FROM:
J Manipulative Physiol Ther 2000 (Jan); 23 (1): 1–9
Rupert RL ~ rrupert@Chiroaccess.com
OBJECTIVE: To investigate the primary care, health promotion activities associated with what has historically been called "maintenance care" (MC) as used in the practice of chiropractic in the United States. This includes issues such as investigating the purpose of MC, what conditions and patient populations it best serves, how frequently it is required, what therapeutic interventions constitute MC, how often it is recommended, and what percent of patient visits are for prevention and health promotion services. It also investigates the economic impact of these services.
DESIGN: Postal survey of a randomized sample of practicing US chiropractors. The questionnaire was structured with a 5-point ordinal Likert scale (28 questions) and brief fill-in questionnaire (12 questions). The 40-question survey was mailed to 1500 chiropractors selected at random from a pool of chiropractors with active practices in the United States. The National Directory of Chiropractic database was the source of actively practicing chiropractors from which doctor selection was made. The sample was derived by using the last numbers composing the zip codes assigned by the US Postal Service. This sampling method assured potential inclusion of chiropractors from all 50 states, from rural areas and large cities, and assured a sample weighting based on population density that might not have been afforded by a simple random sample.
RESULTS: Six hundred and fifty-eight (44%) of the questionnaires were completed and returned. US chiropractors agreed or strongly agreed that the purpose of MC was to optimize health (90%), prevent conditions from developing (88%), provide palliative care (86%), and minimize recurrence or exacerbations (95%). MC was viewed as helpful in preventing both musculoskeletal and visceral health problems. There was strong agreement that the therapeutic composition of MC placed virtually equal weight on exercise (96%) and adjustments/manipulation (97%) and that other interventions, including dietary recommendations (93%) and patient education about lifestyle changes (84%), shared a high level of importance. Seventy-nine percent of chiropractic patients have MC recommended to them and nearly half of those (34%) comply. The average number of recommended MC visits was 14.4 visits per year, and the total revenue represents an estimated 23% of practice income.
CONCLUSIONS: Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.
From the Full-Text Article:
Discussion
Postal surveys have inherent weaknesses but are a well-established form of biomedical research. One of the specific weaknesses in this study involves requesting chiropractors to provide the number of new patients per month, the percentage of income derived from MC, and other data that are not based on accurate counts and calculations but on estimates. In addition, the response rate (44%), although disappointing, was relatively strong for a chiropractic postal survey. Surveys within the profession rarely result in as much as a 50% response rate; previous survey response rates related to chiropractic and prevention have ranged from 22% to 65%. [ 7, 12 ] A control number was assigned to each questionnaire to facilitate follow-up of nonrespondents. However, this did not prove effective because many doctors who did respond either obliterated, marked out, or actually tore off the number from the form to ensure anonymity. With the accuracy of written follow-up compromised, a selected follow-up was made by telephone. Eighty-five doctors for whom there was no record of a completed questionnaire were called and asked [ 1 ] if they completed the survey, [ 2 ] if they did not respond, why, and [ 3 ] if they used MC in their practice. Doctors indicated that the most common reason for nonparticipation was that they were too busy. The majority of nonrespondents also reported that they used some form of MC in their practices.
A review of the demographics of chiropractors who completed and returned questionnaires for this study did not vary significantly from other large contemporary surveys, with the exception of sex. The annual survey conducted in 1995 by the American Chiropractic Association reflected a sex mix within the profession of 88% men and 12% women. [ 20 ] The response to this MC study and previous prevention-related research conducted by Hawk and Dusio [ 7 ] both had a slightly higher percentage of female respondents than the national American Chiropractic Association survey (83% male and 17% female; 81% male and 19% female, respectively). Hawk and Dusio [ 7 ] indicated that the larger number of female respondents may reflect a bias. [ 7 ] However, a recent medical study suggests that female physicians may have a greater interest in prevention activities than male physicians. [ 21 ] This same phenomenon may in fact be operative within chiropractic and may account for the greater participation of women in this prevention-related survey. The average age of respondents in this study was 41 years compared with an average age of 44 years in the 1995 American Chiropractic Association survey. [ 20 ]
Prevalence of use
Previous work outside the United States suggests that the use of MC accounts for a significant amount of services rendered by chiropractors. In England, Breen [ 22 ] noted that after management for conditions like low-back pain, “39% of patients made further visits for maintenance treatment.” The Jamison [ 12 ] study of Australian chiropractors found that 62% performed MC on up to one third of their patients; 32% performed MC on 34% to 66% of their patients; and 6% performed MC on 67% to 100% of their patients. [ 23 ] This study attempted to address the same issues for chiropractors in the United States. Chiropractors were asked to provide the percentage of their patient load that received MC; the mean response was 34.4%. This suggests that a large percentage of chiropractic care given around the world is directed at prevention and health promotion. Shekelle [ 24 ] reported that 42.1% of patient visits to chiropractors were for low-back symptoms followed by 10.3% for neck/face symptoms. However, if as this study suggests, 34.4% of patient visits are for the purpose of MC, then preventive services may be the second most common reason for visits to a chiropractor. In addition to this high percentage of patients receiving MC, a much higher number, 78.7% of US patients, receive the recommendation to continue with preventive MC. This strong recommendation to receive preventive services suggests attitudes that are similar to Australian chiropractors: 41% asserted that everybody would benefit from such care, 38% believed that most would benefit, and 14% believed that some patients would benefit. [ 12 ]
Despite the emphasis by the US Government on initiatives such as Healthy People 2000,1 the medical community continues to face many obstacles to providing preventive and health promotion services. [ 25-28 ] With the use of MC to the extent described in this study, the chiropractic physician appears to place more emphasis on, derive more income from, and perhaps commit more patient time to prevention and health promotion purposes than many other health care professionals.
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