Testimony to the Department of Veterans Affairs’
Chiropractic Advisory Committee

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

  Reprinted from FCER Advance, Spring/Summer 2003 ~ FULL TEXT

George B. McClelland, D.C.

Foundation for Chiropractic Education and Research

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March 25, 2003

To assist in documenting the testimony of my colleague, Dr. James Edwards, I would like to take this opportunity to offer a sampling of citations, which should provide support to several of the elements which he proposed as benchmarks with which to judge the effectiveness of adding chiropractic as a health care option in a core policy.

1. Patient Satisfaction:

From a number of studies, there is little to contradict the assertion that patient satisfaction with chiropractic care, in a variety of settings, has consistently been high. [1–4] Indeed, for matched back pain conditions, patient satisfaction with chiropractic treatment has invariably been shown to be significantly greater than that with conventional management [administered by a primary care physician, an orthopedist, or an HMO provider]. [5–7] Satisfied patients are far more likely to be compliant in their treatment, [8] theoretically bestowing chiropractic patients with yet another advantage over treatment by other providers in terms of outcomes.

2. Cost-effectiveness:

In the treatment of musculoskeletal disorders, despite the fact that most studies have not properly factored in such patient characteristics as severity and chronicity and lack the complete assessment of all direct costs and most indirect costs, the bulk of articles reviewed demonstrate lower costs for chiropractic. [9] This pattern is consistently observed from the perspectives of workers' compensation studies, [10–15] databases from insurers, [16–18] or the analysis of a health economist employed by the provincial government of Ontario. [19–20] Other studies have suggested the opposite [that chiropractic services are more expensive than medical], [5,21,22] but these contain significant flaws [21] which have been refuted. [23]

The cost advantages for chiropractic for matched conditions appear to be so dramatic that Pran Manga, the aforementioned Canadian health economist, has concluded that doubling the utilization of chiropractic services from 10% to 20% may realize savings as much as $770 million in direct costs and $3.8 billion in indirect costs. [20] When iatrogenic effects [yet to be discussed] are factored in, the cost advantages of spinal manipulation as a treatment alternative become even more prominent. In one study, for instance, it was shown that for managing disc herniations, the cost of treatment failures following a medical course of treatment [chymopapain injections] averaged 300 British pounds per patient, while there were no such costs following spinal manipulation. [24] Imagine how failed back surgery might compare. Finally, in no cost studies to date have legal burdens been calculated, which one would expect should be heavily advantageous for chiropractic health management.

3. Unnecessary Surgical Procedures:

In 1974, the Congressional Committee on Interstate and Foreign Commerce held hearings on unnecessary surgery. Their findings from the first surgical second opinion program found that 17.6% of recommendations for surgery were not confirmed. The House Subcommittee on Oversight and Investigations extrapolated these figures to estimate that, on a nationwide basis, there were 2.4 million unnecessary surgeries performed annually resulting in 11,900 deaths at an annual cost of $3.9 billion. [25] With the total number of lower back surgeries having been estimated in 1995 to exceed 250,000 in the U.S. at a hospital cost of $11,000 per patient. [26] This would mean that the total number of unnecessary back surgeries each year in the U.S. could approach 44,000, costing as much as $484 million.

4. Over-utilization of Pharmaceuticals:

In the area of antibiotics alone, the most prominent problem has been the over-utilization of drugs. The Center for Disease Control, for instance, estimates that 1/3 of the antibiotics taken on an outpatient basis in the United States are unnecessary. Increasing use of antibiotics is linked to the increase of their resistance by bacteria; in the United States, 14,000 people die each year from drug-resistant infections picked up in hospitals. [27]

In terms of healthcare costs, the rising use of pharmaceuticals has profound consequences. From 1993 to 1998, for instance, annual drug expenditures in the U.S. nearly doubled from $50.6 billion to $93.4 billion, most of the expenses being borne by third-party payors. [28] Total spending on prescription drugs doubled from 1995 to 2000 and tripled from 1990 to 2000, constituting one of the main factors driving up health care expenditures overall. [29]

5. Medical Errors:

Despite the unquestionable advances in treatments for such major illnesses as heart disease, cancer, or infectious disease, the healthcare system in America is still beset with such statistics as [i] 106,000 deaths per year from non-error, adverse effects of medications, [ii] 12,000 deaths per year from unnecessary surgery, [iii] 80,000 deaths per year from nosocomial [hospital origin] infections, [iv] 7000 deaths per year from medication errors in hospitals, and [v] 20,000 deaths per year from other hospital errors. The total turns out to be some 225,000 deaths per year from iatrogenic causes, [30–31] or even higher [230,000–280,000 deaths per year according to the Institute of Medicine [33–34]]. When one factors in outpatient settings, the manifestations of iatrogenesis become even more numerous. Now one needs to figure in, on an annual basis, 116 million extra physician visits, 77 million extra prescriptions, 8 million hospitalizations, 3 million long-term admissions, and, incredibly, $77 million in extra costs and 199,000 additional deaths. [35]

The CEO of the Beth Israel Deaconess Medical Center in Boston caught the full essence of this problem and made it unmistakably clear:

"When all sources of error are added up, the likelihood that a mishap will injure a patient in a hospital is at least three percent and probably much higher. This is a serious health problem. When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment." [36]

It gets worse. From the time that the Institute of Medicine painted such a discouraging picture of errors in American hospitals in November 1999, [34] little change was noted by December 2002 by Lucian Leape, the Harvard physician who helped to write the original report. Among the reasons cited were: [i] the fierce resistance by doctors and hospitals to accomplish the mandatory reporting of errors, [ii] the lack of governmental oversight, and [iii] the lack of an effective consumer lobby. [37] According to the Chicago Tribune some months ago, [38] 75% of the nation's hospitals have never filed a report with the databank created by the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], a licensing, government-sanctioned watchdog agency charged with oversight of the nation's hospitals. [38] As many as "tens of thousands" of patient deaths, and potentially preventable deaths, may never have been reported. The JCAHO turned to its seven-year database and, lo and behold, found only ten such reports involving 53 patients. The reason? According to the JCAHO President, Dennis O'Leary, this egregious underreporting was deemed possible because "many healthcare organizations do not consider the incidents as errors." [39]

Mr. Chairman and Members of the Committee, these are the most salient references that I can offer at this time to highlight the importance of each of these five elements, which must be addressed by any health care policy.

In closing, while I have not addressed the issue of treatment effectiveness or outcomes, I would remind you of the article published last year, by Meeker and Haldeman, in the February issue of the Annals of Internal Medicine. [40] In that article the authors noted that at least 73 randomized clinical trials [RCT] assessing manipulation [adjustment] had been published in English-language, peer-reviewed, scientific journals. Of those, 43 addressed the treatment of low back pain, 30 of those favored manipulation over the comparison interventions, and 13 were equivocal. [This is an even greater data base than the 13 RCTs assessed by the interdisciplinary panel that supported the use of manipulation in the 1994 AHCPR Guideline #14, [41] on acute low back pain.] In the 2002 Annals article, another 20 RCTs evaluated manipulation in the treatment of neck pain and headache. Again the majority of these favored manipulation over the comparative interventions with the remainder showing the outcomes to be equivocal at worst.

Certainly, it is important to our veterans to have available a satisfying, cost effective, lower risk form of intervention that has demonstrated effectiveness in treating numerous neuromusculoskeletal complaints. It should be especially important when that intervention, chiropractic manipulative treatment/adjustment, is provided by skilled doctors of chiropractic, broadly trained in the all aspects of clinical assessment and conservative management of neuromusculoskeletal conditions.

Thank you for permitting the opportunity to provide these comments. I will be happy to respond to any questions you may have at this time.

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REFERENCES:

1   Sawyer C, Kassak K
Patient Satisfaction With Chiropractic Care
J Manipulative Physiol Ther 1993 (Jan); 16 (1): 25–32

2   Verhoef MJ, Page SA, Waddell SC
The Chiropractic Outcome Study: Pain, Functional Ability
and Satisfaction With Care
J Manipulative Physiol Ther 1997 (May); 20 (4): 235–240

3   Hawk C, Long CR, Boulanger KT
Patient Satisfaction With the Chiropractic Clinical Encounter:
Report From a Practice-based Research Program
Journal of the Neuromusculoskeletal System 2001: 9 (4): 109–117

4   Gemmell HA, Hayes BM.
Patient Satisfaction With Chiropractic Physicians
In An Independent Physicians' Association
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5   Carey TS, Garrett J, Jackman A, et al.
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Among Patients Seen by Primary Care Practitioners,
Chiropractors, and Orthopedic Surgeons
New England J Medicine 1995 (Oct 5); 333 (14): 913–917

6   Cherkin, D.C. and MacCornack, F.A.
Patient Evaluations of Low Back Pain Care From
Family Physicians and Chiropractors
Western Journal of Medicine 1989 (Mar); 150 (3): 351–355

7   Hertzman-Miller RP, Morgenstern H, Hurwitz EL, et al.
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Randomized to Receive Medical or Chiropractic Care:
Results From the UCLA Low-back Pain Study
Am J Public Health 2002 (Oct); 92 (10): 1628–1633

8   Williams B.
Patient satisfaction: A valid concept?
Social Science and Medicine 1994; 509-516

9   Branson RA.
Cost Comparison of Chiropractic and Medical Treatment of Common
Musculoskeletal Disorders: A Review of the Literature After 1980
Topics in Clinical Chiropractic 1999; 6 (2): 57–68

10   Jarvis K.B., Phillips R.B., Morris E.K.
Cost Per Case Comparison of Back Injury Claims of Chiropractic
Versus Medical Management For Conditions With
Identical Diagnostic Codes
J Occup Med 1991 (Aug); 33 (8): 847–852

11   Nyiendo J, Lamm L
Disabling Low Back Oregon Workers' Compensation Claims. Part I:
Methodology and Clinical Categorization of Chiropractic and Medical Cases
J Manipulative Physiol Ther 1991 (Mar-Apr); 14 (3): 177–184

12   Nyiendo J
Disabling Low Back Oregon Workers' Compensation Claims.
Part II: Time Loss
J Manipulative Physiol Ther 1991 (May); 14 (4): 231–239

13   Nyiendo J
Disabling Low Back Oregon Workers' Compensation Claims. Part III:
Diagnostic and Treatment Procedures and Associated Costs
Journal of Manipulative and Physiological Therapeutics 1991 (Jun); 14 (5): 287-297

14   Johnson M.R., Schultz M.K., Ferguson A.C.
A Comparison of Chiropractic, Medical and Osteopathic Care
for Work-related Sprains and Strains
J Manipulative Physiol Ther 1989 (Oct); 12 (5): 335–344

15   Wolk S
An Analysis of Florida Workers' Compensation Medical Claims
for Back-related Injuries
Journal of the American Chiro Association 1988; 25 (7): 50–59

16   Dean H, Schmidt R
A Comparison of the Cost of Chiropractors Versus Alternative Medical Practitioners
Richmond, VA: Virginia Chiropractic Association, 1992

17   Stano M, Smith M
Chiropractic and Medical Costs of Low Back Care
Medical Care 1996 (Mar); 34 (3): 191–204

18   Smith M, Stano M.
Costs and Recurrences of Chiropractic and Medical Episodes of Low-back Care
Journal of Manipulative and Physiological Therapeutics 1997 (Jan); 20 (1): 5–12

19   Manga P, Angus D, Papadopoulos C, Swan W
The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain
Richmond Hill, Ontario: Kenilworth Publishing, 1993

20   Manga P
Enhanced Chiropractic Coverage Under OHIP as a Means for Reducing
Health Care Costs, Attaining Better Health Outcomes and
Achieving Equitable Access to Health Services
Report to the Ontario Ministry of Health, 1998

21   Shekelle PG, Markovich M, Louie R
Comparing the Costs Between Provider Types of Episodes of Back Pain Care
Spine 1995 (Jan 15); 20 (2): 221–227

22   Cherkin DC, Deyo RA, Battie M, Street J, Barlow W
Comparison of Physical Therapy, Chiropractic Manipulation, and
Provision of an Educational Booklet for the Treatment
of Patients With Low Back Pain
New England Journal of Medicine 1998; 339(14): 1021-1029

23   Rosner A
[Letter to the editor regarding] Comparing the Costs Between
Provider Types of Episodes of Back Pain Care
Spine 1995 (Dec); 20 (23): 2595–2596

24   Burton AK, Tillotson KM, Cleary J
Single-blind Randomised Controlled Trial of Chemonucleolysis and Manipulation
in the Treatment of Symptomatic Lumbar Disc Herniation
European Spine Journal 2000 (Jun); 9 (3): 202–207

25   US Congressional House Subcommittee Oversight Investigation.
Cost and quality of health care: Unnecessary surgery.
Washington, DC: Government Printing Office, 1976

26   Herman R   Back surgery.
Washington Post [Health Section], April 18., 1995

27   Abuse of antibiotics.
Lead editorial. International Herald Tribune June 19, 2000, p. 8

28   National Institute for Health Care Management Research and Education Foundation
report prepared by the Barents Group LLC, July 9, 1999

29   Report from the Department of Health and Human Services,
reported in the New York Times, January 8, 2002

30   Leape L
Unnecessary surgery
Annual Review of Public Health 1992; 13: 363-383

31   Phillips D, Christenfeld N, Glynn L
Increase in US medication-error deaths between 1983 and 1993
Lancet 351: 643-644

32   Lazarou J, Pomeranz B, Corey P
Incidence of adverse drug reactions in hospitalized patients
Journal of the American Medical Association 1998 (Apr 15); 279 (15): 1200-1205

33   Schuster M, McGlynn E. Brook R
How good is the quality of health care in the United States?
Milbank Quarterly 1998; 76 (4): 517-563

34   Kohn LT, Corrigan JM, Donaldson M, eds.
To Err Is Human: Building a Safer Health System
Washington, DC: Institute of Medicine (Nov 1999)

35   Weingart SN, Wilson RM, Gibberd RW, Harrison B
Epidemiology and medical error
British Medical Journal 2000 (Mar 18); 320 (7237): 774-777

36   Reinertsen JL
Let's talk about error. Leaders should take responsibility for mistakes
British Medical Journal 2000 (Mar 18); 320 (7237): 730

37   The Washington Post, December 3, 2002

38   Berens MJ
Oversight panels don't see all facts of medical mistakes cases series:
Dangerous care: Nurses' hidden role in medical error.
Chicago Tribune, September 12, 2000

39   Associated Press release, January 23, 2003

40   Meeker, W., & Haldeman, S. (2002).
Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216–227

41   Stanley J. Bigos, MD, Rev. O. Richard Bowyer, G. Richard Braen, MD, et al.
Acute Lower Back Problems in Adults. Clinical Practice Guideline No. 14.
Rockville, MD: Agency for Health Care Policy and Research, [AHCPR Publication No. 95-0642].
Public Health Service, U.S. Department of Health and Human Services; 1994

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