In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine. How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education? Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course? A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.
Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination. This suggests that training in musculoskeletal medicine is inadequate in both medical school and nonorthopaedic residency training programs. Among the nonorthopaedists, scores were significantly better if they had taken a medical school course or residency rotation in orthopaedics, suggesting that a rotation in orthopaedics would improve the general level of musculoskeletal knowledge.
Educating Medical Students About Musculoskeletal Problems: Are Community Needs Reflected in the Curricula of Canadian Medical Schools?
There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.
This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that “we therefore believe that medical school preparation in musculoskeletal medicine is inadequate” and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.
According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. NOTE: This is a follow-up article to the study cited below, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. Ask yourself: What would the headlines scream if, after 4 years, chiropractors had failed to improve their skills in musculoskeletal assessment and management? Why is medicine is shown more slack?
For those who received care from DCs (n = 266), the mean number of compensated days lost from work was at least 2.3 days less than for those who were treated by MDs (n = 494; p less than 0.025) and at least 3.8 days less than for those who were treated by DOs (n = 102; p less than 0.025). Consequently, much less money in employment compensation was paid, on the average, to those who saw DCs.
Disabling Low Back Oregon Workers’ Compensation Claims Part I: Methodology and Clinical Categorization of Chiropractic and Medical Cases
This paper reports on a case-control study of 201 randomly selected workers’ compensation cases involving disabling low back injuries. To control for claim severity prior to comparison studies on time loss and treatment cost, a classification scheme based on documented clinical signs and symptoms was used to subgroup the claims from two provider groups, chiropractic (DC) and medical (MD), into three categories of clinical presentation.
Soft tissue strain/sprain predominated in both provider groups. The two provider groups differed in the proportion of claimants who had physical factors contributing to low back compromise. DC claimants were less likely than MD claimants to have sought initial treatment in the emergency room, more likely to have a history of chronic, recurrent low back pain and more likely to have suffered exacerbation episodes. These differences suggest a greater level of chronicity among chiropractic claimants.
This paper reports on time loss incurred by chiropractic (DC) and medical (MD) claimants with disabling low back work-related injuries in Oregon. Clinical categorization was accomplished using medical records and was based on reported symptomatology, objective clinical findings and functional impairment. The median time loss days for cases with comparable clinical presentation (severity) was 9.0 for DC cases and 11.5 for MD cases.
Chiropractic claimants had a higher frequency of return to work with 1 wk or less of time loss. No difference was seen in time loss days for MD or DC claimants with no documented history of low back pain. However, for claimants with a history of chronic low back problems, the median time loss days for MD cases was 34.5 days, compared to 9 days for DC cases. It is suggested that chiropractors are better able to manage injured workers with a history of chronic low back problems and to return them more quickly to productive employment.
Disabling Low Back Oregon Workers’ Compensation Claims Part III: Diagnostic and Treatment Procedures and Associated Costs
Claimants in Oregon with disabling low back injuries attending chiropractors were found to have more treatments over a longer duration and at greater cost than claimants attending medical physicians with similar clinical presentations. These findings are attributed to: a) a higher proportion of chiropractic claimants than medical physician claimants with low back risk factors which may have adversely affected the course of recovery (chronic or recurrent low back conditions, obesity, extremity symptomatology, frequency of exacerbations); b) differences in age and gender of DC and MD claimants; c) the greater physician-patient contact hours characteristic of chiropractic practice; d) differences in therapeutic modalities employed; and e) the physician reimbursement permitted under Oregon workers’ compensation law. The findings of this study emphasize the need for prospective studies of treatment outcome.
Cost Per Case Comparison of Back Injury Claims of Chiropractic Versus Medical Management for Conditions With Identical Diagnostic Codes
This workers’ compensation study conducted in Utah compared the cost of chiropractic care to the costs of medical care for conditions with identical diagnostic codes. The study indicated that costs were significantly higher for medical claims than for chiropractic claims. The sample consisted of 3062 claims or 40.6% of the 7551 estimated back injury claims from the 1986 Workers’ Compensation Fund of Utah. For the total data set, cost for care was significantly more for medical claims, and compensation costs were 10-fold less for chiropractic claims.
Although work is in progress to control for possible variations in case mix and to compare outcomes in addition to costs, these preliminary results suggest a significant cost-saving potential for users of chiropractic care. The results also suggest the need to reexamine insurance practices and programs that restrict chiropractic coverage relative to medical coverage.
The analysis of well-insured patients in plans that do not restrict the chiropractic benefit strengthens results previously reported. In this study, therefore, the favorable cost patterns for chiropractic patients cannot be attributed to insurance restrictions limiting reimbursement for chiropractic services relative to other services. Because adjustments for patient characteristics systematically reduce the cost advantages of chiropractic patients as compared to mean differences derived from unadjusted data, the results also demonstrate that adjusted values should be used for meaningful comparisons between the two groups of patients.
These are economically significant differences in the costs of back pain care of persons seeing chiropractors, general practitioners, internists, and orthopedists.
Preliminary Findings of Analysis of Chiropractic Utilization and Cost in the Workers’ Compensation System of New South Wales, Australia
The methodology used was found to be able to provide a basis for comparison of costs for care apportioned to chiropractic and other interventions. An analysis of 20 randomly selected cases from the WCA suggested that chiropractic intervention for certain conditions may be more cost-effective than other forms of intervention.
This study compares health insurance payments and patient utilization patterns for episodes of care for common lumbar and low back conditions treated by chiropractic and medical providers. Using 2 years of insurance claims data, this study examines 6,183 patients who had episodes with medical or chiropractic first-contact providers. Multiple regression analysis, to control for differences in patient, clinical, and insurance characteristics, indicates that total insurance payments were substantially greater for episodes with a medical first-contact provider.
Patients who “cross over” between providers for multiple episodes are more likely to return to chiropractic providers, which suggests that chronic, recurrent low-back cases may gravitate to chiropractic care over time. The findings from this and related studies point out the importance of appropriately operationalizing cost and outcome variables in analyses of care for conditions such as chronic and/or recurrent low-back pain.
The integration of chiropractic care can take many forms, including extending hospital privileges to chiropractors, use in community health centers, interdisciplinary group practices and clinics, and partnerships across disciplinary boundaries. This integration of chiropractic care into health care organizations should be complemented by moving chiropractic colleges into universities; employment of chiropractors in Ministries of Health, Workers Compensation Boards, and public and private insurance corporations; and greater public funding for scientific research of chiropractic care. Although some of this is occurring already, it is far too little. At the same time, there is clear evidence of a resistance to change and reform. The case for the fuller integration of chiropractic care into the health care system will have to be made forcefully and repeatedly over the foreseeable future.
Single-blind Randomised Controlled Trial of Chemonucleolysis and Manipulation in the Treatment of Symptomatic Lumbar Disc Herniation
This single-blind randomised clinical trial compared osteopathic manipulative treatment with chemonucleolysis (used as a control of known efficacy) for symptomatic lumbar disc herniation. Forty patients with sciatica due to this diagnosis (confirmed by imaging) were treated either by chemonucleolysis or manipulation. Outcomes (leg pain, back pain and self-reported disability) were measured at 2 weeks, 6 weeks and 12 months. The mean values for all outcomes improved in both groups. By 12 months, there was no statistically significant difference in outcome between the treatments, but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks. A similar number from both groups required additional orthopaedic intervention; there were no serious complications. Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. Further study into the value of manipulation at a more acute stage is warranted.
Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial
In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
In 2002, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers’ compensation, the results of which were published in February 2003. According to the report, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. They found: Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs. These findings were even more intertesting: The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.
Cost Effectiveness of Physiotherapy, Manual Therapy, and General Practitioner Care for Neck Pain: Economic Evaluation Alongside a Randomised Controlled Trial
A hands-on approach to treating neck pain by manual therapy may help people get better faster and at a lower cost than more traditional treatments, according to this study. After seven and 26 weeks, they found significant improvements in recovery rates in the manual therapy group compared to the other 2 groups. For example, at week seven, 68% of the manual therapy group had recovered from their neck pain vs. 51% in the physical therapy group and 36% in the medical care group.
A Practice-Based Study of Patients With Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-up
Study findings were consistent with systematic reviews of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP. Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers, and third-party payers in identifying health services for patients with LBP.
In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population.
An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. These results (of this file review) indicate that patients use chiropractic care as a direct substitution for medical care.
An Evaluation of Medical and Chiropractic Provider Utilization and Costs: Treating Injured Workers in North Carolina
These data, with the acknowledged limitations of an insurance database, indicate lower treatment costs, less workdays lost, lower compensation payments, and lower utilization of ancillary medical services for patients treated by DCs. Despite the lower cost of chiropractic management, the use of chiropractic services in North Carolina appears very low.
Comparative Analysis of Individuals With and Without Chiropractic Coverage: Patient Characteristics, Utilization, and Costs
Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.
Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.
Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain.
Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain
Among employer groups with chiropractic coverage compared with those without such coverage, there is a significant reduction in the use of high-cost and invasive procedures for the treatment of low back pain and neck pain. The presumed mechanism of this effect is the substitution of chiropractic care for medical care for the treatment of back and neck pain. The resultant chiropractic care is far less likely to lead to the use of these invasive procedures. This reduction is more pronounced when measured on a per-episode basis than on a per-patient basis.
Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association: An Additional 3-year Update
During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. Decreased utilization was uniformly achieved by all CAM-oriented PCPs, regardless of their licensure. The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.
Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer
This study provides a unique opportunity to evaluate an insured population with open access (including identical co-pays and deductibles) and an unlimited number of visits to providers via self-referral. Our results support a growing body of evidence that chiropractic treatment of low back pain is less expensive than traditional medical care. We found that episode cost of care for LBP initiated with a DC is less expensive than care initiated through an MD. Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC are 20% less expensive than episodes initiated with an MD. Our results suggest that insurance companies that restrict access to chiropractic care for LBP may, inadvertently, be paying more for care than they would if they removed these restrictions.
This systematic review of the cost-effectiveness of treatments endorsed in the APS-ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain..
Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence
In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.
The results of this study support the value of chiropractic services offered at on-site health centers. Offering patients evidence-based, integrative, and convenient care, treatment at on-site chiropractic services was associated with lower utilization of certain health care services, as well as improved functional outcomes. Future research into potential indirect and direct cost savings would supplement this study and further demonstrate the advantages of on-site chiropractic care.
This review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. However, as this conclusion is primarily based on single studies more high quality research is needed to identify whether these findings are applicable in other settings.
The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems
While health care conversations increasingly mention chiropractic care as a viable option for back and neck pain – and research increasingly supports its utility from a clinical standpoint – this nationwide study of complementary and alternative medicine (CAM)-related health care expenditures by 12,000-plus adults (ages 17 and older) with spinal conditions lends support to the suggestion that CAM in general, and chiropractic specifically, is also a cost-effective alternative to traditional medical care.
Cost-Effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions: A Systematic Review and Narrative Synthesis of Evidence From Randomized Controlled Trials
Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients.
Tracking Low Back Problems in a Major Self-Insured Workforce: Toward Improvement in the Patient’s Journey
Although employers and their occupational health personnel are not necessarily looking to test the accuracy or appropriateness of guidelines for LBP care per se, they are seeking to better manage the long-term total cost outcomes of their LBP EE/patients. Do guidelines hold much promise for advancing this objective? The bottom line answer from this study is an empirically based yes.
In the current economic and political climate, one of the most important arguments to be made for any health care method is that it is cost-effective. As a result, researchers are redoubling their efforts to identify cost-effective approaches. This includes a growing number of studies addressing the cost-effectiveness of chiropractic services. Chiropractors and chiropractic students need to understand this information and to share it with others.