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This section details the long history of the cost-effectiveness of chiropractic care.

The Cost-Effectiveness of Chiropractic

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

If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary.   If you want information about a specific disease, you can access the Merck Manual.   You can also search Pub Med for more abstracts on this, or any other health topic.

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Newest Studies

Older Studies

Reference Materials

Newest Cost-Effectiveness Studies

	Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain JAMA Netw Open 2022 (Jul 1); 5 (7): e2222062 ~ FULL TEXT Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain. In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.
	Where to Start? A Two Stage Residual Inclusion Approach to Estimating Influence of the Initial Provider on Health Care Utilization and Costs for Low Back Pain in the US BMC Health Serv Res 2022 (May 23); 22 (1): 694 ~ FULL TEXT Total cost of care was lowest when starting with a chiropractor ($5,093) or primary care physician ($5,660), and highest when starting with an orthopedist ($9,434) or acupuncturist ($9,205). This study found that health care utilization and cost varied by the health care provider type seen on the initial visit for individuals with LBP. The first health care provider seen may also affect the use of evidence-based clinical practice guidelines. Finally, early and long-term opioid use for individuals with LBP varied significantly based on the initial health care provider. While a prospective randomized control trial remains the gold standard for controlling for selection bias, this study provides a large-scale, national view of the complex and real-world relationship between the first provider and subsequent health care utilization and costs. While continued research is needed to fully understand the reasons for cost and utilization differences among the providers, this study suggests that US policymakers should consider current insurance, regulatory and government policy to encourage individuals to seek care from providers that follow clinical practice guidelines.
	Characteristics, Expectations, Experiences of Care, and Satisfaction of Patients Receiving Chiropractic Care in a French University Hospital in Toulouse (France) Over One Year: A Case Study BMC Musculoskelet Disord 2022 (Mar 9); 23 (1): 229 ~ FULL TEXT Most participants presented with chronic neck and low back pain and depressive symptoms. We identified facilitators and barriers for patient expectation and satisfaction with chiropractic care in a hospital setting. These will need to be addressed in order to improve our partnership and the satisfaction of our patients. Future study should explore the practitioner’s experience and perspective. This study provides the first data regarding the collaboration between chiropractors and physicians in France. These findings will inform the improvement of our partnership, student’s training and the development of future hospital-based collaborations integrating chiropractic care in a multidisciplinary team.
	Efficiency of Primary Spine Care as Compared to Conventional Primary Care: A Retrospective Observational Study at an Academic Medical Center Chiropractic & Manual Therapies 2022 (Jan 6); 30 (1): 1 ~ FULL TEXT In our evaluation of this innovative model of spine care, patients who were seen and treated by a PSC clinician embedded in an academic primary care clinic experienced significantly less escalation of their spine care within six months of their initial visit and filled significantly fewer prescriptions for opioid pain medication. The PSC model facilitates greater compliance with current evidence-based guidelines for the management of spine care and may offer a more efficient approach to the primary care of spine problems, as compared to conventional primary care.
	Long-Term Medicare Costs Associated With Opioid Analgesic Therapy vs Spinal Manipulative Therapy for Chronic Low Back Pain in a Cohort of Older Adults J Manipulative Physiol Ther 2021 (Dec 5); S0161-4754(21)00106-8 ~ FULL TEXT Adults aged 65 to 84 who initiated long-term treatment for cLBP via opioid analgesic therapy (OAT) incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with spinal manipulative therapy (SMT).
	Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain Frontiers in Pain Ressearch 2021 (Oct 25); 2: 765921 ~ FULL TEXT For the management of LBP, most guidelines recommend SMT, with some discrepancies regarding the circumstances in which it should be administered. [19, 125] For example, the United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines make it imperative that SMT be offered alongside exercise therapy for LBP irrespective of the stage. [113] In contrast, the American College of Physicians' guidelines endorse SMT as a frontline non-invasive intervention, partly because patients with acute LBP improve over time regardless of treatment. [17] Specifically, for acute stages with or without radiculopathy, clinical practice guidelines recommend the addition of SMT to education, advice to remain active, and self-management. [112, 114, 116] For chronic LBP, the guidelines tend to recommend the use of SMT either alone or preferably in combination with other approaches (frequently second to advice, education, and reassurance) for patients with or without leg pain. [114, 115] Recently, a decision aid developed for managing chronic back pain by Canadian colleges of family physicians endorsed exercise and SMT as the only interventions for which benefits likely exceed harms. [15] For low- and middle-income countries, the Global Spine Care Initiative produced guidelines taking into consideration practical aspects such as cost. [18] Their recommendations are to consider the use of manual therapy (SMT and mobilizations) as one of the primary treatment options in patients with both acute and chronic spine pain and SMT specifically for radicular pain. [18]
	Attitudes Towards Chiropractic: A Repeated Cross-sectional Survey of Canadian Family Physicians BMC Family Practice 2021 (Sep 15); 22 (1): 188 ~ FULL TEXT Although generally positive, Canadian family physicians’ attitudes towards chiropractic range from very positive to extremely negative, and most physicians acknowledge that practice diversity within the chiropractic profession presents a barrier to interprofessional collaboration. Efforts to improve relations could include providing evidence-based information on chiropractic during medical training, and increased opportunities for family physicians and chiropractors to interact.
	The Effect of Reduced Access to Chiropractic Care on Medical Service Use for Spine Conditions Among Older Adults J Manipulative Physiol Ther 2021 (Aug 7); S0161-4754 (21) 00071-3 Individuals seeking chiropractic care have a high degree of confidence in the ability of chiropractors to improve their symptoms40 and have a strong preference for the service.17 Health services do not operate within a vacuum. Studies evaluating the service tend to neglect considering how the CMS's chiropractic care benefit affects the healthcare system at large. We found modest evidence of increased spine surgeries and primary care visits among older adults who lost access to chiropractic care after moving. This suggests that the chiropractic care benefit in Medicare may have an indirect effect on the use of other services for spine conditions. This has important implications for health policy decisions, because it suggests that CMS may be recapturing a sizeable proportion of the payout for the chiropractic care benefit through a reduction in medical service use.
	Cost Comparison of Two Approaches to Chiropractic Care for Patients with Acute and Sub-acute Low Back Pain Care Episodes: A Cohort Study Chiropractic & Manual Therapies 2020 (Dec 14);   28 (1):   68~ FULL TEXT Low back pain (LBP) imposes a costly burden upon patients, healthcare insurers, and society overall. Spinal manipulation as practiced by chiropractors has been found be cost-effective for treatment of LBP, but there is wide variation among chiropractors in their approach to clinical care, and the most cost-effective approach to chiropractic care is uncertain. To date, little has been published regarding the cost effectiveness of different approaches to chiropractic care. Thus, the current study presents a cost comparison between chiropractic approaches for patients with acute or subacute care episodes for low back pain.
	Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study J Manipulative Physiol Ther 2020 (Sep); 43 (7): 667–674 ~ FULL TEXT Among patients with spine-related disorders (SRDs) included in this study, implementation of the primary spine care (PSC) model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.
	Primary Care for Low Back Pain: We Don't Know the Half of It Pain. 2020 (Apr); 161 (4): 663–665 ~ FULL TEXT In a new systematic review, Kamper et al. [What is Usual Care for Low Back Pain?] (See it directly below this article) tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, [17] and there is good evidence for what constitutes best first-contact treatment. [6] The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit). [2, 3, 16] Refer to our extensive collection, titled: Initial Provider/First Contact
	What is Usual Care for Low Back Pain? A Systematic Review of Health Care Provided to Patients with Low Back Pain in Family Practice and Emergency Departments Pain. 2020 (Apr); 161 (4): 694–702 ~ FULL TEXT International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis. Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs. Refer to our extensive collection, titled: Initial Provider/First Contact
	Treatment of Patients with Low Back Pain: A Comparison of Physical Therapy and Chiropractic Manipulation Healthcare (Basel). 2020 (Feb 24); 8 (1): pii: E44 ~ FULL TEXT This study analyzed these two strategies and showed that in the short term, chiropractic care is a more cost-effective alternative compared to PT for the treatment of acute low back pain. Chiropractic resulted in a lower cost ($48.56) and higher DALY (0.0043) than the PT over a one-month treatment period and five months follow-up. However, the marginal cost-effectiveness of chiropractic over PT suggests that both treatments were quite similar. Such findings are in line with the earlier studies, which found that the effectiveness and total costs of chiropractic and PT as primary treatments were similar to each other right after treatment and after 6 months follow-up. [3, 22, 32]
	The Features and Burden of Headaches Within a Chiropractic Clinical Population: A Cross-sectional Analysis Complementary Therapies in Medicine 2020 (Jan); 48: 102276 ~ FULL TEXT One in four participants (n = 57; 25.4%) experienced chronic headaches and 42.0% (n = 88) experienced severe headache pain. In terms of headache features, 20.5% (n = 46) and 16.5% (n = 37) of participants had discrete features of migraine and tension-type headache, respectively, while 33.0% (n = 74) had features of more than one headache type. 'Severe' levels of headache impact were most often reported in those with features of mixed headache (n = 47; 65.3%) and migraine (n = 29; 61.7%). Patients who were satisfied or very satisfied with headache management by a chiropractor were those who were seeking help with headache-related stress or to be more in control of their headaches. Many with headache who consult chiropractors have features of recurrent headaches and experience increased levels of headache disability. These findings may be important to other headache-related healthcare providers and policymakers in their endeavours to provide coordinated, safe and effective care for those with headaches.
	Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid: A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid J Chiropractic Humanities 2019 (Dec 10); 26: 31-52 ~ FULL TEXT Using a dynamic scoring model to incorporate savings from 3 primary sources, we found that (1)   chiropractic care provides better outcomes at lower cost, (2)   chiropractic treatment and care leads to a reduction in costs of spinal surgery, and (3)   chiropractic care leads to cost savings from reduced use and abuse of opioid prescription drugs.
	Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care? Proof of Concept Results from a Markov Model Spine (Phila Pa 1976) 2019 (Oct 15); 44 (20): 1456–1464 ~ FULL TEXT Markov modeling of nonpharmacologic interventions for CLBP is feasible and provides useful information about the effectiveness and cost-effectiveness of these interventions relative to usual care. According to model assumptions these interventions all improve health-related quality of life (QALYs) over usual care, and most, significantly so. In addition, most of these interventions appear cost-effective (and even cost saving) from the payer and societal perspectives, and many of the interventions have their largest impacts on those with high-impact chronic pain. Modeling leverages the investment made in existing trials to provide more useful information than is available from the published studies. We recommend this modeling effort be expanded to include data from all existing studies of nonpharmacologic interventions for chronic low back pain.
	Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study J General Internal Medicine 2019 (Aug); 34 (8): 1381-1382 ~ FULL TEXT In this retrospective, controlled, before-after study, we found that implementation of a conservative spine pain treatment pathway was associated with significant reductions in per-member-per-month (PMPM) healthcare expenditures for spine pain care; most cost savings were attributable to reduction in spine surgery costs. Our Poisson model found relatively reduced opioid utilization and relatively increased manual care costs, both anticipated by-products of guideline implementation. [4] While our findings are preliminary, in an era of increasing healthcare costs and use of complex and expensive spine surgery techniques they show promise for meaningful care cost reduction and value enhancement when providers conservatively manage spine pain. Importantly, our analysis underscores the value of using control groups, formal analytics, and academic partnerships to understand the impact of quality improvement and clinical effectiveness projects, measures that have been recommended to improve the robustness of quality improvement efforts. [5]
	Chiropractic Integration Within a Community Health Centre: A Cost Description and Partial Analysis of Cost-utility from the Perspective of the Institution J Can Chiropr Assoc. 2019 (Aug); 63 (2): 64-79 ~ FULL TEXT This study evaluated the cost-utility of chiropractic integration for low back pain services within a primary care CHC setting from the perspective of the healthcare institution. Among the subjects followed in this study, the addition of chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost. These outcomes, along with the potential cost savings of such integration, may have important implications for healthcare institutions and their patients, as well as for policy decision-makers and other health stakeholders. Future comparative cost and effectiveness studies with control of confounding are nevertheless needed to evaluate the impact of chiropractic care with or without usual medical care in these settings.
	Access to Chiropractic Care and the Cost of Spine Conditions Among Older Adults American Journal of Managed Care 2019 (Aug); 25 (8): e230-e236 ~ FULL TEXT This study is among the first to examine whether access to chiropractic care, a health service that provides a significant amount of the nation’s conservative management of nonspecific back pain, has any effect on Medicare spending. We found some evidence of a relationship between lower accessibility of chiropractic care and higher spending on diagnostic imaging and testing. Future work is required to determine if indeed access to chiropractic care for Medicare beneficiaries in any way breaks the pathway to care that is discordant with practice guidelines
	The Use of Complementary and Integrative Health Approaches for Chronic Musculoskeletal Pain in Younger US Veterans: An Economic Evaluation PLoS One. 2019 (Jun 5); 14 (6): e0217831 ~ FULL TEXT According to our propensity score-weighted HLM analysis, in a cohort of younger Veterans with chronic MSD pain during 2010 through 2013, any use of complementary and integrative health (CIH) was not only cost-effective, it was cost saving. Any use of CIH was associated with an average reduction in healthcare costs of $637, a 0.34-point reduction in pain intensity on a 0-10 pain scale, and a less than one percentage point increase in opioid use during the year after CIH start. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.
	Group and Individual-level Change on Health-related Quality of Life in Chiropractic Patients with Chronic Low Back or Neck Pain Spine (Phila Pa 1976) 2019 (May 1); 44 (9): 647–651 ~ FULL TEXT The results of this study contribute to the literature by providing evidence that chiropractic care is associated with improvements in functioning and well-being among individuals with chronic low back or neck pain. The study findings provide empirical verification of why some chronic pain patients utilize chiropractic care on a regular basis. It supports the use of chiropractic care as one option for improving functioning and well-being of patients with chronic low back pain or neck pain. While we are unable to infer the underlying mechanism for the observed improvements in patients, spinal manipulation is designed to relieve pain and improve physical functioning. Studies of the biomechanics indicate that spinal manipulation produces reflex responses and movements of vertebral bodies in the paraphysiologic zone. [27]
	Expenditures and Health Care Utilization Among Adults with Newly Diagnosed Low Back and Lower Extremity Pain JAMA Network Open 2019 (May 3); 2 (5): e193676 ~ FULL TEXT Guideline nonadherence and spinal surgery in patients with newly diagnosed LBP or LEP are associated with a significant economic burden in the United States. Patients who obtain early imaging or receive surgery for LBP and LEP without exhausting conservative therapies account for a disproportionate amount of total costs associated with this common condition.
	Cost-effectiveness of Spinal Manipulation, Exercise, and Self-management for Spinal Pain Using an Individual Participant Data Meta-analysis Approach: A Study Protocol Chiropractic & Manual Therapies 2018 (Nov 13); 26: 46 ~ FULL TEXT Combined analyses of economic data are rarely possible due to differences in resource utilization outcomes, costs and healthcare settings. [56, 57] Additionally, individual clinical trials rarely include a sufficient number of participants to detect important differences in economic outcomes. This project represents a unique opportunity to potentially combine clinical and economic data collected in eight randomized clinical trials using an IPDMA approach. This will provide more precise estimates of the cost-effectiveness of spinal manipulation, exercise therapy, and self-management compared to analysis of the individual trials. Further, an IPDMA approach has many advantages over traditional meta-analysis including the ability to conduct standardized within-study analyses, account for missing data at the individual level, and investigate potential sub-group effects at the participant level which may account for heterogeneity in estimates across studies. [52]
	Comparative Effectiveness of Usual Care With or Without Chiropractic Care in Patients with Recurrent Musculoskeletal Back and Neck Pain J Gen Intern Med. 2018 (Sep); 33 (9): 1469-1477 We found that referred and non-referred participants had comparable clinical outcomes and that chiropractic referral neither added to health care costs nor introduced significant safety concerns. Data suggest that although two thirds of primary care physicians have recommended chiropractic care to their patients, [36] lack of communication remains a major barrier to care coordination. [37, 38] Better integration of chiropractors into conventional care spine management algorithms could represent a sensible approach to enhancing patient-centered care for patients with chronic musculoskeletal pain.
	Primary Care Management of Non-specific Low Back Pain: Key Messages from Recent Clinical Guidelines Medical J Australia 2018 (Apr 2); 208 (6): 272–275 ~ FULL TEXT Changes in management as a result of the guidelines: emphasising simple first line care with early follow-up; encouraging non-pharmacological treatments over pharmacological treatments; and recommending against the use of surgery, injections and denervation procedures.
	Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain Journal of Occupational Rehabilitation 2017 (Sep); 27 (3): 382-392 ~ FULL TEXT The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.
	This On-site Chiropractic Clinic Is Saving a Minnesota Manufacturer Big Money The Star Tribune ~ Jan 1, 2017 ~ FULL TEXT A year into the project, workers report that they are feeling better and like having health care services at their job. Statistics show that they are incurring injuries at much lower rates. They are also recovering quicker when they do get hurt. And when it comes to the bottom line, the results have been better than Friendship Homes and Northwestern expected. For every $1 that the company has invested in the program, it is saving $8 by avoiding more-costly and less-effective treatments, spending less on insurance payments and keeping more workers on the job in the first place, which generates savings through less lost tine for workers and less overtime to compensate for absences.
	Cost-effectiveness of Spinal Manipulative Therapy, Supervised Exercise, and Home Exercise for Older Adults with Chronic Neck Pain Spine J. 2016 (Nov); 16 (11): 1292-1304 Total costs for spinal manipulative therapy (SMT) + home exercise and advice (HEA) were 5% lower than HEA (mean difference: -$111; 95% confidence interval [CI] -$1,354 to $899) and 47% lower than supervised rehabilitative exercise (SRE) + HEA (mean difference: -$1,932; 95% CI -$2,796 to -$1,097). SMT+HEA also resulted in a greater reduction of neck pain over the year relative to HEA (0.57; 95% CI 0.23 to 0.92) and SRE+HEA (0.41; 95% CI 0.05 to 0.76). Differences in disability and quality-adjusted life years (QALYs) favored SMT+HEA.
	Cost-Effectiveness of Non-Invasive and Non- Pharmacological Interventions for Low Back Pain: A Systematic Literature Review Applied Health Econ and Health Policy 2017 (Apr); 15 (2): 173-201 ~ FULL TEXT Thirty-three studies were identified. Study interventions were categorised as: (1) combined physical exercise and psychological therapy, (2) physical exercise therapy only, (3) information and education, and (4) manual therapy. Interventions assessed within each category varied in terms of their components and delivery. In general, combined physical and psychological treatments, information and education interventions, and manual therapies appeared to be cost effective when compared with the study-specific comparators. There is inconsistent evidence around the cost effectiveness of physical exercise programmes as a whole, with yoga, but not group exercise, being cost effective.
	Effectiveness and Economic Evaluation of Chiropractic Care for the Treatment of Low Back Pain: A Systematic Review of Pragmatic Studies PLoS One. 2016 (Aug 3); 11 (8): e0160037 ~ FULL TEXT Six RCTs and three full economic evaluations were scientifically admissible. Five RCTs with low risk of bias compared chiropractic care to exercise therapy (n = 1), physical therapy (n = 3) and medical care (n = 1). Overall, we found similar effects for chiropractic care and the other types of care and no reports of serious adverse events. Three low to high quality full economic evaluations studies (one cost-effectiveness, one cost-minimization and one cost-benefit) compared chiropractic to medical care. Given the divergent conclusions (favours chiropractic, favours medical care, equivalent options), mixed-evidence was found for economic evaluations of chiropractic care compared to medical care.

The Cost-Effectiveness Triumvirate
	Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 229-239 ~ FULL TEXT Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care.
	Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 240-251 ~ FULL TEXT Increases in utilization and charges were the highest among patterns involving MDs, PTs and referral providers. These findings are consistent with previous studies showing that medical specialty, diagnostic imaging, and invasive procedures (eg, spine injections, surgery) [17, 19, 20, 21] are significant drivers of increasing spine care costs. When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population. This is an opportunity to view costs laterally versus a confined, vertical analysis.
	Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 252-262 ~ FULL TEXT A major strength of the study was the large amount of low back pain claims made available to us for analysis. The data were from 3,159,362 claims generated by approximately 66,0000 persons over the 2000-2009 decade in North Carolina, in several different pathways of healthcare services. This study and the series of papers it has generated on the treatment of low back pain, neck pain [25] and headache, [26] provides unique economic examination for healthcare policy makers and legislators. When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population. This is an opportunity to view costs laterally versus a confined, vertical analysis.

	The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients with Chronic Low Back Pain and Multiple Comorbidities J Manipulative Physiol Ther. 2016 (Feb); 39 (2): 63-75 ~ FULL TEXT After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.
	A Systematic Review Comparing the Costs of Chiropractic Care to other Interventions for Spine Pain in the United States BMC Health Serv Res. 2015 (Oct 19); 15: 474 ~ FULL TEXT The search uncovered 1,276 citations and 25 eligible studies, including 12 from private health plans, 6 from WC plans, and 7 that examined clinical outcomes. Chiropractic care was most commonly compared to care from a medical physician, with few details about the care received. Heterogeneity was noted among studies in patient selection, definition of spine pain, scope of costs compared, study duration, and methods to estimate costs. Overall, cost comparison studies from private health plans and WC plans reported that health care costs were lower with chiropractic care. In studies that also examined clinical outcomes, there were few differences in efficacy between groups, and health care costs were higher for those receiving chiropractic care. The effects of adjusting for differences in sociodemographic, clinical, or other factors between study groups were unclear.
	First-Contact Care With a Medical vs Chiropractic Provider After Consultation with a Swiss Telemedicine Provider: Comparison of Outcomes, Patient Satisfaction, and Health Care Costs in Spinal, Hip, and Shoulder Pain Patients J Manipulative Physiol Ther. 2015 (Sep); 38 (7): 477–483 ~ FULL TEXT JMPT's Editor-in-Chief Claire Johnson, DC, MEd, emphasized the importance of the latest findings: “Comparative studies – in other words, research that compares the outcomes between two different providers or modalities – are rare for chiropractic care,” she said. “Thus, this study by Houweling, et al., is especially important if payers and policy-makers are to better understand the 'triple aim' as it relates to chiropractic. Specifically, this study helps us better understand what type of care provides better patient satisfaction, is more cost effective, and improves population health.”
	Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain J American Board of Family Medicine 2015 (Jul); 28 (4): 481–490 ~ FULL TEXT Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services. When extrapolated to the nation (based on our predictions from our adjusted model), we estimate that chiropractic care is associated with a reduction of 0.37 million visits to PCPs for back and/or neck pain at a total cost of $83.5 million (Table 3).
	Tracking Low Back Problems in a Major Self-Insured Workforce: Toward Improvement in the Patient's Journey J Occup Environ Med. 2014 (Jun); 56 (6): 604-620 ~ FULL TEXT This comprehensive new study from the Journal of Occupational and Environmental Medicine reveals that chiropractic care costs significantly less than other forms of low back care, and appears to comply with guideline recommendations more closely than than any of the other 4 comparison groups.
	Cost-Effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions: A Systematic Review and Narrative Synthesis of Evidence From Randomized Controlled Trials J Manipulative Physiol Ther. 2014 (Jul); 37 (6): 343-362 ~ FULL TEXT This review identified limited evidence indicating that manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy consisting of manipulation and mobilization techniques, and chiropractic manipulation), in addition to other treatments or alone, are more cost-effective than usual GP care (alone or with exercise), spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back pain and/or disability. Similarly, one study [57] demonstrated that spinal manipulation in addition to GP care was more cost-effective than GP care alone in reducing shoulder pain and related disability. The extra costs needed for 1-unit improvement in low back or shoulder pain/disability score or 1 QALY gained were lower than the WTP thresholds reported across the studies.
	Cost Analysis Related to Dose-response of Spinal Manipulative Therapy for Chronic Low Back Pain: Outcomes from a Randomized Controlled Trial J Manipulative Physiol Ther. 2014 (Jun); 37 (5): 300–311 ~ FULL TEXT Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were greater age (P = .03), greater disability (P = .01), lower quality-adjusted life year scores (P = .01), and higher costs in the period preceding enrollment (P < .01). Pain-free and disability-free days were greater for all SMT doses compared with control, but only SMT 12 yielded a statistically significant benefit of 22.9 pain-free days (P = .03) and 19.8 disability-free days (P = .04). No statistically significant group differences in quality-adjusted life years were noted. CONCLUSIONS: A dose of 12 SMT sessions yielded a modest benefit in pain-free and disability-free days. Care of chronic LBP with SMT did not increase the costs of treatment plus lost productivity.
	Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care - Study Protocol for a Randomized Clinical Trial   NCT01539863 Trials. 2014 (Apr 2); 15: 102 ~ FULL TEXT This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden.
	Health Care Utilization and Costs Associated with Adherence to Clinical Practice Guidelines for Early Magnetic Resonance Imaging Among Workers with Acute Occupational Low Back Pain Health Serv Res. 2014 (Apr); 49 (2): 645-665 ~ FULL TEXT Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.
	Conservative Spine Care: Opportunities to Improve the Quality and Value of Care Popul Health Manag. 2013 (Dec); 16 (6): 390-396 ~ FULL TEXT A previous article analyzed current practices regarding the use of coronary stents in the chronic stable angina patient. [4] Musculoskeletal disorders represent another diagnostic class that, while usually not life threatening, results in a high prevalence of morbidity and significant societal burden. [5] Low back pain (LBP) management in particular has been linked to inefficiency and waste. [6] This is likely related, in part, to the growing list of treatment approaches recommended for conservative care (pharmacologic and non-pharmaceutical options) and the difficulty in determining the best option for each patient. [7]
	Trends in the Use and Cost of Chiropractic Spinal Manipulation Under Medicare Part B Spine J. 2013 (Nov); 13 (11): 1449–1454 ~ FULL TEXT The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.
	Early Predictors of Lumbar Spine Surgery After Occupational Back Injury: Results From a Prospective Study of Workers in Washington State Spine (Phila Pa 1976). 2013 (May 15); 38 (11): 953-964 ~ FULL TEXT In this sample, 9.2% of workers receiving temporary total disability compensation soon after an occupational back injury went on to have lumbar spine surgery in the next three years. This rate is similar to rates of lumbar spine surgery following occupational back injury reported in other studies (9.8% [17] and 10.8% [27]). Measures in four domains predicted surgery: sociodemographic, pain and function, clinical status, and health care.
	The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems Medical Care 2012 (Dec); 50 (12): 1029-1036 ~ FULL TEXT While health care conversations increasingly mention chiropractic care as a viable option for back and neck pain - and research increasingly supports its utility from a clinical standpoint - this nationwide study of complementary and alternative medicine (CAM)-related health care expenditures by 12,000-plus adults (ages 17 and older) with spinal conditions lends support to the suggestion that CAM in general, and chiropractic specifically, is also a cost-effective alternative to traditional medical care.
	A Systematic Review and Meta-analysis of Efficacy, Cost-effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-back Pain Evid Based Complement Alternat Med. 2012 (Nov 24); 2012: 953139 ~ FULL TEXT Reports of 147 randomized trials and 5 non-randomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically non-significant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature.
	Spinal Manipulation Epidemiology: Systematic Review of Cost Effectiveness Studies J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 655-662 ~ FULL TEXT Six cost-effectiveness and cost-utility analysis were included. All included studies had a low risk of bias scoring =16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP care, exercise and physiotherapy.
	Cost-effectiveness of Conservative Treatments for Neck Pain: A Systematic Review on Economic Evaluations European Spine Journal 2012 (Aug); 21 (8): 1441-1450 ~ FULL TEXT A total of five economic evaluations met the inclusion criteria. All studies were conducted alongside randomised controlled trials and included a cost-utility analysis, and four studies also conducted a cost-effectiveness analysis. Most often, the economic evaluation was conducted from a societal or a health-care perspective. One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. Pooling of the data was not possible as heterogeneity existed between the studies on participants, interventions, controls, outcomes, follow-up duration and context related socio-political differences.
	Value of Chiropractic Services at an On-site Health Center J Occupational and Environmental Medicine 2012 (Aug); 54 (8): 917-921 ~ FULL TEXT Although previous research has demonstrated the benefits of chiropractic care, to the best of our knowledge this study is the first to evaluate its impact when offered at an on-site health center. [6-10, 14-17] Given the convenience and quality of care provided by on-site health centers, it was hypothesized that on-site chiropractic care would be more beneficial than off-site clinic care. Despite some limitations that may have weakened the conclusions, the findings suggest on-site chiropractic services are associated with lower health care utilization of certain services and improved functional status of musculoskeletal conditions.
	A Model of Integrative Care for Low-back Pain J Altern Complement Med. 2012 (Apr); 18 (4): 354-362 ~ FULL TEXT Historically, federal agencies including the National Institutes of Health, the Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid, the Department of Defense, and the Veterans Administration have not sponsored research aimed at evaluating the cost effectiveness — or lack thereof — of emerging models of multidisciplinary, “integrative care” in the treatment of common medical conditions. This study argues that such comparative effectiveness research in this area is feasible, promising, and warranted, at least with regard to adults with persistent LBP.
	Cost-Effectiveness of General Practice Care for Low Back Pain: A Systematic Review European Spine Journal 2011 (Jul); 20 (7): 1012-1023 ~ FULL TEXT Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual general practitioner (GP) care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone.
	The Trials of Evidence: Interpreting Research and the Case for Chiropractic The Chiropractic Report (July 2011) ~ FULL TEXT For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources - whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).
	Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence J Occupational and Environmental Medicine 2011 (Apr); 53 (4): 396-404 ~ FULL TEXT This study found that you are twice as likely to end up disabled if you get your care from a Physical Therapist, rather than from a DC, and that patients were 60% more likely to be disabled if they choose an MD to manage their care, rather than a DC.
	A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98-106 ~ FULL TEXT A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as "excellent.
	Cost-effectiveness of Guideline-endorsed Treatments for Low Back Pain: A Systematic Review European Spine Journal 2011 (Jul); 20 (7): 1024-1038 ~ FULL TEXT This systematic review of the cost-effectiveness of treatments endorsed in the APS-ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain.
	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 J Manipulative Physiol Ther 2010 (Nov); 33 (9): 640-643 ~ FULL TEXT 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. This clearly demonstrates the savings that are possible when a patient is permitted to choose a chiropractor, rather than an MD for their care.
	Cost and Use of Conservative Management of Lumbar Disc Herniation Before Surgical Discectomy Spine J. 2010 (Jun); 10 (6): 463–468 Lumbar discectomy is one of the most common spine surgical procedures. The average charge for discectomy procedure was $7,841. 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. This study reviewed the costs associated with various conservative measures.
	Functional Scores and Subjective Responses of Injured Workers With Back or Neck Pain Treated With Chiropractic Care in an Integrative Program: A Retrospective Analysis of 100 Cases J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 765-771 ~ FULL TEXT 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.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 3 time-based phases of patient status (acute, subacute, and chronic).
	Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending Mercer Health and Benefits LLC (October 12, 2009) ~ FULL TEXT This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.
	Colorado Workers' Compensation: Medical vs Chiropractic Costs for the Treatment of Lowback Pain J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Sup): S108-116 ~ FULL TEXT This study adds to the understanding of differences associated with costs and services provided by DCs and MDs when treating simple and nonspecific LBP. It does not bring about an understanding of patient satisfaction for each provider or explain all potential benefits that might have been achieved by treatment. Results from our study appear to demonstrate that chiropractic care is more expensive than medical care when treating relatively simple forms of LBP. Because costs can greatly increase because of repeated treatments, the difference in expenses is mainly due to more services and longer treatment periods. Further research is needed to evaluate quality of life and patient satisfaction related to different treatment approaches, as well as follow-up of patient's functional status and stability upon return to work, resumption of activities of daily livings, and impacts of relapses. Future evaluations should also examine effectiveness when treating more complex disorders causing spine and LBP. Cost-effectiveness has become very important when choosing a heath care provider for most third-party payers. However, because patients respond differently to different forms of treatment, it would be in the best interest of both the insurance company and the patient for the patient to be provided preferred treatment options for his/her condition and to take an active role in his/her overall treatment plan.
	Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association: An Additional 3-year Update J Manipulative Physiol Ther 2007 (May); 30 (4): 263-269 ~ FULL TEXT A new retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 83% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.
	Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain J Manipulative Physiol Ther 2005 (Oct); 28 (8): 564-569 ~ FULL TEXT For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.
	Cost-effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555-563 ~ FULL TEXT Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain. There are more articles like this in the Low Back Pain Section.
	Cost Effectiveness of Physical Treatments for Back Pain in Primary Care British Medical Journal 2004 (Dec 11); 329 (7479): 1381 ~ FULL TEXT We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with "usual care" in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain.(1) Read more about this at the UK BEAM Trial Page
	Comparative Analysis of Individuals With and Without Chiropractic Coverage: Patient Characteristics, Utilization, and Costs Archives of Internal Medicine 2004 (Oct 11); 164 (18): 1985-1892 ~ FULL TEXT A 4-year retrospective claims data analysis comparing more than 700,000 health plan members within a managed care environment found that members had lower annual total health care expenditures, utilized x-rays and MRIs less, had less back surgeries, and for patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399). The authors concluded: "Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care." You may also enjoy this recent press release and this glowing review on WebMD.
	An Evaluation of Medical and Chiropractic Provider Utilization and Costs: Treating Injured Workers in North Carolina J Manipulative Physiol Ther 2004 (Sep); 27 (7): 442-448 ~ FULL TEXT These data, with the acknowledged limitations of an insurance database, indicate lower treatment costs, less workdays lost, lower compensation payments, and lower utilization of ancillary medical services for patients treated by DCs. Despite the lower cost of chiropractic management, the use of chiropractic services in North Carolina appears very low.
	Chiropractic Care: Is It Substitution Care or Add-on Care in Corporate Medical Plans? J Occup Environ Med 2004 (Aug); 46 (8): 847-855 An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. These results (of this file review) indicate that patients use chiropractic care as a direct substitution for medical care.
	Clinical and Cost Outcomes of an Integrative Medicine IPA J Manipulative Physiol Ther 2004 (Jun); 27 (5): 336-347 ~ FULL TEXT Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame.
	A Practice-Based Study of Patients With Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-up J Manipulative Physiol Ther 2004 (Mar); 27 (3): 160-169 ~ FULL TEXT This study found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients' first year of symptoms.
	Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States Spine (Phila Pa 1976) 2004 (Jan 1); 29 (1): 79-86 ~ FULL TEXT In 1998, total health care expenditures incurred by individuals with back pain in the United States reached 90.7 billion dollars and total incremental expenditures attributable to back pain among these persons were approximately 26.3 billion dollars. On average, individuals with back pain incurred health care expenditures about 60% higher than individuals without back pain (3,498 dollars vs. 2,178 dollars). Among back pain individuals, at least 75% of service expenditures were attributed to those with top 25% expenditure, and per-capita expenditures were generally higher for those who were older, female, white, medically insured, or suffered from disc disorders. CONCLUSIONS: Health care expenditures for back pain in the United States in 1998 were substantial. The expenditures demonstrated wide variations among individuals with different clinical, demographic, and socioeconomic characteristics.
	Patient Attitudes, Insurance, and Other Determinants of Self-referral to Medical and Chiropractic Physicians Am J Public Health 2003 (Dec); 93 (12): 2111–2117 ~ FULL TEXT Chiropractic and other forms of alternative medicine are being increasingly integrated into managed care, at least partly in response to patient preferences. [31, 35, 36] With evidence of differences in costs and some outcome measures (e.g., satisfaction) of low back treatment by provider type, [37–42] a patient’s choice of provider can promote economic efficiency or hinder it. Our results highlight the importance of patients’ attitudes, health status, and third-party payment in self-referral decisions. In particular, by drawing attention to the role of patient attitudes in self-referral, our work highlights the potential role of education as an indirect way to influence attitudes and thus encourage more cost-effective choices.
	Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce JAMA 2003 (Nov 12); 290 (18): 2443–2454 ~ FULL TEXT The American productivity audit surveyed 29,000 working adults to quantify the impact of reduced performance at work due to pain. Researchers questioned respondents regarding the cost implications of reduced performance were due to headaches, arthritis, back pain and other musculoskeletal pain. Respondents were also asked if the common pain conditions had caused them to lose concentration, repeat jobs, do nothing or feel fatigued at work. The cost of lost productive time in the US workforce was found to be $61 billion, and 76% of that cost was attributed to health-related reduced performance. This is consistent with prior studies that concluded loss of productive time is more significant than absenteeism. The data revealed that 1.1% of the workforce were absent one or more days per week because of common pain conditions.
	Cost Effectiveness of Physiotherapy, Manual Therapy, and General Practitioner Care for Neck Pain: Economic Evaluation Alongside a Randomised Controlled Trial British Medical Journal 2003 (Apr 26); 326 (7395): 911 ~ FULL TEXT A hands-on approach to treating neck pain by manual therapy may help people get better faster and at a lower cost than more traditional treatments, according to this study. After seven and 26 weeks, they found significant improvements in recovery rates in the manual therapy group compared to the other 2 groups. For example, at week seven, 68% of the manual therapy group had recovered from their neck pain vs. 51% in the physical therapy group and 36% in the medical care group. You may also enjoy this WebMD review (Thursday, April 24, 2003) titled: Manual Therapy Eases Neck Pain, Cheaply: Hands-On Approach Effective, and More Cost-Effective, than Traditional Treatments.

The Cost-Effectiveness of Chiropractic From:   Testimony to the Department of Veterans Affairs' Chiropractic Advisory Committee George B. McClelland, D.C., Foundation for Chiropractic Education and Research ~ March 25, 2003 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], [11], [12], [13], [14], [15] databases from insurers, [16], [17], [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 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. From:   Testimony to the Department of Veterans Affairs' Chiropractic Advisory Committee

	Chiropractic Treatment of Workers' Compensation Claimants in the State of Texas MGT of America, Austin, Texas (February 2003) In 2002, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers' compensation, the results of which were published in February 2003. According to the report, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. They found: Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs. These findings were even more intertesting: The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.
	Effects of Inclusion of a Chiropractic Benefit on the Utilization of Health Care Resources in Managed Health Care Plan Craig F Nelson, D.C., MS (2003) A four-year longitudinal study using administrative claims data compared 700,000 health plan members with chiropractic coverage to 1 million health plan members without chiropractic coverage. This study demonstrates that the inclusion of a chiropractic benefit in a managed health care plan results in a reduction in the overall utilization of health care resources, and thereby, cost savings. There are four mechanism that produce this cost reduction: A favorable selection process; A substitution effect of chiropractic care for medical care; Lower rates of use of high cost procedures; Lower cost management of care episodes by chiropractors. You might also enjoy this sidebar article on this topic.
	The Muse Report: Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs American Chiropractic Association (June 2001) This June 2001 study was commissioned by the ACA, and is the first study of its type to compare the global, per capita Medicare expenditures of chiropractic patients to those of non-chiropractic patients receiving care in the federal Medicare program.
	Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial Annals of Internal Medicine 2002 (May 21); 136 (10): 713-722 In this randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) compared to the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery.
	Cost-effectiveness Studies of Medical and Chiropractic Care for Occupational Low Back Pain. A Critical Review of the Literature Spine J. 2001 (Mar); 1 (2): 138-147 The current literature suggests that chiropractors and physicians provide equally effective care for OLBP but that chiropractic patients are more satisfied with their care. Evidence on the relative costs of medical and chiropractic care is conflicting. Several methodological deficiencies limit the validity of the reviewed studies. No studies combine high-quality cost data with adequate sample sizes and controls for confounding factors.
	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 Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. In this study 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.
	Economic Case for the Integration of Chiropractic Services into the Health Care System J Manipulative Physiol Ther 2000 (Feb); 23 (2): 118-122 ~ FULL TEXT For much of its history, chiropractic care has been both an alternative therapeutic paradigm and separate from or marginal to the mainstream health care system. Over the past decade, the situation has changed somewhat in that chiropractic care is gradually being integrated within a variety of health care delivery organizations. According to Triano et al,1 by the application of evidence-based health care and good business, there is a surge in cooperation and integration among chiropractors, allopathic physicians, allied health care providers, ancillary therapists, and respective support staff. There is, however, no quantification of the level of integration. Integration may also be more true of the United States than elsewhere. The overall position of chiropractic care as alternative and separate still predominates. This situation does not serve the interests of the chiropractic profession nor the public well. There is a persuasive economic case for a radical shift in the role of chiropractic care to one that may succinctly be described as alternative and mainstream. The chiropractic profession must preserve its identity and its unique therapeutic paradigm and continue to be seen as an alternative to other health care professions, especially medical doctors. However, it should also become mainstream and thus widely available and accessible to the public by being integrated into the wide variety of health care delivery organizations that collectively constitute the health care system.
	Studies on Chiropractic 2000 National Board of Chiropractic Examiners Chiropractic is now firmly rooted in the public consciousness as a primary agent of health care management. According to a 1990 study published in the New England Journal of Medicine, the number of visits to non-medical health care providers in 1990 totaled 425 million, 9.5% more than the total number of visits to all family physicians (Eisenberg et al.1993). A follow-up study determined that, in 1997, total visits to non-medical providers amounted to 629 million, exceeding the total projected visits to all primary care physicians by 63% (Eisenberg et al. 1998). Moreover, a 1998 study published in the New England Journal of Medicine reported chiropractic as the most used non-medical treatment (15.7%) (Astin 1998).
	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 A total of 5 prospective and 19 retrospective studies was identified. Twelve of the 24 studies were published since 1994. Sixteen of the 24 studies average total costs favored chiropractic treatment.
	Managed Care Preapproval and its Effect on the Cost of Utah Worker Compensation Claims J Manipulative Physiol Ther 1997 (Jul); 20 (6): 372–376 Treatment costs in cases managed by chiropractic physicians increased 12% between 1986 and 1989. Treatment cost in cases managed by medical physicians increased 71% in the same time period. Compensation (wage replacement) costs increased 21% for the chiropractic group and 114% for the medical group.
	Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs, Attaining Better Health Outcomes and Achieving Equitable Access to Select Health Services Report to the Ontario Ministry of Health, 1998 PDF Expenditure to improve access to chiropractic services, and the changed utilization patterns it produces, will lead to very substantial net savings in direct and indirect costs. Direct savings to Ontario's health care system may be as much as $770 million, will very likely be $548 million, and will be at least $380 million. The corresponding savings in indirect costs - made up of the short and long term costs of disability - are $3.775 billion, $1.849 billion and $1.255 billion.
	Costs and Recurrences of Chiropractic and Medical Episodes of Low-back Care J Manipulative Physiol Ther 1997 (Jan); 20 (1): 5-12 Total insurance payments within and across episodes were substantially greater for medically initiated episodes. Analysis of recurrent episodes as measures of patient outcomes indicated that chiropractic providers retain more patients for subsequent episodes, but that there is no significant difference in lapse time between episodes for chiropractic vs. medical providers. Chiropractic and medical patients were comparable on measures of severity; however, the chiropractic cohort included a greater proportion of chronic cases.
	Chiropractic and Medical Costs of Low Back Care Medical Care 1996 (Mar); 34 (3): 191-204 This study compares health insurance payments and patient utilization patterns for episodes of care for common lumbar and low back conditions treated by chiropractic and medical providers. Using 2 years of insurance claims data, this study examines 6,183 patients who had episodes with medical or chiropractic first-contact providers. Multiple regression analysis, to control for differences in patient, clinical, and insurance characteristics, indicates that total insurance payments were substantially greater for episodes with a medical first-contact provider.
	The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons New England J Medicine 1995 (Oct 5); 333 (14): 913–917 The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors.
	Preliminary Findings of Analysis of Chiropractic Utilization and Cost in the Workers' Compensation System of New South Wales, Australia J Manipulative Physiol Ther 1995 (Oct); 18 (8): 503-511 The methodology used was found to be able to provide a basis for comparison of costs for care apportioned to chiropractic and other interventions. An analysis of 20 randomly selected cases from the WCA suggested that chiropractic intervention for certain conditions may be more cost-effective than other forms of intervention.
	Comparing the Costs Between Provider Types of Episodes of Back Pain Care Spine (Phila Pa 1976) 1995 (Jan 15); 20 (2): 221-227 There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits. Chiropractors and general practitioners were the primary providers for 40% and 26% of episodes, respectively. Chiropractors had a significantly greater mean number of visits per episode (10.4) than did other practitioners. Orthopedic physicians and "other" physicians were significantly more costly on a per visit basis. Orthopedists had the highest mean total cost per episode, and general practitioners the lowest.
	Further Analysis of Health Care Costs for Chiropractic and Medical Patients J Manipulative Physiol Ther 1994 (Sep); 17 (7): 442-446 The analysis of well-insured patients in plans that do not restrict the chiropractic benefit strengthens results previously reported. In this study, therefore, the favorable cost patterns for chiropractic patients cannot be attributed to insurance restrictions limiting reimbursement for chiropractic services relative to other services. Because adjustments for patient characteristics systematically reduce the cost advantages of chiropractic patients as compared to mean differences derived from unadjusted data, the results also demonstrate that adjusted values should be used for meaningful comparisons between the two groups of patients.
	A Comparison of Health Care Costs for Chiropractic and Medical Patients J Manipulative Physiol Ther 1993 (Jun); 16 (5): 291-299 Nearly one-fourth of patients were treated by chiropractors. Patients receiving chiropractic care experienced significantly lower health care costs as represented by third party payments in the fee-for-service sector. Total cost differences on the order of $1,000 over the 2-yr period were found in the total sample of patients as well as in subsamples of patients with specific disorders. The lower costs are attributable mainly to lower inpatient utilization. The cost differences remain statistically significant after controlling for patient demographics and insurance plan characteristics.
	The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain Richmond Hill, Ontario: Kenilworth Publishing, 1993 A major study to assess the most appropriate use of available health care resources was reported in 1993. This was an outcomes study funded by the Ontario Ministry of Health. The study was conducted by three health economists led by University of Ottawa Professor Pran Manga, Ph.D. The report of the study is commonly called the Manga Report. The Manga Report overwhelmingly supported the efficacy, safety, scientific validity, and cost-effectiveness of chiropractic for low-back pain. Additionally, it found that higher patient satisfaction levels were associated with chiropractic care than with medical treatment alternatives. On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. It also found that many medical therapies are of questionable validity, or are clearly inadequate.
	Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management Within the Victorian WorkCare Scheme Chiropractic Journal of Australia 1992 (Jun); 22 (2): 47-53 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 average payment per claim with medical management.
	A Comparison of the Cost of Chiropractors Versus Alternative Medical Practitioners Richmond, VA: Virginia Chiropractic Association (1992) A 1992 study conducted by L.G. Schifrin, Ph.D., provided an economic assessment of mandated health insurance coverage for chiropractic treatment within the Commonwealth of Virginia. As reported by the College of William and Mary, and the Medical College of Virginia, the study indicated that chiropractic provides therapeutic benefits at economical costs. The report also recommended that chiropractic be a widely available form of health care. This paper is unavailable through PubMed or the Mantis database.
	Cost Per Case Comparison of Back Injury Claims of Chiropractic Versus Medical Management for Conditions With Identical Diagnostic Codes J Occupational and Environmental Medicine 1991 (Aug); 33 (8)\: 847-852 This Workers' Compensation study conducted in Utah compared the cost of chiropractic care to the costs of medical care for conditions with identical diagnostic codes. The study indicated that costs were significantly higher for medical claims than for chiropractic claims. The sample consisted of 3062 claims or 40.6% of the 7551 estimated back injury claims from the 1986 Workers' Compensation Fund of Utah. For the total data set, cost for care was significantly more for medical claims, and compensation costs were 10-fold less for chiropractic claims. See a second review of this study below

A Workers' Compensation Collection A Unique Series of Articles Disabling Low Back Oregon Workers' Compensation Claims. Part I: Methodology and Clinical Categorization of Chiropractic and Medical Cases J Manipulative Physiol Ther 1991 (Mar); 14 (3): 177-184 The two provider groups differed in the proportion of claimants who had physical factors contributing to low back compromise. DC claimants were less likely than MD claimants to have sought initial treatment in the emergency room, more likely to have a history of chronic, recurrent low back pain and more likely to have suffered exacerbation episodes. These differences suggest a greater level of chronicity among chiropractic claimants. Disabling Low Back Oregon Workers' Compensation Claims Part II: Time Loss J Manipulative Physiol Ther 1991 (May); 14 (4): 231-239 for claimants with a history of chronic low back problems, the median time loss days for MD cases was 34.5 days, compared to 9 days for DC cases. It is suggested that chiropractors are better able to manage injured workers with a history of chronic low back problems and to return them more quickly to productive employment. Disabling Low Back Oregon Workers' Compensation Claims Part III: Diagnostic and Treatment Procedures and Associated Costs J Manipulative Physiol Ther. 1991 (Jun); 14 (5): 287-297 Claimants in Oregon with disabling low back injuries attending chiropractors were found to have more treatments over a longer duration and at greater cost than claimants attending medical physicians with similar clinical presentations. These findings are attributed to: a) a higher proportion of chiropractic claimants than medical physician claimants with low back risk factors which may have adversely affected the course of recovery (chronic or recurrent low back conditions, obesity, extremity symptomatology, frequency of exacerbations); b) differences in age and gender of DC and MD claimants; c) the greater physician-patient contact hours characteristic of chiropractic practice; d) differences in therapeutic modalities employed; and e) the physician reimbursement permitted under Oregon workers' compensation law. The findings of this study emphasize the need for prospective studies of treatment outcome.

A Comparison of Chiropractic, Medical and Osteopathic Care for Work-related Sprains and Strains J Manipulative Physiol Ther 1989 (Oct); 12 (5): 335-344 For those who received care from DCs (n = 266), the mean number of compensated days lost from work was at least 2.3 days less than for those who were treated by MDs (n = 494; p less than 0.025) and at least 3.8 days less than for those who were treated by DOs (n = 102; p less than 0.025). Consequently, much less money in employment compensation was paid, on the average, to those who saw DCs.

An Analysis of Florida Workers' Compensation Medical Claims for Back-related Injuries Journal of the American Chiro Association 1988; 25 (7): 50-59 This study of 10,652 Florida Workers’ Compensation cases was conducted by Steve Wolk, Ph.D. , and reported by the Foundation for Chiropractic Education and Research. It was concluded that “a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled, or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors.” The analysis focused on the cost of treatment, frequency of compensable injuries (an injury which disables an individual for more than seven days, resulting in wage compensation benefits), and frequency of hospitalization for workers' compensation claim patient (end of reference).

Editorial: End Medical Mis-Management of Musculoskeletal Complaints Q.   Are medical doctors well-trained to diagnose or treat musculoskeletal complaints? A.   Read the unsettling answer in this series of articles Educational Deficiencies in Musculoskeletal Medicine Journal of Bone and Joint Surgery 2002 (Apr); 84-A (4): 604-608 According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. NOTE: This is a follow-up article to the study cited below, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. Ask yourself:   What would the headlines scream if, after 4 years, chiropractors had failed to improve their skills in musculoskeletal assessment and management? Why is medicine is shown more slack? The Adequacy of Medical School Education in Musculoskeletal Medicine Journal of Bone and Joint Surgery 1998 (Oct); 80-A (10): 1421-1427 This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that "we therefore believe that medical school preparation in musculoskeletal medicine is inadequate" and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. Educating Medical Students About Musculoskeletal Problems: Are Community Needs Reflected in the Curricula of Canadian Medical Schools? Journal of Bone and Joint Surgery 2001 (Sept); 83-A (9): 1317-1320 Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools. A Comparison of Chiropractic Student Knowledge Versus Medical Residents Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255 A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the orthopedic residents. Musculoskeletal Knowledge: How Do You Stack Up? Physician and Sportsmedicine 2002; 30 (8) August One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 5% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership. Musculoskeletal Curricula in Medical Education Physician and Sportsmedicine 2004 (Nov); 32 (11) It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.1 While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training. Adequacy of Education in Musculoskeletal Medicine J Bone Joint Surg Am 2005 (Feb); 87 (2): 310-314 In this study, 334 medical students, residents and staff physicians, specializing in various fields of medicine, were asked to take a basic cognitive examination consisting of 25 short-answer questions - the same type of test administered in the original JBJS 1998 study. The average score among medical doctors, students and residents who took the exam in 2005 was 2.7 points lower than those who took the exam in 1998. Just over half of the staff physicians (52%) scored a passing grade or higher on the 2005 exam. Only 21% of the residents registered a passing grade, and only 5% of the medical students passed the exam. Overall, Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination. More Evidence of Educational Inadequacies in Musculoskeletal Medicine Clin Orthop Relat Res 2005 (Aug); (437): 251-259 A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

Additional (Older) Cost-Effectiveness Studies

Thanks to the NBCE for access to this information!

Practice Analysis of Chiropractic 2020 PDF Practice Analysis of Chiropractic 2015 Practice Analysis of Chiropractic 2010 Job Analysis of Chiropractic 2005 Job Analysis of Chiropractic 2000 Job Analysis of Chiropractic 1993 NBCE's Practice Analysis Archive (See 2 other files)

The National Board of Chiropractic Examiners published reports based on a four-year study of chiropractic. These reports focused on three surveys including full-time, licensed U.S., Canadian and registered Australian and New Zealand chiropractic practitioners. The surveys and their resulting reports are titled Job Analysis of Chiropractic. Following publication of the Job Analysis of Chiropractic, the NBCE began to receive requests for permission to reproduce certain portions of the reports. In response to those requests, the NBCE has condensed relevant portions and reprinted them in this brochure. In recent years, numerous independent researchers and various government agencies have conducted studies which focus on the efficacy, appropriateness and cost-effectiveness of chiropractic treatment. Several of these important studies are listed below.

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• U.S. GOVERNMENT AGENCY REPORT

A 1994 study published by the U.S. Agency for Health Care Policy and Research (AHCPR) and the U.S. Department of Health and Human Services endorses spinal manipulation for acute low back pain in adults in its Clinical Practice Guideline # 14. An independent multidisciplinary panel of private-sector clinicians and other experts convened and developed specific statements on appropriate health care of acute low back problems in adults. One statement cited, relief of discomfort (low back pain) can be accomplished most safely with spinal manipulation, and/or nonprescription medication.

Acute Low Back Problems in Adults ~ AHCPR Clinical Practice Guidelines, No. 14
Clinical Practice Guideline 14
AHCPR Publication No. 95-0642:
December 1994

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• THE MANGA REPORT

A major study to assess the most appropriate use of available health care resources was reported in 1993. This was an outcomes study funded by the Ontario Ministry of Health and conducted in hopes of sharing information about ways to reduce the incidence of work-related injuries and to address cost-effective ways to rehabilitate disabled and injured workers. The study was conducted by three health economists led by University of Ottawa Professor Pran Manga, Ph.D. The report of the study is commonly called the Manga Report. The Manga Report overwhelmingly supported the efficacy, safety, scientific validity, and cost-effectiveness of chiropractic for low-back pain. Additionally, it found that higher patient satisfaction levels were associated with chiropractic care than with medical treatment alternatives.

"Evidence from Canada and other countries suggests potential savings of hundreds of millions annually,"
the Manga Report states.

"The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability."

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

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• RAND STUDY ON LOW-BACK PAIN

A four-phase study conducted in the early 1990s by RAND, one of America's most prestigious centers for research in public policy, science and technology, explored many indications of low-back pain. In the RAND studies, an expert panel of researchers, including medical doctors and doctors of chiropractic, found that:

• chiropractors deliver a substantial amount of health care to the U.S. population.

• spinal manipulation is of benefit to some patients with acute low-back pain.

The RAND reports marked the first time that representatives of the medical community went on record stating that spinal manipulation is an appropriate treatment for certain low-back pain conditions.

The Appropriateness of Spinal Manipulation for Low-Back Pain.
Project Overview and Literature Review
RAND Corp., Santa Monica, CA; 1991

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• THE NEW ZEALAND COMMISSION REPORT

A particularly significant study of chiropractic was conducted between 1978-1980 by the New Zealand Commission of Inquiry. In its 377-page report to the House of Representatives, the Commission called its study "probably the most comprehensive and detailed independent examination of chiropractic ever undertaken in any country." The Commission entered the inquiry with "the general impression ... shared by many in the community: that chiropractic was an unscientific cult, not to be compared with orthodox medical or paramedical services."

By the end of the inquiry, the commission reported itself "irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is a soundly-based and valuable branch of health care in a specialized area...: Conclusions of the Commission's report, based on investigations in New Zealand, the U.S., Canada, the United Kingdom, and Australia, stated:

• Spinal manual therapy in the hands of a registered chiropractor is safe.

• Spinal manual therapy can be effective in relieving musculo-skeletal symptoms such as back pain, and other symptoms known to respond to such therapy, such as migraine.

• Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy.

• In the public interest and in the interests of patients, there must be no impediment to full professional cooperation between chiropractors and medical practitioners.

The New Zealand Report - 1978

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• STATE OF TEXAS WORKERS' COMPENSATION STUDY OF 2003

In 2002, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers' compensation, the results of which were published in February. According to the report, Chiropractic Treatment of Workers' Compensation Claimants in the State of Texas, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. They found: Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs.

These findings were even more intertesting: The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.

Chiropractic Treatment of Workers' Compensation
Claimants in the State of Texas
MGT of America, Austin, Texas ~ February 2003

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• FLORIDA WORKERS' COMPENSATION STUDY

A 1988 study of 10,652 Florida workers' compensation cases was conducted by Steve Wolk, Ph.D. , and reported by the Foundation for Chiropractic Education and Research (FCER). It was concluded that "a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled, or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors." Some of the study results were:

• 51.3 percent shorter temporary total disability duration with chiropractic care

• lower treatment cost by 58.8 percent ($558 vs. $1,100 per case) in the chiropractic group, and

• 20.3 percent hospitalization rate in the chiropractic care group vs. 52.2 percent rate in the medical care group

An Analysis of Florida Workers' Compensation
Medical Claims for Back-related Injuries
J American Chiro Association 1988; 25 (7): 50-59

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• WASHINGTON HMO STUDY

In 1989, a survey administered by Daniel C. Cherkin, Ph.D., and Frederick A. MacCornack, Ph.D., concluded that patients receiving care from health maintenance organizations (HMOs) within the state of Washington were three times as likely to report satisfaction with care from chiropractors as they were with care from other physicians. The patients were also more likely to believe that their chiropractor was concerned about them.

Patient Evaluations of Low Back Pain Care
From Family Physicians and Chiropractors
Western Journal of Medicine 1989 (Mar); 150 (3): 351-355

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• UTAH WORKERS' COMPENSATION STUDY

A workers' compensation study conducted in Utah by Kelly B. Jarvis, D.C., Reed B. Phillips, D.C., Ph.D., and Elliot K. Morris, JD, MBA, compared the cost of chiropractic care to the costs of medical care for conditions with identical diagnostic codes. Results were reported in the August 1991 Journal of Occupational Medicine. The study indicated that costs were significantly higher for medical claims than for chiropractic claims; in addition, the number of work days lost was nearly ten times higher for those who received medical care instead of chiropractic care.

This Compensation Board study found the total treatment costs for back-related injuries cost an average of $775.30 per case when treated by a doctor of chiropractic. When injured workers received standard medical treatment as opposed to chiropractic treatment, the average cost per case was $1,665.43. They also found the mean compensation cost paid out by the Utah Worker's Compensation Board for patients treated by medical doctors was $668.39, while the mean compensation cost paid for patients treated by chiropractic doctors was only $68.38.

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

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• PATIENT DISABILITY COMPARISON

A 1992 article in the Journal of Family Practice reported a study by DC Cherkin, Ph.D., which compared patients of family physicians and of chiropractors. The article stated "the number of days of disability for patients seen by family physicians was significantly higher (mean 39.7) than for patients managed by chiropractors (mean 10.8)." A related editorial in the same issue referred to risks of complications from lumbar manipulation as being "very low."

Family Physicians and Chiropractors:
What's Best for the Patient?
J Family Practice 1992; 35 (5): 505-506

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• OREGON WORKERS' COMPENSATION STUDY

A 1991 report on a workers' compensation study conducted in Oregon by Joanne Nyiendo, Ph.D., concluded that the median time loss days (per case) for comparable injuries was 9.0 for patients receiving treatment by a doctor of chiropractic and 11.5 for treatment by a medical doctor.

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

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• STANO COST COMPARISON STUDY

Miron Stano, PhD, a health care economist at Oakland University, conducted a study comparing the health-care costs for chiropractic and medical patients with neuromusculoskeletal conditions. The database he used came from the records of MEDSTAT Systems, Inc., a health benefits management consulting firm which processes insurance claims for many of the country's largest corporations. This June 1993 Journal of Manipulative and Physiological Therapeutics study involved 395,641 patients, drawn from statistical information on more than two million beneficiaries. Results over a two-year period showed that patients who received chiropractic care incurred significantly lower health care costs than did patients treated solely by medical or osteopathic physicians.



DISTRIBUTION OF TOTAL COST PER CASE FOR SELECTED ICD-9 CODES (MEAN VALUES)
ICD-9 CODE	DIAGNOSIS	TOTAL COST (MEDICAL)	TOTAL COST (CHIROPRACTIC)
722.10	Lumbar Disc	$ 8,175	$ 1,065
724.40	Neuritis/Radiculitis	$ 2,154	$ 531
846.00	Sprain/Sacroiliac	$ 813	$ 537
847.00	Sprain/Strain Cervical	$ 968	$ 586
847.10	Sprain/Strain Thoracic	$ 487	$ 474
847.20	Sprain/Strain Lumbar	$ 969	$ 523
Total Cost of Selected Cases		$ 13,556	$ 3,716
Average Cost Per Case		$ 2,259	$ 619



Also of interest, for those patients receiving both medical and chiropractic care, the Stano/MEDSTAT results revealed:

• 31 percent lower hospital admissions rates;

• 43 percent lower inpatient payments; and

• 23 percent lower total health care costs.

A Comparison of Health Care Costs
for Chiropractic and Medical Patients
J Manipulative Physiol Ther 1993 (Jun); 16 (5): 291-299

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• SASKATCHEWAN CLINICAL RESEARCH

Following a 1993 study, researchers J. David Cassidy, D.C., Haymo Thiel, D.C., M.S., and W. Kirkaldy-Willis, M.D., of the Back Pain Clinic at the Royal University Hospital in Saskatchewan concluded that "the treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective."

Side Posture Manipulation for Lumbar
Intervertebral Disk Herniation
J Manipulative Physiol Ther 1993 (Feb); 16 (2): 96-103

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• UNIVERSITY OF SASKATCHEWAN STUDY OF 1985

In 1985 the University of Saskatchewan conducted a study of 283 patients "who had not responded to previous conservative or operative treatment" and who were initially classified as totally disabled. The study revealed that "81% ... became symptom free or achieved a state of mild intermittent pain with no work restrictions" after daily spinal manipulations were administered.

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• WIGHT STUDY ON RECURRING HEADACHES

A 1978 study conducted by J.S. Wight, D.C. , and reported in the ACA Journal of Chiropractic, indicated that 74.6% of patients with recurring headaches, including migraines, were either cured or experienced reduced headache symptomatology after receiving chiropractic manipulation.

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• 1991 GALLUP POLL

A 1991 demographic poll conducted by the Gallup Organization revealed that 90% of chiropractic patients felt their treatment was effective; more than 80% were satisfied with that treatment; and nearly 73% felt most of their expectations had been met during their chiropractic visits.

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• 1990 BRITISH MEDICAL JOURNAL REPORT

A study conducted by T.W. Meade, a medical doctor, and reported in the June 2, 1990, British Medical Journal concluded after two years of patient monitoring, "for patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management."

More importantly, this article contradicts other articles which maintained that spinal adjusting (manipulation) was only effective for "acute" low back pain. This article found: The benefit is seen mainly in those with chronic or severe pain. It also suggested that "introducing chiropractic into NHS practice should be considered."

Low Back Pain of Mechanical Origin: Randomised
Comparison of Chiropractic and
Hospital Outpatient Treatment
British Medical Journal 1990 (Jun 2); 300 (6737): 1431-1437

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• VIRGINIA COMPARATIVE STUDY

A 1992 study conducted by L.G. Schifrin, Ph.D., provided an economic assessment of mandated health insurance coverage for chiropractic treatment within the Commonwealth of Virginia. This economic analysis found chiropractic care to be a lower cost option for back-related ailments. The researchers concluded that if chiropractic care was insured to the extent of other medical specialties, it would likely emerge as a first option for many patients with certain medical conditions. They also believed this could result in a decrease in the overall treatment costs for these conditions. The study reported that:

• The low cost of chiropractic is due not to its low rate of use, but to its apparently offsetting impacts on costs in the face of high rates of utilization. Chiropractic is a growing component of the health care sector, and it is widely used by the population.

• Formal studies of the cost, effectiveness, or both of chiropractic, usually measured against other forms of treatment, show it to compare favorably with them.

• By every test of cost and effectiveness, the general weight of evidence shows chiropractic to provide important therapeutic benefits, at economical costs. Additionally, these benefits are achieved with apparently minimal, even negligible, impacts on the costs of health insurance.

• The conclusion of this analysis is that chiropractic mandates help make available health care that is widely used by the American public and has proven to be cost-effective.

Mandated Health Insurance Coverage for Chiropractic Treatment:
An Economic Assessment, with Implications for the Commonwealth of Virginia
The College of William and Mary, Williamsburg, Virginia, and Medical College of Virginia, Richmond, Virginia - January 1992.

Return to the Top

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• 1992 AMERICA HEALTH POLICY REPORT

A 1992 review of data from over 2,000,000 users of chiropractic care in the U.S., reported in the Journal of American Health Policy, stated that "chiropractic users tend to have substantially lower total health care costs," and that "chiropractic care reduces the use of both physician and hospital care."

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• 1985 UNIVERSITY OF SASKATCHEWAN STUDY

In 1985 the University of Saskatchewan conducted a study of 283 patients "who had not responded to previous conservative or operative treatment" and who were initially classified as totally disabled. The study revealed that "81% ... became symptom free or achieved a state of mild intermittent pain with no work restrictions" after daily spinal manipulations were administered.

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Further validation of chiropractic care evolved from an antitrust suit which was filed by four members of the chiropractic profession against the American Medical Association (AMA) and a number of other health care organizations in the U.S. (Wilk et al v. AMA et al, 1990). Following 11 years of litigation, a federal appellate court judge upheld a ruling by U.S. District Court Judge Susan Getzendanner that the AMA had engaged in a "lengthy, systematic, successful and unlawful boycott" designed to restrict cooperation between MDs and chiropractors in order to eliminate the profession of chiropractic as a competitor in the U.S. health care system.

Judge Getzendanner rejected the AMA's patient care defense, and cited scientific studies which implied that "chiropractic care was twice as effective as medical care in relieving many painful conditions of the neck and back as well as related musculo-skeletal problems." Since the court's findings and conclusions were released, an increasing number of medical doctors, hospitals, and health care organizations in the U.S. have begun to include the services of chiropractors.

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In order to become a licensed doctor of chiropractic, an individual must meet stringent testing, academic and professional requirements. Currently, an individual must complete the four major steps shown below in order to become a chiropractic practitioner:
.

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CHIROPRACTIC TRAINING

Government inquiries (some of which are described in this brochure), as well as independent investigations by medical practitioners, have affirmed that today's chiropractic academic training is of equivalent standard to medical training in all pre-clinical subjects. High standards in chiropractic education are maintained by the Council on Chiropractic Education (CCE) and its Commission on Accreditation, as recognized by the U.S. Department of Education.

Some Chiropractic colleges require a Bachelor's degree before enrollment. A doctor of chiropractic's training generally requires a minimum of six years of college study (two years of which are undergraduate course work) and an internship prior to entering practice. Post-doctoral training in a variety of clinical disciplines and specialties is also available through accredited colleges and specialty councils.

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CHIROPRACTIC LICENSING

Chiropractic is one of many occupations which are regulated by state licensing agencies. The requirements for chiropractic licensure vary from state to state (and country to country). Some states require a Bachelor's degree as a prerequisite for licensure. To assist the various regulatory agencies in assessing candidates for licensure, the National Board administers examinations to individuals currently in the chiropractic educational system or who have completed a chiropractic educational program. The National Board also offers an examination designed for previously licensed individuals.

A candidate for chiropractic licensure may request that transcripts of scores from National Board examinations be forwarded to licensing agencies which assess eligibility for licensure. Scores from National Board examinations are made available to licensing agencies throughout the U.S. and in some foreign countries including Canada, the United Kingdom, France and Australia.

Reference Materials

	Initial Provider/First Contact and Chiropractic A Chiro.Org article collection Although the Cost Effectiveness page has always painted a rosey picture for patients and Insurers, recent studies have zeroed in on the extent of that savings when chiropractors are the first provider of care. As you will see, when we are the first and only provider, the savings are the greatest. In 1993 Pran Manga, Ph.D. recommended that placing DCs as the gatekeepers in Hospitals and for Work-related MSK injuries would save Ontario. Canada a fortune, and that has been bourne out in the studies that followed.
	Non-pharmacologic Therapy and Chiropractic A Chiro.Org article collection Onc of the few silver linings in the Opioid Epidemic storm cloud was the studies looking at which patients ended up being swallowed by opioid addiction. Chiropractic is an effective approach for managing musculoskeletal pain, and that has saved many of them from starting down that dark path.
	Chiropractic: A Safe and Cost Effective Approach to Health Cleveland College of Chiropractic (2017) ~ FULL TEXT Manipulation, which chiropractors usually refer to as an “adjustment,” continues to meet the threshold of scientific scrutiny for many neurological and musculoskeletal conditions. In addition to the adjustment, chiropractors often advise and instruct on posture, stretching, exercise, rehabilitation, nutrition, hydration, and stress management as part of their care. While often assisting in repair and recovery of patient health, a chiropractor’s focus is primarily on healthy living (now commonly referred to as wellness by the rest of the population) and optimization (helping a patient get the best outcome from their body). I have personally sought their treatment for my own musculoskeletal complaints ranging from operative fatigue, overuse, degenerative disease and to enhance my athletic performance.
	The Cost-Effectiveness of Chiropractic Chapter 2 from: Practice Analysis of Chiropractic 2015 Provided by the National Board of Chiropractic Examiners (NBCE) From Page 23: A recent study of 12,036 records in the Medical Expenditure Panel Survey (MEPS) investigated the costs of treating patients with low back and neck pain (Martin et al., 2012). The study estimated the expenditures for care among complementary and alternative medicine (chiropractic, homeopathy, herbalism, acupuncture, and massage) users relative to non-users. This study included a chiropractic-specific analysis of expenditures for chiropractic users versus non-users, as approximately 75% of all complementary and alternative medicine services were rendered by doctors of chiropractic. Survey data were analyzed for the years 2002-2008. The analysis demonstrated that seeing a CAM/chiropractic provider did not add to overall medical spending. In fact, adjusted annual healthcare costs among chiropractic users were $424 lower for spine-related costs when compared to non-CAM users. Additionally, those who used complementary and alternative providers, including doctors of chiropractic, had significantly lower hospitalization expenditures.
	Chiropractic Cost-Effectiveness Health Insights Today (2011) ~ FULL TEXT In the current economic and political climate, one of the most important arguments to be made for any health care method is that it is cost-effective. As a result, researchers are redoubling their efforts to identify cost-effective approaches. This includes a growing number of studies addressing the cost-effectiveness of chiropractic services. Chiropractors and chiropractic students need to understand this information and to share it with others.
	Chiropractic Cost-Effectiveness Supplement Provided by a Joint Task Force of the ACA, ICA, CAS and the ACC (2009) The following is a collection of studies relating to the cost effectiveness and efficacy associated with chiropractic care and the procedures that doctors of chiropractic provide. The American Chiropractic Association, The International Chiropractic Association, The Congress of State Associations, and the Association of Chiropractic Colleges appreciate the opportunity to provide these materials for your review. This presentation is divided into several parts: Background studies, detailing that LBP is much more complex than the literature leads us to believe; Cost-Effectiveness Studies; Worker's Compensation Studies (National studies) and Worker's Compensation Studies (State specific studies) Additional Research Studies
	Chiropractic Cost-Effectiveness Review (2009) Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC ~ FULL TEXT Enjoy this review of reduced Healthcare expenditures,Chiropractic and medical expenditures and Workers’ Compensation costs when chiropractic is moved to the top slot.

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Since 6–26–1998

Updated 1-02-2024