Original contribution
Characteristics, satisfaction, and
perceptions of patients receiving
ambulatory healthcare from
osteopathic physicians: a comparative
national survey
JOHN C. LICCIARDONE, DO, MS, MBA
KATHRYN M. HERRON, MPH
A national telephone survey was conducted in 1998 using random-digit dialing
and the first Osteopathic Survey of Healthcare in America (OSTEOSURV-I)
instrument to determine patients’ satisfaction with their healthcare, as well as their
perceptions of osteopathic medicine. Of the 1106 respondents, 243 (22.0%) had
received medical care from an osteopathic physician, and another 307 (27.8%)
claimed to be aware of osteopathic physicians. Patients of osteopathic physicians
reported the highest levels of satisfaction in 8 of the 11 elements studied when compared with patients of allopathic physicians, chiropractors, and nonphysician
clinicians other than chiropractors.
Respondents perceived osteopathic manipulative treatment (OMT) to be beneficial for musculoskeletal disorders (P .001). In addition, respondents perceived
that healthcare services provided by osteopathic physicians were similar to those
provided by allopathic physicians (P .001), but not to those provided by chiropractors (P .01). A total of 97.9% of current patients of osteopathic physicians agreed with the statement that osteopathic physicians practiced in their
local community, compared with 80.6% of former patients of osteopathic physicians and 67.8% of patients who had never visited osteopathic physicians (P .001). In general, the most favorable perceptions of osteopathic medicine were
reported by current patients of osteopathic physicians, followed by former patients
of such physicians. The least favorable perceptions came from patients who had
never been patients of osteopathic physicians. The perception that OMT should
be covered by health insurance was significantly associated with the use of osteopathic physicians (odds ratio, 3.2; 95% confidence interval, 1.5 to 6.7, among
patients who had ever been to an osteopathic physician). The results of our survey suggest that greater access to osteopathic services, including OMT, is desirable and that promotional efforts aimed at encouraging the use of osteopathic medical services among the general population are warranted.
(Key words: osteopathic manipulative treatment, osteopathic medicine,
spinal manipulation, Osteopathic Survey of Healthcare in America, healthcare quality, patient satisfaction)
Dr Licciardone is an associate professor and
director of grants and funding in the Department of Family Medicine, Texas College of
Osteopathic Medicine, University of North
Texas Health Science Center at Fort Worth.
Ms Herron is a public health advisor in the
Health Resources and Services Administration,
Public Health Service, US Department of
Health and Human Services, Dallas, Texas.
Correspondence to John Licciardone, DO,
University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth,
TX 76107.
E-mail: [email protected]
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O
steopathic physicians receive 44 million ambulatory healthcare visits
annually, accounting for 6% of such visits in the United States.1 Nevertheless,
little has been published about the
patients who visit osteopathic physicians,
their satisfaction with the healthcare provided by such physicians, and their perceptions of osteopathic medicine. Moreover, the public’s understanding of
osteopathic medicine has not been well
studied. There are at least two reasons to
explore whether the public views osteopathic medicine differently than allopathic medicine. First, it is generally
acknowledged that osteopathic physicians enter primary care specialties at a
proportionately higher rate than do allopathic physicians. For example, 17,446
(48.2%) of the 36,190 active osteopathic physicians nationwide are family practitioners2 compared with 54,213 (8.3%)
of the 656,834 active allopathic physicians in this country.3 Second, osteopathic medicine embraces philosophical
concepts that distinguish it from allopathic medicine.4 Two frequently cited
aspects of osteopathic medicine that contribute to its uniqueness are the holistic
or patient-centered approach, with an
emphasis on preventive care, and the use
of osteopathic manipulative treatment
(OMT) as part of the overall therapeutic
approach.5
Historically, osteopathic physicians
have practiced in medically underserved
areas, particularly in rural communities.6
However, the rapid growth in the number of nonphysician clinicians (NPCs)
may affect the delivery of osteopathic
healthcare in these areas.7 Among others,
NPCs may include traditional providers
(such as nurse practitioners and physician
assistants), specialty providers (such as
optometrists and podiatrists), and alternative providers (such as chiropractors
and acupuncturists).7,8 Although chiropractors have always served as an alternative to osteopathic physicians in the
realm of manual medicine, chiropractic
has gained increasing visibility and public acceptance in recent years. A national survey found that 10.1% of respondents had used chiropractic during 1990,
a figure that increased to 11.0% in a
Licciardone and Herron • Original contribution
1997 follow-up survey.9 Another recent
study found that 15.7% of survey respondents had used chiropractic in the year
previous to the survey. As a result, chiropractic is the most common form of
alternative healthcare in the United
States.10
The objectives of this study were to
describe the patients who visit osteopathic physicians, their satisfaction with
their healthcare, and their perceptions
of osteopathic medicine; to compare these
patients with those who visit allopathic
physicians and NPCs (such as chiropractors); and to ascertain the public’s
understanding of osteopathic medicine.
Methods
Survey methodology
The first Osteopathic Survey of Healthcare in America (OSTEOSURV-I) instrument was developed and pilot-tested in
1998 using respondents throughout the
United States. The Survey Research Center of the University of North Texas conducted the telephone survey during
September 1998 and October 1998. The
Institutional Review Board of the University of North Texas Health Science
Center at Fort Worth approved the survey methods.
The conceptual population for the
survey encompassed all residents of the
United States over 18 years of age having
telephones in their households. Randomdigit dialing was used to generate the
survey sample because it offers the best
coverage of active telephone numbers,
including unlisted numbers. All telephone
exchanges in the United States were identified, and random numbers were generated for each exchange based on proportional population estimates. Telephone numbers were dialed at least five
times, using a rotating schedule of callbacks to ensure that a number was tried
on various combinations of days and
evenings, and on weekdays and weekends. Interviewers completed intensive
training in computer-assisted survey
methodology and survey objectives and
content before conducting the survey.
Of the initial sample of 9994 telephone numbers, 1792 (17.9%) were nonworking, 1303 (13.0%) were not as-
signed to households, 185 (1.9%) were
not primary telephone lines or were
assigned to persons 18 years of age or
younger, and 2994 (30.0%) generated
no contacts despite multiple attempts.
Another 181 (1.8%) respondents were
ineligible because they did not speak
English or were incapable of completing
the interview. Of the remaining 3539 eligible contacts, 1041 (29.4%) completed
the interview on initial request. Subsequently, 2192 attempts were made to
convert a random sample of refusers,
resulting in 1371 contacts. Of these 1371
contacts, 127 (9.3%) were willing to participate without any incentives; however,
only 65 of them were used to fill the
quota of respondents required to estimate population parameters with a sampling error of 3.0%. By extrapolating
our conversion rate to all of the refusers,
we obtained a 36.0% response rate
among eligible contacts (29.4% {9.3%
[100 29.4]}).
The OSTEOSURV-I interview
The OSTEOSURV-I interview was presented as a survey about the ambulatory healthcare of Americans. It included
139 items and was designed to be completed in 20 to 25 minutes. A portion of
OSTEOSURV-I is intended to provide
data relevant to osteopathic medicine.
Subsequent administrations of OSTEOSURV will provide core longitudinal data
on osteopathic medicine as well as other
healthcare topics of general interest. In the
present survey, respondents were asked
about their main healthcare provider
type, services received, satisfaction, quality, perceptions of osteopathic medicine,
sociodemographic characteristics, and
general health status. Other OSTEOSURV-I topics not reported herein included ancillary healthcare services, health
information sources, and biomedical research.
Eleven elements of patient satisfaction, addressing eight aspects of healthcare, were measured using Likert-scale
items adapted from the Patient Satisfaction Questionnaire.11 Health status was
measured using five items from the Medical Outcomes Study Short Form-36 (SF36) survey.12 Respondents were initially
Licciardone and Herron • Original contribution
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split into two groups: “aware” and
“unaware” of osteopathic medicine.
Placement in one or the other category
was based on respondents’ answers to
the following items: “Have you ever
received any medical treatment or care
from a doctor of osteopathic medicine
(DO)?” and “Are you aware of or do
you know about doctors of osteopathic
medicine (DOs)?” The group aware of
osteopathic physicians consisted of
respondents who answered affirmatively to either item, while the group unaware
of osteopathic physicians consisted of
respondents who answered negatively to
both items. Respondents who had
received medical treatment or care from
an osteopathic physician were further
stratified according to their responses to
the item, “Which of the following best
describes your main healthcare provider?” Those respondents who reported an osteopathic physician as their main
healthcare provider were considered current patients of osteopathic physicians,
while those who responded otherwise
were considered former patients of osteopathic physicians. Respondents who identified an allopathic physician as their
main healthcare provider, or who indicated that a chiropractor or other NPC
was their main healthcare provider, were
considered current patients of these
respective providers.
Statistical analysis
Sociodemographic data were collected
using categorical variables and were summarized using means and standard deviations for grouped data whenever feasible.13 All five-point Likert scale items
were standardized as follows: strongly
agree, 1; agree, 0.5; neither agree nor
disagree, 0; disagree, 0.5; strongly disagree, 1. Because patient satisfaction
and health status items included both
positive and negative statements to minimize acquiescence bias, responses to negative statements were subsequently reversed so that higher scores were always
reflective of more favorable responses.
Statistical methods included the Student’s
t-test and analysis of variance with
Tukey’s honestly significant difference
post hoc test for continuous variables,
JAOA • Vol 101 • No 7 • July 2001 • 375
the 2 test for categorical variables, and
multiple logistic regression to compute
odds ratios (ORs) and 95% confidence
intervals (CIs) for factors associated with
use of osteopathic physicians. Hypotheses were tested at the .05 level of significance using the following two software
packages: SYSTAT (SYSTAT version
7.0: Statistics, SPSS Inc, Chicago, Ill)
and Epi Info (Epi Info version 6.0, Centers for Disease Control and Prevention,
Atlanta, Ga).
Results
Characteristics of respondents
A total of 1106 respondents completed
the interview. The known geographical
distribution of respondents was northeast, 185 (17.1%); north central, 300
(27.7%); south, 361 (33.3%); and west
237 (21.9%). A total of 684 (62.0%)
respondents were female, and 930
(86.6%) were white (including Hispanic). These percentages are similar to those
of patients receiving ambulatory medical
care nationally (59.2% female and
85.2% white).1 Respondents’ mean score
on the SF-36 general health scale was
71.6 19.8. This also is comparable to
the figures that have been reported for the
general population of the United States
(72.0 20.3).12 The remaining characteristics of respondents are summarized
in Table 1.
Current healthcare providers included 924 (87.5 %) allopathic physicians, 47
(4.5%) osteopathic physicians, 25 (2.4%)
chiropractors, and 60 (5.7%) NPCs (50
respondents did not specify any provider
type). The characteristics of respondents
according to provider type are presented
in Table 1. Unlike all other provider
types, chiropractors had mostly males as
patients (56.0% male, unadjusted; 63.7%
male when adjusted for the increased
percentage of female survey respondents
compared with females in the general
population). Osteopathic physicians had
the greatest percentage of female patients
among all providers (76.6%, unadjusted;
63.1%, adjusted), and the gender distribution of patients of osteopathic physicians was significantly different than that
of patients of chiropractors (P .01).
The most significant patient differ-
ences among providers involved health
insurance coverage (P .001). More
than one third of patients of chiropractors
and one fourth of patients of other NPCs
did not have any health insurance; these
levels were significantly greater than those
of patients of allopathic and osteopathic physicians. Also, patients of NPCs
reported significantly lower health status scores (64.8 23.0) than patients
of allopathic physicians (72.3 19.6; P
.03).
A total of 243 (22.0%) respondents
had ever received medical care from an
osteopathic physician, and another 307
(27.8%) claimed to be aware of osteopathic physicians. The services most commonly received from osteopathic physicians were primary care, 61.3%; musculoskeletal treatment, 52.3%; surgery,
26.7%; and obstetrics or gynecology,
18.5% (26.0% when adjusted for gender). These exceed 100% because some
respondents received multiple services
from osteopathic physicians.
Satisfaction with healthcare
Patient satisfaction with healthcare is
summarized in Table 2. In general,
respondents were satisfied with most
aspects of their healthcare. They were
most satisfied with their provider’s
respectfulness and courteousness and
with overall performance, and least satisfied with waiting time at the provider’s
office and with availability on nights and
weekends. As shown in Figure 1, when
stratified according to current healthcare
provider, patients of osteopathic physicians reported the highest levels of satisfaction in eight of the eleven elements.
However, no significant differences existed between patients of allopathic physicians and patients of osteopathic physicians in any of these measures. Overall
satisfaction with NPCs was significantly
lower than with allopathic physicians (P
.008).
The most striking finding was that
patients of chiropractors generally disagreed with the statement, “Overall, I
am satisfied with my healthcare provider”
(standardized patient satisfaction score,
0.04 0.59). This finding was in
marked contrast to each of the three other
376 • JAOA • Vol 101 • No 7 • July 2001
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provider types (P .001 for each pairwise comparison). Satisfaction with chiropractors was also significantly lower
than with other providers in terms of
respectfulness and courteousness, time
spent waiting in the office, time spent
during visits, emphasis on wellness, and
fees (Figure 1).
Because chiropractors had relatively
large percentages of male and uninsured
patients, we repeated the analyses for
each of these significant findings using
gender and insurance status as covariates. Similar findings were observed in
these repeated analyses and, with the
exception of satisfaction with fees, all
results continued to demonstrate statistical significance. We then considered the
possibility that lower satisfaction with
chiropractors may have been attributed to
their case mix of patients with musculoskeletal disorders. When we limited
our analyses to those respondents who
had received any treatment for a musculoskeletal disorder, similar findings were
again observed. Last, we attempted to
repeat the analyses using respondents
who received treatment exclusively for a
musculoskeletal disorder. It was not feasible to compare allopathic physicians
with chiropractors in this manner because
only two respondents had visited allopathic physicians exclusively for a musculoskeletal disorder; however, there were
16 respondents who had visited osteopathic physicians exclusively for a musculoskeletal disorder. Again, substantially lower satisfaction scores were reported
among patients of chiropractors compared with patients of osteopathic physicians. However, because of the limited
sample sizes in the latter analyses, the
findings demonstrated only a trend toward statistical significance (P .10) for
all six variables—except time spent during visits, which continued to be statistically significant (P .008).
When all respondents were asked
about their perceptions of healthcare
quality, similar standardized perception
scores were reported by current patients
of allopathic physicians (0.56 0.42),
osteopathic physicians (0.54 0.53),
and chiropractors (0.50 0.50; P .76).
Licciardone and Herron • Original contribution
Table 1
Characteristics of Respondents According to Current Healthcare Provider*
Current healthcare provider
Variable
Overall
Osteopathic
physician
Age, y
44.8 16.1
(n 1104)
46.0 15.4
(n 47)
Allopathic
physician
Chiropractor
Nonphysician
clinician
45.0 16.2
(n 922)
45.4 19.2
(n 25)
46.4 14.0
(n 60)
Gender
Male
Female
Race/
ethnicity
White
Black
Hispanic
Asian/Pacific
Islander
American
Indian/Native
American
Marital
status
Married
Separated/
divorced
Widowed
Never
married
Residential
status
Urban
Suburban
Rural
P†
Post-hoc
tests‡§
.90
.05
DODC
420 (38.0)¶
684 (62.0)
11 (23.4)
36 (76.6)
348 (37.7)
574 (62.3)
14 (56.0)
11 (44.0)
21 (35.0)
39 (65.0)
880 (81.9)
100 (9.3)
50 (4.7)
44 (93.6)
1 (2.1)
0 (0.0)
740 (82.3)
84 (9.3)
43 (4.8)
21 (87.5)
1 (4.2)
0 (0.0)
45 (80.4)
7 (12.5)
1 (1.8)
27 (2.5)
2 (4.3)
19 (2.1)
1 (4.2)
1 (1.8
17 (1.6)
0 (0.0)
13 (1.4)
1 (4.2)
2 (3.6)
636 (58.0)
27 (57.4)
537 (58.8)
11 (44.0)
33 (55.0)
159 (14.5)
81 (7.4)
9 (19.1)
2 (4.3)
123 (13.5)
73 (8.0)
4 (16.0)
5 (20.0)
19 (31.7)
1 (1.7)
220 (20.1)
9 (19.1)
181 (19.8)
5 (20.0)
7 (11.7)
257 (23.8)
460 (42.6)
363 (33.6)
12 (25.5)
18 (38.3)
17 (36.2)
211 (23.5)
388 (43.2)
300 (33.4)
6 (24.0)
12 (48.0)
7 (28.0)
15 (25.4)
21 (35.6)
23 (39.0)
.20
.49
.74
*Results are presented as mean SD (n) for continuous variables and as number and percent for categoric variables.
Totals may not add to 1106 because of nonresponse to item. The stratified results do not include 50 respondents who
did not specify a provider type.
on analysis of variance for continous variables and the 2 test for categoric variables.
‡Post-hoc tests were performed only when P.05, and included pairwise comparisons using Tukey’s honestly significant
differences for continuous variables and the 2 test for categoric variables. Direction of results refers to the first value listed
for each variable.
§DO, osteopathic physician; MD, allopathic physician; DC, chiropractor; NPC, nonphysician clinician (nonchiropractic).
¶Unless otherwise indicated, numbers in parentheses are percentages.
†Based
Perceptions of osteopathic
medicine
Perceptions of osteopathic medicine
among the 550 (49.7%) respondents
aware of osteopathic physicians are summarized in Table 3. Osteopathic manipulative treatment was not only perceived
to be beneficial for musculoskeletal dis-
orders (standardized perception score,
0.38 0.32, P .001), but also for disorders involving internal organs (0.05
0.46, P .02). Not surprisingly, the
perceived level of benefit of OMT for
musculoskeletal disorders was significantly greater than for disorders involving internal organs (P .001). Respon-
Licciardone and Herron • Original contribution
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(continued )
dents also perceived the healthcare provided by osteopathic physicians to be
similar to that provided by allopathic
physicians (standardized perception
score, 0.17 0.49, P .001), but not
to that provided by chiropractors (0.06
0.50, P .01).
Respondents generally disagreed with
JAOA • Vol 101 • No 7 • July 2001 • 377
Table 1 (continued)
Characteristics of Respondents According to Current Healthcare Provider*
Current healthcare provider
Chiropractor
P†
Post-hoc
tests‡§
.31
Variable
Overall
Education, y
14.2 2.1
(n 1103)
14.1 2.3
(n 47)
14.2 2.1
(n 921)
13.4 1.8
(n 25)
14.2 2.1
(n 60)
43.3 24.3
(n 1023)
41.7 23.1
(n 44)
43.8 24.6
(n 854)
39.1 23.1
(n 23)
40.8 23.1
(n 56)
Household
income,
in $1000s
Allopathic
physician
Nonphysician
clinician
Osteopathic
physician
Any health
insurance
Yes
978 (88.5)
43 (91.5)
832 (90.1)
16 (64.0)
44 (73.3)
No
127 (11.5)
4 (8.5)
91 (9.9)
9 (36.0)
16 (26.7)
Medicare
insurance
Yes
No
187 (16.9)
918 (83.1)
8 (17.0)
39 (83.0)
164 (17.8)
759 (82.2)
5 (20.0)
20 (80.0)
6 (10.0)
54 (90.0)
66.9 21.3
(n 47)
72.3 19.6
(n 920)
70.8 19.0
(n 24)
64.8 23.0
(n 60)
General
health status
Short
Form-36
score
.62
.001
DCDO,
MD
NPCDO,
MD
.48
71.6 19.8
(n 1101)
.01
NPCMD
*Results are presented as mean SD (n) for continuous variables and as number and percent for categoric variables.
Totals may not add to 1106 because of nonresponse to item. The stratified results do not include 50 respondents who
did not specify a provider type.
on analysis of variance for continous variables and the 2 test for categoric variables.
‡Post-hoc tests were performed only when P.05, and included pairwise comparisons using Tukey’s honestly significant
differences for continuous variables and the 2 test for categoric variables. Direction of results refers to the first value listed
for each variable.
§DO, osteopathic physician; MD, allopathic physician; DC, chiropractor; NPC, nonphysician clinician (nonchiropractic).
¶Unless otherwise indicated, numbers in parentheses are percentages.
†Based
the perception that osteopathic physicians usually practice in urban areas,
though the result was not statistically significant (standardized perception score,
0.03 0.45, P .24). There were no
significant differences among urban, suburban, and rural respondents on this item
(P .16). Nevertheless, only 72.2% of
rural respondents reported that osteopathic physicians practiced in their community, compared with 84.4% of urban
respondents and 84.3% of suburban
respondents (P .007). A total of 97.9%
of current patients of osteopathic physicians agreed with the statement that
osteopathic physicians practiced in their
local community, compared with 80.6%
of former patients of osteopathic physicians and 67.8% of patients who had
never been to an osteopathic physician (P
.001). These findings suggest that
access to osteopathic physicians may be
limited in certain geographic areas. Perceptions of osteopathic medicine among
the aware group respondents, stratified
according to osteopathic patient status,
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are presented in Figure 2. The most favorable and accurate perceptions of osteopathic medicine were generally reported
by current patients, followed by former
patients and, lastly, by patients who had
never been to osteopathic physicians.
Use of osteopathic physicians
Factors associated with the use of osteopathic physicians are presented in Table
4. The sociodemographic characteristics
of current and former patients of osteopathic physicians were not significantly
Licciardone and Herron • Original contribution
Table 2
Satisfaction With Current Healthcare Provider
Element of patient satisfaction
Reported
satisfaction
Standardized patient
satisfaction score*
No.† (%)
Mean‡ (SD)
Access
Waiting time to get an appointment (n1085)
Waiting time at office (n1091)
691 (63.7)
620 (56.8)
0.18 (0.55)
0.09 (0.56)
Convenience of services
Travel time to office (n1094)
922 (84.3)
0.41 (0.41)
Emergency care
Available for urgent or emergency care (n1070)
803 (75.0)
0.35 (0.47)
Cost of care
Fees are reasonable (n1069)
702 (65.7)
0.22 (0.50)
Continuity of care
Available nights and weekends (n1041)
624 (59.9)
0.14 (0.55)
Quality of care
Emphasis on wellness (n1087)
Provides educational materials (n1094)
820 (75.4)
689 (63.0)
0.34 (0.46)
0.20 (0.50)
Interpersonal manner
Respectful and courteous (n1099)
Time spent with provider (n1091)
1031 (93.8)
715 (65.5)
0.54 (0.29)
0.21 (0.50)
Overall satisfaction
Overall patient satisfaction (n1097)
941 (85.8)
0.46 (0.37)
*Greater values reflect more favorable responses.
†Number that strongly agree or agree with the transformed survey item representing favorable satisfaction
of the total number of respondents (n) for the item.
‡P.001 for all 11 elements in testing the hypothesis that the mean standardized patient satisfaction
score equals zero (neither agree nor disagree with the survey item).
different than those of patients who had
never visited osteopathic physicians but
said they were aware of such physicians.
The only consistently significant finding in these analyses was the perception
that OMT should be covered by health
insurance (OR, 3.2; 95% CI, 1.5 to 6.7
among patients who had ever been to
osteopathic physicians). A highly significant finding among current patients
of osteopathic physicians was the
decreased perception of healthcare provided by allopathic physicians being
good or excellent (OR, 0.1; 95% CI,
0.0 to 0.3); there was no analogous finding with respect to the healthcare provided by chiropractors (OR, 1.1; 95%
CI, 0.4 to 2.5).
Comments
The results of OSTEOSURV-I indicate
that patients visiting osteopathic physicians are similar to those visiting allopathic physicians with regard to sociodemographic characteristics, including
residence, health insurance coverage,
and general health (Table 1). The percentage of female patients visiting osteopathic physicians was greater than for
any of the other provider types and significantly greater than for chiropractors. One possible explanation for this
finding is that osteopathic physicians
commonly provide primary care, potentially including gynecological screening
and obstetrical services for women. Men,
however, are less likely to seek general
Licciardone and Herron • Original contribution
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or preventive care.14 Our results are consistent with a large national study of
first-contact providers for low back care
that found a preponderance of males
among chiropractic patients but a majority of females among medical patients.15
Satisfaction with osteopathic physicians surpassed that reported for any
of the other provider types in eight of the
eleven elements studied (Figure 1). There
were no statistically significant differences between allopathic and osteopathic physicians; however, satisfaction
with chiropractors was significantly
lower than with allopathic or osteopathic physicians in six of the eleven
elements, including overall satisfaction.
Our findings regarding chiropractors
JAOA • Vol 101 • No 7 • July 2001 • 379
Figure 1. Standardized patient satisfaction scores according to type of current healthcare provider. The bars represent
means for each element of patient satisfaction described in Table 2. Positive and negative values reflect favorable and unfavorable responses, respectively. DO, osteopathic physician; MD, allopathic physician; DC, chiropractor; NPC, nonphysician clinician (other than chiropractor)
are in contrast to a previous study that
used similar items based on the Patient
Satisfaction Questionnaire; however,
the latter study was limited to patients
of a nonrandom sample of chiropractors in Minnesota and Wisconsin.16
Nevertheless, studies in North Carolina using random methods also found
higher levels of patient satisfaction
among chiropractic patients with low
back pain as compared with medical
patients.17,18 In our study, patient sat-
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isfaction findings for chiropractors
could not be adequately explained by
their greater likelihood of having
patients that were male or without
health insurance, nor could the findings be explained by musculoskeletal
Licciardone and Herron • Original contribution
Table 3
Perceptions of Osteopathic Medicine
Reported perception
Standardized perception score*
Perception of
osteopathic medicine†
No.‡ (%)
OMT is beneficial for
musculoskeletal disorders (n480)
361 (75.2)
0.38 (0.32)
.001
OMT is beneficial for disorders
involving internal organs such as the
lungs and stomach (n451)
185 (41.0)
0.05 (0.46)
.02
Cost of OMT should be covered
by health insurance (n514)
432 (84.0)
0.46 (0.32)
.001
Quality of healthcare offered by DOs
is good or excellent (n425)
312 (73.4)
0.32 (0.56)
.001
Healthcare provided by DOs is similar
to that provided by MDs (n512)
301 (58.8)
0.17 (0.49)
.001
Healthcare provided by DOs is similar
to that provided by DCs (n487)
194 (39.8)
0.06 (0.50)
.01
DOs and MDs practice in common
settings (n509)
371 (72.9)
0.31 (0.42)
.001
DOs practice in my community (n509)
412 (80.9)
0.39 (0.37)
.001
DOs usually practice in urban areas
rather than in rural areas (n467)
165 (35.3)
0.03 (0.45)
.24
Mean (SD)
P§
*Greater values reflect stronger agreement with perception.
†OMT, osteopathic manipulative treatment; DO, osteopathic physician; MD, allopathic physician; DC, chiropractor.
‡Number that strongly agree or agree with survey item of the total number of respondents (n) for the item. Potential respondents
were limited to the 550 who claimed to be aware of or know about osteopathic physicians.
§Test of hypothesis that the mean standardized perception score equals zero (neither agree nor disagree with the survey item).
case mix. One possible explanation for
lower patient satisfaction scores among
patients of chiropractors is that these
findings were based only on those
respondents who used a chiropractor as
their main healthcare provider, thereby
excluding a larger and potentially more
representative sample of respondents
who use chiropractors, but not as their
main healthcare providers.
Osteopathic manipulative treatment
was perceived to be more beneficial for
musculoskeletal disorders than for disorders involving internal organs. This
finding mirrors the prevailing thoughts
within the biomedical community
regarding spinal manipulation. The
Agency for Healthcare Research and
Quality found moderate research-based
evidence that spinal manipulation can
be helpful for patients with acute low
back problems without radiculopathy
when used within the first month of
symptoms.19 However, the effectiveness
of manipulation for patients with chronic low back problems or for conditions
other than musculoskeletal disorders has
not been established. Further, it has been
hypothesized that musculoskeletal symptoms may represent remote manifestations of subclinical visceral disease via
viscerosomatic reflexes, 20 and that
manipulative therapy may effectively
modulate autonomic tone in such visceral disorders21 or inadvertently mask
the progression of disease.22 None of
these mechanisms has been clinically validated.
Licciardone and Herron • Original contribution
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Eight of the nine perceptions of osteopathic medicine studied in our survey
were significantly influenced by familiarity with osteopathic physicians as
determined by current, former, or “never” patient status (Figure 2). Patients
who had never visited an osteopathic
physician and, to a lesser extent, former
patients had less favorable and accurate
impressions of osteopathic medicine. It
may be argued that these favorable
impressions of osteopathic medicine are
compatible with self-selection as a current patient of an osteopathic physician.
Although this may be true to some
degree, the fact that even former patients
of osteopathic physicians had more
favorable impressions of osteopathic
medicine than patients who had never
JAOA • Vol 101 • No 7 • July 2001 • 381
Figure 2. Standardized perception scores for osteopathic medicine according to patient status. The bars represent means for each
perception of osteopathic medicine described in Table 3. Positive and negative values reflect agreement and disagreement with
the perception, respectively. OMT, osteopathic manipulative treatment; DO, osteopathic physician; MD, allopathic physician;
DC, chiropractor; N, never; F, former; C, current; pt, patient.
been to an osteopathic physician suggests that exposure to osteopathic physicians has a positive impact on perceptions of osteopathic medicine. Further,
the findings for patient satisfaction
according to provider type (Figure 1),
which are all based on patient self-selection, provide additional data in support
of the healthcare provided by osteopathic physicians. The findings of our
survey, when extrapolated nationally,
indicate that almost 200 million Americans have never visited osteopathic
physicians and may be appropriate targets for osteopathic promotional efforts.
The distribution of rural residents
among patients of osteopathic physicians did not differ significantly from
the patient composition for other provider types (Table 1). Significantly fewer
rural respondents reported that osteo-
pathic physicians practiced in their community compared with urban respondents. Nevertheless, current patients were
significantly more likely to disagree with
the perception that osteopathic physicians usually practice in urban areas
rather than in rural areas than were
patients who had never visited osteopathic physicians (Figure 2). Perhaps
this reflects a greater awareness of the
historical roots of osteopathic medicine
among established patients of osteopathic physicians. According to our multivariate analyses, the perception that
OMT should be covered by health insurance is the most consistently significant
factor associated with use of osteopathic physicians (Table 4). Because these
analyses adjusted for health insurance
coverage, this finding suggests that lack
of physician reimbursement for OMT
382 • JAOA • Vol 101 • No 7 • July 2001
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services may serve as an additional barrier to receiving OMT for patients who
are otherwise covered for healthcare services.
A secular trend of declining use of
OMT among osteopathic family practitioners has been reported,23 leading some
to question the future role of OMT in
distinguishing the osteopathic medical
profession from the allopathic medical
profession.24 Indeed, 94% of spinal
manipulation in the United States is performed by chiropractors,25 even though
the number of chiropractors is not substantially greater than that of osteopathic
physicians.7 Possible explanations for
the decline in OMT use include osteopathic physicians training more often in
allopathic residency programs, practitioner time constraints, and reimbursement limits imposed by capitated insurLicciardone and Herron • Original contribution
Table 4
Multivariate Odds Ratios (OR) for Use of Osteopathic Physicians According to Patient Status*
Patient status
Ever a patient
(N 149)
Current patient
(N 32)
Former patient
(N 117)
Variable†
OR
95% CI
OR
95% CI
OR
95% CI
Age
45 y‡
46 y
1.0
1.3
...
0.8 to 2.1
1.0
0.6
...
0.3 to 1.5
1.0
1.5
...
0.9 to 2.5
Gender
Male‡
Female
1.0
1.4
...
0.9 to 2.3
1.0
1.4
...
0.6 to 3.5
1.0
1.5
...
0.9 to 2.5
Race
White‡
Nonwhite
1.0
0.8
...
0.4 to 1.8
1.0
0.2
...
0.0 to 1.7
1.0
1.1
...
0.5 to 2.4
Residence
Urban or suburban‡
Rural
1.0
1.2
...
0.7 to 2.0
1.0
1.5
...
0.6 to 3.9
1.0
1.1
...
0.6 to 1.9
Education
15 y‡
16 y
1.0
0.9
...
0.5 to 1.4
1.0
1.1
...
0.4 to 2.6
1.0
0.8
...
0.5 to 1.4
Any health insurance
No‡
Yes
1.0
0.7
...
0.3 to 1.4
1.0
0.9
...
0.2 to 3.9
1.0
0.6
...
0.3 to 1.4
Perception that OMT
is beneficial for
musculoskeletal disorders
Neutral or disagree‡
Agree
1.0
1.9
...
1.0 to 3.4
1.0
2.9
...
0.9 to 9.7
1.0
1.7
...
0.9 to 3.3
Perception that OMT
is beneficial for disorders
involving internal organs
Neutral or disagree‡
Agree
1.0
0.9
...
0.5 to 1.4
1.0
0.5
...
0.2 to 1.2
1.0
1.0
...
0.6 to 1.6
Perception that the cost of
OMT should be covered by
health insurance
Neutral or disagree‡
Agree
1.0
3.2
...
1.5 to 6.7
1.0
6.1
...
1.2 to 31.3
1.0
2.7
...
1.2 to 6.1
Perception that the quality
of healthcare provided by
MDs is good or excellent
Disagree‡
Agree
1.0
0.5
...
0.2 to 1.0
1.0
0.1
...
0.0 to 0.3
1.0
0.7
...
0.3 to 1.8
Perception that the quality
of healthcare provided by
DCs is good or excellent
Disagree‡
Agree
1.0
0.8
...
0.5 to 1.3
1.0
1.0
...
0.4 to 2.5
1.0
0.8
...
0.5 to 1.2
*Analyses were limited to those respondents who either used or were aware of osteopathic physicians and
provided data for all variables. Results are based on multiple logistic regression using never patients (N 194)
as control subjects, and are presented as odds ratios (OR) and 95% confidence intervals (CI).
†OMT, osteopathic manipulative treatment; MD, allopathic physician; DC, chiropractor.
‡Referent category.
Licciardone and Herron • Original contribution
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JAOA • Vol 101 • No 7 • July 2001 • 383
ance plans. Additionally, we identified
potential geographic access barriers to
receiving OMT among former patients of
osteopathic physicians and patients who
had never visited osteopathic physicians.
Although females were more likely
than males to be patients of osteopathic
physicians in our multivariate analyses,
the results did not achieve statistical significance. This may reflect decreased statistical power in these analyses because of
the exclusion of respondents with missing data. In addition, these analyses suggest that female DO patient status may
be confounded by other factors, such as
perceived benefit of OMT, desire for
insurance coverage of OMT, and quality of healthcare alternatively available
through allopathic physicians.
The desirability of improving access to
osteopathic physicians and OMT is
underscored by the reported levels of
patient satisfaction in this survey with
regard to osteopathic physicians and the
healthcare services they provide. Also,
unlike with allopathic physicians and
NPCs (including chiropractors), manipulation—in the form of OMT—can be
readily integrated with other primary
healthcare services when patients visit
osteopathic physicians. Research has
shown that 9% to 30% of patients initially seeking care for low back pain from
a medical provider and 19% of patients
initially seeking care from a chiropractor
eventually use multiple provider types,
thereby substantially increasing the cost
of their care.26 Findings from a large
national database have shown that
ambulatory patients visiting osteopathic physicians for back symptoms are significantly more likely to present within 3
weeks and tend to return for continuing care at a higher rate than patients
visiting allopathic physicians.27 Further,
osteopathic physicians make fewer referrals to other physicians and admit a
lower percentage of patients to hospitals than allopathic physicians.27 Osteopathic physicians have also been shown
to treat episodes of back pain with fewer
visits than chiropractors (mean, 5.3 vs.
10.4 visits for chiropractors).28
Potential limitations of our survey
include a response rate of 36% and an
overrepresentation of women. A secular trend in lower survey response has led
some researchers to offer financial incentives for participation.9 When such incentives were offered in recent national telephone surveys using random-digit dialing
and instruments of comparable length
to ours, 31% to 37% of initial refusers
were converted to responders, thereby
yielding response rates of approximately 60%.9,29 Thus, if we had offered similar incentives, we would likely have
achieved a response rate between 51%
and 55%. However, it is less clear whether an increased response rate achieved
by special incentives lowers the amount
of bias in survey estimates, particularly
if the respondents who receive incentives
are more likely to give inaccurate responses.30 Providing incentives may
reduce bias by obtaining a more representative sample; however, this did not
appear necessary in our survey because
respondents were similar to adult ambulatory patients in the United States with
regard to gender, race, and general health
status.1,12 The percentage of females
among our survey respondents is consistent with previous telephone surveys in
a variety of settings,31-33 and has been
attributed to the greater frequency of
females as the initial contact and to the
fact that they incorrectly claim to be the
appropriate respondent when strategies
are used to attempt to equalize responses by gender.33,34
One half of survey respondents
claimed to be aware of osteopathic physicians, and more than one fifth had visited
osteopathic physicians. Current patients
of osteopathic physicians were most likely to be seen for primary care. These
patients, a substantial majority of whom
were female, reported high levels of satisfaction with the healthcare provided
by osteopathic physicians. Although
osteopathic physicians were perceived
to be similar to allopathic physicians and
dissimilar to chiropractors, respondents
also believed in the benefits of OMT
and supported coverage of OMT by
health insurance. The results of our survey suggest that greater access to osteopathic services, including OMT, is desirable and that promotional efforts aimed
384 • JAOA • Vol 101 • No 7 • July 2001
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at the general population with regard to
osteopathic medicine are warranted.
Acknowledgments
We are indebted to Robert Gracy, PhD,
and Samuel Coleridge, DO, for their
general support of this project and for
review of the survey instrument and
manuscript; to Fernando Treviño, PhD,
for review of the survey instrument; and
to Gilbert Ramírez, DrPH, and James
Glass, PhD, for review of the manuscript.
This project was partially funded by the
Carl Everett Charitable Lead Trust Fund.
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