J Manipulative Physiol Ther 2006 (Jul); 29 (6): 455–462 ~ FULL TEXT
Gary Gaumer, PhD
School of Health Studies,
Department of Health Care Administration,
Boston, Mass. 02115, USA
Chiropractic patient satisfaction has been reported to be very high in the scientific literature. A review of the literature found 8 studies that compared chiropractic care to care from medical doctors (MD). 6 studies showed higher satisfaction with chiropractic care while 1 found higher satisfaction with MD care and 1 was equivocal. The data for this study was collected by a national phone survey and involved contacting 400 adults who had received chiropractic services and 400 who never received chiropractic care. The 22–minute phone interview found that 50% of all former chiropractic patients had seen a chiropractor in the past year. Family or friends had referred 66% of chiropractic patients while 12% were referred by their MD. Further analysis concluded that 12% of the adult US population had visited a chiropractor in the past 12 months. 83% of the chiropractic patients reported they were satisfied or very satisfied while only 9% were dissatisfied with care received. The researchers concluded that the chiropractor’s communication quality appeared to be a significant predictor of patient satisfaction. Patients responded that the doctors of chiropractic explained health problems and choices and seemed to be concerned about them as individuals in addition to their overall health.
OBJECTIVE: The purpose of this study is to review the recent literature on satisfaction with chiropractic care and offer a multivariate analysis of a national household survey data to understand which aspects of care and behavior contribute most to patient satisfaction with chiropractors.
METHODS: A national phone survey of households was done to measure attitudes, utilization, and health practices of chiropractic users and nonusers. A 73% response rate was achieved. Satisfaction with chiropractic services is analyzed using both descriptive and multivariate methods.
RESULTS: 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.
CONCLUSIONS: The evidence about the factors that underlie high levels of chiropractic satisfaction is not consistent. Communication quality seems to be a consistent predictor of patient satisfaction with chiropractors. More research is needed to understand the role of perceived effectiveness of treatment, intensity of use, accessibility, and financing issues in determining patient satisfaction levels.
From the FULL TEXT Article:
Patient satisfaction with chiropractic care has been reported a number of times in the recent literature, usually concluding that satisfaction levels are higher for doctors of chiropractic (DCs) than for medical doctors (MD). Although somewhat compelling on the face of it, this satisfaction advantage needs to be validated by knowledge about why a differential in satisfaction exists in the eyes of the patient. Some very inconsistent evidence exists in the literature on the matter of “why.”
A profile of 11 prior satisfaction research projects is provided in Table 1. Of the 11 studies, 3 are studies of only chiropractic patients, offering no comparisons. [1–3] Eight of the studies compare satisfaction levels between chiropractors and other health professionals. Three of these studies were able to randomly assign patients to providers. The results of these randomized studies were mixed. One of the controlled trials comparing chiropractic care to outpatient physical therapy treatment of low back pain found that patients were more satisfied with chiropractic care.  A second trial compared chiropractic treatment to McKenzie method of physical therapy treatment and found no difference in satisfaction between groups of patients.  A third study for patients with low back pain found satisfaction with DCs higher than satisfaction with MD providers. 
The remaining 5 studies, all observational, found satisfaction with DCs higher in 4 of the cases, [7–10] and satisfaction with medical care higher in the other.  Of course, these studies are not definitive because patients have “self-selected” their provider type and their illness severity, and attitudes about many things may not be comparable between DCs and MDs. So, in summary, of the 8 comparative studies, 6 show higher satisfaction levels with DC care, 1 shows higher satisfaction with MD care, and 1 shows no difference.
The body of work to date (primarily on low back pain patients) is fairly compelling, though inconclusive.  Of course, these favorable satisfaction results cannot directly be generalized to other types of patients. In a 1997 review of the literature on comparative performance of chiropractors, the authors concurred with this general conclusion that chiropractic patients are more satisfied, stating,  “Generalist (MD) care seems to be as effective and less expensive—but also less satisfying—to patients with low back pain.”
Unless there is some underlying science about what aspects of care determine satisfaction levels, the overall differences in satisfaction are not actionable and, in the case of the observational studies, not verifiable. Why would patients be more satisfied with chiropractic care? Several options for an explanation might be of the following: (1) “Is chiropractor care a more satisfying alternative because patients believe it achieves better outcomes or gets faster results?” or, (2) “Are chiropractors able to provide better service quality than other alternatives (more convenient access, better communications, more friendly and compassionate attitude, etc)?” or, (3) “Are chiropractic methods and the care process for achieving results somehow more agreeable to most patients (more frequent visits, no pharmaceuticals, emphasis on self-help and prevention, etc)?” The implications of knowing that the “satisfaction gap” arises because of 1 of these reasons, or the other, are profound.
The literature on chiropractic satisfaction offers some evidence on which of these 3 plausible explanations about the underlying drivers of satisfaction may be the basis for the apparent margin of satisfaction enjoyed by chiropractors. There are only a handful of studies that have looked at the correlates of satisfaction, and on most issues, there is only inconsistency to report. Three studies document a linkage between self-assessed health improvement (lowered pain, range of motion, etc) and satisfaction levels. [1, 2, 6] One of these studies also reported that confidence in the effectiveness of the treatment was positively related to satisfaction.  A fourth study was not able to document a statistically significant relationship between perceived DC outcomes and satisfaction. 
There is also lack of consistency about how satisfaction relates to financial issues (copays, insurance). One study finds that higher financial burdens are negatively related to satisfaction,  but 2 studies show that insurance coverage and copayment amounts are unrelated to satisfaction. [1, 6] In the service quality area, there is a consistency (across only a few studies) showing that satisfaction and perceived service quality are linked. Two studies find a positive relationship between conduct of clinic operations (including communication and explanation quality) and overall satisfaction, with no study finding otherwise. [2, 6] Two of these studies also examined practice access measures (waiting time, travel time, scheduling ease), finding that access and satisfaction are positively correlated. [2, 11] One of these studies  found DC patients to be less satisfied than those seeing doctors of osteopathy (appointment waits, office wait time, night and weekend access).
Aspects of the chiropractic model of care have been shown to be related to satisfaction. Two studies found that the number of visits in the episode was positively associated with satisfaction. [2, 11] A third study used a measure of “duration of the episode” and found it also positively associated with satisfaction.  Two studies showed that the intensity of advice given by the provider was positively associated with satisfaction level, as was the length of visit. [6, 11] Though no analysis was done of correlation, the second of these 2 studies showed dissatisfaction with the length of DC visits and low overall satisfaction score. 
In the most applicable of the prior studies, Hertzman-Miller et al  used a multivariate strategy to try and explain the differential in overall satisfaction between DCs and MDs (favoring the DCs). Approximately half of the unadjusted difference between the 2 provider groups was explained by the model (and half remained unexplained). By far the most powerful drivers of the provider type differences in satisfaction scores are the amount of self-care advice received and the explanation of treatment. Factors not explaining much or any of the differences in satisfaction were more or longer visits, copayment levels, improvement in pain, and confidence in treatment.
This literature, in sum, fails to point consistently to the underlying factors which may systematically favor chiropractors over other providers. This article reviews the recent literature on satisfaction with chiropractic and offers a multivariate analysis of a national household survey data in an effort to understand which aspects of care and behavior contribute most to patient satisfaction with chiropractic care.
The results here generally confirm the findings elsewhere in the literature. Of the 23% of the adult population who have ever visited a chiropractor, overall rates of satisfaction are once again found to be quite high (83% satisfied or better) and the number dissatisfied is quite low (less than 10% dissatisfied or very dissatisfied). This is remarkable given the fact that much of the financial burden of the care is borne by patients, and the preponderance of care is for difficult chronic problems of back and neck.
What factors are most highly correlated with high (or low) satisfaction? Here, little is added to the somewhat ambiguous literature about what aspects of practice and patients influence overall satisfaction with providers. The present study finds that some factors are positively correlated (P < .05) with overall satisfaction including “understandable explanation of treatment and choices,” “ordering and interpretation of laboratory results,” and “concern about me as a person.” These notions of communication quality and empathy are strongly correlated with overall satisfaction with chiropractic care (eg, persons who rate these aspects of their DC high are also very likely to rate their chiropractor highly overall; similarly, persons who rate their chiropractor low on these traits are likely to rate their chiropractor low overall). That is to say that these aspects of chiropractic care tend to discriminate between high and low levels of overall satisfaction. The importance of good communication by providers does stand out as a consistent determinant of overall satisfaction here and elsewhere in the literature.
Many aspects of chiropractic care are not found to be good consistent discriminators of overall provider satisfaction. Willingness to refer, accessibility and timeliness issues, and providing good well-care advice are not found to be correlated with overall satisfaction. One access measure has a surprising negative association with overall satisfaction: “my chiropractor allows appointment to be made in a timely way.” The implication is that persons who disagreed with the statement (ie, they experienced difficulty in getting timely appointments) had higher levels of overall satisfaction. This makes sense if the most satisfying providers are also the busiest, and if patients overlook the access difficulty when rating satisfaction. This is possible but cannot be tested here. More likely, the “difficulty in getting appointment” measure is serving as a proxy for some other excluded variable (size of practice, employed or not, etc). More research is clearly needed on this matter.
Perceived effectiveness as a provider is ambiguously related to overall satisfaction. Perceived effectiveness in dealing with serious problems is not correlated at all with overall satisfaction (P < .625), but being perceived as effective in dealing with less serious problems is marginally associated with overall satisfaction (P < .055). As noted above, being effective in providing good well-care advice is not associated with overall satisfaction score (P < .961), even though the “amount” of self-care advice was found to be a strong correlate with satisfaction in 1 prior study.  Overall, it is not clear that perceived effectiveness is correlated with overall satisfaction. This ambiguity is troubling but is a reflection of the ambiguous literature, where perceived outcomes are found to be associated with satisfaction [1, 2, 6] and yet not to be associated with measured outcomes. 
More research will be needed to clarify the relationships among outcomes, perceived effectiveness, and satisfaction. One important kind of study would be of “switchers” of chiropractic providers. This somewhat difficult-to-find group may be useful in understanding and isolating those factors that are important in determining patient satisfaction with providers. This sample was simply too small to have a large nested sample of switchers to study. However, doing large-scale quantitative or even randomized studies is not the only way to make progress here. Careful qualitative research will also be needed to help understand how attitudes and perceptions about health care and providers relate to expectations.
More research will be also needed to fully understand the satisfaction gap between DCs and other providers. Two parameters need to be researched using satisfaction surveys of large samples of persons getting care in offices of different types of providers. More needs to be known about which factors consistently drive satisfaction for office-based care (regardless of type of provider). And, second, we also need to know the extent to which some subsets of these factors are actually different between the MDs and DCs, favoring the DCs. At this writing, it seems that the gap is best explained (though only partially) by DCs providing more self-care advice and providing better explanations of condition and treatment.
The evidence about the factors that underlie high levels of chiropractic satisfaction is not consistent. Communication quality seems to be a consistent predictor of patient satisfaction with chiropractors.