J Manipulative Physiol Ther. 2015 (Oct); 38 (8): 533–544 ~ FULL TEXT
William B Weeks, MD, PhD, MBA, Christine M Goertz, DC, PhD,
William C Meeker, DC, MPH, Dennis M Marchiori, DC, PhD
Clinical and Health Services Research Program,
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
The Dartmouth Institute for Health Policy and Clinical Practice,
The Geisel School of Medicine at Dartmouth,
OBJECTIVES: The purpose of this study was to determine whether general perceptions of doctors of chiropractic (DCs) varied according to likeliness to use chiropractic care, whether particular demographic characteristics were associated with chiropractic care use, and whether perception of DCs varied according to the per-capita supply of DCs in local health care markets.
METHODS: We performed a secondary analysis of results from a 26–item nationally representative survey of 5422 members of The Gallup Panel that was conducted in the spring of 2015 (response rate, 29%) that sought to elicit the perceptions and use of DCs by US adults. We compared survey responses across: (1) respondents who had different likelihoods to use DCs for treatment of neck or back pain and (2) respondents who had different experiences using DCs. We linked respondents' zip codes to hospital referral regions for which we had the per-capita supply of DCs. Using the ?(2) test, we examined relationships between likeliness to use a DC, experience using a DC, respondent demographic variables, perceptions of DCs, and the per-capita supply of DCs in the local health care market.
RESULTS: Most (61.4%) respondents believed that chiropractic care was effective at treating neck and back pain, 52.6% thought DCs were trustworthy, and 24.2% thought chiropractic care was dangerous; however, as respondents' likelihood to use a DC increased, perceptions of effectiveness and trustworthiness increased, and perceptions of danger decreased. Of all 5422 survey respondents, 744 or 13.7% indicated that they had seen a DC within the last 12 months. As one moved from distant to more recent experience using a DC, respondents were more likely to be female, married, white, and employed; those who had a distant history of using a DC were older and more likely to be retired than the other groups. A higher per-capita supply of DCs was associated with higher utilization rates and showed a more favorable regard for DCs.
CONCLUSIONS: US adults often use chiropractic care, generally regard DCs favorably, and largely perceive that chiropractic care is safe. Where there is a higher per-capita supply of DCs in the local health care market, utilization and positive perceptions of chiropractic are higher.
KEYWORDS: Chiropractic; Health Services Research
From the FULL TEXT Article:
In the general US population, back and neck problems are among the symptoms most commonly encountered, and expenditures for patients with spine problems are substantially higher and are growing more rapidly, than those for patients without spine problems.  Compared to matched controls, patients with back pain have more comorbidities (including musculoskeletal and neuropathic pain conditions, common sequelae of pain, and depression) and greater pharmacotherapy use [2, 3] and higher overall health care costs. [4, 5] In addition, the problem of back pain has been accelerating, perhaps because of the combination of the graying of America, the fact that patients are more likely to experience back pain with age, and differences in how providers treat back pain. 
Most chronic low back pain complaints can be managed nonsurgically.  Randomized controlled clinical trials have demonstrated that chiropractic spinal manipulation is an effective, conservative treatment option for certain types of low back and neck pain and for some headaches. [8–10] A meta-analysis indicates that combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low back pain. [11, 12] The American College of Physicians and the American Pain Society  as well as the Task Force of Neck Pain and its Associated Disorders  recommend spinal manipulation for the treatment of certain spinal pain conditions. In addition, there is some evidence that use of chiropractic spinal manipulation is associated with lower health care costs. [15–17]
In the context of rising health care costs and suggestions that chiropractic is a relatively effective and inexpensive treatment for an increasingly common disorder, the use and perceptions of chiropractic care are of national interest. Over the last 15 years, a number of studies have estimated the use of chiropractic care services by US adults. A literature review examining reports published between 1965 and 2005 found that the prevalence of chiropractic care use varied between 6% and 12%.  More recent analyses of the National Health Interview Study (NHIS) found that the prevalence of chiropractic care use among US adults remained relatively stable, fluctuating between 7.5% and 8.6%. [19–23] Analyses of 2012 NHIS data found substantial geographic variation in prevalence of chiropractic use across US districts that ranged from 16.4% in the West North Central district of the United States to 6.2% in West South Central district. 
Analyses of the Medical Expenditure Panel Survey (MEPS) tend to generate slightly lower prevalence estimates, ranging from 5.1% among US adults in 1980 [24, 25] to an estimated doubling of that rate in 1988 ; differences in the prevalence of chiropractic use according where the patient lived, sex, age, race, and sex were evident in those studies. More recent MEPS studies indicated that 3.7% of US adults used a doctor of chiropractic (DC) in 1997,  5.6% did so in 2006,  and 5.2% did so in 2008.  Additional MEPS analyses have found that rural-dwelling patients  and patients with concurrent mental health illnesses  are more likely to use chiropractic care. Virtually all studies have demonstrated that patients who use chiropractic care are more likely to be white and female.
Although the prevalence of chiropractic use has been estimated, few studies have examined how US adults perceive DCs. A 1998 study of 800 US adults found that an increased willingness to use DCs for routine care was associated with prior use of chiropractic care, but that both DC users and nonusers preferred physician assistants and nurse practitioners in the primary care role.  A 2002 study of medical claims in western Washington State found that insurance coverage and living in less populous counties were associated with being more likely to use chiropractic care.  In addition, a small (n = 163) 2004 survey of chiropractic patients from a single teaching chiropractic clinic in the US found that only 19% of patients saw their DC as their primary care physician: although virtually all of these patients thought that DCs could treat musculoskeletal conditions, many also thought that they could treat other conditions as well. 
We sought to improve and update information on the prevalence of use and general perceptions of DCs by analyzing data from a national Gallup survey of US adults conducted in the spring of 2015. The objectives of this study were to determine whether general perceptions of DCs varied according to likeliness to use chiropractic care, whether demographic characteristics (such as age, sex, employment status, and the local per-capita supply of DCs) were associated with chiropractic care use, and whether perception of DCs varied according to the per-capita supply of DCs in local health care markets.
This study is the first large, nationally representative study to report on a national survey of US adults' general perceptions of DCs. We found that approximately 14% of US adults reported that they had used chiropractic care in the prior 12 months. We also found that slightly over ½ of US adults had ever used a DC for health care and over ¼ would choose chiropractic care as a first treatment for neck or back pain.
Most respondents thought that chiropractic care can effectively treat neck or back pain, believed they understood what DCs do, and thought that DCs are trustworthy; fewer patients thought that chiropractic care was dangerous, required too many visits, or was expensive. Among recent chiropractic users, 40.8% reported that they wanted to use their DC only for back and neck problems, whereas a much smaller proportion reported that they would choose to have DCs as a first contact when talking about their health or to discuss general health and wellness issues. This finding is consistent with a 2007 study of the NHIS that found that chiropractic patients use DCs in different ways: sometimes for treatment and sometimes for health promotion,  and it highlights the challenge in defining the appropriate role of DCs,  particularly in a changing health care marketplace. 
As has been reported previously in the literature, patients who use DCs are different than those who do not: we found that recent chiropractic care users were more likely to be female, white, and employed full time. We also found that chiropractic care users differed from nonusers when considering marital status and employment status. Intriguingly, we found that, when compared to more recent chiropractic users, patients who had used chiropractic care in the distant past were more like those who had never used chiropractic care when considering sex, marital status, race, employment status, and income levels. This suggests that the demographics of the chiropractic care market have changed in the recent past, perhaps due to increased market penetration of chiropractic, particularly in areas with relatively low rates of chiropractic use.
We found that respondents who indicated a high likelihood of using a DC were more likely to have used one previously, that knowledge that chiropractic care was covered by insurance was associated with a higher likelihood of using a DC, and that living in a health care market with a high per-capita supply of (or a high per-capita use of) DCs was associated with a greater likelihood of use. This finding is consistent with a 2008 Medicare study that found a correlation between the per-capita supply of DCs and the utilization and use intensity of chiropractic care services  and suggests that familiarity with chiropractic care increases positive perceptions of chiropractic.
Our findings suggest 4 actions that chiropractic professional associations should consider.
First, a large proportion of respondents who were not likely to use chiropractic care answered that they “did not know” about chiropractic care effectiveness, danger, utilization patterns, or expense. This suggests that educational outreach designed to inform the public on these aspects of chiropractic care may further improve perceptions and use of DCs for neck and back pain. Such educational outreach could also inform patients about whether their insurance covers chiropractic care, thereby eliminating a potential barrier to access to such care. 
Second, our findings appear to indicate that familiarity with chiropractic is associated with increased trust and perceived knowledge of DCs. Therefore, efforts to increase the supply of DCs in areas of low per-capita supply might increase patients' likelihood to use DCs to treat neck or back pain. Professional organizations might provide incentives or support to practice in low-supply areas.
Third, we found that, although some patients want to see a DC for reasons other than neck or back pain, far fewer indicated that they wanted DCs to be the first provider that they talked to about their health or that they wanted to talk to a DC about general health and wellness issues. Although there has long been a division within the chiropractic profession about the role of DCs in overall health care management,  these findings suggest that a professional focus on spine care and treatment may best meet patients' expectations, thereby making the educational efforts recommended above easier.
Finally, a relatively high proportion of recent DC users indicated that they would visit a DC more often if it did not cost so much and that sentiment appeared to be related to whether chiropractic care was covered by insurance. This suggests that DCs might work to improve insurance coverage of chiropractic care to enhance access ; however, those who use chiropractic may be more likely to know that their insurance covers it. Nonetheless, almost 40% of DC users whose insurance does cover chiropractic care also report that expense is a barrier to higher utilization. Further study in this area is warranted.
Our study has several limitations. First, results are from an anonymous survey; to the degree that respondents did not answer questions accurately, our results are inaccurate. Second, the survey's response rate was 29%; it is possible that respondents who were either interested in chiropractic care or had strong views on chiropractic care services were more likely to answer the survey. As we were not able to compare the demographics (or key variables, such as experience using a DC) of our sample to those of nonrespondents, the possibility of selection bias cannot be eliminated; in part, such bias may explain the high rate of utilization that we found. However, our counterfactual analysis does not suggest that the high rates that we found were due to respondents living in geographic areas with high prevalence of chiropractic care use and the fact that survey respondents did not know that the survey was about chiropractic perceptions until they agreed to participate in the survey both mitigate against such bias. Third, our study was a cross-sectional, retrospective survey: our findings are associative, not causative. Longitudinal analyses that repeat measures over time are required to make causative claims. Fourth, our analysis of health care markets was limited to approximately 75% of respondents who provided a valid zip code; had we been able to include all respondents in this subanalysis, our results might have been different. Finally, our study relied on survey data from US adults; studies of adults in other countries may generate different results. Finally, our study relied on survey data from US adults; studies of adults in other countries may generate different results.
Strengths and Future Study
Our study's strength rests in its large size and its use of national, weighted data collected by a renowned, highly skilled survey research firm. The weighting process allowed us to generate robust national estimates of the perceptions of US adults. The size and scope of the dataset allowed us to examine multiple associations that warrant future study. Such studies should include efforts to determine whether particular interventions—such as increasing the per-capita supply of DCs, providing education on chiropractic, or changing payment structures—improve perceptions or increase use of DCs. In addition, analyses of future surveys would determine whether perceptions of DCs are changing over time.
Our findings suggest that US adults often use chiropractic care, that they generally perceive DCs in a positive manner, and that they think chiropractic care is safe. Where there is a higher per-capita supply of DCs in the local health care market, utilization and positive perceptions of chiropractic are higher.
Funding Sources and Potential Conflicts of Interest
No conflict of interest was reported for this study. Palmer College of Chiropractic funded the study.
Concept development (provided idea for the research): W.B.W., C.M.G., W.C.M., D.M.M.
Design (planned the methods to generate the results): W.B.W., C.M.G., W.C.M., D.M.M.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): C.M.G., W.C.M., D.M.M.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): C.M.G., W.C.M., D.M.M.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): W.B.W.
Literature search (performed the literature search): W.B.W.
Writing (responsible for writing a substantive part of the manuscript): W.B.W.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): C.M.G., W.C.M., D.M.M.
A national sample of US adults showed that 14.0% of US adults have used chiropractic care
in the prior 12 months.
A majority of US adults (61.4%) believed that chiropractic care was effective
at treating neck and back pain.
Among survey respondents, 52.6% thought DCs were trustworthy,
whereas 24.2% perceived chiropractic care as being dangerous.
As respondents' likelihood to use a DC increased, perceptions of effectiveness
and trustworthiness increased and perceptions of danger decreased.
A higher per-capita supply of DCs in the local health care market was
associated with a higher utilization rate and more positive perception of DCs.
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