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Cost Minimization Analysis of LBP Claims Data for Chiropractic vs. Medicine
Brian Grieves, DC, MPH, J. Michael Menke, MA, DC, Kevin Pursel, DC
Objective: A managed care organization (MCO) examined differences in allowed cost for managing low back pain by medical providers vs. chiropractors in an integrated care environment. The purpose of this study is to provide a retrospective cost analysis of administrative data of chiropractic vs. medical management of low back pain in a managed care setting.
Methods: All patients with a low back pain-related diagnosis presenting for health care from January 2004 to June 2004 who were insured by an MCO in northeast Wisconsin were tracked. The cumulative health care costs incurred by this MCO during the two-year period from January 2004 to December 2005 related to these back pain diagnoses were collected.
Results: Allowed costs of chiropractic treatment were 12% greater than medical primary care and 60% less per case than other types of medical care combined, on a per-case basis: Median cost of medical primary care was $365, chiropractic care was $417, and medical nonprimary care was $669.
Conclusion: This study suggests chiropractic management as less expensive compared with medical management of back pain when care extends beyond primary care. Primary care management alone is virtually indistinguishable from chiropractic management in terms of costs.
Nonsurgical Approach to Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk
Donald Murphy, DC, Eric Hurwitz, DC, PhD, Ericka McGovern, DC
Objective: This study presents the outcomes of patients with lumbar radiculopathy secondary to disk herniation treated after a diagnosis-based clinical decision rule.
Methods: A prospective observational cohort study was conducted at a multidisciplinary, integrated clinic that includes chiropractic and physical therapy health care services. Data on 49 consecutive patients were collected at baseline, at the end of conservative, nonsurgical treatment and a mean of 14.5 months after cessation of treatment. Disability was measured using the Bournemouth Disability Questionnaire (BDQ) and pain using the Numerical Rating Scale for pain. Fear beliefs were measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Patients also self-rated improvement.
Results: Mean duration of complaint was 60.5 weeks. Mean self-rated improvement at the end of treatment was 77.5%. Improvement was described as "good" or "excellent" in nearly 90% of patients. Mean percentage improvement on the BDQ was 60.4%. Numerical Rating Scale improved 4.1 points and FABQ improved 4.8 points. Clinically meaningful improvements in pain and disability were seen in 79% and 70% of patients, respectively. Mean number of visits was 13.2.
After an average long-term follow-up of 14.5 months, mean self-rated improvement was 81.1%. "Good" or "excellent" improvement was reported by 80% of patients. Mean percentage improvement in BDQ was 67.4%. Numerical Rating Scale improved 4.2 points and FABQ 4.5 points. Clinically meaningful improvements in pain and disability were seen in 79% and 73% of patients, respectively.
Conclusions: Management based on the decision rule yielded favorable outcomes in this cohort study. Improvement appeared to be maintained over the long term.
The Difference Between Integration and Collaboration in Patient Care
Heather Boon, PhD, Silvano Mior, DC, Jan Barnsley, PhD, et al.
Objectives: Despite the growing interest in integrative health care, collaborative care, and interdisciplinary health care teams, there appears to be little consistency in terminology and clarity regarding the goal for these teams, other than "working together" for the good of the patients. The purpose of this study was to explore what the terms integration and collaboration mean for practitioners and other key informants working in multiprofessional health care teams, with a specific look at chiropractic and family physician teams in primary care settings.
Methods: Semistructured interviews were conducted with 16 key informants until saturation was obtained in the key emerging themes. All interviews were audio-recorded, and the transcripts were coded using qualitative content analysis.
Results: Most participants differentiated collaboration from integration. They generally described a model of professions working closely together (i.e., collaborating) in the delivery of care, but not subsumed into a single organizational framework (i.e., integration). Our results suggest that integration requires collaboration as a precondition, but collaboration does not require integration.
Conclusions: Collaboration and integration should not be used interchangeably. A critical starting point for any new interdisciplinary team is to articulate the goals of the model of care.
Hospital-Based Chiropractic Integration Within a Large Private Hospital System: A 10-Year Example
Richard Branson, DC
Objective: The purpose of this article is to describe a model of chiropractic integration developed over a 10-year period within a private hospital system in Minnesota.
Methods: Needs were assessed by surveying attitudes and behaviors related to chiropractic and complementary and alternative medicine (CAM) of physicians associated with the hospital. Analyzing referral and utilization patterns assessed chiropractic integration into the hospital system.
Results: One hundred five surveys were returned after two mailings for a response rate of 74%. Seventy-four percent of respondents supported integration of CAM into the hospital system, although 45% supported the primary care physician as the gatekeeper for CAM use. From 2006 to 2008, there were 8,294 unique new patients in the chiropractic program. Primary care providers (medical doctors and physician assistants) were the most common referral source, followed by self-referred patients, sports medicine physicians, and orthopedic physicians.
Overall examination of the program identified that facilitators of chiropractic integration were (1) growth in interest in CAM; (2) establishing relationships with key administrators and providers; (3) use of evidence-based practice; (4) adequate physical space; and (5) creation of an integrated spine care program. Barriers were (1) lack of understanding of chiropractic professional identity by certain providers; and (2) certain financial aspects of third-party payment for chiropractic.
Conclusion: This article describes the process of integrating chiropractic into one of the largest private hospital systems in Minnesota from a business and professional perspective, and the results achieved once chiropractic was integrated into the system. This study identified key factors that facilitated integration of services and demonstrates that chiropractic care can be successfully integrated within a hospital system.
Injured Workers With Back or Neck Pain Treated With Chiropractic Care in an Integrative Program
Donald Aspegren, DC, MS, Brian Enebo, DC, PhD, Matt Miller, MD, et al.
Objective: The purpose of this study is to report on integrative care for the treatment of injured workers with neck or back pain referred to a doctor of chiropractic from a medical or osteopathic provider.
Methods: This retrospective case series study evaluated data on 100 patients referred for chiropractic care of work-related spinal injuries involving workers' compensation claims. De-identified data included age, sex, visual analog scale scores for pain, pre- and posttreatment Functional Rating Index (FRI) scores, and subjective response to chiropractic care.
Based on date of injury to first chiropractic treatment, patients were subdivided as acute, subacute, or chronic injured workers. Cases were analyzed for differences in pretreatment FRI scores, posttreatment FRI scores, FRI change scores (posttreatment FRI minus pretreatment FRI score), and subjective percentage improvement using a one-way analysis of variance. Treatment included manual therapy techniques and exercise.
Results: Injured workers with either an acute or subacute injury had significantly lower posttreatment FRI scores compared with individuals with a chronic injury. The FRI change scores were significantly greater in the acute group compared with either the subacute or chronic injured workers. Workers in all categories showed improved posttreatment tolerance for work-related activities and significantly lower posttreatment subjective pain scores.
Conclusions: The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional scores and subjective response was noted in all three time-based phases of patient status (acute, subacute, and chronic).
JMPT abstracts appear in DC with permission from the journal. Due to space restrictions, we cannot always print all abstracts from a given issue. Visit www.journals.elsevierhealth.com/periodicals/ymmt for access to the complete November-December 2009 issue of JMPT.