Articles on Chiropractic Research

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Testimony to the

Department of Veterans Affairs’

Chiropractic Advisory Committee

To assist in documenting the testimony of my colleague, Dr. James Edwards, I would like to take this opportunity to offer a sampling of citations, which should provide support to several of the elements which he proposed as benchmarks with which to judge the effectiveness of adding chiropractic as a health care option in a core policy.

1.  Patient satisfaction:

From a number of studies, there is little to contradict the assertion that patient satisfaction with chiropractic care, in a variety of settings, has consistently been high.^1-4 Indeed, for matched back pain conditions, patient satisfaction with chiropractic treatment has invariably been shown to be significantly greater than that with conventional management [administered by a primary care physician, an orthopedist, or an HMO provider].^5-7 Satisfied patients are far more likely to be compliant in their treatment,⁸ theoretically bestowing chiropractic patients with yet another advantage over treatment by other providers in terms of outcomes.

2.  Cost-effectiveness:

In the treatment of musculoskeletal disorders, despite the fact that most studies have not properly factored in such patient characteristics as severity and chronicity and lack the complete assessment of all direct costs and most indirect costs, the bulk of articles reviewed demonstrate lower costs for chiropractic.⁹ This pattern is consistently observed from the perspectives of workers' compensation studies,^10-15 databases from insurers,^16-18 or the analysis of a health economist employed by the provincial government of Ontario.^19-20 Other studies have suggested the opposite [that chiropractic services are more expensive than medical],^5,21,22 but these contain significant flaws²¹ which have been refuted.²³

The cost advantages for chiropractic for matched conditions appear to be so dramatic that Pran Manga, the aforementioned Canadian health economist, has concluded that doubling the utilization of chiropractic services from 10% to 20% may realize savings as much as $770 million in direct costs and $3.8 billion in indirect costs.²⁰ When iatrogenic effects [yet to be discussed] are factored in, the cost advantages of spinal manipulation as a treatment alternative become even more prominent. In one study, for instance, it was shown that for managing disc herniations, the cost of treatment failures following a medical course of treatment [chymopapain injections] averaged 300 British pounds per patient, while there were no such costs following spinal manipulation.²⁴ Imagine how failed back surgery might compare. Finally, in no cost studies to date have legal burdens been calculated, which one would expect should be heavily advantageous for chiropractic health management.

3.  Unnecessary surgical procedures:

In 1974, the Congressional Committee on Interstate and Foreign Commerce held hearings on unnecessary surgery. Their findings from the first surgical second opinion program found that 17.6% of recommendations for surgery were not confirmed. The House Subcommittee on Oversight and Investigations extrapolated these figures to estimate that, on a nationwide basis, there were 2.4 million unnecessary surgeries performed annually resulting in 11,900 deaths at an annual cost of $3.9 billion.²⁵ With the total number of lower back surgeries having been estimated in 1995 to exceed 250,000 in the U.S. at a hospital cost of $11,000 per patient.²⁶ This would mean that the total number of unnecessary back surgeries each year in the U.S. could approach 44,000, costing as much as $484 million.

4. Over-utilization of pharmaceuticals:

In the area of antibiotics alone, the most prominent problem has been the over-utilization of drugs. The Center for Disease Control, for instance, estimates that 1/3 of the antibiotics taken on an outpatient basis in the United States are unnecessary. Increasing use of antibiotics is linked to the increase of their resistance by bacteria; in the United States, 14,000 people die each year from drug-resistant infections picked up in hospitals.²⁷

In terms of healthcare costs, the rising use of pharmaceuticals has profound consequences. From 1993 to 1998, for instance, annual drug expenditures in the U.S. nearly doubled from $50.6 billion to $93.4 billion, most of the expenses being borne by third-party payors.²⁸ Total spending on prescription drugs doubled from 1995 to 2000 and tripled from 1990 to 2000, constituting one of the main factors driving up health care expenditures overall.²⁹

5. Medical errors:

Despite the unquestionable advances in treatments for such major illnesses as heart disease, cancer, or infectious disease, the healthcare system in America is still beset with such statistics as [i] 106,000 deaths per year from non-error, adverse effects of medications, [ii] 12,000 deaths per year from unnecessary surgery, [iii] 80,000 deaths per year from nosocomial [hospital origin] infections, [iv] 7000 deaths per year from medication errors in hospitals, and [v] 20,000 deaths per year from other hospital errors. The total turns out to be some 225,000 deaths per year from iatrogenic causes,^30-32 or even higher [230,000-280,000 deaths per year according to the Institute of Medicine^33-34]. When one factors in outpatient settings, the manifestations of iatrogenesis become even more numerous. Now one needs to figure in, on an annual basis, 116 million extra physician visits, 77 million extra prescriptions, 8 million hospitalizations, 3 million long-term admissions, and, incredibly, $77 million in extra costs and 199,000 additional deaths.³⁵

The CEO of the Beth Israel Deaconess Medical Center in Boston caught the full essence of this problem and made it unmistakably clear:

"When all sources of error are added up, the likelihood that a mishap will injure a patient in a hospital is at least three percent and probably much higher. This is a serious health problem. When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment."³⁶

It gets worse. From the time that the Institute of Medicine painted such a discouraging picture of errors in American hospitals in November 1999,³⁴ little change was noted by December 2002 by Lucian Leape, the Harvard physician who helped to write the original report. Among the reasons cited were: [i] the fierce resistance by doctors and hospitals to accomplish the mandatory reporting of errors, [ii] the lack of governmental oversight, and [iii] the lack of an effective consumer lobby.³⁷ According to the Chicago Tribune some months ago,³⁸ 75% of the nation's hospitals have never filed a report with the databank created by the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], a licensing, government-sanctioned watchdog agency charged with oversight of the nation's hospitals.³⁸ As many as "tens of thousands" of patient deaths, and potentially preventable deaths, may never have been reported. The JCAHO turned to its seven-year database and, lo and behold, found only ten such reports involving 53 patients. The reason? According to the JCAHO President, Dennis O'Leary, this egregious underreporting was deemed possible because "many healthcare organizations do not consider the incidents as errors."³⁹

Mr. Chairman and Members of the Committee, these are the most salient references that I can offer at this time to highlight the importance of each of these five elements, which must be addressed by any health care policy.

In closing, while I have not addressed the issue of treatment effectiveness or outcomes, I would remind you of the article published last year, by Meeker and Haldeman, in the February issue of the Annals of Internal Medicine.⁴⁰ In that article the authors noted that at least 73 randomized clinical trials [RCT] assessing manipulation [adjustment] had been published in English-language, peer-reviewed, scientific journals. Of those, 43 addressed the treatment of low back pain, 30 of those favored manipulation over the comparison interventions, and 13 were equivocal. [This is an even greater data base than the 13 RCTs assessed by the interdisciplinary panel that supported the use of manipulation in the 1994 AHCPR Guideline #14,⁴¹ on acute low back pain.] In the 2002 Annals article, another 20 RCTs evaluated manipulation in the treatment of neck pain and headache. Again the majority of these favored manipulation over the comparative interventions with the remainder showing the outcomes to be equivocal at worst.

Certainly, it is important to our veterans to have available a satisfying, cost effective, lower risk form of intervention that has demonstrated effectiveness in treating numerous neuromusculoskeletal complaints. It should be especially important when that intervention, chiropractic manipulative treatment/adjustment, is provided by skilled doctors of chiropractic, broadly trained in the all aspects of clinical assessment and conservative management of neuromusculoskeletal conditions.

Thank you for permitting the opportunity to provide these comments. I will be happy to respond to any questions you may have at this time.

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¹Sawyer C, Kassak K. Patient satisfaction with chiropractic care. Journal of Manipulative and Physiological Therapeutics 1993; 16(1): 25-32.

²Verhoef MJ, Page SA, Waddell SC. The chiropractic outcome study: Pain, functional ability and satisfaction with care. Journal of Manipulative and Physiologial Therapeutics 1997; 20(4): 235-240.

³Hawk C, Long CR, Boulanger KT. Patient satisfaction with the chiropractic clinical encounter: Report from a practice-based research program. Journal of the Neuromusculoskeletal System 9(4): 109-117.

⁴Gemmell HA, Hayes BA. Patient satisfaction with chiropractic physicians in an independent physicians' association. Journal of Manipulative and Physiological Therapeutics 2001; 24(9): 556-559.

⁵Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR, North Carolina Back Pain Project. The outcomes and costs for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. New England Journal of Medicine 1995; 333(14): 913-917.

⁶Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. Western Journal of Medicine 1989; 150: 351-355.

⁷Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P, Kominski GF. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: Results from the UCLA Low-Back Pain Study. American Journal of Public Health 2002; 92(10): 1628-1633.

⁸Williams B. Patient satisfaction: A valid concept? Social Science and Medicine 1994; 509-516.

⁹Branson RA. Cost comparison of chiropractic and medical treatment of common musculoskeletal disorders: A review of the literature after 1980. Topics in Clinical Chiropractic 1999; 6(2): 57-68.

¹⁰Jarvis KB, Phillips RB, Morris EK. Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. Journal of Occupational Medicine 1991; 33(8): 847-852.

¹¹Nyiendo J, Lamm L. Disability low back Oregon workers' compensation of claims. Part I: Methodology and clinical categorization of chiropractic and medical cases. Journal of Manipulative and Physiological Therapeutics 1991 14(3): 177-184.

¹²Nyiendo J. Disability low back Oregon workers' compensation of claims. Part II: Time loss. Journal of Manipulative and Physiological Therapeutics 1991; 14(4): 231-239.

¹³Nyiendo J. Disability low back regon workers' compensation of claims. Part III: Diagnostic and treatment procedures and associated costs. Journal of Manipulative and Physiological Therapeutics 1991; 14(5): 287-297.

¹⁴Johnson MR. A comparison of chiropractic, medical and osteopathic care for work-related sprains/strains. Journal of Manipulative and Physiological Therapeutics 1989; 12(5): 335-344.

¹⁵Wolk S. An analysis of Florida workers' compensation medical claims for back-related injuries. Journal of the American Chiropractic Association 1988; 27(7): 50-59.

¹⁶Dean H, Schmidt R. A comparison of the cost of chiropractors versus alternative medical practitioners. Richmond, VA: Virginia Chiropractic Association, 1992.

¹⁷Stano M, Smith M. Chiropractic and medical costs of low back care. Medical Care 34(3): 191-204.

¹⁸Smith M, Stano M. Costs and recurrences of chiropractic and medical episodes of low-back care. Journal of Manipulative and Physiological Therapeutics 1997; 20(1): 5-12.

¹⁹Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Richmond Hill, Ontario: Kenilworth Publishing, 1993.

²⁰Manga P. Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Report to the Ontario Ministry of Health, 1998.

²¹Shekelle PG, Markovich M, Louie R. Comparing the costs between provider types of episodes of back care. Spine 1995; 20(2): 221-227.

²²Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. Comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998; 339(14): 1021-1029.

²³Rosner A. Letter to the editor. Spine 1995; 20(23): 2595-2598.

²⁴Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Europ Spine J 9: 202-207, 2000.

²⁵US Congressional House Subcommittee Oversight Investigation. Cost and quality of health care: Unnecessary surgery. Washington, DC: Government Printing Office, 1976.

²⁶Herman R. Back surgery. Washington Post [Health Section], April 18., 1995.

²⁷Abuse of antibiotics. Lead editorial. International Herald Tribune June 19, 2000, p. 8.

²⁸National Institute for Health Care Management Research and Education Foundation report prepared by the Barents Group LLC, July 9, 1999.

²⁹Report from the Department of Health and Human Services, reported in the New York Times, January 8, 2002.

³⁰Leape L. Unnecessary surgery. Annual Review of Public Health 1992; 13: 363-383.

³¹Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet 351: 643-644.

³²Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. Journal of the American Medical Association 1998; 279: 1200-1205.

³³Schuster M, McGlynn E. Brook R. How good is the quality of health care in the United States? Milbank Quarterly 1998; 76: 517-563.

³⁴Kohn LT, Corrigan JM, Donaldson M, eds. To Err is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, 1999.

³⁵Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology and medical error. British Medical Journal 2000; 320: 774-777.

³⁶Reinertsen JL. Let's talk about error. Leaders should take responsibility for mistakes. British Medical Journal 2000; 320: 730.

³⁷The Washington Post, December 3, 2002.

³⁸Berens MJ. Oversight panels don't see all facts of medical mistakes cases series: Dangerous care: Nurses' hidden role in medical error. Chicago Tribune, September 12, 2000.

³⁹Associated Press release, January 23, 2003.

⁴⁰Meeker WC, Haldeman S. Chiropractic: A profession at the Crossroads of Mainstream and Alternative Medicine. Annals of Internal Medicine 2002; 136(3): 216-227.

⁴¹Bigos S, Bowyer O, et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. Rockville, MD:1994. AHCPR publication no. 95-0642.

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