Patient Experience and Satisfaction With Chiropractic Care:
A Systematic ReviewThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Patient Experience 2024 (Dec 25): 11:23743735241302992 ~ FULL TEXT
OPEN ACCESS Dave Newell, PhD • Michelle M Holmes, PhD
AECC School of Chiropractic,
Health Sciences University,
Bournemouth, UK.
Despite numerous studies that measure satisfaction in patients undergoing chiropractic care, these have not yet been systematically summarized. The aim of this study was to perform a systematic review of existing literature to identify factors that contribute to high levels of satisfaction in chiropractic care. A comprehensive search was conducted to identify quantitative, qualitative, or mixed-methods studies exploring patient experience with chiropractic care. Forty-three studies were included in the review. The findings showed that patient satisfaction was consistently high in comparison to other professions. The review identified key factors that contribute to patient experience, which were not limited to clinical outcomes, but also the clinical interaction and clinician attributes. The findings of this review provide a core insight into patient experience, identifying both positive and negative experiences not just within chiropractic care but in the wider healthcare sector. Further work should explore factors that impact patient satisfaction and how this understanding may further improve healthcare to enhance patient experience.
Keywords: chiropractic; pain management; patient experience; patient satisfaction.
From the FULL TEXT Article:
Introduction
The rapidly expanding health workforce encompasses a diverse array of professions beyond traditional medicine, to meet the multifactorial healthcare needs of national populations. Chiropractic is a statutorily regulated profession, with chiropractors qualified to deliver a package of care, including pain education, self-management advice, manipulation and manual therapy treatments, and tailored exercise recommendations. [1] Chiropractors identify as spinal health experts, focusing on improving function in the neuromuscular system and overall health and wellbeing of patients, predominately seeing patients with musculoskeletal conditions. [2, 3] Contemporary meta-analyses support the use of spinal manipulative therapy, a key component of chiropractic care, for such conditions. [4, 5] However, there is a shift to measure the impact of healthcare provision in a more patient-centered manner, considering not only clinical outcomes, but also patient experience and satisfaction measures as key metrics in determining quality of care.
Previous reviews synthesizing existing research on patient satisfaction identified that patients tend to report high levels of satisfaction with chiropractic care. [6] In addition, patients are often more satisfied with chiropractic care compared to encounters with other healthcare professionals. Despite the overwhelming support for chiropractic care, there is limited understanding of the drivers for these high levels of patient satisfaction. One explanation for the high levels of satisfaction, is around the pivotal role that effective communication plays in patient care, [6] with clinicians communication to identify their patients’ main concerns and other information as key. [7, 8] However, while communication is recognized as a potential driver of patient satisfaction in chiropractic care, there is limited exploration of this factor.
Despite the presence of numerous studies that measure patient experience and satisfaction within chiropractic care, these valuable insights have not yet been systematically gathered and comprehensively explored. Understanding patient experiences is thus important in the context of a value-based healthcare paradigm as a measure of the value of an intervention over and above traditional clinical outcomes. [9] The aim of this review was to identify, categorize, and summarize the published literature pertaining to the experiences and satisfaction levels of patients undergoing chiropractic care.
Method
This systematic review has been written up in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. [10]
Literature Search
Table 1 An initial scoping search was conducted in 2020 to refine the research question and construct a full review protocol, published on PROSPERO, ID: CRD42020203251. Terms included derivatives of chiropractic and patient experience and satisfaction, an example search string can be seen in Table 1. The search was restricted to research published after 2005, following a systematic review published on patient satisfaction. [6] Several databases were searched yielding the following search results:
PubMED (506),
Cochrane (115),
Excerpta Medical Database and Allied and Alternative Medicine (EMBASE) (355),
CINAHL (517),
Index to Chiropractic Literature (ICL) (1758), and
Web of Science (158) by MH in 2021.A bibliography search was also conducted to check for relevant studies.
Article Selection
Articles that met the following criteria were eligible for inclusion in this review:(1) focused on patient satisfaction or patient experience within chiropractic care,
(2) primary empirical studies: qualitative, quantitative, and mixed methods, and
(3) published in English.Papers were excluded if they were:
(1) focus on perceptions of chiropractic care,
(2) co-delivered interventions, and
(3) case studies, pilot studies, conference abstracts, and non-empirical and secondary studies.
Figure 1 Titles and abstracts were examined by at least one reviewer, with full-texts examined by two reviewers (DN and MH). There was 100% agreement on the final inclusion between the two reviewers. The screening and selection of studies is documented in the PRISMA in Figure 1.
Data Extraction and Analysis
Data extraction included citation, country, aims, participants, setting, study design, measures of patient satisfaction and experience, other outcome measures, analysis, intervention groups (where appropriate), and relevant results. Quality assessment was carried out using Markoulakis and Kirsh rubric, [11] with broadly defined score descriptions, allowing for assessment of the methodological implications of the paper despite heterogenous study designs. Narrative synthesis was used to collate and integrate the findings of the included studies with textual descriptions developed to combine results and analyze the relationships between the studies. [12, 13] Data extraction and synthesis was conducted by two reviewers (DN and MH), with 25% of articles checked.
Results
Study Characteristics and Overview
Table 2 Forty-three studies were eligible for inclusion (see Figure 1 and Table 2). The studies were conducted across the United Kingdom, Europe, North America, Australia, and South Africa. Chiropractic care was delivered in a variety of settings: private practice, university clinics, specialized clinics (military medical centers, therapeutic community facility). The studies included participants seeking chiropractic care for a variety of conditions (spinal pain, low back pain, neck pain, leg pain, headaches, and musculoskeletal conditions) and treatment of specialized populations (pediatric patients, pregnant mothers, older adults, military personnel, and athletes).
Generally, chiropractic patients are very satisfied with their care with high proportions generating consistently high satisfaction scores. [14, 15] This includes patient groups receiving care in both the independent and public sector. [16] Studies recruiting patients presenting with conditions commonly seen by chiropractors reported high to very high satisfaction/experience scores with care. [17–20] This is also true of parental satisfaction with pediatric care where scores range from around 75% to 95% satisfaction. [21–24]
Results of the quality assessment identified that reporting quality was mixed. However, no studies were marked as very poor or poor. The main methodological weaknesses identified were limited details on patient recruitment and the setting of chiropractic care. Within the quantitative studies, the main limitations were potential for respondent bias, and no details or limited details on generalizability. Taking into consideration the implications of these methodological flaws, no findings were deemed inappropriate and all concepts from the studies were included in the synthesis.
Comparison of Patient Satisfaction to Other Interventions
Table 3 Ten included studies were randomized-clinical trials (Table 3). Notwithstanding their heterogeneity, all compared chiropractic treatment or spinal manipulative therapy delivered by chiropractors to a comparator group, including exercise, medication, light massage, or a variety of sham interventions. Five trials used a combined intervention with manipulation as an addition to standard medical care [25, 26] and a further 2 explored adding spinal manipulation to a form of home exercise [27, 28] or home exercise and advice. [29]
For all trials, chiropractic care either alone or as adjunctive to other interventions generated significantly higher satisfaction scores than comparator interventions (see Table 3). Most comparators where chiropractic care performed better were either some form of home exercise, medication, or standard medical care. Where clinicians were involved in delivering substantive interventions such as forms of supervised exercise, chiropractic care either scored equal satisfaction or in one case less satisfaction (see Table 3). Furthermore, the addition of chiropractic care to an existing treatment generated better satisfaction than the existing treatment alone. [25, 26] This was also seen in audits of chiropractic care, where a package of manual care added to usual care generated significantly greater satisfaction than usual care plus medication. [30]
Three national surveys where chiropractors were compared to medical care were included. [31-33] Patients attending for chiropractic care were nearly twice as likely to be satisfied with the care received than those seen by medical doctors (odds ratio [OR]: 1.79 [1.35-2.39]) and 1.5 times as likely to be satisfied with the results of care (OR: 1.52 [1.15-2.02]). [31] Gaumer, Gemmen [32] reported that patients with prior experience of chiropractic care compared to none were less satisfied with other health care providers (87.3% satisfaction compared to 97.3% respectively). In a study of Medicare beneficiaries (n = 12?170) with a diagnosis of musculoskeletal disease visiting either private chiropractic care or medical care, those receiving chiropractic had higher satisfaction with follow-up after initial visit and with information provided about what was wrong with them. [33]
Haas, Sharma, Stano [34] followed a cohort of patients who chose chiropractic care compared to medical care. Patient satisfaction significantly favored chiropractic care with satisfaction scores of 86.4% for chronic patients and 90% among acute patients, whereas for medical doctors these scores were 71% and 76%, respectively. Furthermore, using a healthcare attitudes scale, trust in chiropractors was around 95% in those patients choosing chiropractic care whereas this figure was around 60% in those choosing medical care. Additionally, confidence in the provider of choice was 83% to 93% and 61% to 75% for those choosing chiropractors and medical doctors, respectively.
Satisfaction and Dissatisfaction With Chiropractic Care
An in-depth exploration of satisfaction and quality judgments by Canadian patients explored their experiences of visiting physicians and chiropractors. [35] Chiropractic care was judged predominantly on treatment outcomes where high satisfaction was associated with positive outcomes and low satisfaction with less positive outcomes. Chiropractors’ diversity of treatment options and the perceived ability to handle multiple problems simultaneously generated high satisfaction. Cost was not a factor for dissatisfaction in chiropractic care despite patients attending chiropractic care 5 times more often on average than seeing their physician.
As an alternative to satisfaction Ryan, Too, Bismark [36] looked at patient complaints comparing chiropractic, physiotherapy, and osteopathic settings in Australia. Chiropractors had significantly higher complaints than both osteopaths (3 times higher) and physiotherapists (6 times higher). Concerns around professional conduct accounted for half of all complaints with male practitioners, individuals over 65 years of age, and those practicing in metropolitan areas at higher risk of complaints. Among chiropractors only, around 1 in 100 practitioners were subject to more than one complaint. This accounted for 36% of all complaints within the profession suggesting that a small number of individuals significantly skew professional dissatisfaction from patients.
Factors Impacting Chiropractic Patient Satisfaction
Treatment outcomes and reactions were suggested to impact patient satisfaction scores. In qualitative interviews with patients receiving spinal manipulative therapy or exercises, common determinants of satisfaction were perceived treatment effect and changes in pain. [37] Similarly, negative treatment outcomes conversely influenced satisfaction. In a cohort study following patients’ outcomes of chiropractic care, patients had a mean score of 9.1 out of 10, but their satisfaction was negatively impacted if they perceived they had symptomatic reactions and were 19% more likely to report “poor” satisfaction (95% confidence interval [CI] 0.78-1.79). [38] These findings are similar with parental satisfaction with pediatric chiropractic care, [24] with moderate negative correlations between distress after care and parental satisfaction (?0.31) and moderate positive correlations between improvement scores and parental satisfaction (0.42).
From qualitative interviews embedded in a randomized controlled trial, content analysis was used to identify the common determinants of satisfaction. [37] Participants felt that the interaction with clinicians and their attributes were important, as well as information regarding exercises, tailored care, and information on the cause, prevention and prognosis of the condition. [37] In sport settings, where chiropractic care was delivered by students, satisfaction levels were statistically significantly linked to patients’ ratings of their assessment (P = .005), the communication of the student (P = .006), their views of student competence (P = .01) and conduct of the student (P = .036). [39]
In private chiropractic clinics in the United States, chronic low back pain and neck pain patients’ global ratings of their care were positively associated with the length of time they had been receiving chiropractic care prior to the study (r = 0.07; P = <.05), length of time seeing the chiropractor in the study (r = 0.09; P < .0001), number of visits to the chiropractor in the study (r = 0.05; P = <.05). [18] Previous experience of chiropractic care was associated with patient satisfaction levels in athletes receiving chiropractic care in sports settings. [39]
Included studies explored organizational issues with care most often waiting times, length of consultations, care delivery settings and costs. In a study by Brown, Bonello, Fernandez-Caamano, Eaton, Graham, Green [40] a large proportion either strongly agreed or agreed that they were satisfied with waiting times and the length of consultation times for chiropractors (92.9% and 94.6%, respectively). Similarly, patients’ expectations that their chiropractor would allow sufficient time for their consultation were substantively met with 97% indicated that this has happened [41] or that the consultation time was the right amount (84.5%). [42] MacPherson, Newbronner, Chamberlain, Hopton [41] also reported that in terms of the clinical setting, more than 90% of patients’ expectations and experiences corresponded.
Patient Experiences With Chiropractic Care
An observational study used the Consultation and Relational Empathy questionnaire within a chiropractic teaching clinic. [42] High proportions of patients (88%-97%) scored “very good” or “excellent” across all questions. In addition, 45.4% of participants achieved the maximum score. However, the authors suggest that the student patient encounter may skew scores, particularly in relation to the increased time students spend with patients.
Foley, Steel, Adams [43] explored the perceived experience of patients presenting with chronic conditions to complementary medicine setting including chiropractic care compared to medical care. Using the Perceived Provider Support Scale, higher scores were also found for chiropractors compared to medical doctors around issues including caring, acceptance, personal attention, talking openly, and trust.
Patient experiences are not universally positive. In a cross-sectional survey of chiropractic patients in the United Kingdom, despite chiropractic patients reporting a high level of satisfaction, patients’ expectations were least well met concerning information on the cost of the treatment at the first consultation. [41] There were also mismatched expectations concerning the chiropractor's contact with the patient's general practitioner and referral to other healthcare professionals, which did not happen as frequently as expected. [41]
In qualitative work, patients valued their interaction with their chiropractor: “Everyone was always courteous, kind, friendly…willing to answer any questions”. [44] Participants appreciated being listened to and valued the opportunity to express their concerns. This was noted as important for patients throughout the lifespan, from children seeking chiropractic care and feeling their condition was being taken seriously [45] to older adults receiving care. [46] Patients valued the professionalism of their practitioners, which they noted in the way chiropractors communicated with them. In general chiropractic practice [47] and following a randomized trial of chiropractic care [46] patients valued effective communication of their diagnosis and the treatment plan. This was also reflected in pregnant patients’ experiences of seeking chiropractic treatment, with participants noting their chiropractor explaining their condition, and involving the patient in developing a management plan. [48] Patients wanted help for their diagnosis and were appreciative of any individualized help advice including referrals to other healthcare professionals. [46]
Studies also explored the relationship between patients and their chiropractor. In patients receiving care for chiropractors in the Netherlands, patients completed the WAV-12 to measure working alliance between the chiropractor and the patient. [49] Their mean score was 49.14 (standard deviation [SD] 7.12) rated out of 60. The mean patient score, measured on a 1 to 5 Likert scale was 4.09 (SD ±0.59), with 5 representing an optimal alliance. [49] In a study comparing perceived support between chiropractic care and medical care, mean perceived support was higher for chiropractic care, this included components such as: practitioner caring about patient, practitioner accepting patient, trust for practitioner, talking openly with practitioner. [43] Trust was also examined in chiropractic teaching clinics, with 84.3% of participants reporting trusting their student chiropractor. Elements of the therapeutic relationship were also noted in qualitative literature, with participants noting that compassion, enthusiasm, genuineness, and helpfulness were important for their relationship. [46]
Discussion
This systematic review provides a comprehensive overview of patient satisfaction with chiropractic care finding that patients reported high levels of satisfaction and positive experiences with their care. Patient experiences are more positive across several important domains including empathy, patient centredness, and perceived support when compared to medical doctors. Generally, where substantive clinician time or attention was involved, patients were more satisfied. Patients noted good communication, being listened to, the development of a strong therapeutic relationship and key traits such as trustworthiness and caring as being central in underpinning positive experience.
The findings of this work suggest the need for an explanation for high levels of satisfaction. For example, it is known that chronic pain patients can face long waits in seeking help without satisfaction from mainstream healthcare sources with minimal contact time with clinicians and poor experiences. [50] One explanation may be that compared with such negative experiences, attending care in a private setting where clinicians may have more time to communicate and spend time caring, higher satisfaction levels are reported. In this case, it is not clear, whether high satisfaction and good experiences are due to the chiropractic care itself or because of the relative experiences encountered in past health seeking activity. Furthermore, patient choice seems important in determining satisfaction levels and little is available outside of condition-based categorisation 3 within the literature that explores the underlying reasons for such choices in patients seeking and maintaining the use of chiropractic care.
Interestingly, satisfaction levels and positive patient experiences reported here were not associated with either technical or manipulative elements of the chiropractic encounter but often with perceptions of good communication, good relationships, trust, and care. Indeed a strong theme around the value of good communication was also found in a recent General Chiropractic Council survey of public perceptions of chiropractic care and chiropractors. [51] There is ample evidence to suggest that such contextual elements are centrally important in generating positive outcomes [52-54] and it is important for the profession to continue to develop a more complete understanding concerning the entirety of the therapeutic encounter, including patient practitioner relationships, as impactful in generating both clinical and experience related positive outcomes. For practitioners caring for patients, empathy, communication, and building trust are central to their patients’ positive experience along with a highly patient centered clinical paradigm. It is important that these skills and approaches are prioritized in therapeutic encounters.
Our study has several limitations. The study only focused on published manuscripts in English. There may be unpublished, or studies conducted and published in another language that have not been included which may have provided additional or contrasting findings. With some limited details on patient recruitment and variety of setting of chiropractic care, this has the potential for respondent bias and limited understanding on generalizability. However, given this review included studies in diverse settings and geographies, with a range of quantitative methodological designs and supportive qualitative work all pointing strongly in the same direction, it is unlikely that further studies concerning general satisfaction levels will change the overall positive conclusions. Further work should focus on factors that impact on patient satisfaction and how these can be improved to enhance patient experience, such as communication.
Conclusion
This systematic review suggests that high and consistent levels of both satisfaction and positive experiences are widely reported in the literature concerning patients undergoing chiropractic care. This was independent of study design, presenting conditions, age groups, and referral routes. Factors influencing satisfaction included clinical outcomes as well as the patients’ interaction with their chiropractor. Further research is required to explore the underlying reasons for the predominately positive experience including the influence of patient-practitioner relationships to generate positive experiences and clinical outcomes.
Authors’ Contributions:
MH ran the search. MH and DN completed article selection, data extraction, and synthesis. Both authors were involved in the write-up
Conflicts of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding:
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the General Chiropractic Council.
ORCID iD: Michelle M Holmes https://orcid.org/0000-0002-6018-2235
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