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A Study to Examine the Effectiveness
and
Cost-Effectiveness of Chiropractic
Management of Low-Back Pain
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Full download version
available in Adobe Acrobat format. 
Funded By The Ontario Ministry Of Health
written by:
1 Pran Manga, Ph.D.
2 Douglas E. Angus, M.A.
3 Costa Papadopoulos, MHA
4 William R. Swan, B.Comm.
August 1993
1 Professor and Director, Masters in Health Administration
Program, University of Ottawa; and President, Pran Manga
and Associates Inc., Ottawa.
2 Adjunct Professor, University of Ottawa and Project
Director, The Cost-Effectiveness of the Canadian Health
Care System, Queen's - University of Ottawa Economic Projects.
3 Health Care Consultant and Associate of Pran Manga
and Associates, Inc.
4 Consultant in Health Care Economics.
The support of the Ministry of Health, Government of
Ontario, which solely funded the project, is gratefully
acknowledged. The views and opinions expressed in this report
are those of the authors only, and should not be attributed
to the MHA Program, University of Ottawa, the Ministry of
Health or the Ontario Chiropractic Association.
EXECUTIVE SUMMARY
Introduction
The serious fiscal crisis of all governments in Canada
is compelling them to contain and reduce health care costs.
It has brought a new and unprecedented emphasis on evidence-based
allocation of resources, with an overriding objective of
improving the cost-effectiveness of health care services.
The area of low-back pain (LBP) offers governments and
the private sector an excellent opportunity to attain the
twin goals of greater cost-effectiveness and a major reduction
in health car costs. Today LBP has become one of the most
costly causes of illness and disability in Canada - a phenomenon
which does not appear to be generally appreciated or understood
in medical and government circles in Canada. Studies on
the prevalence and incidence of LBP suggest that it is ubiquitous,
probably the leading cause of disability and morbidity in
middle-aged persons, and by far the most expensive source
of workers' compensation costs in Ontario - as indeed in
most other jurisdictions.
Much of the treatment of LBP appears to be inefficient.
Evidence from Canada, the USA, the UK and elsewhere shows
that there are conflicting methods of treatment, many with
little - if any scientific evidence of effectiveness, and
very high costs of treatment. Despite this, levels of disability
from LBP are increasing.
In the Province of Ontario LBP is managed mostly by physicians
and chiropractors, with physiotherapists also playing a
significant role. While medical services are fully insured
under Medicare, chiropractic care services are only partially
covered. LBP patients incur the highest out-of-pocket expenses
for chiropractic services. Virtually no out-of-pocket expenses
are incurred for medical treatment, with the exception of
drugs, and out-of-pocket expenses incurred for physiotherapy
services fall somewhere in between the two.
Medical physicians, chiropractors, physiotherapists and
an assortment of other professionals together offer about
thirty-six therapeutic modalities for the treatment of LBP.
In this study we focused principally on the effectiveness
and cost effectiveness of chiropractic and medical management
of LBP.
FINDINGS
F1.
On the evidence, particularly the most scientifically valid
clinical studies, spinal manipulation applied by chiropractors
is shown to be more effective than alternative treatments
for LBP. Many medical therapies are of questionable validity
or are clearly inadequate.
F2.
There is no clinical or case-control study that demonstrates
or even implies that chiropractic spinal manipulation is
unsafe in the treatment of low-back pain. Some medical treatments
are equally safe, but others are unsafe and generate iatrogenic
complications for LBP patients. Our reading of the literature
suggests that chiropractic manipulation is safer than medical
management of low-back pain.
F3.
While it is prudent to call for even further clinical evidence
of the effectiveness and efficacy of chiropractic management
of LBP, what the literature revealed to us is the much greater
need for clinical evidence of the validity of medical management
of LBP. Indeed, several existing medical therapies of LBP
are generally contraindicated on the basis of the existing
clinical trials. There is also some evidence in the literature
to suggest that spinal manipulations are less safe and less
effective when performed by non-chiropractic professionals.
F4.
There is an overwhelming body of evidence indicating that
chiropractic management of low-back pain is more cost-effective
than medical management. We reviewed numerous studies that
range from very persuasive to convincing in support of this
conclusion. The lack of any convincing argument or evidence
to the contrary must be noted and is significant to us in
forming our conclusions and recommendations. The evidence
includes studies showing lower chiropractic costs for the
same diagnosis and episodic need for care.
F5.
There would be highly significant cost savings if more management
of LBP was transferred from medical physicians to chiropractors.
Evidence from Canada and other countries suggests potential
savings of many hundreds of millions annually. The literature
clearly and consistently shows that the major savings from
chiropractic management come from fewer and lower costs
of auxiliary services, much fewer hospitalizations, and
a highly significant reduction in chronic problems, as well
as in levels and duration of disability. Workers' compensation
studies report that injured workers with the same specific
diagnosis of LBP returned to work much sooner when treated
by chiropractic physicians than by medical physicians. This
leads to very significant reductions in direct and indirect
costs.
F6.
There is good empirical evidence that patients are very
satisfied with chiropractic management of LBP and considerably
less satisfied with physician management. Patient satisfaction
is an important health outcome indicator and adds further
weight to the clinical and health economic results favoring
chiropractic management of LBP.
F7.
Despite official medical disapproval and economic disincentive
to patients (higher private out-of-pocket cost), the use
of chiropractic has grown steadily over the years. Chiropractors
are now accepted as a legitimate healing profession by the
public and an increasing number of medical physicians.
F8.
In our view, the constellation of the evidence of:
- the effectiveness and cost-effectiveness of chiropractic
management of low-back pain.
- the untested, questionable or harmful nature of many
current medical therapies .
- the economic efficiency of chiropractic care for low-back
pain compared with medical care.
- the safety of chiropractic care.
- the higher satisfaction levels expressed by patients
of chiropractors, together offers an overwhelming case
in favor of much greater use of chiropractic services
in the management of low-back pain.
F9.
The government will have to instigate and monitor the reform
called for by our overall conclusions, and take appropriate
steps to see that the savings are captured. The greater
use of chiropractic services in the health care delivery
system will not occur by itself, by accommodation between
the professions, or by actions on the part of the Workers'
Compensation Board and the private sector generally.
RECOMMENDATIONS
Our recommendations for reform include the following:
R1.
Current policy discourages the utilization of chiropractic
services for the management of LBP. There should be a shift
in policy to encourage and prefer chiropractic services
for most patients with LBP.
R2.
Chiropractic services should be fully insured under the
Ontario Health Insurance Plan, removing the economic disincentive
for patients and referring health providers. This one step
will bring a shift from medical to chiropractic management
that can be expected to lead to very significant savings
in health care expenditure, and even larger savings if a
more comprehensive view of the economic costs of low-back
pain is taken.
R3.
Chiropractic services should be fully integrated into the
health care system. Because of the high incidence and cost
of LBP, hospitals, managed health care groups (community
health centres, comprehensive health organizations, and
health service organizations) and long-term care facilities
should employ chiropractors on a full-time and/or part-time
basis. Additionally such organizations should be encouraged
to refer patients to chiropractors.
R4.
Chiropractors should be employed by tertiary hospitals in
Ontario. Hospitals already employ chiropractic in the United
States with good effect. Similar recommendations have been
made recently by government inquiries in Australia and Sweden,
and following government funded research in the U.K. and
other countries. Unnecessary or failed surgery is not only
costly but also represents low quality care. The opportunity
for consultation, second opinion and wider treatment options
are significant advantages we foresee from this initiative
which has been employed with success in a clinical research
setting at the University Hospital, Saskatoon.
R5.
Hospital privileges should be extended to all chiropractors
for the purposes of treatment of their own patients who
have been hospitalized for other reasons, and for access
to diagnostic facilities relevant to their scope of practice
and patients' needs.
R6.
Chiropractors should have access to all pertinent patient
records and tests from hospitals, physicians, and other
health care professionals upon the consent of their patients.
Access should be given upon the request of chiropractors
or their patients.
R7.
Since low-back pain is of such significant concern to workers'
compensation, chiropractors should be engaged at a senior
level by Workers' Compensation Board to assess policy, procedures
and treatment of workers with back injuries. This should
be on an interdisciplinary basis with other professional,
technical and managerial staff so that there is early development
of more constructive relationships between chiropractors,
physicians, physiotherapists and Board staff and consultants.
A very good case can be made for making chiropractors the
gatekeepers for management of low-back pain in the workers'
compensation system in Ontario.
R8.
The government should make the requisite research funds
and resources available for further clinical evaluation
of chiropractic management of LBP, and for further socioeconomic
and policy research concerning the management of LBP generally.
Such research should include surveys to obtain a better
understanding of patients' choices, attitudes and knowledge
of treatments with respect to LBP. The objective of these
surveys should be better information for health policy,
programme planning and consumer education purposes.
R9.
Chiropractic education in Ontario should be in the multidisciplinary
atmosphere of a university with appropriate public funding.
Chiropractic is the only regulated health profession in
Ontario without public funding for education at present,
and it works against the best interests of the health care
system for chiropractors to be educated in relative isolation
from other health science students.
R10.
Finally, the government should take all reasonable steps
to actively encourage cooperation between providers, particularly
the chiropractic, medical and physical therapy professions.
Lack of cooperation has been a major factor in the current
inefficient management of LBP. Better cooperation is important
if the government is to capture the large potential savings
in question and, it should be noted, is desired by an increasing
number of individuals within each of the professions.
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