Complement Ther Clin Pract. 2019 (Aug); 36: 82–87 ~ FULL TEXT
Joel Alcantara, Andrew Whetten, Jeanne Ohm, Joey Alcantara
ICPA Media, PA, USA;
Faculty of Graduate Studies,
Southern Cross University,
Lismore, NSW, Australia.
Following a course of chiropractic care, our responders assessed their care as effective/very effective (87%) while only 11% assessed their care as ineffective/very ineffective.
Chiropractic wellness patients were highly satisfied with their care as reflected in the mean satisfaction rating of 95% (0% = poor rating; 100% = excellent rating) with their overall visit.
The reported prevalence of minor adverse events (i.e., minor and self-limiting) from our responders ranged from 6.3% to 11.3% and were lower than those previously reported.
Motivation for care did not affect patient satisfaction.
Patients experiencing no adverse event reported higher patient satisfaction compared to those patients experiencing an adverse event.
From the FULL TEXT Article
As part of its strategy to improve the quality of healthcare, the
Institute of Medicine's (IOM's) Committee on Quality of Health Care in
America identified deficiencies related to patient safety with its 2000
publication, To Err is Human: Building a Safer Health System.  This
was followed with the 2001 publication entitled, Crossing the Quality
Chasm: A New Health System for the 21st Century. This document provided
a guiding framework for improving quality of care that prescribed
that care should be safe, effective, patient-centered, timely, efficient,
and equitable.  To achieve fundamental improvements in patient
care, this overarching social purpose must be embraced by all health
care systems and clinical practices, including chiropractors.
Of the so-called “complementary and alternative medicine” (CAM)
healthcare professions, chiropractic is the largest and most regulated
and has become a commonly utilized form of alternative healthcare. [2, 3] A multitude of factors determines a population's use of healthcare
services. These include socio-economic status, availability of healthcare
providers, health status and of particular interest by the investigators
are patient satisfaction, perceived safety and effectiveness of care.
Studies indicate that a patient's perceptions of their care and actual
healthcare experiences contribute to their overall patient satisfaction
level [4, 5] and utilization. 
A number of studies have characterized that people use of alternative
therapies (including the use of spinal manipulation (SM)) in an
effort to promote general well-being or wellness, rather than to help
manage symptoms of a health problem. [7, 8] To provide insight on the
patterns and utilization of chiropractic services for chiropractic patients
motivated by “wellness care” and explore the a priori hypothesis that
high patient satisfaction is associated with perceptions of safe and effective
care in a large cohort of patients receiving care in a practicebased
research network (PBRN).
This study was approved by the Institutional Review Board of Life
University (Marietta, GA, USA). We invited Doctors of Chiropractic
(DCs) to participate in a study examining the sense of coherence (SOC)
and quality of life (QoL) of patients receiving care in a PBRN.
Requirements for PBRN participation by DCs were:
(a) the DC must be in good standing with their licensing authority;
(b) complete the National Institute of Health online course entitled, “Protecting Human Research Participants” ;
(c) agree to a number of terms for participation as an ICPA PBRN participant – most notably that PBRN participation
must not be used for practice-building or marketing and
(d) the DC provided care for the patient responder.
The participating practices
were encouraged to recruit patients as responders for this study. Inclusion
criteria for patient participation were:
(a) the individual was a current patient during the study period,
(b) the patient was ≥18 years of age;
(c) was capable of reading and responding in English and
(d) provided consent.
Baseline (T1) (i.e., at study participation) and comparative (T2)
(i.e., follow-up) surveys were implemented with a course of chiropractic
care. The T1 survey examined responders' socio-demographic
information, SOC and QoL along with a number of covariates such as
patient status (i.e., new patient versus established patient), primary
medical provider, motivation for care, and duration of symptom(s)/
complaint(s) (if any). At T2, the responders’ SOC, QoL, ratings of effectiveness,
adverse events (AEs) experienced during the study period
and patient satisfaction (i.e., using the RAND VSQ9 ) were determined.
The RAND VSQ9 is a 9–item questionnaire adapted by the
American Medical Group  from the Visit Rating Questionnaire used
in the RAND Medical Outcomes Study.  The VSQ9 utilized a 5–level
response scale that were linearly transformed (i.e., poor = 0; fair = 25;
good = 50; very good = 75; excellent = 100).
The comprehensive patient
satisfaction score for each patient was calculated as the mean of
the score of the 9 items. The SOC-29 is a 29–item questionnaire based on
a 7–level response. Responses to some items were reversed to maintain
consistency of the level of the responses (i.e., 1 = minimum level of
response; 7 = maximum level of response). The SOC score for each
respondent is the composite score of the sum of the 29 items (i.e.,
minimum score = 29; maximum score = 203). A high score corresponds
to a higher measure of SOC. The SOC-29 has demonstrated reliability,
validity, and cross culturally applicability to measure how
people manage stressful situations and stay well.  The PROMIS data
was analyzed using PROMIS scoring manuals. For each PROMIS short
form in the PROMIS-29 (i.e., anxiety, physical functioning, pain interference)
and PROMIS Global Health, a scoring table was developed to
associate the raw scores to a T score metric, which is referenced to (and
centered upon) the US General population with a mean of 50 and
standard deviation of 10.  The greater the T score, the greater the
measured QoL domain. These instruments have been shown to be valid. [15, 16]
Due to the volume of data collected, it is beyond the scope of this
manuscript to address all our findings. We will present in subsequent
publications our findings on the changes in SOC and QoL of this cohort
of patients. We explore in this manuscript the a priori hypothesis that
high patient satisfaction is associated with perceptions of safe and effective
care in a large cohort of chiropractic patients receiving care in
an established chiropractic practice-based research network (PBRN).
In addition to descriptive statistics (i.e., frequencies and percentages,
means and standard deviations), correlational analysis utilized
Pearson's r while mean comparisons involving 2–levels was analyzed
with the t-test.  To examine the relationship between comprehensive
patient satisfaction, motivation for care and experiencing an AE, a
linear mixed model (LLM) was performed and reported using an
ANOVA summary table (rather than a maximum likelihood estimates
table) to report the amount of variance explained by each variable in
our model and the corresponding significance of the variable. A maximum
likelihood estimates table would allow for the parameterization
effect of each variable, whereas the ANOVA table explains the amount
of variance explained by each variable.
As a follow-up to this analysis,
we performed a post-hoc comparison of group means to determine if we
could detect any significant differences between groups corresponding
to the covariates in the model. Practitioner was implemented as a
blocking factor (N = 140) to account for between practitioner variance
in the modelling given that differences in patient satisfaction between
practitioners may be significant. Within a PBRN, patients are cared for
by chiropractors differing in chiropractic technique (i.e., method of
spinal adjustment), different adjunctive therapies and overall different
styles of practice. Analysis was performed in R.  Statistical significance
was set at p-value<0.05.
A convenience sample of 1419 responders (1,060 females; 341
males; 18 not indicating) comprised our study population. Their
average age was 40.96 years (SD = 14.31; range = 18–88 years). The
responders were highly educated with 87% (N = 1,240) attaining some
college education or higher (i.e., Some College (N = 297); Associate's
Degree (N = 187); Baccalaureate degree (N = 485); Master's
(N = 183); PhD or Doctorate (N = 88)). Fifteen (N = 1%) had “some
high school education” while 164 (N = 12%) graduated from high
The majority of responders were current patients (N = 1,230;
86.68%) followed by new patients (i.e., attended 1–2 visits) (N = 118;
8.31%) and previous patients returning for care (i.e., a patient who
ceased care or has not received care at the clinic for a period of time and
has returned for care) (N = 71; 5.00%). The majority (N = 720; 51%)
indicated as their primary care provider an MD/DO, followed by a
Doctor of Chiropractic (N = 563; 40%), a Nurse Practitioner (N = 73;
5%) and “other” (N = 63; 4%).
When asked to indicate the duration (i.e., days, weeks, months,
years) of suffering with a symptom or physical complaint, the following
frequencies of responders of responders were indicated for the specific
duration: years (N = 841; 59.3%); months (N = 215; 15.2%); weeks
(N = 58; 4.1%); days (N = 47; 3.3%). Eighty-three responders (i.e.,
5.85%) indicated as not being able to recall the duration while 201
responders (i.e., 14.16%) indicated as not receiving chiropractic care to
address their physical symptom(s) or complaint(s). Note that of these
201 responders, 24 responders indicated a duration of complaint (i.e.,
weeks (N = 1); months (N = 2); years (N = 20)) with one indicated “I
Motivation for chiropractic care was indicated by the majority of
responders (i.e., N = 963; 68%) as a combination of wellness care and
symptom care followed by symptom care only (N = 255; 18%) and
wellness care only (N = 201; 14%).
At comparative measures, the responders were asked to provide
their perceived rating of effectiveness (i.e., a 5–level Likert response:
very ineffective to very effective) of their chiropractic care. The overwhelming
majority assessed their chiropractic care as effective/very
effective (87%; N = 1,238), 20 (1.5%) were neutral and 11% (N = 161)
assessed their chiropractic care as ineffective/very ineffective.
When asked to respond to a yes or no answer (i.e., “Have you experienced
any negative experiences to the chiropractic adjustment?“),
89 responders (i.e., 6.3%) indicated as experiencing an AE. In a followup
question, we asked the responders to choose from a list of known
AEs (i.e., stiffness, increasing pain, increasing headaches) the AE they
experienced or choose “I did not experience a negative reaction to the
spinal adjustment.” Eighty seven percent (N = 1,236) chose the response
to indicate not experiencing a negative reaction to the spinal
adjustment, 1.6% (N = 22) were non-responders while 161 (11.3%)
indicated as experiencing an AE. In this follow-up question, we have a
prevalence of reported AE of 11.3%. These 2 questions pertaining to
experiencing an AE with chiropractic care resulted in disparate responses.
Only 80 of the 89 indicating experiencing an AE chose from
the list of known AEs. Of the 1,236 responders indicating as not experiencing
an AE, 4 responders indicated an AE from the list of AEs.
The results of the VSQ9 survey at T2 is provided in Table 1. “Convenience
of the location of the office” received the lowest rating at a
mean score of 87.16 while the personal manner of the provider was
rated the highest at a mean score of 95.95. The overall visit was rated
with a mean score of 95.01 while the total mean score of all 9 items was
90.97 (SD = 17.29). We found no correlation between responders' age
and overall mean VSQ9 score (Pearson's r = –0.0146; N = 1,419; 2–tail
p-value = 0.0972). An unpaired t-test found no differences in the mean
VSQ9 score of male versus female responders (df = 1,399; t = 0.4121;
p = 0.6803).
Table 2 displays the results of our LMM analysis using an ANOVA
summary table. The interaction term was initially included between
motivation and AE, but this term was determined to be nonsignificant.
From Table 2 it can be concluded that changes in the levels motivation
for treatment does not have a significant effect on patient satisfaction.
However, we observed strong evidence that a patient experiencing an
AE had a significant effect on patient satisfaction. The blocking factor
also had a highly significant effect. This confirms our use of the
blocking factor to account for the presence of significant differences in
patient satisfaction between practitioners.
In Figs. 1 and 2, the individual and collaborative effects of each
factor level are examined with respect to patient satisfaction. Fig. 1
reaffirmed the significant levels from the ANOVA summary tables (see
Table 2). Fig. 2 demonstrated that levels of patient satisfaction for the 3
types of motivations for care (i.e., wellness care alone, symptom care
alone and combination of both) are almost indistinguishable (i.e.,
means of patient satisfaction ratings with overlapping confidence intervals)
while levels of patient satisfaction for those experiencing an AE
versus or not have very dissimilar means and no overlap in the confidence
In Table 3, all six levels corresponding to the
combinations of motivation for care and experiencing an AE or not are
visualized as box-plots. Even though the interaction between these two
factors was insignificant, it is worth noting that the 2–way factor level
corresponding to patients experiencing an AE have some potentially
significant differences between groups. Consider that those patients
reporting symptom care as a motivation for care reported possibly
lower or less patient satisfaction. Post-hoc multiple hypothesis testing
was performed using Tukey adjustment for multiple comparisons of
group means. Instead of reporting a table of p-values of significant
differences between each pairwise comparison, this was more efficiently
summarized using a table of lettered grouping (see Table 3).
Groups that share a designated letter labeling are not statistically significant
from each other whereas groups that have a different lettering
are significantly different from each other. Patients indicating wellness
care as motivation and did not experience an AE were significantly
different from the other types/groups of patients (see Fig. 3).
According to the National Board of Chiropractic Examiner's (NBCE)
practice analysis of chiropractic , chiropractic patients are characterized
as more commonly female than male, between 18 and 64
years of age with the majority at 31–50 years of age. This is consistent
with the socio-demographics of our survey responders and previous
studies. However, we note that the NBCE analysis found a 59% prevalence
of patients as females while our study found a much larger
prevalence of 75%. This over-representation may be characteristic of
this patient population characterized as predominantly “wellness patients.”
In a recent scoping review of the literature to characterize the
consumers of, motivations for and utilization of chiropractic, Beliveau
et al.  found that individuals who sought chiropractic care were
more likely to be female with a median age of 43.4 years.
this recent review of the literature found that the most common reasons
for chiropractic care involved symptom care involving the musculoskeletal
system (i.e., for low back or spinal conditions). Our findings
differ in this respect given that a large proportion of our responders
indicated wellness care, either singly or in combination with symptom
care as a motivation for receiving chiropractic care. Wellness care as a
health promotion strategy for chiropractic patients have previously
been documented in the scientific literature. [21–24] In a large cohort
of adults (i.e., N = 34,525) using alternative therapies, Stussman and
colleagues  examined their wellness-related reasons for the use of
natural product supplements, yoga, and SM.
From the responders reported
using SM in the past 12 months, the investigators found that
general wellness or disease prevention was the most common wellnessrelated
reason for care. One in four SM users indicated as using this
form of care due to its whole person approach and focus (i.e., mind,
body, and spirit). In this era of healthcare reform, with an emphasis on
the importance of health and wellness, the implications of wellness care
under the auspices of chiropractic care deserves further investigation.
This is one of the largest cohort of chiropractic patients characterized. A
large proportion of our responders indicated their chiropractor as their
primary healthcare provider, are established patients (i.e., long-term
chiropractic care) and suffering from physical symptoms or complaints
of chronic duration.
Patient safety/adverse events
A handful of systematic reviews have examined the prevalence and
risk of harm associated with chiropractic SM in adult patients. In 2009,
Gouveia and colleagues  reported on 46 articles that associated or
attributed AEs to chiropractic care were examined. Most of the documented
AEs were mild (i.e., benign and transitory) but severe AEs (i.e.,
arterial dissection, myelopathy, vertebral disc extrusion, and epidural
hematoma) were also reported. Gouveia and colleagues  found the
prevalence of AEs as between 33% and 60.9% with the frequency of
serious/severe adverse events varying from 5 strokes/100,000 SMs,
1.46 serious adverse events/10,000,000 SMs and 2.68 deaths/
10,000,000 SMs. In an examination of randomized-controlled trials and
non-randomized prospective studies in chiropractic, Swait and Finch  found the prevalence of only mild AEs and ranged from 23% to
83%. Other research designs revealed the prevalence of mild AEs at
30% to 50% following manual treatment for back and/or neck pain.
Sample sizes among the RCTs ranged from 70 to 767 and, for prospective
cohort studies, from 68 to 19,722.
No serious or severe AEs
were reported in the reviewed studies. Paige and colleagues  systematically
reviewed studies addressing the effectiveness and harms of
SM for acute (≤6 weeks) low back pain. From cohorts and RCTs, the
investigators found a prevalence for mild AEs of 42%–67% patients
treated with SMT by chiropractors, physiotherapists or osteopaths. The
sample size of the reviewed studies ranged from 68 patients involving
11 chiropractors  to 1058 patients involving 102 chiropractors.  In a prospective study of 19,722 patients consisting of 28,807
treatment consultations and 50,276 SMs to the cervical spine, Thiel and
colleagues  estimated the risk of serious AEs at approximately 1 per
10,000 treatment consultations immediately after cervical spine SM,
approximately 2 per 10,000 treatment consultations up to 7 days after
treatment and approximately 6 per 100,000 cervical spine SM. Our
study involved 140 chiropractors providing fullspine care to 1, 419
patients attending a total of 5,889 visits at the time of surveillance.
findings of AEs is unique when compared to that previously reported in
terms of the heterogeneity of patients presenting for care and the type
of care received with high external validity. Overall, we report a lower
prevalence of AE experienced with chiropractic care (i.e., range of reported
prevalence of AEs = 6.3% –11.34%) than those previously reported.
Patient satisfaction and perceived effectiveness
Our findings of overall high satisfaction with chiropractic care is
consistent with findings from previous studies.  Our use of the
VSQ9 instrument is consistent with the Donabedian framework of
evaluating quality of care in terms of structure (i.e., infrastructure of
care setting), process (both technical and interpersonal) and outcomes
(i.e., perceived effectiveness of care).  Our findings of high patient
satisfaction is consistent with the use of the VSQ9 in other chiropractic
patient populations. [21, 24, 33] Interestingly, in both chiropractic studies
utilizing the VSQ9 [21, 24], convenience of the location of the office
received the lowest satisfaction rating while the personal manner (i.e.,
courtesy, respect, sensitivity, friendliness) of the attending chiropractor
was rated with the highest satisfaction rating. Our findings highlight
the need to measure patient satisfaction on multiple levels in terms of
structure, process of care (i.e., both technical and interpersonal), and
outcomes. The importance of patient satisfaction as an outcome measure
in chiropractic was reviewed by Alcantara et al. [21, 24] As pointed
out by the authors, patient satisfaction is an important measure of the
quality of care as evidenced by reimbursement metrics by the Centers
for Medicare & Medicaid Services. Furthermore, satisfied patients lead
to greater compliance, a more active and continued participation in
their care, as well as maintaining a specific system of care (i.e., chiropractic).
Although some have found that effectiveness outcomes do not necessarily
correlate well with patient satisfaction , our overall
findings are consistent with those studies supporting a correlation between
patient satisfaction and perceptions of effectiveness (i.e., improvement)
of care and safety. [35–37] An examination of chiropractic
care and the use of perceived effectiveness as an outcome measure revealed
a handful of articles on the subject. We consulted Pubmed
(1966–2019) for chiropractic literature documenting “perceived effectiveness”
or “self-reported perceived effectiveness.” Documented improvements
with chiropractic care as measured with qualitatively
measured perceived treatment effects have been published by Stochkendahl
et al. , Hall et al.  and Maiers et al. 
highlighted the important role of the provider-patient relationship and
its association with perceptions of safe and effective care. The use of the
Global Perceived Effect to document improvements with chiropractic
care can be attributed to Dissing et al. , Peterson et al.  and
Gemmel and Miller.  Similar to our use of a Likert scale to examine
perceived effectiveness of care, Goertz et al.  recently found that
adjusted odd ratios at week 6 were statistically significant in favor of
usual medical care plus chiropractic care based on perceived improvement
and self-reported pain medication use.
Our regression analysis reported as an ANOVA summary table
revealed that levels of motivation for care does not have a significant
effect on patient satisfaction. However, we found strong evidence that a
patient experiencing an AE with chiropractic care and the chiropractor
providing care had a significant effect on patient satisfaction rating.
This is consistent with the findings that patient satisfaction is influenced
by different chiropractors and possibly practice styles. Interestingly,
Mace and colleagues  (i.e., N = 186; response rate = 75%) found
that chiropractors practicing wellness care with higher frequency of
care had lower patient satisfaction scores when compared to those with
less frequent care sessions. In addition, these investigators found that
overall patient satisfaction and QoL scores were highest in clinics with
treatments times over 20 min. These disparate findings of wellness care
and patient satisfaction requires further investigation.
As with all surveys, there is the element of subjectivity and recall
bias. Survey responders may have emotional states that fluctuate over
time and may influence the data at a specific point in time but not
objectively measure, for example, their overall healthcare experience.
Chiropractic care is often described as individualized rather than
standardized. Patients will have different expectations and experiences
with chiropractic resulting in survey responses that may vary widely
despite similar care approaches or as in a PBRN setting, different
healthcare providers. Despite the large sample size in our study, their
generalizability to the adult chiropractic population remains uncertain.
Our chiropractor participants were all members of chiropractic professional
organization. Membership in this organization reflects a support
of its missions and goals – the promotion of salutogenic care
through chiropractic care.  As such an element of selection bias
may be present. Conversely, with 6,000 chiropractic members worldwide,
our insight on the chiropractic wellness care of patients may be
representative as such.
Wellness patients are predominantly female, rating their care as
effective/very effective and with high satisfaction. Adverse events reported
were minor (i.e., self-limiting) with a prevalence ranging from
6.3% to 11.3%. Experiencing an AE and the chiropractor providing care
had a significant effect on patient satisfaction ratings. We support
continued research in characterizing the patterns and utilization of
chiropractic services for wellness chiropractic patients.
This study was funded by the International Chiropractic Pediatric
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