of Chiropractic Management of Low-Back Pain
1. Pran Manga, Ph.D. 1
1 Professor and Director, Masters in Health Administration Program, University of Ottawa; and President, Pran Manga and Associates Inc., Ottawa.
2 Adjunct Professor, University of Ottawa and Project Director, The Cost-Effectiveness of the Canadian Healthcare System, Queen's - University of Ottawa Economic Projects.
3 Healthcare Consultant and Associate of Pran Manga and Associates, Inc.
4 Consultant in Healthcare Economics.
The support of the Ministry of Health, Government of Ontario, which solely funded the project, is gratefully acknowledged. The views and opinions expressed in this report are those of the authors only, and should not be attributed to the MHA Program, University of Ottawa, the Ministry of Health or the Ontario Chiropractic Association .EXECUTIVE SUMMARY
The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce healthcare costs. It has brought a new and unprecedented emphasis on evidence-based allocation of resources, with an overriding objective of improving the cost-effectiveness of healthcare services.
The area of low-back pain (LBP) offers governments and the private sector an excellent opportunity to attain the twin goals of greater cost-effectiveness and a major reduction in healthcare costs. Today LBP has become one of the most costly causes of illness and disability in Canada - a phenomenon which does not appear to be generally appreciated or understood in medical and government circles in Canada. Studies on the prevalence and incidence of LBP suggest that it is ubiquitous, probably the leading cause of disability and morbidity in middle-aged persons, and by far the most expensive source of workers' compensation costs in Ontario - as indeed in most other jurisdictions.
Much of the treatment of LBP appears to be inefficient. Evidence from Canada, the USA, the UK and elsewhere shows that there are conflicting methods of treatment, many with little - if any scientific evidence of effectiveness, and very high costs of treatment. Despite this, levels of disability from LBP are increasing.
In the Province of Ontario LBP is managed mostly by physicians and chiropractors, with physiotherapists also playing a significant role. While medical services are fully insured under Medicare, chiropractic care services are only partially covered. LBP patients incur the highest out-of-pocket expenses for chiropractic services. Virtually no out-of-pocket expenses are incurred for medical treatment, with the exception of drugs, and out-of-pocket expenses incurred for physiotherapy services fall somewhere in between the two.
Medical physicians, chiropractors, physiotherapists and an assortment of other professionals together offer about thirty-six therapeutic modalities for the treatment of LBP. In this study we focused principally on the effectiveness and cost effectiveness of chiropractic and medical management of LBP.FINDINGS
(a) the effectiveness and cost-effectiveness of chiropractic management of low-back pain.
(b) the untested, questionable or harmful nature of many current medical therapies .
(c) the economic efficiency of chiropractic care for low-back pain compared with medical care.
(d) the safety of chiropractic care.
(e) the higher satisfaction levels expressed by patients of chiropractors, together offers an overwhelming case in favor of much greater use of chiropractic services in the management of low-back pain.
The government will have to instigate and monitor the reform called for by our overall conclusions, and take appropriate steps to see that the savings are captured. The greater use of chiropractic services in the healthcare delivery system will not occur by itself, by accommodation between the professions, or by actions on the part of the Workers' Compensation Board and the private sector generally.
Our recommendations for reform include the following:
Current policy discourages the utilization of chiropractic services for the management of LBP. There should be a shift in policy to encourage and prefer chiropractic services for most patients with LBP.
Chiropractic services should be fully insured under the Ontario Health Insurance Plan, removing the economic disincentive for patients and referring health providers. This one step will bring a shift from medical to chiropractic management that can be expected to lead to very significant savings in healthcare expenditure, and even larger savings if a more comprehensive view of the economic costs of low-back pain is taken.
Chiropractic services should be fully integrated into the healthcare system. Because of the high incidence and cost of LBP, hospitals, managed healthcare groups (community health centres, comprehensive health organizations, and health service organizations) and long-term care facilities should employ chiropractors on a full-time and/or part-time basis. Additionally such organizations should be encouraged to refer patients to chiropractors.
Chiropractors should be employed by tertiary hospitals in Ontario. Hospitals already employ chiropractic in the United States with good effect. Similar recommendations have been made recently by government inquiries in Australia and Sweden, and following government funded research in the U.K. and other countries. Unnecessary or failed surgery is not only costly but also represents low quality care. The opportunity for consultation, second opinion and wider treatment options are significant advantages we foresee from this initiative which has been employed with success in a clinical research setting at the University Hospital, Saskatoon.
Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs.
Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians, and other healthcare professionals upon the consent of their patients. Access should be given upon the request of chiropractors or their patients.
Since low-back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with back injuries. This should be on an interdisciplinary basis with other professional, technical and managerial staff so that there is early development of more constructive relationships between chiropractors, physicians, physiotherapists and Board staff and consultants. A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the workers' compensation system in Ontario.
The government should make the requisite research funds and resources available for further clinical evaluation of chiropractic management of LBP, and for further socioeconomic and policy research concerning the management of LBP generally. Such research should include surveys to obtain a better understanding of patients' choices, attitudes and knowledge of treatments with respect to LBP. The objective of these surveys should be better information for health policy, programme planning and consumer education purposes.
Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public funding. Chiropractic is the only regulated health profession in Ontario without public funding for education at present, and it works against the best interests of the healthcare system for chiropractors to be educated in relative isolation from other health science students.
Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physical therapy professions. Lack of cooperation has been a major factor in the current inefficient management of LBP. Better cooperation is important if the govemment is to capture the large potential savings in question and, it should be noted, is desired by an increasing number of individuals within each of the professions.