Los Angeles , CA - Chiropractic may be a more economical approach to the problem of back pain than conventional medical management, a new study has found.

Using almost 2 million members of a healthcare plan, Dr Antonio P Legorreta (University of California, Los Angeles School of Public Health) and colleagues compared healthcare expenditures between those with and those without Chiropractic Coverage. They report their findings in the October 2004 issue of the Archives of Internal Medicine [ 1].

 This study “offers a tantalizing glimpse into possible large-scale economic benefits obtained through access to chiropractic coverage by large groups of insured patients,” comments an accompanying editorial [2]. Drs Jose Ness and Nicole Nisly (University of Iowa, Iowa City) note, however, that “critical questions remain regarding which subsets of patients could derive the most benefit from Chiropractic Care and yet incur fewer health expenditures.”

LOWER COSTS AND LOWER UTILIZATION OF SERVICES WITH CHIROPRACTIC

In their 4-year retrospective claims database analysis, Legorreta et al found that the 700 000 health-plan members with an additional Chiropractic Coverage benefit had lower annual total healthcare expenditures compared with the 1 million members of the same plan who did not have the Chiropractic Coverage ($1463 vs $1671 per member per year, p<0.001).

Having Chiropractic Coverage was associated with a 1.6% decrease (p=0.001) in total annual healthcare costs at the health-plan level. Back-pain patients with Chiropractic Coverage, compared with those without, also had lower utilization of plain radiographs, low back surgery, hospitalizations, and magnetic resonance imaging.

USE OF MEDICAL TESTS AND PROCEDURES IN PATIENTS WITH AND WITHOUT CHIROPRACTIC COVERAGE

Access to managed Chiropractic Care may reduce overall healthcare expenditure in several ways, say Legorreta et al. For example, there seems to be a substitution of chiropractic for traditional medical care, particularly for spinal conditions, and Chiropractic appears to have lower costs than traditional medical care, they note.

“The estimated cost saving appears to more than offset the amount spent to cover the associated costs of the Chiropractic Benefit,” they observe.

However, they warn that there are limitations to their study. For instance, there was a significantly more favorable profile of the plan members who selected Chiropractic Coverage (they were younger and had less comorbidity burden). This “poses some concern regarding the generalizability of these results to a sicker, older population,” they note.

“As the average age of the American population continues to increase in the next decade, the safety and appropriateness of Chiropractic Care for elderly patients will need to be more thoroughly evaluated,” they say. In addition, the study portrays a population specific to a particular health-care plan and within a particular state, and there was a lack of information regarding patient ethnicity.

The researchers also warn that a few back-pain cases are caused by severe underlying conditions. “Accurate diagnosis and appropriate referral are essential for this subset of low back pain cases and demand an integrative approach. This point is especially important in light of the substitution between Doctors of Chiropractic and internists found by this study.”

ONE OF THE LARGEST ANALYSES EVER OF THE ECONOMIC IMPACT OF CHIROPRACTIC

In their editorial, Ness and Nisly say the new study: “raises the intriguing possibility that Chiropractic may in fact be the more economical approach to the management of the ill-defined, recurrent, and often refractory symptom of back pain.”

Chiropractic manipulation may prove to be a safer alternative when compared with the use of NSAIDs ( nonsteroidal anti-inflammatory drugs) or opiates in frail patients who are highly susceptible to the development of devastating medication adverse effects.

“One of the study’s greatest strengths clearly lies in the sheer magnitude of the sample investigated, resulting, to our knowledge, in one of the largest analyses ever performed on economic impact of chiropractic,” they add.

However, they too warn of limitations similar to the authors’. In addition, they say that future studies should also consider the safety of chiropractic, with perhaps the defining of a subset of patients who would be at high risk for major complications from chiropractic “and in whom the intervention would cease to be appropriate, let alone cost-effective.”

On the other hand, “Chiropractic Manipulation may prove to be a safer alternative when compared with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or opiates in frail patients who are highly susceptible to the development of devastating medication adverse effects,” they observe.

“Legorreta et al identify potential cost savings related mostly to the management of back pain and related neuromuscular ailments but do not assess the economic feasibility of a more comprehensive model of chiropractic ‘primary care,’ ” they conclude. “Extensive research in this area is warranted as chiropractic moves toward novel and/or broader roles in healthcare delivery.”

Sources

1. Legorreta AP, Metz RD , Nelson CF, et al. Comparative analysis of individuals with and without chiropractic coverage. Arch Intern Med 2004; 164:1985-1992. Ness J and Nisly N. Cracking the problem of back pain: is chiropractic the answer? Arch Intern Med 2004; 164:1953-1954.