February 2011 Newsletter from Malik Slosberg, DC, MS

Bishop PB, DC, MD, PhD et al. The Chiropractic Hospital based Interventions Research Outcomes (CHIRO) Study: a randomized controlled study on the effectiveness of clinical practice guidelines in medical and chiropractic management of patients with acute mechanical LBP. Spine J 2010;10:1055-64.

Richard L. Liliedahl, MD, Michael D. Finch, PhD, David V. Axene, FSA, FCA, MAAA, Christine M. Goertz, DC, PhD. Cost of Care for Common Back Pain Conditions initiated with DC vs MD/DO as First Physician: Experience of one of Tennessee-based General Health Insurer. JMPT 2010;33(9):640-43.
Greetings to all subscribers of the Research Update. Hope you are all survivng this snowy, cold winter and are looking forward to spring's arrival. This month I present two chiropractic studies which will have substantial impact on the utilization of chiropractic spinal manipulation in addition to enhancing chiropractic's standing in the research and insurance worlds as a result of very credible, hard evidence. The first of the studies demonstrates that the use of chiropractic spinal manipulation in conjunction with other documented clinical practices results in significantly better outcomes than usual care provided by primary medical doctors in hospital-based spine program outpatient clinic. The second study is a cost-analysis of treatment for acute mechanical back pain, in an enormous patient population, initiated by either a chiropractor or a medical doctor. The findings demonstrate substantial cost savings when insured members are allowed unrestricted access to chiropractic care. I hope you will find the following information helpful.

Bishop PB, DC, MD, PhD et al. The Chiropractic Hospital based Interventions Research Outcomes (CHIRO) Study: a randomized controlled study on the effectiveness of clinical practice guidelines in medical and chiropractic management of patients with acute mechanical LBP. Spine J 2010;10:1055-64.

Evidence-based clinical practice guidelines (CPGs) for the management of patients (Pts) with acute mechanical low back pain (AM-LBP) (<4 weeks) have been defined on an international scale as a result of many goverment funded multidisciplinary panels developing evidenced-based guidelines. Multiple trials demonstrate that most AM-LBP Pts don’t receive CPG-based treatment (Tx). This prospective, randomized controlled trial (RCT) is to determine if full CPGs-based care (CPGC) which fulfills 7 of 7 criteria of CPGs results in greater improvement in functional outcomes than primary care physician (PCP)–directed usual care (UC) (consistent with only 2 of 7 CPG criteria) in Tx of AM-LBP. Txs were performed in a hospital-based spine program outpatient clinic.

Patients: 19 to 59 years with 2-4 weeks of AM-LBP.

Outcomes: Roland-Morris Disability Questionnaire (RDQ) baseline at 16 wks (the end of the acute phase), 8 & 24 wks. Short Form-36 bodily pain scale (BP) & physical functioning scale (PF) scores at 8, 16, & 24 wks.

Methods: Pts assessed by a spine physician & randomized to Group 1. CPGC: reassurance, avoidance of passive Tx (bed rest, heat, back supports/corsets/braces), acetaminophen, a progressive walking program, a maximum of 4 wks of chiropractic delivered lumbar spinal manipulation (SM: 2-3x/wk of side posture, high velocity low amplitude technique), no exercise program, & return to work within 8 wks.
Group 2. Primary care physician (PCP) directed usual care (UC).

Results: 36 CPGC & 35 UC Pts completed all follow-ups. Baseline prognostic variables were similar in both groups. Improvement in RDQ scores, was significantly greater in CPGC group than in the UC group. RDQ scores were also greater in the CPGC group at other time points, particularly at 24 weeks (p<.004). Improvements in SF-36 PF scores favored the SC group at all time points; but differences weren’t statistically significant. The evidence-based care group demonstrated significantly greater improvements in reported function through 6 months of follow-up. There were high rates of opioid use (78%) & passive modalities (60%) in PCP ‘‘usual care’’ group, but much less aerobic exercise or SM (6%) used. 78% of Pts in the UC group, vs 0% of CPGC Pts were taking narcotic analgesic meds. This use of narcotic analgesics would normally bias the SF-36 BP scores in favor of the UC group; yet, CPGC Pts showed comparable improvement in BP scores.

Conclusion: There were high rates of opioid use & passive modalities in UC at a university-based hospital. Implementation of CPGC may be truly beneficial to Pts & not just to payers’ strategy to minimize costs. This is the first RCT assessing the efficacy of full, multimodal, CPG-based therapy for AM-LBP. Two previous studies demonstrated that UC by PCPs are often highly guideline discordant. Studies demonstrate that PCPs are highly resistant to changing their practice patterns for managing AM-LBP Pts. This study demonstrates that in AM-LBP of <4 wks of comprehensive CPGC including chiropractic SM had great improvement in condition-specific functioning (RDQ scores) at 16 wks, that is throughout the entire duration of the acute phase of the clinical course. Whether Pts in either Tx group later experience reoccurrences or go on to develop CLBP is the subject of a future study. The importance of improving Pts outcomes within the acute phase is important because the development of chronic & often refractory LBP is commonly preceded by a poor outcome from the management of the Pts’ AM-LBP. CPG based care was significantly greater than guidelines-discordant care at 16 wks, & this benefit was maintained at 24 wks.

Commentary: This important hospital based study demonstrates that clinical practice guideline consistent care including chiropractic spinal manipulation resulted in consistently better results at 8, 16, & 24 wk for multiple outcome measures than usual, non-clinical practice guideline consistent care provided by primary care medical doctors in a hospital based spine outpatient clinic. Even in measures for reduction of back pain, clinical practice guideline consistent care with only acetaminophen and SM resulted in as much pain reduction as the use of opiods in the usual, non-clinical practiced guideline based care. Spinal manipulation, an integral part of the clinical practice based guideline care, is an effective, international validated and accepted, mainstream intervention in acute mechanical back pain that when used in conjunction with other validated interventions (acetaminophen, a progressive walking program, avoidance of bed rest and no exercise training in the acute phase) results in better results at 8, 16, and 24 wks of follow-up. In addition, as noted in the discussion section of the paper, the improved outcomes at the end of the acute phase, as well as, at 24 weeks may increase the likelihood of better long-term outcomes. This is the subject of a future prospective, longitudinal study which is based on long-term follow-up of the two patient groups in this clinical trial. Previous published research indicates that the development of chronic and/or recurrent back pain is often preceded by poor outcomes during the acute phase. The improved 16 & 24 week outcomes may predict significantly better outcomes at one year or possibly longer follow-ups. This is a very significant study.

*See associated images under "Bishop" in the right hand column.


Richard L. Liliedahl, MD, Michael D. Finch, PhD, David V. Axene, FSA, FCA, MAAA, Christine M. Goertz, DC, PhD. Cost of Care for Common Back Pain Conditions initiated with DC vs MD/DO as First Physician: Experience of one of Tennessee-based General Health Insurer. JMPT 2010;33(9):640-43.

A retrospective claims analysis study (October 2004 thru Sept 2006) on Blue Cross Blue Shield of Tennessee’s intermediate & large group fully insured population to determine if there are differences in the cost of LBP care, including visits & medications (narcotic, analgesic, nonsteroidal, and muscle relaxants), when a Pt can choose Tx w a MD or a DC. Coverage included unrestricted access to primary & specialty providers of their choice & unlimited services, except for a 20-visit/yr year limit on physical therapy. There were no differences in this population for co-pays or deductibles based on provider type. Pts had open access to MDs & DCs thru self-referral w/o any limit to the number of visits or differences in co-pays to these 2 provider types. Analysis is based on episodes of care for LBP: reimbursed care delivered between the 1st & last visit with a health care provider for LBP. A 60 day window w/o Tx is considered a new episode.

Results: Paid costs for episodes of LBP care initiated with a chiropractor were almost 40% less than episodes initiated with an MD. Even after risk adjusting each Pt’s costs (determining the severity of clinical presenting symptoms), episodes of care initiated with a DC were 20% lower than those initiated with an MD.

Conclusions: 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, episodes of care initiated w a DC are 20% less expensive than episodes initiated w an MD. 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. Savings to the payer for allowing unrestricted access to chiropractic care would result in a saving of $2.3 million per year.

Commentary: This retrospective claims analysis of some 85,402 patients insured by Blue Cross Blue Shield in Tenessee who sought help for LBP initiated by either a DC or MD demonstrates that treatment for an episode of LBP with a chiropractor results in lower costs for LBP care than episodes initiated by an medical doctor even after controlling for severity of Pts presenting complaints. This is a very large population of Pts insured by one of the major insurers in the USA. The discussion section explains that by restricting access to chiropractic care, insurers may be paying more for management of LBP episodes than if they allowed unrestricted access to chiropractic care. A $2.3 million per year savings is substantial and, clearly, cost-effective. This is a very significant finding which may cause health insurance companies to reappraise their policies concerning restricted access to chiropractic care.

*See associated images under "Liliedahl" in the right hand column.