Dr. Ebrall compared two matched samples of 998 patients each where "management was solely by either a chiropractor or a medical practitioner." Excerpts from the study are printed below:
"Comparisons of costs and outcomes were made between the two samples with the results being: (i) a significantly lower number of claimants requiring compensation days when chiropractic management was chosen, (ii) fewer compensation days taken by claimants who received chiropractic management, (iii) a greater number of patients progressed to chronic status when medical management was chosen, and (iv) a greater payment per claim with medical management. A further result, namely, a higher average practitioner payment with chiropractic management, suggests a more intense level of practitioner/patient interaction by chiropractors. These results demonstrate a significant benefit to the community by chiropractic participation within the Victorian compensation scheme for work-related low back pain."
While in summation these results seem quite impressive, the detail behind each outcome is even more so:
Results
1. For the outcome "the number of claimants requiring 'compensation days' in each sample" (Table 3), the number of claimants requiring compensation days were significantly lower in the sample receiving chiropractic management (X2 obs = 301. p 0.001). ..................<.....<...........<.....<.................
Table 3
Compensation Days
Chiropractor Medical Practitioner n % n %Claimants where
comp. days = 0 606 30.4 224 11.3Claimants where
comp. days > 0 392 19.6 774 38.7 Total 998 50.0 998 50.0 X2 obs = 301, p 0.001, % shown is of total sample, n=1996. 2. For the outcome "the number of 'compensation days' taken by claimants within each sample," the average number of compensation days for all claims is lower among claimants with chiropractic management. 3. For the outcome "the occurrence of chronicity" among claimants requiring compensation days, there was a greater progression to chronicity among claimants receiving medical management. 4. For the outcome "the costing of claims within each sample," the average payment per claim was greater with medical management ($2,308) than with chiropractic management ($963). (Table 4)
Table 4
Average Payments Per Claimant
Chiropractic Medical Practitioner $ $ All payments 963.47 2,308.10Compensation
payment 392.02 1,569.93Non-compensation
payment 571.45 738.17Provider
payment 369.01 209.60 Other payments 202.44 528.57(provider + other) = non-compensation payments
(non-compensation + compensation) = all payments
5. Other findings: A notable consideration for all claims is the higher average practitioner payment with chiropractic management. It is 1.75 times that of medicine ($369 chiropractic, $209 medical). The meaning of this finding will be discussed.
If this study is recording outcomes of palliative care by medical practitioners, then the social impact of such an approach is high. With respect to these 1,996 identified claims alone, medical management costs the community an additional $1,344 per claimant, which is an additional $1.3 million across the sample. If the Victorian chiropractors managed a similar portion (40%) of these injuries as do Oregon chiropractors,14 then the direct savings within the Victorian WorkCare scheme for this period would have been $10 million over 7,482 claims.
The real costs of the medical sample, however, must also include the cost to the employer of the greater number of compensation days (time off work). Claimants within the chiropractic sample required only one-quarter of the number of days off work, which would roughly translate to only one-quarter of the cost to the employer. The medical sample required an additional 19,270 days of compensation (total compensation days equal 6,243 d chiropractic, 25,513 d medical). The chiropractic management of MLBP clearly produces wide-ranging savings.25,27
Some of Dr. Ebrall's conclusions had far reaching significance for the citizens of Victoria. They are listed as follows:
"The financial and social savings inherent in the chiropractic approach could be maximized by:
(i) an increased participation rate by chiropractors in the WorkCare system, and
(ii) increased early referral of claimants with MLBP by medical practitioners to chiropractors.
"There is a higher average practitioner payment with chiropractic management, but this can be understood as reflecting a management process that is practitioner-intense, and is more than offset by other savings.
"The findings from this study firmly shift the onus onto chiropractors to report and critically analyze the components of their management for MLBP. Nachemson has identified the criteria to be met by research into work-related (occupational) MLBP.29 There is a need to determine what it is within the chiropractic management package that achieves such significant effectiveness. The RAND Corporation, in conjunction with the Consortium for Chiropractic Research and the Foundation for Chiropractic Education and Research are actively addressing these issues.30 Finally, close assessment of the medical package is indicated with a view to reducing the community's reliance on what has been indicated by this study to be a more expensive and less effective management of work-related MLBP."
References
14. Vernon H. Chiropractic: A model of incorporating the illness behaviour model in the management of low back pain patients. J Manipulative Physiol Ther 1991; 14:379-89.25. Patijn J, Durinck JR. Effects of manual medicine on absenteeism. J Manual Med 1991; 6:49-53.
27. Johnson MR, Schultz MK, Ferguson AC. A comparison of chiropractic, medical and osteopathic care for work-related sprains and strains. J Manipulative Physiol Ther 1989; 12:335-44.
29. Nachemson A. Research methods in occupational low back pain. Spine 1991; 16:666-7.
30. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brok RH. The appropriateness of spinal manipulation for low-back pain. Santa Monica: RAND, 1991.
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