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Farabaugh R, Hawk C, Taylor D, Daniels C, Noll C, Schneider M, McGowan J, Whalen W, Wilcox R, Sarnat R, Suiter L, Whedon J. Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review. Chiropr Man Therap 2024; 32:8. [PMID: 38448998 PMCID: PMC10918856 DOI: 10.1186/s12998-024-00533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/08/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain. METHODS A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators. RESULTS The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures. CONCLUSION Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.
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Affiliation(s)
- Ronald Farabaugh
- American Chiropractic Association, 2008 St. Johns Avenue, Highland Park, Illiois. 60035, Arlington, VA, USA.
| | - Cheryl Hawk
- Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX, 77505, USA
| | - Dave Taylor
- Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX, 77505, USA
| | - Clinton Daniels
- VA Puget Sound Health Care System, 9600 Veterans Drive Southwest Tacoma, Tacoma, WA, 98493-0003, USA
| | - Claire Noll
- Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX, 77505, USA
| | - Mike Schneider
- University of Pittsburgh, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219, USA
| | - John McGowan
- Saint Louis University, 3674 Lindell Blvd, St. Louis, MO, 63108, USA
| | - Wayne Whalen
- Clinical Compass-Past Chairman, 9570 Cuyamaca St Ste 101, Santee, CA, 92071, USA
| | - Ron Wilcox
- Private Practice, 204 Pinehurst Dr. SW, Suite 103, Tumwater, 9850, USA
| | - Richard Sarnat
- LP AMI Group, AMI Group, LP; 2008 St. Johns Avenue, Highland Park, IL, 60035, USA
| | - Leonard Suiter
- Clinical Compass-Past Chairman, 9570 Cuyamaca St Ste 101, Santee, CA, 92071, USA
| | - James Whedon
- Southern California University of Health Sciences, 16200 Amber Valley Drive, Whittier, CA, 90604, USA
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Meyer KW, Al-Ryati OY, Cupler ZA, Bonavito-Larragoite GM, Daniels CJ. Integrated clinical opportunities for training offered through US doctor of chiropractic programs. THE JOURNAL OF CHIROPRACTIC EDUCATION 2023; 37:90-97. [PMID: 37246958 PMCID: PMC11095651 DOI: 10.7899/jce-22-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/05/2022] [Accepted: 11/28/2022] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The primary objective of this study was to assess, summarize, and compare the current integrated clinical learning opportunities offered for students who matriculated in US doctor of chiropractic programs (DCPs). METHODS Two authors independently searched all accredited DCP handbooks and websites for clinical training opportunities within integrated settings. The 2 data sets were compared with any discrepancies resolved through discussion. We extracted data for preceptorships, clerkships, and/or rotations within the Department of Defense, Federally Qualified Health Centers, multi-/inter-/transdisciplinary clinics, private/public hospitals, and the Veterans Health Administration. Following data extraction, officials from each DCP were contacted with a request to verify the collected data. RESULTS Of the 17 DCPs reviewed, all but 3 offered at least 1 integrated clinical experience, while 41 integrated clinical opportunities were the most offered by a single DCP. There was an average of 9.8 (median 4.0) opportunities per school and an average of 2.5 (median 2.0) clinical setting types. Over half (56%) of all integrated clinical opportunities were within the Veterans Health Administration, followed by multidisciplinary clinic sites (25%). CONCLUSION This work presents preliminary descriptive information of the integrated clinical training opportunities available through DCPs.
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Deodhar A, Kiwalkar S, Mehendale T, Bhalerao S. Axial Spondyloarthritis in the Chiropractic Care Setting: A Systematic Literature Review. J Clin Rheumatol 2022; 28:e589-e595. [PMID: 34294660 PMCID: PMC8860198 DOI: 10.1097/rhu.0000000000001776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Diagnosis of axial spondyloarthritis (axSpA), an immune-mediated inflammatory disease, is commonly associated with chronic inflammatory back pain (IBP) and often occurs years after initial onset of clinical symptoms. Recognition of IBP is important for timely referral of patients with suspected axSpA to a rheumatologist. Patients with all types of back pain are treated in chiropractic care, but the proportion of patients with undiagnosed axSpA is unknown. This systematic literature review investigated the presence of axSpA in patients treated by chiropractors and identified the chiropractor's role in axSpA diagnosis, referral, and management. A PubMed search was conducted using the following search strings: "chiropract*" AND ("sacroiliac" OR "back pain" OR "spondyloarthritis" OR "ankylosing spondylitis"); English language, since 2009; and (chiropractic OR chiropractor) AND (ankylosing spondylitis OR axial spondyloarthritis), with no date limits. Of 652 articles identified in the searches, 27 met the inclusion criteria. Although back pain was identified as a common reason for patients seeking chiropractic care, there was no mention of axSpA, ankylosing spondylitis, or the distinction between mechanical and IBP. Data from relevant articles suggested that the majority of patients seeking chiropractic care have lower back pain, whereas no articles reported axSpA in this patient population. The near absence of any identified articles on axSpA in chiropractic care may be due to underrecognition of axSpA, resulting in delayed rheumatology referral and appropriate management. Better awareness and increased use of validated screening tools could reduce diagnostic delay of axSpA in chiropractic care.
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Affiliation(s)
- Atul Deodhar
- From the Oregon Health & Science University, Portland, OR
| | - Sonam Kiwalkar
- From the Oregon Health & Science University, Portland, OR
| | - Teja Mehendale
- From the Oregon Health & Science University, Portland, OR
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Abstract
PURPOSE OF REVIEW Axial spondyloarthritis (axSpA) affects 0.5-1% of the population in many regions of the world. This review summarizes the challenges in medical education around axSpA with attention to evidence around delayed diagnosis, clinician familiarity with typical axSpA features, such as inflammatory back pain and adherence to accepted management principles. RECENT FINDINGS Clinicians who commonly manage patients with chronic back pain or other typical axSpA features are not consistently aware of the concept of inflammatory back pain and common extra-spinal manifestations. Further, clinicians may not be familiar with the nonradiographic spectrum of axSpA. Management of patients with possible axSpA does not consistently follow principles that would establish an axSpA diagnosis, and diagnosis of axSpA remains delayed by 6-7 years on average, with evidence suggesting management disparities on the basis of sex and race in some cases. Referral recommendations have increased the probability of axSpA diagnosis up to about 40% and, may complement educational efforts in axSpA. SUMMARY Educational efforts in axSpA should focus on providing front-line clinicians with a better understanding of inflammatory back pain, the nonradiographic form of axSpA, and accepted principles in axSpA management.
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Affiliation(s)
- Anand Kumthekar
- Division of Rheumatology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York
| | - Mohamad Bittar
- Division of Rheumatology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Maureen Dubreuil
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine
- Section of Rheumatology, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
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Danve A, Deodhar A. Axial spondyloarthritis in the USA: diagnostic challenges and missed opportunities. Clin Rheumatol 2018; 38:625-634. [DOI: 10.1007/s10067-018-4397-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022]
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Hurwitz EL, Vassilaki M, Li D, Schneider MJ, Stevans JM, Phillips RB, Phelan SP, Lewis EA, Armstrong RC. Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis. J Manipulative Physiol Ther 2018; 39:229-39. [PMID: 27166404 DOI: 10.1016/j.jmpt.2016.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 11/01/2015] [Accepted: 01/01/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina. METHODS Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns. RESULTS The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care. CONCLUSIONS Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.
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Affiliation(s)
- Eric L Hurwitz
- Professor, Office of Public Health Studies, University of Hawaii at Mānoa, Honolulu, HI.
| | - Maria Vassilaki
- Research Associate, Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dongmei Li
- Associate Professor, Clinical and Translational Science Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Michael J Schneider
- Associate Professor, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Joel M Stevans
- Assistant Professor, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | | | - Shawn P Phelan
- Doctor of Chiropractic, Private Practice of Chiropractic, Wake Forest, NC
| | - Eugene A Lewis
- Doctor of Chiropractic, Private Practice of Chiropractic, Greensboro, NC
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Hurwitz EL, Li D, Guillen J, Schneider MJ, Stevans JM, Phillips RB, Phelan SP, Lewis EA, Armstrong RC, Vassilaki M. Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis. J Manipulative Physiol Ther 2016; 39:240-51. [PMID: 27166405 DOI: 10.1016/j.jmpt.2016.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 11/01/2015] [Accepted: 01/01/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina. METHODS This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP). RESULTS Care patterns with single-provider types and no referrals incurred the least average charges for both UNP and CNP. When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers. CONCLUSIONS Chiropractic care alone or DC with MD care incurred appreciably fewer charges for UNP or CNP compared to MD care with or without PT care, when care included referral providers or services. This finding was reversed when care did not include referral providers or services. Risk-adjusted charges for UNP and CNP patients were lower for DC care patterns.
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Affiliation(s)
- Eric L Hurwitz
- Professor, Office of Public Health Studies, University of Hawaii at Mānoa, Honolulu, HI.
| | - Dongmei Li
- Associate Professor, Clinical and Translational Science Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jenni Guillen
- Graduate Research Associate, Office of Public Health Studies, University of Hawai`i at Mānoa, Honolulu, HI
| | - Michael J Schneider
- Associate Professor, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Joel M Stevans
- Assistant Professor, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | | | - Shawn P Phelan
- Doctor of Chiropractic, Private Practice of Chiropractic, Wake Forest, NC
| | - Eugene A Lewis
- Doctor of Chiropractic, Private Practice of Chiropractic, Greensboro, NC
| | | | - Maria Vassilaki
- Research Associate, Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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