support for chiropractic and osteopathy
among Australian GPs, this was not absolute and theheterogeneity ofresponses suggests that there remain
tensions between theprofessions. The significant interfacebetween chiropractic and osteopathy may be due in
part to the inclusion of theseprofessionsin thepubliclysubsidisednational healthcare delivery scheme. The
significant impact ofchiropractic and osteopathy and general practice in rural and regional Australian healthcare
delivery should serve as an impetus for increased research intochiropracticand osteopathy practice, policy and
regulation inthese areas.
Keywords: Chiropractic, Osteopathy,General practice, Rural healthcare, Healthservices, Referral, Interdisciplinary
care, Primarycare
*Correspondence:[email protected]
1FacultyofHealth,UniversityofTechnologySydney,235-253JonesSt,
Ultimo,NSW2007,Australia
2NetworkofResearchersinthePublicHealthofComplementaryand
AlternativeMedicine(NORPHCAM),www.norphcam.org
©2013Wardleetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
Wardleetal.Chiropractic&ManualTherapies2013,21:5 Page2of9
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Background significantreferralpatterns,withanationalsurveyindicat-
Therisinguseofcomplementaryandalternativemedicine ing 60% of Australian GPs regularly (at least a few times
(CAM) - a diverse group of health care practices not peryear)refertochiropractors,and23%regularlyreferto
considered part of conventional medicine - has emerged osteopaths [7]. These referrals form a significant part of
asasignificantpublichealthissueinAustraliaoverrecent the chiropractic and osteopathic patient load in Australia,
decades, with visits to CAM practitioners accounting for with 20% of all chiropractic patients and 16% of osteo-
up to half of all health consultations [1]. The professions pathicpatientspresentingviareferralfromaconventional
of chiropractic and osteopathy form a significant part of medicalpractitioner[13].
the Australian CAM practitioner sector. Chiropractors Althoughtheredoappeartobehighlevelsofsupportfor
are the second largest CAM profession in Australia, after chiropractic and osteopathy amongst Australian GPs, such
naturopaths [2,3]. Although smaller than chiropractic, support is not uniform and significant heterogeneity in GP
osteopaths were the fastest growing CAM profession in attitudes towards these professions exists. Although a na-
Australia inthe ten years between 1996 and 2006[3]. Be- tional survey of Australian GPs uncovered high levels of
tween them, chiropractors and osteopaths represent 45% supportamongstGPsforreferraltochiropracticandosteo-
ofthe ‘primary-care capable’CAM practitionerworkforce pathic services, it also showed that a significant number of
inrural andregional New SouthWales[2]. Inadditionto GPs would actively discourage patient use of chiropractic
theirsignificantpresenceintermsofpractitionernumbers, (16%) and osteopathy (21%) [7]. Medical practitioner sup-
both chiropractic and osteopathy professions are being in- port for chiropractic and osteopathic services may also be
creasingly integrated into healthcare delivery in Australia limited to their use in specific circumstances only; such
[4], with practitioners in both professions recently being distinctions were observed in a postal survey of Canadian
included in the Australian national registration scheme for GPs, which uncovered high levels of GPsupport for CAM
health practitioners [5], as well as consultations with incertaincircumstances(suchaschiropracticformusculo-
practitionersinbothprofessionsbeingandeligibleforpub- skeletal problems) but did not infer general support (such
licsubsidies(Medicare)fortheirservices[6]. aschiropracticforgeneralcare,whichwasratedthelowest
GeneralpracticeisonebranchofmedicinewhereCAM ofallCAMforgeneralhealthcaretreatment)[17].
is making its presence felt, with data from Australian Research is also uncovering geographical differences in
surveys indicating significant levels of referral from gen- CAM consumption both in Australian and internation-
eral practitioners (GPs) to CAM practitioners [7-9]. ally, with increased use by rural populations when
WhilstthesestudiesindicatethatGPreferraltootherGPs compared to their urban counterparts [18]. Previous
practising CAM therapies is more common than referral studies have shown high utilisation of chiropractic and
to those trained specifically in CAM modalities [9], there osteopathy services in rural and regional Australia
isalsoevidenceofthedevelopmentofacloserworkingre- [12,14,19]. Additionally, in the Australian setting, the
lationship between CAM practitioners and GPs [7,8]. distribution of CAM practitioners in some regional and
However, CAM integration is still an evolving and highly rural areas may be as great as conventional primary
contestedpracticeissuewithinprimaryhealthcare[10,11] health care providers; with chiropractor and osteopath
and the trend has been towards uneven integration with numbers being 40% of the numbers of GPs in rural and
different therapies attracting different levels of support regional New South Wales [2]. However, rather than re-
fromGPs[7]. placing conventional providers in underserved areas,
Morespecifically,chiropracticandosteopathyaremajor CAM practitioner density appears to follow conven-
forms of CAM that are highly utilised by the Australian tional provider density [2,20], and patients in rural
public, with surveys indicating utilisation rates estimated areas may express dissatisfaction in the level of CAM
tobebetween16%and26% [12-15].Therealsoappearto services in their community as well as the level of con-
be relatively high levels of support for chiropractic treat- ventional providers [21,22]. Research has also indicated
ment amongst the Australian general practitioner (GP) that some CAM practitioners, such as chiropractors
community (compared to other CAM therapies), with a [23] appear to have a broader scope of practice and
national survey indicating 72% of GPs rate chiropractic treat a wider variety of conditions in rural areas than
as moderately or highly effective while only 44% of they do in urban areas.
respondents report the same of osteopathy [7]. However, Thehighlevelofintegrationofchiropracticandosteop-
issues such as the medico-legal implications of referral to athy in the Australian healthcare sector, relative to other
CAMprovidersmayconstitutebarrierstoreferralsarising CAM professions, has significant implications for general
fromsuchhighlevelsofsupportforchiropracticandoste- practice and healthcare delivery in rural and regional
opathy amongst Australian GPs [16]. Support for chiro- Australia, especially whenviewedinthe context of higher
practic and osteopathy amongst Australian GPs still use of these therapies in non-urban areas. However, des-
appears, in part, to have translated into practice through pitetheextensivepresenceofchiropracticandosteopathic
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practitioners, and the significant interactions that appear osteopaths, relative to other professions, in rural and re-
to occur between these practitioners and conventional gional NSW specifically [2]. To minimise the effects of
medical providers, there has been little research to date local variation, every rural and regional GP in Australia’s
exploring the level of integration at the grass-roots or largest state(New South Wales)wassurveyed.
the factors that underlie any integration of chiropractic Questionnaire data was analysed using descriptive
and osteopathy in general practice in rural and regional statisticsviafrequencydistributionsandcross-tabulations.
Australia. This paper provides a first step in addressing Demographic and practice characteristics of GPs who re-
thisresearchgapbyexploringthereferralpatternsofGPs ferred to chiropractors and osteopaths often (at least
inrelation to chiropractic and osteopathy inrural and re- monthly) and seldom or never were compared using chi-
gionalNewSouthWales,Australia. square tests. Logistic regression modelling, that included
all practitioner and practice characteristics variables, was
Methods conducted using a backwards stepwise method of elimin-
A 27-item questionnaire (Additional file 1) was mailed ation using a likelihood ratio test, to parsimoniously pre-
by post to all 1486 GPs registered as practising in rural dict referral to chiropractors and osteopaths. Statistical
and regional General Practice Divisions of NSW, with a significance was set at the α=0.05 level. Data were
reminder card sent after two months. The questionnaire analysedusingthesoftwareprogramSTATA11.
was adapted for rural and regional use from previous
Australian surveys of GP attitudes, use and practices of Results
CAM[7,8].Thesurvey waspiloted at the Departmentof A total of 585 questionnaires were returned completed,
General Practice, School of Medicine and Public Health, with 49 questionnaires returned uncompleted as ‘no
University of Newcastle, with modifications made based longer at this address’; giving a response rate of 40.7%.
on feedback to ensure the instrument was clinically rele- Respondents had anaverage age between 45and 54years
vant. GPs were asked about their knowledge, attitudes, and were53.5% male. Over three-quarters of respondents
and practice and referral patterns to chiropractors and (77.8%,n=456)hadcompletedtheirmedicaltrainingatan
osteopaths and about CAM use in their areas more Australian university. Aside from a slight over-
generally. representation of women, the respondent profile was
The final survey questionnaire contained 27 items broadly representative of the GP community in the study
which included multiple choice and multiple response areainrelationtoaverageageandtraininglocation[25].
close endedquestions. Thesurvey had five general areas: Referral rates of rural GPs to chiropractors and
the GPs’ assumptions on chiropractic and osteopathy osteopaths are shown in theTable 1. One quarter (23.1%,
use by patients in their area; the GPs’ personal use and n=135) of GPs referred to a chiropractor or osteopath at
knowledge of chiropractic and osteopathy; the GPs’ pro- least once per month, witha further 41.0% (n=240) refer-
fessional relationship with chiropractic and osteopathy ring a few times per year. Most GPs were either actively
practice and practitioners; the GPs’ information seeking referring to chiropractors and osteopaths, or would con-
behavioursonchiropractic andosteopathy, and;theGPs’ sider referring in the right circumstances, however ap-
specific opinions on chiropractic and osteopathy. GPs proximately one-fifth (21.7%, n=127) of GPs stated that
were also asked for demographic and practice informa- theywouldnotrefertoachiropractororosteopathunder
tion such as gender, age, number of years in practice, lo- any circumstances. Most GPs were aware of local
cation of practice, number of patients seen per week and chiropractorsand osteopathsin their area, withonly 2.2%
country ofgraduation. Ethical approvalfor the study was ofrespondentsunabletoidentifypractitionerstoreferto.
obtained from the School of Population Health Research Some GPs also perform chiropractic or osteopathic
Ethics Committee of the University of Queensland techniques themselves, with 10.4% (n=61) identifying
(JW130508) and the Human Research Ethics Committee that they had performed manipulative therapies on a
oftheUniversity ofNewcastle(H-2008-0344).
Table1ReferralratesofruralGPstochiropractorsand
Rural and regional areas were defined by their classifi-
osteopathsinthepast12months(n=585)
cation in the Rural, Remote and Metropolitan Area
Atleastweekly 45(7.7%)
(RRMA) classifications [24]. The RRMA classification
categorises areas based on population and remoteness as Atleastmonthly 90(15.4%)
large or small metropolitan (1–2), large, small and other Afewtimesperyear 240(41.0%)
rural centres (3–5); and remote or other remote (6–7). Ihavenotreferredbutwouldconsider 70(12.0%)
Rural and regional NSW was chosen as the study area
Iwouldneverrefer 127(21.7%)
due to research indicating high use of chiropractic and
Idonotknowofanypractitioners 13(2.2%)
osteopathy in rural Australia [12,14,18,19], and further
Noresponse 0(0%)
research indicating high prevalence of chiropractors and
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patient during the past 12 months (data not shown). patients askingabout CAM (p<0.001), personal CAM use
One-fifth (21.2%; n=124) of GPs had a personal profes- bytheGP(p<0.001),patientrequestforreferral(p<0.001),
sional relationship with a specific individual chiropractor not having other options available (p=0.005), having had
or osteopath. More GPs had professional relationships positive results with chiropractors or osteopaths previ-
with individual chiropractors (18.4%, n=108) than with ously (p<0.001), using CAM practitioners as a major
individualosteopaths (5.6%, n=33). sourceforCAMinformation(p<0.001),usingpatientsasa
Table 2 shows a comparison between GPs who referred major source for CAM information (p=0.001), belief in
to a chiropractor often (at least weekly or at least theefficacyofchiropracticorosteopathy(p<0.001),having
monthly) and seldom (less than a few times per year or prescribed CAM previously to patients (p<0.001) and
never) by demographic characteristics. GPs were signifi- beingcomfortablewithreferraltoachiropractororosteo-
cantlymorelikelytorefertoachiropractororosteopathif path(p<0.001).
they had a high (over 151 patients per week) patient load
(p<0.001). There was no significant association between Predictivefactors
referral to a chiropractor or osteopath and sex, age, level The result of multiple logistic regression modelling to
of rurality, nation of graduation from medical school and determine independent predictive factors for referring to
whethertheyhadinitiallycomefromaruralarea. chiropractors and osteopaths is shown in Table 4. GPs
Table 3 shows a comparison between GPs who referred who believed in the efficacy of chiropractic or osteop-
toachiropractoroften(atleastweeklyoratleastmonthly) athy were 3.39 (95% CI: 2.19, 5.25) times more likely to
and seldom (less than a few times per year or never) by refer to a chiropractic or osteopath at least once per
other factors. Referral to a chiropractor or osteopath was month than those who did not. GPs who had seen posi-
significantly associated with level of knowledge about tive results from chiropractic or osteopathy previously
chiropractic or osteopathy (p<0.001), the number of were 1.67 (95% CI: 1.02, 2.75) times more likely to refer
Table2Demographicandpracticecharacteristicsassociatedwithreferraltochiropracticorosteopathybyruraland
regionalGPsinNewSouthWales,Australia(n=585*)
Referraltochiropracticorosteopathy
Demographiccharacteristics Weeklyormonthly Seldomornever p-value
% %
Sex Male 50.9 58.1 0.096
Female 49.1 41.9
Age 25-34 8.3 10.0 0.539
35-44 21.3 21.9
45-54 37.6 38.1
55-64 26.7 21.4
>65 6.1 8.6
RRMA 3 27.5 30.0 0.067
4 45.6 34.8
5 23.5 28.1
6 3.5 1.4
7 0.0 5.7
Australiangraduate? Yes 77.6 78.6 0.786
No 22.4 21.4
Initiallyfromaruralarea? Yes 36.3 25.2 0.066
No 63.7 74.8
Patientload(perweek) <50 17.3 13.8 0.001
51-100 35.5 37.1
101-150 24.8 38.6
151-200 16.5 5.7
>200 5.9 4.8
*exceptforRRMA,wheren=579.
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Table3OtherfactorsassociatedwithreferraltochiropracticorosteopathybyruralandregionalGPsinNewSouth
Wales,Australia(n=585)
Referraltochiropracticorosteopathy
Factors Weeklyormonthly Seldomornever p-value
% %
GPslevelofknowledgeofchiropracticandosteopathy Excellent 3.5 7.1 <0.001
VeryGood 15.5 11.9
Satisfactory 54.3 37.6
Poor 26.1 34.3
VeryPoor 0.8 9.1
PercentageofpatientswhohaveaskedaboutCAM <10% 28.5 47.6 <0.001
11-25% 4.1 44.8
26-50% 9.9 5.2
>50% 20.5 2.4
GP’spersonaluseofCAM Regularly 17.6 4.3 <0.001
Often 15.7 21.4
Once/Rarely 35.2 22.9
Never,butwouldconsider 15.2 9.1
Never,andwouldnotconsider 15.2 41.0
Accesstomedicalspecialistsisaproblem Yes 2.4 3.3 0.509
No 97.6 96.7
Patientrequestforreferral Yes 51.2 30.0 <0.001
No 48.8 70.0
Lackofotheroptions Yes 13.9 6.7 0.005
No 86.1 93.3
Positiveresultspreviously Yes 58.7 30.5 <0.001
No 41.3 69.5
CAMpractitionersareamajorsourceofinformationonCAM Yes 26.9 6.2 <0.001
No 73.1 93.8
PatientsareamajorsourceofinformationonCAM Yes 52.3 38.1 0.001
No 47.7 61.9
Beliefinefficacy Yes 69.3 31.4 <0.001
No 30.7 68.6
GPinterestedinincreasingCAMknowledge? Yes 57.1 51.9 0.173
No 42.9 48.1
GPhasprescribedCAMtopatientspreviously Yes 79.5 58.6 <0.001
No 20.5 41.4
CGP’scomfortlevelwithchiropracticandosteopathy Comfortableingeneral 30.9 4.8 <0.001
Onlyinspecificcircumstances 52.4 22.9
OnlyifIknewtheminperson 14.0 14.3
Iwouldnotrefer 1.9 58.1
to a chiropractor or osteopath at least once per month for CAM use were 12.5 (95% CI: 2.4, 50.0) times more
than those who had not and were 2.41 (95% CI: 1.18, likely to refer to a chiropractor or osteopath more than
5.12) times more likely to often refer if they perceived once per month than those who did. No demographic
there were no other options available. GPs who factors were predictive for referral to chiropractors or
perceived access to medical specialists not being a driver osteopaths.
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Table4PredictivefactorsforreferralbyGPstochiropracticandosteopathyatleastoncepermonthbyruraland
regionalGPsinNewSouthWales,Australia(n=573)
Factor Oddsratio 95%CI
PercentageofpatientswhohaveaskedaboutCAM <10% 1.00 ─
11-25% 2.48 1.41,4.37
26-50% 7.64 3.54,16.47
>50% 3.59 1.12,11.55
Accesstomedicalspecialistsisaproblem No 1.00 ─
Yes 0.08 0.02,0.41
Lackofotheroptions No 1.00 ─
Yes 2.41 1.18,5.12
Positiveresultspreviously No 1.00 ─
Yes 1.67 1.02,2.75
BeliefinEfficacy No 1.00 ─
Yes 3.39 2.19,5.25
CAMpractitionersamajorsourceofinformationonCAM No 1.00 ─
Yes 4.39 2.04,9.41
Discussion indicative of support for chiropractic and osteopathic
Thisisthefirstfocusedexaminationofconventionalmed- treatments. Previous research on naturopaths in rural
ical practitioner referral to chiropractors and osteopaths Australia, for example, indicates that although patients
in rural and regional Australia. Our study findings show have a high level of support for CAM services, rural
that a significant level of interaction exists between GPs patients are often unable or unwilling to pay fully out-of-
and chiropractors and osteopaths in this area. The high pocket costs associated with these services, and actively
prevalence of personal professional relationships and re- seek more cost-effective ways to access the advice of
ferralbetweenGPsandchiropractorsandosteopathsmay CAM practitioners [27]. With the introduction of other
beindicativeofhighpresenceofpractitionersinthestudy CAM professions into Australia’s national regulation
area, as previous research has identified chiropractor and scheme(Chinesemedicinehasalreadybeenincludedfrom
osteopath numbers around 40% of GP numbers in rural July 2012, and naturopaths have been recommended for
andregionalNewSouthWales[2]. later inclusion [28]), there may be pressure to publicly
However,thehighlevelofprofessionalrelationshipsand subsidise these services as well, removing the current
referral amongst GPs with chiropractors and osteopaths monopoly chiropractors and osteopaths regarding
may also be related to formal referral arrangements that publicly-subsidisedCAMservicesinAustralia.
exist for chiropractic and osteopathic services in the However, the issue of how government reimbursements
Australian public health care system. Chiropractic and orformalizedarrangementsaffectreferralpatternsbetween
osteopathic patients are eligible to receive a subsidy of conventional and specific CAM providers has not been
$51.95 from the Australian government when referred by exploredindepth.Suchexplorationmaybewarranted,par-
a medical practitioner under the MedicareExtendedCare ticularly as chiropractic more than any other profession
Plan (MBS Item Numbers 10964, 10966, 81345 and appears to be driving high CAM practitioner use in rural
81350;figures correct as at August2012) [26]. This inter- areasinAustralia[12,14].WhetherpatientrequeststoGPs
pretationissupported bythefindingsofthisstudy,which (andsubsequentreferralsbyGPs)arespecificallyforchiro-
show that the numbers of patients enquiring with their practic and osteopathy services, or whether the formalised
GPaboutCAMisasignificantpredictivefactorforGPre- arrangementsmeanthatchiropractorsandosteopathssim-
ferraltochiropractorsandosteopaths. plyprovideaconvenientavenueforGPstorefertoaCAM
Chiropractors and osteopaths are currently the only provider, will have a significant impact on which services
CAMpractitionerseligibleforsuchsubsidiesinAustralia. GPschoosetorefertoasmorepractitioneroptionsbecome
Formalised arrangements and subsidies for chiropractic available.ThefindingfromthisstudythatGPswhorelyon
and osteopathic services may therefore provide a cost- CAMprovidersasmajorsourcesofCAMinformationmay
effectiveavenue(fromthepatient’sperspective)forGPsto not only indicate higher levels of interaction with CAM
explore CAM approaches to healthcare when such providers amongst referrers than non-referrers, but also
referralsarerequestedbypatients,ratherthanbeingsolely that GPs are willing to communicate and refer to a broad
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variety of CAM practitioners beyond chiropractors and Rural and regional issues associated with patient CAM
osteopaths.Withmedicalreferralscomprisingnearlyone- use and practice may also affect chiropractic referral, as
fifth the patient load for Australian chiropractors and somecommentatorshavesuggestedthathigherCAMuse
osteopaths [13], increasing subsidised access to other in rural and regional areas may be related to lower levels
CAM professions could have significant impacts on ofconventionalhealthcareproviders(e.g.specialists,allied
the professions of chiropractic and osteopathy, with health) in theseareas[35].Althougha lack of othertreat-
reductions in referrals one possible scenario as GPs share ment options for patients was predictive of increased
their formal CAM referrals amongst a broader range of referral rates to chiropractors and osteopaths by rural
practitioners. Whilst this may benefit patients in terms of and regional Australian GPs in our study, limited access
improvedaccesstoabroaderrangeoftherapeuticoptions, to medical specialists was in contrast predictive of
itcouldalsoposeprofessionalchallengestothechiroprac- lower levels of referral. As such, increased referral to
ticandosteopathycommunities. chiropractorsand osteopathsmayberelated more toGPs
Although our study results suggest that chiropractors referring to CAM after exhausting their own treatment
andosteopathsmaybelargelyacceptedbythemajorityof options for patients, rather than serving as alternative re-
the Australian rural and regional GP community, our ferral recipients when specialist treatment is sought. This
findings also help identify remaining tensions between may be partly related to previous study findings that
conventionalmedicineandthetwoCAMmodalities,with have suggested that rather than replacing conventional
one-fifth of GPs maintaining that they would never refer practitioners in areas of high need, CAM practitioner
to a chiropractor or osteopath under any circumstances. density often follows that of conventional practitioners,
Thisfindingmirrorsthoseofapreviousnationalsurveyof with areas of high service need experiencing shortages in
Australian GPs which indicated both significant levels of both conventional and CAM practitioners [2,20]. Add-
support for, and opposition to, chiropractic and osteop- itionally, although previous large-scale surveys have
athy referrals amongst the Australian GP community [7]. highlighted a lack ofaccesstoordissatisfactionwithcon-
SuchtensionshaveachievedrecentattentioninAustralia, ventionalmedicalservicesasassociatedwithhigherCAM
withcallsfromwithintheconventionalmedicalsectorfor use, such studies have also uncovered dissatisfaction in
chiropracticandosteopathicpracticetoreceivenofurther CAMserviceproviderprovisioninruralareas[21,22].Ra-
mainstream medical attention [29]. Findings from this ther, other historical and cultural drivers (such as positive
study suggest that such ideologically opposed views to community connections, rural patient’s increased inde-
chiropracticandosteopathydonotseemrepresentativeof pendence and stoicness, underlying community affinity
the majority of medical practitioners in our study area. forholisticprinciplesandincreasedvalueofruralpatients
However, significant tensions between the professions do on experiential over empirical forms of evidence) may be
highlighttheneedforfurtherdetailedresearchintofactors pushfactorsforCAMusebyruralpopulations[18],which
that influence conventional practitioner opinion on CAM in turn may increase patient requests for CAM services
professionssuchaschiropracticandosteopathy. andreferralsforGPsinruralareas.
However, other factors beyond ideological or profes- The high prevalence of professional relationships with
sional opposition may also result in GPs being unwilling individual practitioners may also be partly related to the
to refer to chiropractors and osteopaths, even if they ex- rural and regional nature of the sample in this study, as
hibit positive attitudes towards the professions. Medico- smaller communities may facilitate increased interaction
legalconcernsrelatingtoGPreferraltochiropractorshave betweenCAMandconventionalproviders[18,19,36].This
been disseminated to the practice community via a num- may facilitate an increased level of referrals by rural and
ber of high profile court cases [16,30,31] and such regional GPs as compared to their urban counterparts.
concernsmaybeexacerbatedbythefocusofmedicalpro- Further investigation of referral patterns in the broader
fessional literature to the risks associated with CAM, ra- GPpopulation,orcomparativeworkwithurbanGPs,will
ther than broader discussions of efficacy [32]. Indeed, assist in further ascertaining what role, if any, geographic
previous Australian surveys of GPs have highlighted pa- factors such as the level of rurality have on the interface
tientriskasamajordeterminantofGPopiniononCAM, betweenCAMandgeneralpractice.
often more than efficacy [7,8,33,34]. Further exploration Though limited to one state (New South Wales), the
of factors that make GPs less willing to refer to CAM large and varied study area was chosen to be broadly
practitioners (including osteopaths and chiropractors), as representative of Australian rural and regional general
well as those factors that predict referral, would assist in practice demographics [25]. Nevertheless, the demo-
providing further insights into the interface between graphics of the GPs in this study compared to national
CAM and general practice, the impact of CAM on pri- statistics (being as they are drawn from rural and re-
mary health care, and the role that chiropractic and oste- gional areas and exhibiting a higher proportion of
opathycanplayinthebroaderhealthcaresystem. females) should be considered in generalising the
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