The Prevalence, Patterns, and Predictors of
Chiropractic Use Among US Adults: Results
From the 2012 National Health Interview SurveyThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Spine (Phila Pa 1976) 2017 (Dec 1); 42 (23): 1810–1816 ~ FULL TEXT
Jon Adams, PhD, Wenbo Peng, PhD, Holger Cramer, PhD, Tobias Sundberg, PhD, Craig Moore, Masters of Clinical Trials Research, Lyndon Amorin-Woods, MPH, David Sibbritt, PhD, Romy Lauche, PhD
Australian Research Centre in Complementary and Integrative Medicine (ARCCIM),
Faculty of Health, University of Technology Sydney,
Sydney, New South Wales, Australia.
STUDY DESIGN: Secondary analysis of a national survey.
OBJECTIVE: The aim of this study was to investigate the prevalence, patterns, and predictors of chiropractic utilization in the US general population.
SUMMARY OF BACKGROUND DATA: Chiropractic is one of the largest manual therapy professions in the United States and internationally. Very few details have been reported about the use of chiropractic care in the United States in recent years.
METHODS: Cross-sectional data from the 2012 National Health Interview Survey (n = 34,525) were analyzed to examine the lifetime and 12–month prevalence and utilization patterns of chiropractic use, profile of chiropractic users, and health-related predictors of chiropractic consultations.
RESULTS: Lifetime and 12–month prevalence of chiropractic use were 24.0% and 8.4%, respectively. There is a growing trend of chiropractic use among US adults from 2002 to 2012. Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being. A substantial number of chiropractic users had received prescription (23.0%) and/or over-the-counter medications (35.0%) for the same health problem for which chiropractic was sought and 63.8% reported chiropractic care combined with medical treatment as helpful. Both adults older than 30 years (compared to younger adults), and those diagnosed with spinal pain (compared to those without spinal pain) were more likely to have consulted a chiropractor in the past 12 months.
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All About Chiropractic PageCONCLUSION: A substantial proportion of US adults utilized chiropractic services during the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common. Studies on the current patient integration of chiropractic and conventional health services are warranted.
KEYWORDS: chiropractic; prevalence; patterns; predictors; health services research; pain; national survey; adults; back pain; USA
From the FULL TEXT Article:
INTRODUCTION
Chiropractic is one a commonly used complementary healthapproaches in the United States (US) and internationally. [1, 2] It is characterized by manual therapy techniques usually delivered to treat musculoskeletal and neurological disorders. [3, 4] Certain chiropractic servicessuch asspine manipulation are covered by Medicare and Medicaid for all adults in the US. [5] Also, chiropractic care is one of the health benefits included in the workers’ compensation systems in most US States. [6] It is worth noting that there is growing utilization of chiropractic care in the US over near recent years [7] with more than 70,000 chiropractors practicing in the US6 and the total expense of visits to chiropractors in the US estimated to be over 10 billion in 2013. [8]
Previous work in a number of countries has shown inconsistent findings regarding the characteristics of chiropractic users and predictors of chiropractic utilization. For example, a large cohort study conducted inone State of Australia in 2005 revealed that adults who experiencedback problems and/or had a pension as the main source of income were more likely to visit a chiropractor, while those who were older than 55 years and/or consumed medication for certain health problems such as hypertension and high cholesterolwere less likely to use chiropractic services. [9] A large-scale US surveyfocusing upon the use of health care and health insurance coverage in 2008 reported that participants who were female, white, with higher family income, and/or with arthritis were more likely to use chiropractic. [10] Meanwhile, asurvey undertaken in Switzerland in 2009 found patients aged 31–50 years,those who experienced low back pain,and/or experienced pelvic pain or injury without leg pain were more likely to seek help from chiropractors. [11]
The National Health Interview Survey (NHIS) is the principal and reliable source of comprehensive health care informationin the US, utilizing a nationally representative sample of the civilian non-institutionalized population of the US. [12] An overview of chiropractic practiceamong US adults has been previously undertaken by analysing the data collected in the 2002 and 2007 NHIS surveys. The focus of this previous work has been predominantly upon the broad use of a range of complementary health care approaches, [13, 14] while only a few specific details have been revealed regarding chiropractic such as prevalence rates of chiropractic use and examination of the chronic conditions treated by chiropractic. [15–17] The 2012 NHIS survey is the most recent source providing data on the use of complementary health care approaches by adults in the US. The objective of this present paper is to update the examination of the lifetime and 12–month prevalence of chiropractic use among US adultsand advance our understanding of the patterns and predictors of chiropractic care by drawing upon the 2012 NHISsurvey dataset.
MATERIALS AND METHODS
Design and setting
Secondary analysis based on the NHIS nationally representative survey monitoring the health of the US population in 2012.
Data and measures
For this analysis, data from the Family Core, the Sample Adult Core, and the Adult Complementary and Alternative Medicine questionnaire were used. The Family Core and the Sample Adult Core collected data regardingparticipants’ socio-demographic characteristics including age, gender, ethnicity, region, marital status, education, annual household income and self-perceived general health status. The Adult Complementary and Alternative Medicine questionnaire collected data on the use of a number of modalities including the use of chiropractic. Lifetime prevalence of chiropractic use was determined with the following question:Have you ever seen a provider or practitioner for chiropractic or osteopathic manipulation for yourself? Those who answered ‘Yes’ were presented with an additional question asking whether they also had consulted a chiropractic or osteopathic manipulation practitioner during the past 12–months. They were further queried which of the practitioners they had consulted most (with the options of chiropractor, osteopathic physician, refused, and do not know), and which of those they had consulted most often.
Those participants who had consulted a chiropractor in the past 12 months were asked to provide more details, such as the number of consultations, the costs per each consultation, insurance coverage and the purchase of self-help books or other materials to learn about chiropractic. These respondents were questioned about the reasons for their use of chiropractic (including general reasons and specific medical conditions – a total of 88 possible conditions) as well as theirdisclosure/non-disclosure of chiropractic care to their personal health care provider and reasons for non-disclosure (where relevant), their perceived benefits of chiropractic use, and their use of information sources about chiropractic.
Statistical Analyses
A total of 42,366 households were eligible and 34,525 adults provided data (response rate: 79.7%). [18] Population-based estimates were calculated using weights calibrated to the 2010 census-based population estimates for age, gender, and ethnicity of the US civilian non-institutionalized population.
Lifetime and 12–month prevalence of chiropractic use were analyzed descriptively, as were details on chiropractic care and reasons for use. Results were reported as means and standard deviations, medians and ranges, weighted frequencies and distributions as reasonable.
Socio-demographic characteristics were compared between those who had consulteda chiropractorever in their life or within the prior 12 months and those non-chiropractic users via chi square tests. Independent predictors of chiropractic utilization (ever used, used in prior 12 months) were identified using multiple logistic regression analysis. The following socio-demographic predictors were considered: age (18–29; 30– 39; 40–49; 50–64, 65 or older), gender (female; male), ethnicity (non-Hispanic White; Hispanic; African American; Asian; Other), region (West; Northeast; Midwest; South), marital status (not in relationship; in relationship), education (less than college; some college or more), and annual household income (less than $20,000; $20,000 to $34,999; $35,000–$64,999; $65,000 or more). Additionally, health-related factors such as general health status (excellent or very good; good; fair or poor), BMI (<18.5; 18.5–25; 25–30; 30 or more), smoking (non-smoker, smoker), alcohol consumption (alcohol abstainer; light drinker; regular or heavy drinker), exercise behavior (low level exerciser; moderate level exerciser; high level exerciser); and medical conditions or diseases (chronic pain conditions; rheumatologic disorders; mental health disorders) were also used as potential predictors.
A backward stepwise procedure with a likelihood-ratio-statistic p-value of ≤0.005 was chosen, and adjusted odds ratios with 95% confidence intervals were calculated. Only those associated with chiropractic use at a p-value of ≤0.10 (chi-square test) were included in the regression analyses. Statistical analysis was performed using the Statistical Package for Social Sciences software (IBM SPSS Statistics for Windows, release 22.0. Armonk, NY: IBM Corp.).
RESULTS
A total of 54.6 million adults in the US had ever consulteda chiropractor (lifetime prevalence 24.0%), and 19.1 million adults had consulted a chiropractor within the prior 12 months (12–month prevalence 8.4%).
Predictors for lifetime and 12–months prevalence of chiropractic utilization are presented in Table 1. For lifetime prevalence of chiropractic utilization the following statistically significant factors were identified. Adults above 30 years of age were more likely to have ever used chiropractic (30–39: OR = 1.53; 95%CI:1.33 to 1.77; 40–49: OR = 2.00; 95%CI:1.74 to 2.29; 50–64: OR = 2.06; 95%CI:1.79 to 2.36; 65 or above: OR = 2.23; 95%CI:1.80 to 2.78)compared to adults under 30 years of age, as were those with a college or more education (OR = 1.31; 95%CI:1.17 to 1.45)compared to those being less than college-educated, those living in a relationship (OR = 1.12; 95%CI:1.02 to 1.24) compared to those not in a relationship, those with light (OR = 1.32; 95%CI:1.17 to 1.48) or moderate to heavy (OR = 1.17; 95%CI:1.02 to 1.33) alcohol consumption compared to abstainers, and those who were diagnosed with spinal pain (OR = 2.18; 95%CI:2.00 to 2.43), headache or migraine (OR = 1.21; 95%CI:1.08 to 1.37), or arthritis (OR = 1.26; 95%CI:1.11 to 1.43) compared to those without those diagnoses. On the other hand, those of Hispanic (OR = 0.48; 95%CI:0.41 to 0.56), Black (OR = 0.46; 95%CI:0.38 to 0.55) or Asian (OR = 0.27; 95%CI:0.21 to 0.34) ethnic origin were less likely to have ever used chiropractic compared to Non-Hispanic Whites, as were those living in the Northeast (OR = 0.79; 95%CI:0.69 to 0.91) or South (OR = 0.69; 95%CI:0.61 to 0.78) compared to those living in the West, those who smoked (OR = 0.75; 95%CI:0.66 to 0.85) compared to non-smokers, and/or those respondents who were diagnosed with phobia (OR = 0.74; 95%CI:0.61 to 0.90), depression (OR = 0.78; 95%CI:0.68 to 0.88), coronary heart disease (OR = 0.68; 95%CI:0.48 to 0.96) or asthma (OR = 0.74; 95%CI:0.65 to 0.84) compared to those without these diagnoses.
Table 1 shows that those aged older than 30 years were more likely to have used chiropractic in the past 12 months (30–39: OR = 1.44; 95%CI:1.22 to 1.71; 40–49: OR=1.63; 95%CI:1.38 to 1.92; 50–64: OR = 1.51; 95%CI:1.29 to 1.78; 65 or above: OR = 1.72; 95%CI:1.34 to 2.20) compared to younger adults, as were those living in the Mid-West (OR = 1.28; 95%CI:1.11 to 1.48) compared to those living in the West, and those diagnosed with spinal pain (OR = 2.64; 95%CI:2.36 to 2.94) compared to those without. On the other hand those living in the South (OR = 0.84; 95%CI:0.73 to 0.98) were less likely to have used chiropractic in the past 12 months compared to those living in the West, as were those of Hispanic (OR = 0.59; 95%CI:0.49 to 0.72), Black (OR = 0.37; 95%CI:0.28 to 0.48) or Asian (OR = 0.32; 95%CI:0.23 to 0.45) ethnic origin compared to Non-Hispanic Whites, those who had a BMI lower than 18.5 (OR = 0.54; 95%CI:0.32 to 0.93) or above 30 (OR = 0.83; 95%CI:0.72 to 0.95) compared to adults with a normal BMI, those who smoked (OR = 0.63; 95%CI:0.54 to 0.73) compared to non-smokers, those who reported a good self-reported health status (OR = 0.78; 95%CI:0.69 to 0.89)compared to those with excellent/very good health status, and/or those diagnosed with phobia (OR = 0.65; 95%CI:0.51 to 0.84), depression (OR = 0.65; 95%CI:0.55 to 0.77), coronary heart disease (OR = 0.50; 95%CI:0.31 to 0.81) or asthma (OR = 0.68; 95%CI:0.58 to 0.80) compared to those without these diagnoses.
The majority of those who had consulted a chiropractor within the past 12 months (83.3%) were able to recall the number of times they consulted a chiropractor; the average number of consultations being 9.8±11.3 times (median:6; 25th percentile:3; 75th percentile:12). Insurance covered some costs of consultations in 60.2% of respondents, and in 31.7% of those with coverage they were reimbursed 100% of the costs. The average of cost per chiropractic consultation visit as reported by 60.9% of the participants was US$42.2±51.8 (median:30; 25th percentile:20; 75thpercentile:46). The average total amount of expense for those who only paid out-of-pocket costs for chiropractic per year (approximately 5.9 out of 19.1 million users) is estimated at US$2.2 billion and the average total amount of expense for those who have partial reimbursement from health insurance for chiropractic per year (5.7 out of 19.1 million users) is estimated at US$1.4 billion. Only 1.3% of respondents reported purchasing a self-help book or other materials to learn about chiropractic; spending a total of US$36.0±41.3 on average for such items (median:25; 25th percentile:15; 75th percentile:50).
Table 2 shows,in the past 12 months,that only a small percentage of chiropractic users reported the use of information sources for the utilization of chiropractic, including the internet (8.1%), books, magazines or newspapers (4.1%) and scientific articles (3.7%). Most respondents reported consulting a chiropractor for general wellness or disease prevention (43.3%), to improve their energy (16.3%), or to improve athletic or sports performance (15.4%). Many respondents reported positive outcomes of chiropractic utilization agreeing that such care had helped them to improve overall health and make them feel better (66.9%), to sleep better (41.9%) and to reduce stress or to relax (40.2%).
Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific health problems for which people consulted a chiropractorin the past 12 months, followed by joint pain/stiffness (13.6%) and other pain conditions. Around two in three users (64.5%) reported that chiropractic had helped a great deal to address these health problems. Chiropractic was used mainly due to respondents believing it would help when combined with their medical treatment (64.8%), due to a perception that it treated the cause and not just the symptoms of their health problem (61.9%), and due to it being considered natural (37.5%). A large proportion of chiropractic users also received over-the-counter (OTC) medication (35.2%)and/or prescription medication (23.2%)for the same health problem for which chiropractic was sought and 33.8% of respondents used chiropractic because they considered medical treatments to not be working for their condition (Table 2).
Chiropractic was mainly recommended by family (32.2%), friends (25.9%) and medical doctors (17.7%) in the past 12 months. The use of chiropractic was disclosed to their conventional health care provider by 59.8% of respondents, and the main reasons for not disclosing their use of chiropractic included that the provider did not ask (56.3%), the respondent thought the provider did not need to know (44.2%) or conventional health care was not used at the time (29.1%). Less than 5% of respondents were worried that their conventional health care provider would discourage their chiropractic use (Table 2).
DISCUSSION
To the best of our knowledge this paper is the first to analyse the details of the prevalence, patterns and predictors of chiropractic care in a large-scale nationally representative sample based on the complementary healthcare approaches statistics in the 2012 NHIS survey. The 12–month prevalence rate of chiropractic care among US adults (8.4%) shown in our study is higher than that reported from the 2002 NHIS survey (7.5%). [13] Due to the lack of reporting of an exclusive prevalence rate for chiropractic use in the 2007 NHIS survey (8.6% of US adults sought chiropractic or osteopathic care), [3] we are unable to directly compare the rate of chiropractic use in 2007 to our relevant finding (8.4%). However, in light of the small difference between the exclusive prevalence of chiropractic care in 2012 and that of chiropractic or osteopathic care in 2007, our analysis suggests the use of chiropractic practice in the US population has increased from the period 2002 to 2012. The growing trend of chiropractic use in US adults over these years is consistent with findings from the US Medical Expenditure Panel Survey [7] as well as the US Medicare Current Beneficiary Survey. [19] However, the motivations behind this growing trend in chiropractic use and the feedback of such individuals about their experience of chiropractic care remain unclear and is deserving of further research focus.
Our analyses show that, among the US adult population, spinal pain and problems – specifically for back pain and neck pain – have positive associations with the use of chiropractic. This finding is in agreement with that identified in a number of previous studies conducted in the US and elsewhere showing that the most common complaints encountered by a chiropractor are back pain and neck pain [11, 20–22] and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain. [23, 24] Our analysis also shows that having mental health problems, coronary heart disease, and asthma are negatively associated with seeking chiropractic care. Indeed, no convincing rationale or evidence exists for the use of chiropractic for mental health disorders or cardiovascular conditions and systematic reviews have failed to identify sufficient evidence to support the efficacy of chiropractic treatment for asthma. [25–27]
Our analyses indicate that a substantial proportion of chiropractic users also consume prescription medications and/or OTC medications for the same health problem for which they seek chiropractic care. Notably, in our analyses more than 60% of those in the US who consulted a chiropractor did so due to a belief that chiropractic would be helpful in combination with their medical treatment. Such concurrent use of chiropractic care and conventional medications and health provision is in line with previous studies. [28–30] Further, previous randomized controlled trials have suggested the co-management of chiropractic and medical care is likely to show more improvement in pain relief than medical care alone. [31–33]
Our study found that a recommendation for an adult to consult a chiropractor is rarely initiated by a conventional health care provider, and many respondents reported that their conventional health care provider failed to enquire about their possible chiropractic use. These results are similar to those identified in some previous studies which have specifically investigated the referral patterns of chiropractors in the US. [34–36], a recent national workforce survey of Australian chiropractic showed approximately half of the chiropractors initiate and/or receive referrals to/from general practitioners and one-third initiate and/or receive referrals to/from physiotherapists. [37] As such, further research examining the interface between chiropractors and conventional health providers is warranted to help tease out possible opportunities and challenges to safe, effective coordinated patient care.
The findings of our analyses need to be considered in light of a number of limitations. The NHIS survey relies on self-reported responses and this may lead to potential recall bias and measurement error. Moreover, the statistics of the 2012 NHIS regarding use of complementary health care including chiropractic were drawn from a cross-sectional survey, and our results can only suggest associations in the data. Nevertheless, the NHIS dataset drawn upon in our study provides a large-scale nationally representative sample regarding chiropractic use and the results of our analyses provide important insights regarding the recent prevalence rate, patterns, and predictors of chiropractic utilization among US adults.
Chiropractic services are an important component of the healthcare provision for patients affected by musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall wellbeing. Despite the substantive findings concerning the prevalence, patterns, and predictors of chiropractic use in the US general population as reported in this manuscript, there nevertheless remains a wide research gap in chiropractic care. Further studies on the details in chiropractic care and the relationship between chiropractic and conventional/allied health providers and services in patient management in the US are warranted.
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