Half of Your Patient List Is Already Gone

Ask a practice owner how big their patient list is and you'll get a confident number. Three thousand. Eight thousand. Twelve.

It's usually accurate and almost always misleading, because it counts addresses rather than people who are still paying attention.

We recently measured this properly. Across [VERIFY: 250] chiropractic practices, we looked at engagement across 642,637 patient email addresses — every open and click over the preceding twelve months.

Here's the distribution:

Last engaged	Addresses	Share
Within 90 days	232,577	36.2%
91–180 days	49,297	7.7%
181–365 days	47,209	7.3%
Nothing in 12+ months	313,554	48.8%

Nearly half of every patient list we looked at had shown no sign of life in a year.

The shape matters more than the number

The 48.8% is the headline, but it isn't the useful part. Look at the middle of that table.

If engagement decayed gradually, you'd expect the buckets to step down smoothly — 36%, then maybe 25%, then 18%, then the remainder. That's not what happens.

It goes 36.2%, then falls off a cliff to 7.7%, then 7.3%, then half the list.

There's no gentle slope. Patients are either recent or they're gone. The 91-to-180-day bucket — the group you'd think of as "cooling off" — is barely a fifth the size of the recent group. Very few patients sit in a slow fade. They engage, and then relatively quickly they stop.

That changes what reactivation is for.

What this means in practice

The window is narrower than it feels. If a patient hasn't engaged in six months, they're statistically much closer to the silent half than to the active third. The instinct to "get to reactivation next quarter" is expensive, because the population you're planning to reactivate is crossing that line while you plan.

Consistency beats campaigns, again. We keep finding this and this is the clearest version of why. A practice that sends every week keeps patients in the recent bucket. A practice that sends in bursts lets them cross the cliff between bursts, and getting someone back across is much harder than keeping them from crossing.

Your list is smaller than you think, and that's fine. A practice with 8,000 addresses probably has around 2,900 that are genuinely reachable. That's still a large number of people who already chose you once. It just isn't 8,000, and planning as though it is leads to disappointment that gets blamed on the email rather than the arithmetic.

The honest caveats

Three things this data doesn't say.

Silent doesn't mean gone as a patient. Someone can ignore every email you send and still book when their back goes out. Email engagement measures attention to email, not the strength of the relationship. A patient who never opens anything may still walk in next March.

Some of that 48.8% is dead addresses. Old work emails, changed providers, addresses that were mistyped at intake. We can't cleanly separate "ignoring you" from "no longer exists," and both live in that bucket.

The engaged number is generous. "Engaged" includes opens, and opens are inflated by Apple Mail Privacy Protection, which registers an open whether or not a human looked. So the genuinely-paying-attention share of that 36.2% is smaller than it appears. The gap between the active third and the silent half is probably wider than the table suggests, not narrower.

We'd rather state that than quietly benefit from a number that flatters the argument.

The other number

Alongside those 642,637 active addresses, these same practices had accumulated 251,280 unsubscribes over the life of their lists.

That's not a failure. It's what a healthy list looks like over a decade — people leave, and the ones who stay are the ones worth talking to. But it's worth seeing next to the engagement data, because it's the other half of the same story: a patient list isn't a static asset you build once. It's a population that turns over continuously.

Which means the only version of this that works is the one that keeps running.

What we'd do with this

If we were sitting in a practice looking at these numbers, three things:

Work out your own split. Take your total patient count, subtract everyone seen in the last 90 days, and you have your dormant population. Most practices have never done that subtraction and are surprised by the answer. There's a calculator for it if you'd rather not do it by hand.

Start before it feels urgent. The cost of waiting a quarter isn't a quarter of lost revenue — it's a slice of your list moving from recoverable to not.

Stop optimizing and start sending. Almost every practice we talk to is thinking about what to send. Almost none of the difference in outcomes comes from that. It comes from whether anything goes out at all, every week, for long enough that patients' own timing catches up with you.

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Everything here comes from twelve months of engagement data across the practices we run email for. We'll keep publishing what we find, including the findings that don't flatter us — the last one didn't.

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