Developing an initial set of quality indicators for chiropractic care: a scoping review

Background Quality indicators are standardized, evidence-based measures of health care quality. Currently, there is no basic set of quality indicators for chiropractic care published in peer-reviewed literature. The goal of this research is to develop a preliminary set of quality indicators, measurable with administrative data. Methods We conducted a scoping review searching PubMed/MEDLINE, CINAHL, and Index to Chiropractic Literature databases. Eligible articles were published after 2011, in English, developing/reporting best practices and clinical guidelines specifically developed for, or directly applicable to, chiropractic care. Eligible non-peer-reviewed sources such as quality measures published by the Centers for Medicare and Medicaid Services and the Royal College of Chiropractors quality standards were also included. Following a stepwise eligibility determination process, data abstraction identified specific statements from included sources that can conceivably be measured with administrative data. Once identified, statements were transformed into potential indicators by: 1) Generating a brief title and description; 2) Documenting a source; 3) Developing a metric; and 4) Assigning a Donabedian category (structure, process, outcome). Draft indicators then traversed a 5-step assessment: 1) Describes a narrowly defined structure, process, or outcome; 2) Quantitative data can conceivably be available; 3) Performance is achievable; 4) Metric is relevant; 5) Data are obtainable within reasonable time limits. Indicators meeting all criteria were included in the final set. Results Literature searching revealed 2562 articles. After removing duplicates and conducting eligibility determination, 18 remained. Most were clinical guidelines (n = 10) and best practice recommendations (n = 6), with 1 consensus and 1 clinical standards development study. Data abstraction and transformation produced 204 draft quality indicators. Of those, 57 did not meet 1 or more assessment criteria. After removing duplicates, 70 distinct indicators remained. Most indicators matched the Donabedian category of process (n = 35), with 31 structure and 4 outcome indicators. No sources were identified to support indicator development from patient perspectives. Conclusions This article proposes a preliminary set of 70 quality indicators for chiropractic care, theoretically measurable with administrative data and largely obtained from electronic health records. Future research should assess feasibility, achieve stakeholder consensus, develop additional indicators including those considering patient perspectives, and study relationships with clinical outcomes. Trial registration Open Science Framework, https://osf.io/t7kgm Supplementary Information The online version contains supplementary material available at 10.1186/s12913-024-10561-8.


Background
The Agency for Healthcare Research and Quality (AHRQ) defines quality as "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" [1].Formal attempts to improve quality occurred at least as early as the 1800s with Florence Nightingale, who strove to improve clinical outcomes by challenging contemporary practices, encouraging critical thinking, and promoting standardized processes thought to positively influence care [2].In the late 20 th century, Avedis Donabedian proposed a systematic framework for assessing health care quality using quantitative measures, referred to as quality indicators.Donabedian's framework describes indicators matching 3 major categories: Structure, Process, and Outcome [3].
Structural indicators describe the attributes of a setting where care occurs.Attributes include physical facilities, clinical equipment, organizational policies, and human resources.Process indicators refer to the steps taken to provide care such as examination, treatment, care planning, and scheduling.Outcome indicators describe the effects of care on patients and populations, such as short and long-term clinical improvement, satisfaction, and costs [4,5].The goal of quality assessment is to improve clinical outcomes.Structural indicators are fundamental to supporting care delivery (process), which in turn, influence outcomes.
In 2001, the Institute of Medicine (IOM) published a seminal report describing quality indicators as measurable elements of health care developed from scientific evidence, standards of practice and expert opinions that contribute to high-quality care.The 6 domains recommended in the IOM report as most relevant to health care quality include: 1. Safe; 2. Effective; 3. Patient-centered; 4. Timely; 5. Efficient; and 6.Equitable [3].IOM domains reflect the most important aspects of health care that quality indicators should improve or maintain.Donabedian categories organize indicators according to their application.Both IOM domains and Donabedian categories are distinct, yet complementary, frameworks for classifying and developing quality indicators.
Historically, quality indicators were developed to measure hospital quality performance, which is evident in the definition still used by the Agency for Healthcare Research and Quality: "standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes" [6].However, quality indicators are no longer confined to in-patient hospital settings.A variety of healthcare disciplines and settings have developed, and continue to develop, quality indicators.For example, the Joint Commission uses quality indicators to assess and accredit home health services, nursing care centers, behavioral healthcare, ambulatory care centers and laboratory services [7].Individual professions and specialty groups within professions have also developed quality indicators [8][9][10][11].
Chiropractic is a health profession focused primarily on nonpharmacological care for musculoskeletal conditions, with special emphasis on the spine and related conditions [12][13][14].Chiropractic professionals function in both private, public, and multidisciplinary practice settings [12,15,16].As a health profession, chiropractic carries an ethical obligation to conduct a variety of continuous learning activities directed toward improving the quality of clinical care [17].However, without objectively measuring key aspects of care relating to quality, systematic quality improvement activities cannot be evidence-informed.Currently, there is no standard set of quality indicators for chiropractic care published in peer reviewed literature.
Stelfox and colleagues recommend conducting a multistep process for developing and validating quality indicators [18,19].The first step is conducting a systematic literature review to identify best practices and other evidence to support draft indicators obtainable from administrative data.A variety of potential validation processes should follow, using consensus and other research methods.The long-term goal of this line of research is to develop and validate a set of quality indicators for chiropractic care.The objective of this study is to identify current professional knowledge from clinical guidelines, best practice publications, and professional standards to: A) develop a preliminary set of quality indicators for chiropractic care, measurable with administrative data without the need for individual file audits; B) identify gaps and opportunities for additional quality indicator development; and C) inform future research directions for subsequent refinement and validation.

Methods
We conducted a scoping review because: 1) there was a need for systematic literature search methods designed to closely examine a topic on which limited and/or disparate knowledge exists, to identify gaps, and to systematically organize information to direct further research [20,21]; 2) the source literature in this study was known to include non-peer reviewed sources [22]; 3) the study objectives addressed questions beyond those about effectiveness of interventions, focused instead on transforming recommendations into potential quantitative measures [21]; 4) critical appraisal of included sources was not required [23]; and 5) transparent reporting of data synthesis methods was vital [23].This scoping review followed PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for scoping reviews (PRISMA-ScR), prospectively registered with Open Science Framework on 30 August, 2022 (https:// doi.org/https:// doi.org/ 10. 17605/ OSF.IO/ T7KGM) [24].Consistent with recommendations for developing quality indicators, we used a deductive approach to identify evidence-based concepts and recommendations from clinical guidelines, best practice publications, and quality standards [3,18].Once identified, we transformed these findings into more specific and measurable quality indicators consistent with the frameworks proposed by Donabedian and the IOM [3,19].

Search strategy
A systematic literature search was conducted by a health sciences librarian (JS) on August 31, 2022 of PubMed/ MEDLINE, CINAHL (EBSCOhost interface), and Index to Chiropractic Literature databases.Results were restricted to English language studies published between January 1, 2012-August 31, 2022.Search terms consisted of subject headings specific to each database and free text words related to chiropractic, musculoskeletal pain, and quality indicators.The complete search strategies for each database are available as Supplementary file 1.The search was validated using a sample of 24 articles identified by the authors as potentially eligible and therefore should appear in search results (Supplementary file 2).General internet search engines were also used to explore potential quality indicators or other quality standards not otherwise available in peer reviewed literature.An updated search was performed on April 19, 2023 to account for potential articles published during the eligibility determination and data abstraction and transformation stage of this study.Reference searching was not employed because we only included the most recent versions of source documents.

Eligibility criteria
Because care standards, best practices, and clinical guidelines are designed to adapt as new evidence emerges, we limited our article eligibility to 10-years from our original search (2012-present) [25].Eligible articles were written in English, measured an aspect of chiropractic care quality, and developed best practices or clinical guidelines directly applicable to chiropractic care.Non-peerreviewed literature sources were eligible when quality indicators or quality standards pertaining to chiropractic care were included, such as quality measures published by the Centers for Medicare and Medicaid Services, quality standards published by Royal College of Chiropractors, U.K., and low back pain clinical care standards published by the Australian Commission on Safety and Quality in Health Care [26][27][28].
Ineligible articles included those that did not explicitly develop quality indicators for chiropractic care, studies reporting on the efficacy or effectiveness of interventions, guideline reviews, guidelines for other health disciplines, and epidemiological research.Best practice and guideline documents for which an updated publication was available were also ineligible.Articles reporting on studies conducted with animals, tissues, or cadaveric specimens, conference proceedings or abstracts, editorials, commentaries, articles recommending care practices based on narrative reviews, and case reports or case series, were also ineligible.
Article eligibility was assessed by 2 authors (BA, DW) in sequential steps beginning with article titles, followed by abstract review, then full text review of remaining articles.Ineligible articles were removed at each stage.Discrepancies were resolved through consensus discussion among both reviewers.When eligibility was unclear, the lead investigator (RV) rendered the final determination.

Data abstraction
Primary data abstraction was performed independently by 2 authors (RV, BA), with over 45 years of combined chiropractic clinical and research experience.A data abstraction form facilitated this process, which included the categories for abstracting the evidence source, condition addressed, title of potential indicator, description, corresponding Donabedian category and IOM domain(s), evidence level, and metric.Data abstraction involved identifying specific statements within the included literature that may conceivably be measured.Once identified, the statements were recorded on the data abstraction form, initiating the transformation process.

Quality indicator transformation
Quality indicator development lacks transparent methodological reporting for some healthcare disciplines [29].We adopted a stepwise transformation process to review included literature and transform statements and recommendations into quality indicators (Fig. 1).The process included: 1. Generating a brief title and descriptive statement 2. Developing a Metric (e.g., policy, human or physical infrastructure description, or numerator and denominator) and documenting an evidence source 3. Assigning a primary Donabedian category and relevant IOM domain 4. Assessing potential quality indicators according to the following criteria [30]: • Describes a narrowly defined structure, process, or outcome while also matching   After initial data abstraction and transformation, authors (JS, ZA, DW) used a standardized checklist (Supplementary file 3) to guide critical review of each transformed potential indicator.
While we initially reported evidence levels, it became apparent that most indicators were rated with an evidence level of 5 (expert opinion or based on physiology, bench research, or first principles).Conducting separate literature reviews to confirm the accuracy of these ratings was beyond the scope of this project.Therefore, evidence rating was discontinued to avoid potential misreporting.
A total of 204 quality indicators were abstracted and transformed from included sources.Of those, 57 did not meet 1 or more criteria for specificity, measurement with administrative data, practicality, relevance, or timely data collection.The remaining 147 were then sorted by topic area.

Discussion
To the authors' knowledge, this is the first study to propose an initial set of quality indicators using scoping review methodology and a transparent process for abstracting and transforming data from recent clinical guidelines, best practice publications, and quality standards for chiropractic care.Quality standards and quality indicators share some similar characteristics.The Royal College of Chiropractors quality standards describe chiropractic care ideals while offering sample metrics, several of which are measurable through individual file audits [27].Alternatively, this project developed indicators consistent with the definition from the Agency for Healthcare Research and Quality, which are derived largely from administrative data.Indicators obtained from administrative data offer quality assessment across a health organization while avoiding dependence on individual file audits and limitations related to inadequate sample size, and the lack of expertise and potential bias of auditors.
Angel-Garcia et al., reported 178 quality indicators for hospital-based physical therapy, several of which share similarities with those developed in this study, such as conducting an exam, obtaining informed consent, and depression screening [51].Newell et al., demonstrated the feasibility of collecting patient reported outcomes from chiropractic patients using online survey methods [52].More recently, Blanchette et al., proposed a set of indicators to evaluate chiropractic performance on a provincial or national scale in Canada and the Australian Commission on Safety and Quality in Health Care published low back pain clinical care standards largely applicable to chiropractic [28,48].This study is unique for the following reasons: 1) we used systematic and transparent literature search methods; 2) we focused on developing indicators for chiropractic care at the health organization level and measurable with administrative data; 3) we developed indicators consistent with the guiding frameworks described by Donabedian and the IOM; and 4) we proposed a preliminary set of indicators for subsequent refinement and validation.

Practical considerations
Structural indicators are largely measurable through policies and documents describing a health organization, such as facilities, technical capacities, and mission [5,53].Most proposed process and outcome indicators are theoretically measurable with structured data contained in electronic health records, though modifying individual systems may be needed.Metrics developed in this study did not designate specific timeframes for each indicator, leaving those decisions to individual health organizations as they consider resources, goals, and other factors unique to each setting.The importance, value, and implementation of some indicators can depend on distinct characteristics of each health organization and patient population where chiropractic services are offered.
Quality indicators have historically been used in multiprovider settings.Therefore, the indicators developed in this study are likely most applicable to multi-provider organizations with the capacity to conduct ongoing quality assessment and improvement processes.Although most chiropractic care has historically been available from sole practitioners, there is a growing presence in multi-provider and multidisciplinary settings.Chiropractic services are now offered in hospital-based health      [54][55][56][57].Given the increasing sophistication of electronic health records, it is conceivable that using quality indicators may also be feasible for individual providers.Activities involved in delivering and recording health care are interrelated and complex, posing challenges for data collection and interpretation.If documenting quality indicator data impedes clinical flow, extends appointment durations, burdens provider documentation, distracts provider focus, or negatively impacts provider morale, there could be an unintended negative influence on the quality of care [58,59].Readers are encouraged to consider these practical factors when developing data collection methods, including what is most important for the setting, quality assessment timelines, impact on how services are delivered, and resources needed [60].

Interpreting quality indicator data
There are several factors relevant to accurately interpreting data from quality indicators proposed in this study.First, quality indicators are individually measurable components associated with quality care.No single indicator represents a comprehensive assessment of quality.Accurate interpretation may require carefully assessing data from multiple indicators combined with context knowledge about health organization characteristics, clinical processes, populations served, and an understanding of how structure, process, and outcome indicators interrelate.
For example, shared decision-making is a central attribute of patient-centered care and a feature of quality [61].To collect shared decision-making data from electronic health records, administrative support, technological capacity, and provider training are likely needed.Should these structural elements support systematic documentation in electronic health records, data would reflect how often providers engage in shared decision-making processes.However, engaging in a process does not guarantee a desired outcome.Patient generated data (e.g., surveys) are needed to determine if the clinical processes are effective.
Second, because this study sought to propose an initial set of indicators for chiropractic care, there was a concerted effort to include those thought to be theoretically attainable rather than only those known to be attainable (e.g., those previously measured and reported such as functional outcome measures).This methodological process helped maximize the number of preliminary indicators developed in this study while minimizing unintentional author bias by presuming that indicators could be measured when it was unclear if measurement was possible [62,63].Further, all indicators developed in this study may not be feasible for every health organization.Additional study is needed to refine and validate these findings and to develop potentially missing indicators.
Third, quality indicators were not developed to assess appropriate imaging use because imaging decisions are dependent on multiple factors unique to each patient and clinical scenario.Quality indicators are instead designed to be derived from administrative data, without the need for individual file review.Given the persistent challenge of unnecessary imaging in healthcare [64,65], quality improvement programs may consider if limited file review in such areas is needed.
Fourth, this study did not detect sources specifically identifying recommendations, best practices, or clinical standards generated from patient perspectives.Additional research is needed to develop meaningful indicators informed by patients.Given the initial set of indicators developed in this study, a logical next step is to begin a validation process through expert review and consensus among various stakeholders such as patients, clinicians, health system administrators, and researchers [19].

Multimodal chiropractic care plans
The sources included in this review consistently recommended multimodal chiropractic care regardless of patient population or condition.However, recommendations about multimodal care were described incongruently.For example, some clinical guideline recommendations focused primarily on specific interventions [34,36].Other source recommendations focused on whole person approaches, describing multimodal care in categorical terms (e.g., active care, passive care) [27,44].Condition-specific education was variably described, though routinely recommended as a fundamental component of care [27,28,32,34,35,41,47,49]. The disparate nature of statements within source publications led to developing overlapping draft care plan indicators.To address this challenge, we developed an indicator representing a synthesis of recommendations which assess if care plans include: • Active therapies such as supervised or unsupervised exercise; • Manual therapies such as joint manipulation, mobilization, myofascial therapies, and passive muscle stretching; • Education about one's condition, including pain physiology when appropriate; • Self-management advice and/or activities.

• Therapeutic goals
Structuring care plans to include these categories theoretically facilitates: 1) Care consistent with existing guidelines, best-practice recommendations, and quality standards; 2) Addressing biological, psychological, social, and environmental factors; 3) Freedom to construct care plans individually; 4) Education to help patients understand a problem and make more informed decisions; 5) Applied learning focused on reducing/preventing dependence on providers and supporting self-management capacity; and 6) Active patient engagement.The multimodal care plan approach may also support outcomes beyond pain reduction.For example, education, self-management activities, and active therapies may help improve condition specific health literacy and self-efficacy while personalized care and mutually agreed goals foster therapeutic alliance [66].
Because some elements may not be needed in individual circumstances, including treatments for each intervention category should not be mandatory in every care plan.However, it is possible to efficiently document a reason why a category was not included (e.g., patient declines).In addition, the source literature obtained in this study was oriented toward care for patients with singular pain-related conditions.Future study is needed to assess if the multimodal care plan indicator proposed in this study is feasible for non-pain-focused care, such as improving or maintaining physical function, when chiropractic care is part of an interdisciplinary care plan, or when addressing more than 1 problem [67][68][69].

Limitations
Despite systematic search and eligibility determination methods, it is possible some relevant articles, including non-English publications and other non-peer reviewed sources, were missed.We used a data abstraction and transformation process including defined criteria and multiple levels of review to develop this initial set of quality indicators.Nevertheless, all indicators reported may not be measurable or necessarily contribute to health care quality in every setting where chiropractic services are available.Some overlap may exist among some indicators and data may not be obtainable in some settings due to missing or limited human and/or other infrastructure such as electronic health record systems.
Though systematic, the process of quality indicator development required human interpretation and judgment.Examples include transforming quality indicators generated from sources referencing specific conditions or patient groups (e.g., low back pain, neck pain, pediatric patients) into general indicators because the concepts were considered to apply universally (e.g., informed consent, red flag screening, multimodal care).We also combined redundant draft indicators, a process requiring human judgment.Finally, we did not assess the strength of evidence supporting each proposed indicator because performing secondary literature searches for each was beyond the scope of this project.Should the proposed quality indicators be adopted by health organizations, the data generated from their use can be used to further test, develop, and validate potential associations with clinical outcomes.

Conclusions
This article proposes a preliminary set of 70 quality indicators for chiropractic care.Most fit Donabedian categories of process and structure, highlighting a need to develop additional outcome measures, especially those meaningful to patients.Few indicators developed in this study relate to IOM categories of Timely, Equitable, and Efficient.Future work should focus on refining and expanding this preliminary set by engaging with relevant stakeholders and assessing the feasibility of collecting and analyzing quality indicator data through quality improvement/assurance processes.
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Fig. 1
Fig. 1 Graphic depiction of the quality indicator abstraction and transformation process.*Donabedian categories: Structure (attributes of a setting where care occurs such as physical facilities, clinical equipment, policies, and human resources); Process (measurable activities performed to provide care, such as examination and treatment); Outcomes (measurable effects of care on patients and populations); ‡: Institute of Medicine, now referred to as the National Academy of Medicine, United States After combining redundant indicators, 70 unique items remained.The largest number of indicators developed in this study match the Donabedian category of process (n = 35).These indicators were developed from statements within 19 different included sources.Most indicators relating to organizational structure (n = 31) were derived from quality standards published by the Royal College of Chiropractors (U.K.) [27].Only 4 indicators match the Donabedian category of outcome.IOM domains from most to least common included: Effective (n = 25), Safe (n = 21), Patient-Centered (n = 16), Efficient (n = 5), Timely (n = 2), and Equitable (n = 1).

Fig. 2
Fig. 2 PRISMA flow diagram 3. Statements, standards, and recommendations to avoid specific activities (e.g., routine imaging for acute low back pain) were not transformed because individual case-level review is needed to assess clinical reasoning and determine appropriateness.4. Statements, recommendations, and standards focused on specific conditions or presentations (e.g., neck pain, headache, pregnancy) were transformed into generalized indicators when they applied universally (e.g., Informed consent, Examination, Red flag screening). 5. Though some indicators can potentially relate to multiple IOM domains, only the domain judged most relevant was assigned.6. Descriptions and metrics for some indicators, such as those derived from the Royal College of Chiropractors and Centers for Medicare and Medicaid, were revised for consistent formatting.7. Comparable (i.e., redundant) indicators were combined into single indicators.

Table 1
displays titles, descriptions, and metrics for quality indicators matching the Donabedian category of structure.Table2displays process-related indicators, and Table3displays indicators related to outcomes of care.

Table 1
Quality indicators related to organizational structure

Table 2
Quality indicators related to clinical processes

Table 3
Quality indicators related to outcomes of care