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Chiropractic and Economic Cost Effectiveness 2010



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December 28, 2010

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ChiropracticEconomic cost effectiveness studies are crucial to all health professions and perhaps even more important to the chiropractic profession.  In terms of financial cost and for specific conditions there have been several recent studies that support chiropractic treatment.  In an article published this month (Dec. 2010) a comparison was made in a Blue Cross Blue Shield of Tennessee claims analysis for "common" back pain between medical and chiropractic care.  The study concluded that  "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 were 20% less expensive than episodes initiated with an MD."

In a second study published in the Spine Journal the cost of chiropractic and other conservative treatments were evaluated for patients prior to possible surgical discectomy.  The question was: is conservative care for patients who are believed to need surgery warranted?  Are enough individuals able to avoid the dangers and cost of surgery to warrant the cost of conservative management prior to scheduling surgery?  This study concluded that "Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate."  For some conditions e.g. adult scoliosis, sufficient evidence does not yet exist to warrant chiropractic care.  This review concluded "This study questions the value of nonoperative treatment commonly used for adult scoliosis patients. Documented costs are substantial and no improvement in health status was observed."  This is not to say that chiropractic care cannot help adult scoliosis but the study does say that there is yet to be research to support health improvement.

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.  [LINK]

J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):640-3. Epub 2010 Oct 18.

Liliedahl RL, Finch MD, Axene DV, Goertz CM.
Axene Health Partners, Winchester, Calif, USA.

OBJECTIVE: The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types.

METHODS:
A retrospective claims analysis was performed on Blue Cross Blue Shield of Tennessee's intermediate and large group fully insured population between October 1, 2004 and September 30, 2006. The insured study population had open access to MDs and DCs through self-referral without any limit to the number of visits or differences in co-pays to these 2 provider types. Our analysis was based on episodes of care for low back pain. An episode was defined as all reimbursed care delivered between the first and the last encounter with a health care provider for low back pain. A 60 day window without an encounter was treated as a new episode. We compared paid claims and risk adjusted costs between episodes of care initiated with an MD with those initiated with a DC.

RESULTS:
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 were 20% less expensive than episodes initiated with an MD.

CONCLUSIONS: Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.

Cost and use of conservative management of lumbar disc herniation before surgical discectomy.  [LINK]

Spine J. 2010 Jun;10(6):463-8. Epub 2010 Apr 1.

Daffner SD, Hymanson HJ, Wang JC.
Department of Orthopaedics, West Virginia University, Morgantown, WV 26506-9196, USA. sdaffner@hsc.wvu.edu

BACKGROUND CONTEXT: Lumbar discectomy is one of the most common spine surgical procedures. With the exception of true emergencies (eg, cauda equina syndrome), lumbar discectomy is usually performed as an elective procedure after a prudent trial of nonoperative treatment. Although several studies have compared costs of definitive operative or nonoperative management of lumbar disc herniation, no information has been published regarding the cost of conservative care in patients who ultimately underwent surgical discectomy.

PURPOSE: The purpose of this study was to determine the financial costs (and relative distribution of those costs) associated with the nonoperative management of lumbar disc herniation in patients who ultimately failed conservative care and elected to undergo surgical discectomy.

STUDY DESIGN: This is a retrospective database review.

PATIENT SAMPLE: The sample comprises patients within the database who underwent lumbar discectomy.

OUTCOME MEASURES: The outcome measures were frequency of associated procedures and the costs of those procedures.

MATERIALS AND METHODS: A search was conducted using a commercially available online database of insurance records of orthopedic patients to identify all patients within the database undergoing lumbar discectomy between 2004 and 2006. Patients were identified by American Medical Association Current Procedural Terminology code. The associated charge codes for the 90-day period before the surgery were reviewed and categorized as outpatient physician visits, imaging studies, physical therapy, injection, chiropractic manipulation, medication charges, preoperative studies, or miscellaneous charges. The frequency of each code and the percentage of patients for whom that code was submitted to the insurance companies were noted, as were the associated charges.

RESULTS: In total, 30,709 patients in the database met eligibility criteria. A total of $105,799,925 was charged during the 90 days preoperatively, an average of $3,445 per patient. Average charge for discectomy procedure was $7,841. Charges for injection procedures totaled $16,211,246 or 32% of total charges, diagnostic imaging $15,648,769 (31%), outpatient visits $6,552,135 (13%), physical therapy visits $5,723,644 (11%), chiropractic manipulation $1,177,406 (2%), preoperative studies $426,976 (0.8%), medications $263,039 (0.5%), and miscellaneous charges $1,177,371 (2%).

CONCLUSIONS: Charges for preoperative care of patients with lumbar disc herniation are substantial and are split almost evenly between diagnostic charges (outpatient visits, imaging, laboratory studies, and miscellaneous) and therapeutic charges (injections, physical therapy, chiropractic manipulation, and medications). Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate. Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial.

The costs and benefits of nonoperative management for adult scoliosis.  [LINK]

Spine (Phila Pa 1976). 2010 Mar 1;35(5):578-82.

Glassman SD, Carreon LY, Shaffrey CI, Polly DW, Ondra SL, Berven SH, Bridwell KH.
Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA. tallgeyer@spinemds.com

STUDY DESIGN: A prospective cohort of adult scoliosis patients treated nonoperatively had a minimum of 2-year follow-up during which time data were collected on the type and quantity of nonoperative treatment used.

OBJECTIVE:
To quantify the use, cost, and effectiveness of nonoperative treatment for adult scoliosis.

SUMMARY OF BACKGROUND DATA:
A 2007 systematic review of nonsurgical treatment in adult scoliosis revealed minimal data, and concluded that evidence for nonoperative care was lacking.

METHODS:
Duration of use and frequency of visits were collected for 8 specific treatment methods: medication, physical therapy, exercise, injections/blocks, chiropractic care, pain management, bracing, and bed rest. Costs for each intervention were determined using the Medicare Fee schedule. Outcome measures were the SRS-22, SF-12, and ODI. Analysis was performed for the entire group, and for subsets of high (ODI, >40), mid (ODI = 21-40) and low (ODI, <or=20) symptom patients.

RESULTS: A total of 123 patients (111 females, 12 males) with a mean age of 53.3 (18-79) years were evaluated. In 55 scoliosis patients who received no treatment, the only significant change in HRQOL measures over the 2-year period was in SRS satisfaction subscore (0.3 points, P = 0.014). Among the 68 adult scoliosis patients who used nonoperative resources, there was no significant change in any of the HRQOL outcome parameters. Mean treatment cost over the 2-year period was $10,815. Mean cost over the 2-year period averaged $9704 in the low symptom patients, $11,116 in the mid symptom, and $14,022 in the high symptom patients.

CONCLUSION: This study questions the value of nonoperative treatment commonly used for adult scoliosis patients. Documented costs are substantial and no improvement in health status was observed. An important caveat is that treatment was not randomized and therefore the treatment group might have deteriorated if not for the treatment they received.
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