Objectives
To identify relative provider costs, clinical outcomes, and patient satisfaction for
the treatment of low back pain (LBP).
Methods
This was a practice-based, nonrandomized, comparative study of patients self-referring
to 60 doctors of chiropractic and 111 medical doctors in 51 chiropractic and 14 general
practice community clinics over a 2-year period. Patients were included if they were
at least 18 years old, ambulatory, and had low back pain of mechanical origin (n =
2780). Outcomes were (standardized) office costs, office costs plus referral costs
for office-based care and advanced imaging, pain, functional disability, patient satisfaction,
physical health, and mental health evaluated at 3 and 12 months after the start of
care. Multiple regression analysis was used to correct for baseline differences between
provider types.
Results
Chiropractic office costs were higher for both acute and chronic patients (P < .01). When referrals were included, there were no significant differences in either
group between provider types (P > .20). Acute and chronic chiropractic patients experienced better outcomes in pain,
functional disability, and patient satisfaction (P < .01); clinically important differences in pain and disability improvement were
found for chronic patients only.
Conclusions
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.
Key Indexing Terms
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Manipulative & Physiological TherapeuticsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Estimates and patterns of direct health care expenditures among individuals with back pain in the United States.Spine. 2004; 29: 79-86
- An overview of the incidences and costs of low back pain.Orthop Clin North Am. 1991; 22: 263-271
- Comparison of spinal health indicators in preducting spinal status in a 1-year longitudinal study.Spine. 1993; 18: 54-60
- Unconventional medicine in the United States: prevalence, costs, and patterns of use.N Engl J Med. 1993; 328: 246-252
- Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.JAMA. 1998; 280: 1569-1575
- Association between use of unconventional therapies and conventional medical services.JAMA. 1999; 282: 651-656
- The chiropractic services market: a literature review.Ad Health Econ Health Serv Res. 1992; 13: 191-204
- Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.Ann Intern Med. 2003; 138: 871-881
- Efficacy of spinal manipulative therapy for low back and neck pain: a systematic review and best evidence synthesis.Spine J. 2004; 4: 335-356
- A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain.Ann Intern Med. 2003; 138: 871-881
- Chronic spinal pain. A randomized clinical trial comparing medication, acupuncture, and spinal manipulation.Spine. 2003; 28: 1490-1503
- Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care.Fam Pract. 2003; 20: 662-669
- A randomized controlled clinical trial of stay-active care versus manual therapy in addition to stay-active care: functional variables and pain.J Manipulative Physiol Ther. 2004; 27: 431-441
- United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.BMJ. 2004; 329: 1377-1381
- 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.J Manipulative Physiol Ther. 2004; 27: 160-169
- Cost-effectiveness of chiropractic care in a managed care setting.Am J Manag Care. 1996; 2: 280-282
- Chiropractic and medical costs of low back care.Med Care. 1996; 34: 191-204
- Costs and recurrences of chiropractic and medical episodes of low-back care.J Manipulative Physiol Ther. 1997; 20: 5-12
- Comparing the costs between provider types of episodes of back pain care.Spine. 1995; 20: 221-227
- The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons.N Engl J Med. 1995; 333: 913-917
- A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain.N Engl J Med. 1998; 339: 1021-1029
- Cost-effectiveness studies of medical and chiropractic care for occupational low back pain: a critical review of the literature.Spine J. 2001; 1: 138-147
- Costs, outcomes, and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: a critical review of the literature and proposed methodologic standards.Ann Intern Med. 1997; 127: 52-60
- Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.Arch Intern Med. 2004; 164: 1985-1992
- United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care.BMJ. 2004; 329: 1381-1385
- Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain.Spine. 1997; 22: 2167-2177
- One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain.Spine. 1998; 23: 1875-1884
- Chiropractic and medical care costs of low back care: results from a practice-based observational study.Am J Manag Care. 2002; 8: 802-809
- Patient characteristics and physicians' practice activities for chronic low back pain patients: a practice-based study of primary care and chiropractic physicians.J Manipulative Physiol Ther. 2001; 24: 92-100
- Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians.Am J Public Health. 2003; 93: 2111-2117
- Preferences for health outcomes and cost-utility analysis.Am J Manag Care. 1997; 3: S8-S20
- Assessing the effectiveness of health interventions.in: Gold MR Siegel JE Russell LB Weinstein MC Cost-effectiveness in health and medicine. Oxford University Press, New York1996: 135-175
- Assessing the effectiveness of health interventions for cost-effectiveness analysis.J Gen Intern Med. 1997; 12: 551-558
- The measurement of clinical pain intensity: a comparison of six methods.Pain. 1986; 27: 117-126
- A revised Oswestry Disability Questionnaire.in: Roland MO Jenner JR Back pain: new approaches to rehabilitation and education. Manchester University Press, New York1989: 187-204
- A comparison of outcome measures for use with back pain patients; results of a feasibility study.J Manipulative Physiol Ther. 1993; 16: 67-73
- Responsiveness of the revised Oswestry Disability Questionnaire.Eur J Chiropr. 1997; 45: 9-14
- A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity.Med Care. 1996; 34: 220-233
- Reliability, validity, and responsiveness of the short form 12-item survey (SF-12) in patients with back pain.Spine. 2003; 28: 1739-1745
- User's manual: depression TyPE specification.InterStudy, St. Paul (Minn)1990
- User's manual: low back pain TyPE specification.1st ed. Quality Quest, Bloomington (Minn)1989
- The prevention of chronic pain and disability: a preliminary investigation.Behav Res Ther. 1991; 29: 443-450
- Follow-up among women with an abnormal mammogram in an HMO: is it complete, timely, and efficient?.Am J Manag Care. 2000; 6: 1102-1113
- Treatment of back pain: outpatient service charges, 1993.Stat Bull Metrop Insur Co. 1995; 76: 32-39
- A study of the natural history of low-back pain part II: development of guidelines for trials of treatment in primary care.Spine. 1983; 8: 145-150
- SAS Version 8.2.The SAS Institute, Cary (NC)2001
- Pain, disability and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians.J Manipulative Physiol Ther. 2001; 24: 433-439
- It's the prices, stupid: why the United States is so different from other countries.Health Aff (Millwood). 2003; 22: 89-105
- US health care spending in an international context.Health Aff (Millwood). 2004; 23: 10-25
- Economic evaluation of four treatments for low-back pain: results from a randomized controlled trial.Med Care. 2005; 43: 428-435
- Health care episodes: definition, measurement and use.Med Care Rev. 1985; 42: 163-218
- Why we need observational studies to evaluate the effectiveness of health care.BMJ. 1996; 312: 1215-1218
- Chiropractic scope of practice: what the law allows: update 1999.J Neuromusculoskel Syst. 1999; 7: 102-106
Article info
Publication history
Received in revised form:
July 7,
2005
Received:
May 24,
2005
Footnotes
Sources of support: This study was supported by the Health Resources and Services Administration, Department of Health and Human Services, Rockland, Md (grant no. R18 AH10002) and by a competitive challenge grant from the Foundation for Chiropractic Education and Research, Norwalk, Iowa (grant no. 940502) with funds donated to the foundation by the National Chiropractic Mutual Insurance Corporation, Des Moines, Iowa.
Identification
Copyright
© 2005 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
