The use of PROMIS and the RAND VSQ9 in chiropractic patients receiving care with the Webster Technique

Patient Experience and Satisfaction With Chiropractic Care: A Systematic Review

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.

What Gets Measured Gets Managed: A Scoping Review of Musculoskeletal Research Conducted Within Practice-Based Research Networks

ABSTRACT

Musculoskeletal conditions are often managed in primary care settings. To facilitate research and healthcare quality, practice-based research networks offer sustained collaborations between clinicians and researchers. A scoping review was conducted to describe characteristics of practice-based research networks used for musculoskeletal research and musculoskeletal research conducted through practice-based research networks. Practice-based research networks were identified from 1) musculoskeletal-studies identified in OVID Medline, CINAHL, and Embase databases from inception to 5 February 2023 and in ClinicalTrials.gov and 2) from practice-based research network registries and websites. Among active musculoskeletal-focused practice-based research networks (i.e., currently recruiting and conducting research), an assessment of practice-based research network research good practices was performed. After screening 3025 records, 85 studies from 46 unique practice-based research networks met our eligibility criteria. Common conditions studied were low back pain (28%), musculoskeletal conditions not otherwise specified (25%), and osteoarthritis (19%). Thirty-two practice-based research networks (70%) were deemed to be active. Among active musculoskeletal-focused practice-based research networks, best practice data management information was retrievable for most (53%). Because of the scarcity of publicly available information, a large proportion of practice-based research network research good practice items was not assessable. Practice-based research networks have provided an avenue to assess clinical practice and patient outcomes related to musculoskeletal conditions. Further work to increase the transparency of musculoskeletal practice-based research network research practices is warranted.

Mixed methods systematic review of the literature base exploring working alliance in the chiropractic profession

BACKGROUND

The construct of working alliance has been used to operationalise the patient-clinician relationship. Research evidence from the rehabilitation literature has established an association between the construct and several patient outcomes. The aim of this systematic literature review was to study working alliance in the chiropractic discipline.

METHOD

This review followed a mixed method systematic review methodology: EBSCO (The Allied and Complementary Medicine Database), EBSCO (MEDLINE), EBSCO PsycINFO, Web of Science Core Collection, Chiro index, and grey literature were searched for quantitative, qualitative, and mixed methods studies on 17th March 2021. Qualitative appraisal was conducted using the Mixed Methods Appraisal Tool, version 2018. The qualitative component was synthesised via thematic synthesis and explored patients' and chiropractors' perceptions of the nature and role of working alliance. The quantitative component was synthesised via narrative synthesis to examine how the construct has been measured in research and what its effect on clinical outcomes and patient satisfaction is. The findings were integrated in the discussion section.

RESULTS

Thirty studies were included. The qualitative component found that both patients and chiropractors consider working alliance as a key factor in the treatment journey. The findings illustrated that the construct includes the bond between a patient and a chiropractor which is underpinned by trust and attentiveness to patients' needs, values and preferences. Qualitative data also suggested that strong working alliance has the potential to improve patients' adherence to treatment and that it is characterised by ongoing negotiation of expectations about the goals of care and the tasks involved in the treatment plan. The quantitative component highlighted that even though working alliance is relevant to the chiropractic discipline, very few studies have quantitatively measured the construct and its effect.

CONCLUSION

The findings of this review emphasise the subjective importance of working alliance in the chiropractic clinical encounter. However, there were not enough homogenous studies measuring the effect of working alliance on clinical outcomes and patient satisfaction to conduct a meta-analysis. Future research should focus on evaluating potential direct and mediated effects on patient outcomes.

Experiences With Chiropractic Care for Patients With Low Back or Neck Pain

Background

Musculoskeletal disorders are the second leading cause of disability worldwide.

Objective

Examine experiences of chiropractic patients in the United States with chronic low back or neck pain.

Method

Observational study of 1853 chronic low back pain and neck pain patients (74% female) who completed an online questionnaire at the 3-month follow-up that included Consumer Assessment of Healthcare Providers and Systems (CAHPS) items assessing their experiences with care.

Results

We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points).

Conclusions

The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Chiropractors' Perspectives on the Meaning and Assessment of Quality of Life Within Their Practice in New Zealand: An Exploratory Qualitative Study

OBJECTIVE

The purpose of this study was to gain an understanding on what quality of life (QOL) and its assessment means to chiropractors in everyday practice.

METHODS

This study captured chiropractors' perspectives on the QOL construct and its assessment using a qualitative descriptive methodology that comprised 2 focus groups, each with 4 participants using semi-structured, open-ended questioning. Participants from Aotearoa, New Zealand, were also asked to evaluate 4 QOL patient-reported outcome measurements from a clinical perspective.

RESULTS

Two of the participants were faculty at the New Zealand College of Chiropractic, 5 were in full-time practice, and 1 was practicing part time. Using qualitative content analysis, 3 main themes were identified. These chiropractors perceived that patients have misconceptions about how chiropractic can affect QOL. They lacked clarity in communicating QOL and its related concepts to establish a clinically meaningful patient encounter. Finally, there is uncertainty in how and when to measure QOL, which appears to affect how they discuss and assess QOL in practice.

CONCLUSION

There is a complex combination of factors that makes communication regarding QOL challenging. This exploratory qualitative study helps to understand the challenges faced in how and when to communicate and assess QOL more effectively in chiropractic practice.

Use of PROMIS-29® in US Veterans: Diagnostic Concordance and Domain Comparisons with the General Population

BACKGROUND

PROMIS® items have not been widely or systematically used within the Veterans Health Administration (VA).

OBJECTIVE

To examine the concordance of PROMIS-29® scores and medical record diagnosis in US Veterans and to compare Veteran scores relative to US population norms.

DESIGN/PARTICIPANTS

Cross-sectional multi-site survey of Veterans (n = 3221) provided sociodemographic and PROMIS-29® domain data. Electronic medical records provided health condition (depression, anxiety, sleep disorders, pain disorders) diagnosis data.

MAIN MEASURES

For each domain, we calculated PROMIS® standardized T scores and used t tests to compare PROMIS® scores for Veterans diagnosed with each targeted health condition vs. those without that documented clinical diagnosis and compare mean Veterans' PROMIS-29® with US adult population norms.

KEY RESULTS

Veterans with (vs. without) a depression diagnosis reported significantly higher PROMIS® depression scores (60.3 vs. 49.6, p < .0001); those with an anxiety diagnosis (vs. without) reported higher average PROMIS® anxiety scores (62.7 vs. 50.9, p < .0001). Veterans with (vs. without) a pain disorder reported higher pain interference (65.3 vs. 57.7, p < .0001) and pain intensity (6.4 vs. 4.4, p < .0001). Veterans with (vs. without) a sleep disorder reported higher sleep disturbance (55.8 vs. 51.2, p < .0001) and fatigue (57.5 vs. 51.8, p < .0001) PROMIS® scores. Compared with the general population norms, Veterans scored worse across all PROMIS-29® domains.

CONCLUSIONS

We found that PROMIS-29® domains are selectively sensitive to expected differences between clinically-defined groups, suggesting their appropriateness as indicators of condition symptomology among Veterans. Notably, Veterans scored worse across all PROMIS-29(^R) domains compared with population norms. Taken collectively, our findings suggest that PROMIS-29® may be a useful tool for VA providers to assess patient's physical and mental health, and because PROMIS® items are normed to the general population, this offers a way to compare the health of Veterans with the adult population at large and identify disparate areas for intervention.

Group and Individual-level Change on Health-related Quality of Life in Chiropractic Patients With Chronic Low Back or Neck Pain

STUDY DESIGN

A prospective observational study.

OBJECTIVE

The aim of this study was to evaluate group-level and individual-level change in health-related quality of life among persons with chronic low back pain or neck pain receiving chiropractic care in the United States.

SUMMARY OF BACKGROUND DATA

Chiropractors treat chronic low back and neck pain, but there is limited evidence of the effectiveness of their treatment METHODS.: A 3-month longitudinal study of 2024 patients with chronic low back pain or neck pain receiving care from 125 chiropractic clinics at six locations throughout the United States was conducted. Ninety-one percent of the sample completed the baseline and 3-month follow-up survey (n = 1835). Average age was 49, 74% females, and most of the sample had a college degree, were non-Hispanic White, worked full-time, and had an annual income of $60,000 or more. Group-level (within-group t tests) and individual-level (coefficient of repeatability) changes on the Patient-Reported Outcomes Measurement Information System (PROMIS-29) v2.0 profile measure was evaluated: six multi-item scales (physical functioning, pain, fatigue, sleep disturbance, social health, emotional distress) and physical and mental health summary scores.

RESULTS

Within-group t tests indicated significant group-level change (P < 0.05) for all scores except for emotional distress, and these changes represented small improvements in health (absolute value of effect sizes ranged from 0.08 for physical functioning to 0.20 for pain). From 13% (physical functioning) to 30% (PROMIS-29 v2.0 Mental Health Summary Score) got better from baseline to 3 months later according to the coefficient of repeatability.

CONCLUSION

Chiropractic care was associated with significant group-level improvement in health-related quality of life over time, especially in pain. But only a minority of the individuals in the sample got significantly better ("responders"). This study suggests some benefits of chiropractic on functioning and well-being of patients with low back pain or neck pain.

LEVEL OF EVIDENCE

3.

Feasibility of Distinguishing Performance Among Provider Groups Using Patient-reported Outcome Measures in Older Adults With Multiple Chronic Conditions

OBJECTIVE

To examine minimum sample sizes and follow-up times required for patient-reported outcome-based performance measures (PMs) to achieve acceptable reliability as PMs.

PARTICIPANTS

We used 2 groups of patients age 65+ with at least 2 of 13 chronic conditions. The first was a sample of Medicare Advantage beneficiaries, who reported health-related quality of life (HRQoL) at baseline and 2 years. The second was a sample of primary care patients, who reported HRQoL at baseline and 6 months.

MEASURES

Medicare Advantage beneficiaries completed the Veterans RAND 12-Item Short Form (VR-12), while the primary care sample completed the Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure (PROMIS-29). We constructed binary candidate PMs indicating stable or improved physical or mental HRQoL at follow-up, and continuous PMs measuring mean change over time.

RESULTS

In the Medicare Advantage sample, with a sample size per entity profiled of 160, the most promising PM achieved a reliability of 0.32 as a PM. A sample size of 882 per entity would have been needed for this PM to achieve an acceptable reliability of 0.7. In the prospective sample, with a sample size of 27 per clinic, the most promising PM achieved a reliability of 0.16 as a PM. A sample size of 341 patients (at the clinic level) would have been needed for this PM to achieve a reliability of 0.7.

CONCLUSIONS

Achieving acceptable reliability for these PMs and conditions would have required minimum sample sizes of 341 at the clinic level or 880 at the health plan level. These estimates can guide the design of future patient-reported outcome-based PMs.

Evaluating the PROMIS-29 v2.0 for use among older adults with multiple chronic conditions

PURPOSE

The Patient-Reported Outcomes Measurement Information System 29-item profile (PROMIS-29 v2.0), which measures health-related quality of life (HRQoL), has had limited evaluation among older adults (age 65+) with multiple chronic conditions. Our purpose was to establish convergent validity for PROMIS-29 in this population.

METHODS

We collected the PROMIS-29 v2.0 and the Veterans RAND 36 (VR-36) for 1359 primary care patients aged 65 + with at least 2 of 13 chronic conditions, oversampling those aged 80+. We conducted multiple analyses to examine score differences across subgroups, differential item functioning (DIF), and comparisons of PROMIS-29 v2.0 and VR-36 scores.

RESULTS

The mean age was 80.7, and all patients had at least 2 of 13 chronic conditions. Older age, female sex, Hispanic ethnicity, and more chronic conditions were associated with worse physical health scores (PHS) and mental health scores (MHS) on the PROMIS-29 v2.0-findings which are in the expected direction. None of the 700 pairs of items met criteria for DIF. PHS and MHS were highly intercorrelated (r = 0.74, p < 0.001 for this and all other findings). PHS was more highly correlated with the VR-36 Physical Component Score (PCS) than the Mental Component Score (MCS) (r = 0.85 and 0.32, respectively), while MHS was highly correlated with both (r = 0.70 and 0.64, respectively).

CONCLUSIONS

PROMIS-29 v2.0 demonstrates expected bivariate relationships with key person-level characteristics and does not show DIF. PROMIS-29 v2.0 scores are highly correlated with VR-36 scores. These results provide support for the validity of PROMIS-29 v2.0 as a measure of HRQoL among older adults with multiple chronic conditions.

Correlation of PROMIS CAT instruments with Oswestry Disability Index in chiropractic patients

BACKGROUND

The inefficiency associated with collecting standard validated instruments has been a barrier to routine use. We utilized computer adaptive testing (CAT) instruments available through Patient-Reported Outcomes Measurement Information System (PROMIS) and correlated these with the Oswestry Disability Index (ODI).

METHODS

All measurements were collected at a routine chiropractic visit. The ODI assessment was used for comparison as a widely used patient reported outcomes instrument.

RESULTS

The average time to complete all questions during an office visit was 170 ± 67 s (average ± Stdev) to answer 25 ± 6 questions. Regression analysis revealed a good linear fit between ODI and both PROMIS pain behavior and physical function with R² values of 0.5219 and 0.6754 respectively, and a good linear fit between anxiety and depression with R² values of 0.5236.

CONCLUSIONS

PROMIS CAT instruments can be efficiently administered during routine clinical visits and correlations values found validate the utility when compared to ODI.

The Quality of Life of Children Under Chiropractic Care Using PROMIS-25: Results from a Practice-Based Research Network

OBJECTIVES

To characterize pediatric chiropractic and assess pediatric quality of life (QoL).

DESIGN

A prospective cohort. Setting/Locations: Individual offices within a practice-based research network located throughout the United States.

SUBJECTS

A convenience sample of children (8-17 years) under chiropractic care and their parents.

EXPOSURE

Chiropractic spinal adjustments and adjunctive therapies.

OUTCOME MEASURES

Survey instrument measuring sociodemographic information and correlates from the clinical encounter along with the Patient Reported Outcomes Measurement Information System (PROMIS)-25 to measure QoL (i.e., depression, anxiety, and pain interference). Sociodemographic and clinical correlates were analyzed using descriptive statistics (i.e., frequencies/percentages, means, and standard deviations). The PROMIS-25 data were analyzed using scoring manuals, converting raw scores to T score metric (mean = 50; SD = 10). A generalized linear mixed model was utilized to examine covariates (i.e., sex, number of visits, and motivation for care) that may have played an important role on the PROMIS outcome.

RESULTS

The original data set consisted of 915 parent-child dyads. After data cleaning, a total of 881 parents (747 females, 134 males; mean age = 42.03 years) and 881 children (467 females and 414 males; mean age = 12.49 years) comprised this study population. The parents were highly educated and presented their child for mainly wellness care. The mean number of days and patient visits from baseline to comparative QoL measures was 38.12 days and 2.74 (SD = 2.61), respectively. After controlling for the effects of motivation for care, patient visits, duration of complaint, sex, and pain rating, significant differences were observed in the probability of experiencing problems (vs. no reported problems) across all QoL domains (Wald = 82.897, df = 4, p < 0.05). Post hoc comparisons demonstrated the children were less likely to report any symptoms of depression (Wald = 6.1474, df = 1, p < 0.05), anxiety (Wald = 20.603, df = 1, p < 0.05), fatigue (Wald = 22.191, df = 1, p < 0.05), and pain interference (Wald = 47.422, df = 1, p < 0.05) after a trial of chiropractic care.

CONCLUSIONS

The QoL of children improved with chiropractic care as measured by PROMIS.

The Use of the Patient Reported Outcomes Measurement Information System and the RAND VSQ9 to Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients Under Chiropractic Care Utilizing the Webster Technique

Objective: To quantify the quality of life (QoL) and visit-specific satisfaction of pregnant women.

Design: A prospective cohort within a practice-based research network (PBRN).

Setting/Locations: Individual chiropractic offices.

Subjects: Pregnant women (age ≥18 years) attending chiropractic care.

Intervention(s): Chiropractic care (i.e., The Webster Technique, spinal adjustments, and adjunctive therapies).

Main outcome measures: The RAND VSQ9 to measure visit-specific satisfaction and the Patient Reported Outcomes Measurement Information System (PROMIS^®)-29 to measure QoL.

Results: A convenience sample of 343 pregnant patients (average age = 30.96 years) comprised their study population. They were highly educated with 75% attaining a 2-year associate's degree or higher. The pregnant patients presented for chiropractic care with a mean week of gestation of 25.67 weeks (median = 28 weeks; range = 0–42 weeks) and parity (i.e., the number of live births) of 0.92 live births (median = 1; range = 0–6). From baseline (i.e., at study entrance with minimum first visit) and comparative (i.e., following a course of chiropractic care), the VSQ9 measurements revealed increasingly high satisfaction on the part of the subjects (i.e., the mean difference of baseline minus comparative measures = −0.7322; p < 0.005). The median number of visits (i.e., visits attended) at baseline and comparative measures was 1.00 (standard deviation [SD] = 22.69) and 3.30 (SD = 22.71), respectively. Across outcomes, QoL improved from baseline to comparative measurement after holding constant for visit number and time lapse, trimester of pregnancy, and care provider type. There was a reduction in mean T scores associated with fatigue (p < 0.05), pain interference (p < 0.05), sleep disturbance (p < 0.05), and an improvement in satisfaction with social roles (p < 0.05). A significant decrease was also found with pain interference (p < 0.05). No evidence was found that anxiety (p = 0.1404) or depression (p = 0.8785) changed.

Conclusion: A PBRN study was successfully implemented among chiropractors to find pregnant patients highly satisfied and their QoL scores improving with care beyond chance.