Chiropractic Outcomes & Patient Satisfaction Synopsis

Dr. Tim Bertelsman - September 22, 2021

Purpose

The following synopsis details how the chiropractic profession ranks in terms of four key healthcare performance indicators.

  • Patient satisfaction

  • Clinical outcomes (Results)

  • Cost-effectiveness

  • Safety

Source

*Data for this 2021 COPS synopsis comes from the 2021 ChiroUp network dataset (1) – an analysis of 631,970 clinical diagnoses collected from more than 2,200 evidence-based chiropractic providers between July 2019 and June 2021, plus additional comparison data as referenced below. Patient satisfaction and clinical outcome metrics were derived from an emailed anonymous follow-up questionnaire sent to all patients (20.01% response rate). 

Part 1: Patient Satisfaction

Overall Chiropractic Patient Satisfaction

Historically, the chiropractic profession has performed well in terms of patient satisfaction. (2-8) As far back as three decades ago, studies were documenting high levels of chiropractic patient satisfaction:

“Satisfaction levels with chiropractic care are quite high (83% of persons are satisfied or very satisfied). High satisfaction is related to several factors, including whether the chiropractor orders and interprets laboratory tests, whether the chiropractor displays concern about patient’s overall health and the extent to which the chiropractor explains the condition and the treatment.” (2)

More recent evidence from the 2021 ChiroUp network dataset suggests that chiropractic patient satisfaction levels remain high.

 
 

Patient Satisfaction Comparison by Provider Type

Patient satisfaction data suggests that chiropractors perform well relative to other healthcare providers. One study of 797 patients treated by either a chiropractor or family physician measured satisfaction in nine areas and found:

“With one exception, satisfaction was higher for patients attending chiropractors [as compared to family medicine physicians].” (8)

Another study found that patient satisfaction nearly doubled when chiropractic manipulation was added to standard medical care. (9)

 
 

Likelihood to Refer 

A consumer’s likelihood to recommend a particular service or product is considered an essential prognosticator for the utility of any business. A standardized question for measuring this metric in healthcare is, “On a scale of 1-10, how likely are you to recommend this provider to others?”

The 2021 ChiroUp network dataset demonstrated that chiropractic patients are extremely likely to recommend their provider to others.

 
 

Overall Net Promoter Score (NPS)

The Net Promoter Score (NPS) is the gold standard gauge of consumer satisfaction and loyalty. (10-12) A wide array of healthcare service providers have implemented the NPS survey to measure patient satisfaction. (13-18) 

NPS scores for healthcare providers can be calculated from the likelihood that someone would recommend their provider to others (0-10 scale).

 
 

The 2021 ChiroUp network dataset found that, as a whole, chiropractors receive exceptionally high NPS scores from their patients.

 
 

Net Promoter Scores by Country

More than 90 countries have established chiropractic practices. (19,20) Direct access to chiropractic care is available in 90% of those countries, and the majority (51%) provide at least some degree of insurance reimbursement for chiropractic care. (20)

 
 

The following global breakdown illustrates that chiropractic patients worldwide share similar high levels of enthusiasm for recommending their chiropractors to others.

 
 
 

NPS Comparison by Provider Type

In general, NPS scores for the healthcare industry are favorable, averaging between 16 and 38. (21,22) NPS scores for primary care physicians average around 35.  (23) 

Chiropractors are primary care providers in many areas (24). However, their average NPS score differs from other PCP’s. The 2021 ChiroUp network dataset cumulative NPS score for chiropractors is 89.8, ranking among the highest in healthcare.

 
 

Online Satisfaction Reviews- Google

Online ratings provide another independent mechanism to gauge patient satisfaction. And an important one, since nearly three-quarters (71%) of patients now use online reviews as their first step in finding a new doctor. (25)

Consumer research has found that, in general, online reviews for healthcare providers (i.e., Google, Yelp, HealthGrades, etc.) tend to mirror the provider’s NPS score. (26,27) The 2021 ChiroUp network dataset supports that correlation. 

An analysis of nearly 5000 providers found that the average medical physician’s online rating is 3.8 out of 5 possible stars. (28) An earlier and more comprehensive analysis by NPR placed that number slightly lower at 3.6. (29) In contrast, the 2021 ChiroUp network average Google rating for chiropractors is 4.9 out of 5. 

 
 

Online Satisfaction Reviews- Yelp

A more detailed analysis of the Yelp dataset reinforces the finding that, on average, online satisfaction ratings for chiropractic physicians are higher than other specialists. (25,27)

 
 

Online Satisfaction Reviews- Healthgrades

An analysis of Healthgrades® US consumer ratings for 212,933 health care providers found that chiropractors performed very well compared to medical specialists (4.0) and surgeons (4.2). (30)

 
 

Part 2: Chiropractic Diagnoses

Reasons to Visit a Chiropractor

The 2021 ChiroUp network dataset highlights the most common regional complaints in chiropractic offices.

 
 

* This 2021 COPS Synopsis data parallels findings from a 2017 scoping review (31) defining the frequency of common chiropractic presentations: Back conditions (49.7%), Neck conditions (22.5%), Extremity problems (10.0%), Non-musculoskeletal conditions (3.1%).

Top 10 Chiropractic Diagnoses

A more specific condition breakdown of the 2021 ChiroUp network dataset highlights the ten most common diagnoses made in chiropractic offices.

 
 

Most Common Spinal Diagnoses

Four out of five adults will experience neck or back pain that limits their daily activity at some point in their lifetime. (32,33) It should come as no surprise that spine-related diagnoses are the leading conditions in chiropractic offices. The 2021 ChiroUp network dataset provides a breakdown of the most common spinal diagnoses in chiropractic offices.

 
 

Top Diagnoses by Region

Chiropractors are trained to assess and treat various complaints outside of the spine, including problems ranging from headaches to plantar fasciitis. The following breakdown lists the three most common musculoskeletal diagnoses per region.

 
 

Treating Causes vs. Symptoms

Functional deficits (muscle imbalances) comprise four of the top fourteen diagnoses made in evidence-based chiropractic offices. Additionally, functional deficits represent more than 21% of all chiropractic diagnoses. This focus on identifying the underlying biomechanical cause (i.e. hip abductor weakness), as opposed to the more simplistic ICD-10-defined structural result (i.e. hip osteoarthritis), may help explain the above-average clinical outcomes shown in the subsequent section.

 
 

Part 3: Clinical Outcomes

Average Improvement

Results of the 2021 ChiroUp network dataset confirm that chiropractic patients experience significant average improvement within 30 days of initiating care.

 
 

Chiropractic Effectiveness

Significant data has shown that chiropractic care, including spinal manipulation, is an effective solution for various musculoskeletal disorders. 

The UK Evidence Report (34) provided a “comprehensive summary of the scientific evidence for manual therapy” and concluded that spinal manipulation/mobilization is effective in adults for the conditions listed below. Subsequent studies have confirmed these findings. (Additional references included)

  • Acute, subacute, and chronic low back pain (35-52)

  • Migraine (53-62)

  • Cervicogenic headache (63-76)

  • Cervicogenic dizziness (77-79)

  • Acute/subacute neck pain (41, 80-98)

  • Several extremity joint conditions (see below)

Other extensive studies have defined the specific extremity conditions where manipulation/mobilization has proven merit:

  • Rotator cuff problems (99-109)

  • Lateral epicondylopathy (tennis elbow) (100,110-122)

  • Carpal tunnel syndrome (123,124)

  • Hip and knee osteoarthritis (125-141)

  • Ankle sprains (99,142)

  • Plantar fasciitis (143-152)

  • TMD (jaw pain) (153-155)

 
 

Most Responsive Diagnoses

In recent years, the healthcare industry has focused on defining the most effective treatment for each condition. Evidence-based chiropractors concentrate on identifying the most amenable diagnoses and collaboratively referring conditions that lie outside of their expertise. 

The 2021 ChiroUp network dataset defined conditions showing the greatest percent of average improvement after 30 days of initiating chiropractic care.

 
 

Outcomes By Provider Type

Multiple published studies have shown that chiropractors perform very well compared to other healthcare providers for musculoskeletal complaints. (8,9, 156-158) Studies comparing chiropractic or manual therapy clinical outcomes to standard medical care and physical therapy highlight a consistent theme: 

The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group. (158) 

[Low back manipulation] provides greater short-term reductions in self-reported disability and pain compared with usual medical care. (156)

One study compared 30-day low back pain outcomes of patients treated by chiropractors vs. those treated by MD/ family physicians and found:

Patients with chronic low-back pain treated by chiropractors showed greater improvement and satisfaction at one month than patients treated by family physicians. A higher proportion of chiropractic patients (56% vs. 13%) reported that their low-back pain was better or much better, whereas nearly one-third of medical patients reported their low-back pain was worse or much worse. (8)

 
 

Collaborative Outcomes

Healthcare clinicians and researchers have found that adding chiropractic treatment to standard medical care for back pain resulted in less pain, less disability, improved function, lower use of pain medication, and higher satisfaction.

The results of this trial suggest that CMT [chiropractic manipulative therapy] in conjunction with SMC [standard medical care] offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care… 73% of participants in the SMC plus CMT group rated their global improvement as pain completely gone, much better, or moderately better, compared with 17% in the SMC group.”(9)

 
 

In response to abundant credible data regarding the utility of manipulation for back and neck pain, various medical authorities have endorsed spinal manipulation or conservative chiropractic care including, the American College of Physicians (159), US FDA (160), and US CDC. (161) One study highlights a growing theme: 

“PCPs [primary care providers] utilizing an integrative medical approach emphasizing a variety of CAM therapies [complementary alternative medicine therapies, including chiropractic] had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone.” (157)

Part 4: Cost-Effectiveness

Value

In the US alone, musculoskeletal pain, led by spinal disorders, is estimated to cost the healthcare system nearly one trillion dollars per year and is the most common cause of severe long-term pain and disability. (162)

Cost-effectiveness or value is a crucial metric for evaluating the merit of any treatment. The Value of any intervention for managing a specific condition is roughly calculated by dividing the clinical outcome by the cost of delivering that care. 

 
 

Considering that evidence-based chiropractors deliver above-average clinical outcomes at low expense, consumers could expect their value to the healthcare system to be high. While the 2021 ChiroUp network dataset did not directly measure cost-effectiveness, multiple other studies have assessed that metric and concluded that chiropractic is highly cost effective (157, 158, 163,164,185-189) . The following sections summarize a small portion of that data.

Cost Comparison by Provider Type

An extensive systematic review (157) compared chiropractic care to standard medical care and physiotherapy for musculoskeletal pain and concluded: 

Manual therapy techniques [including chiropractic manipulation] were more cost-effective than usual general practitioner care …for improving low back and shoulder pain/disability. (157)

Multiple other studies have come to the same conclusion:

A claims analysis of Blue Cross Blue Shield of Tennessee’s low back pain claims data showed that care initiated with a doctor of chiropractic (DC) saves nearly 40 percent on healthcare costs compared with care initiated through a medical doctor (MD). (163)

 
 

A cost analysis of various spine, hip, and shoulder problems treated by chiropractors vs. medical providers showed that mean treatment costs over four months were significantly lower in patients initially consulting a chiropractor. (164)

 
 

A British Medical Journal cost comparison for neck pain treatment costs found an even more significant disparity: “The total costs of manual therapy were around one-third of the costs of physiotherapy and general practitioner care.” (158)

 
 

Ancillary Costs – Healthcare Referrals

Healthcare expenditures rise when additional providers enter the clinical picture. The choice of initial provider plays a dramatic role in predicting the likelihood of future referrals, tests, and procedures. 

Several studies have found that patients saw fewer total providers throughout their episode of care when treatment is initiated with a chiropractor. (165-167) Data from Optum Healthcare shows that spinal patients who initiate care with a chiropractor see an average of 1.7 different providers compared to 3.2 different providers for spinal patients starting with other specialties. (167)

 
 

Ancillary Costs – Surgery

The majority of musculoskeletal problems can be resolved without surgery. Many issues that were once thought to necessitate surgery are now being effectively managed conservatively. A 2020 study concluded that 97% of lumbar disc herniations are successfully managed nonoperatively. (168) 

The choice of initial provider is significantly associated with the likelihood of subsequent surgery. A Spine journal study found that approximately 42.7% of injured workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. (166)

 
 

Ancillary Costs – Opioids & Other Drugs

Research shows that chemicals [drugs] are largely ineffective for managing mechanical musculoskeletal problems like back pain. (169-173) Even powerful medications including opioids, have questionable outcomes and undesired side effects. (173) 

 
 

In addition to questionable benefits, opioids carry undeniable risks. In 2018, over 67,000 people died from drug overdoses – most (73%) from prescription opioid medicine. (174) And in the prior decade, overdose death rates and substance use rates increased 3-4 fold – in parallel to sales of prescription pain relievers. (175)

Recent studies have shown that chiropractic care is a natural solution that may help solve the opioid epidemic. A 2019 Pain Medicine journal systematic review found that patients participating in chiropractic care were 64% less likely to receive an opioid prescription than nonusers. (176)

 
 

A 2020 systematic review found that spinal pain patients who engaged with chiropractic care “had half the risk of filling an opioid prescription” over the next six years. (177) 

 
 

Ancillary Costs – Hospitalization, Surgery & Medication

One 4-year study demonstrated that integrating complementary care, notably chiropractors, into standard medical care can substantially decrease healthcare expenditures (157):

 
 

Value to Healthcare Plans

Because of their ability to deliver high-value care with lower secondary costs, chiropractors become more appealing to patients and healthcare payors. An Optum analysis concluded that healthcare plans that formally incorporate chiropractic typically realize a 2:1 return for every dollar spent. (178)

 
 

Part 5: Safety

Spinal Manipulation Safety

Attitudes have changed as researchers have learned more about the safety of spinal manipulation. The Journal of the American Medical Association recently concluded “spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.” (179)

Another landmark study found that “risk of injury to the head, neck or trunk within seven days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.” (180)

Malpractice Claims Per Provider

Malpractice claims data reinforces the safety record of chiropractic care. An analysis of the National Practitioner Data Bank, Adverse Actions and Medical Malpractice Reports (1990-2017), and US Census Bureau defined the percentage of US malpractice claims by various provider types (181):

 
 

Malpractice Premium Costs Per Provider

The cost of insuring a provider is another reliable predictor of risk. An analysis of malpractice insurance premium rates per provider illustrates that chiropractors pay some of the lowest rates in healthcare (182,183):

 
 

Conclusion

This 2021 COPS synopsis confirms that chiropractors demonstrate above-average performance for the essential healthcare consumer needs. Evidence-based chiropractors should play a vital role in the future healthcare model because of their ability to safely and cost-effectively deliver excellent musculoskeletal clinical outcomes with high patient satisfaction.

Notes

The 2021 ChiroUp network dataset (1) summarized data from more than 2,200 evidence-based chiropractic practices (ChiroUp network). These providers share a common mission to achieve exceptional & timely clinical outcomes with high patient satisfaction by sharing and adhering to research-based best practices. Prior studies have shown that evidence-based chiropractors significantly outperform their non-evidence-based peers. (184) Hence, the outcomes reported in this study may not necessarily reflect the entire chiropractic profession. 

About the Author

ChiroUp.com was founded in 2015 by Tim Bertelsman DC, CCSP, DACO and Brandon Steele DC, DACO. ChiroUp provides chiropractors with evidence-based resources to improve clinical outcomes and patient satisfaction. The platform is currently being used by over 2,000 chiropractors in fourteen different countries. 

Reprints & Reproduction

To use this infographic or its data for any purpose, or to embed the graphic on another website, please include proper credit and link to the original article on chiroup.com

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