Table 2
Summary of included studies 2018–2022
| References | Year | Design | Data source | Sample | Intervention and comparison | Costs or other related factors measured | Time interval | Outcomes |
|---|---|---|---|---|---|---|---|---|
| Bezdjian [29] | 2022 | CO | Patient EHR | 2692 adult patients with new dx of spine-related disorder | Primary Spine Care DC vs PCMD | Frequency of escalated care | 6 mo | DC patients: Less likely to be hospitalized |
| including ED visits, imaging, injections, hospitalizations, surgeries, | (OR = .47), fill opioid prescription (OR = .43), receive spinal injection | |||||||
| specialist referrals and opioid prescriptions | (OR = .56), or visit specialist (OR = .48) | |||||||
| Spinal diagnostic imaging | ||||||||
| DC, 8% vs. MD, 14% | ||||||||
| Harwood [5] | 2022 | CS | 2015–2016 Health Care Cost Institute (HCCI) | 3,799,593 adults with new diagnosis of LBP | Cohorts formed by provider first seen for initial LBP diagnosis: | “Downstream” utilization of: | 1-year post-LBP diagnosis | Opioid prescriptions |
| 1) AC | Opioids | Lowest for DC, AC or PT | ||||||
| 2) APRN | MRI, CT, radiography | Early prescription lower with AC or DC first and highest for EM or advanced practice RN | ||||||
| 3) DC | LBP surgery | Total cost lowest for DC ($5093) and PCMDs ($5660) first; highest for Ortho ($9434) or AC ($9205) first | ||||||
| 4) EM | ED visit | Out-of-pocket costs lowest for PCMD ($853) and DC ($911) first; highest for AC ($1415) and PM&R ($1238) first | ||||||
| 5) Ortho | In-patient hospitalization | · MRI/CT rate: 37%, 7% DC | ||||||
| 6) PM&R | Serious illness related to LBP | Beginning care with conservative provider resulted in significantly lower use of imaging and opioids | ||||||
| 7) PT | Total costs over 1 year | |||||||
| 8) PCMD | ||||||||
| Jin [36] | 2022 | CO | IBM Watson Health MarketScan claims database 2007–2016 | 679,030 new-onset neck pain patients | Patients who did not receive early conservative care vs. those who did receive conservative care | Total healthcare costs, opioid use, healthcare service utilization (inpatient and outpatient) | 1 year post-diagnosis | Early conservative therapy associated with 25% lower long term healthcare costs & with associated decreased opioid and ESI use |
| Whedon [9] | 2022 | CO | Medicare claims 2012–2016 | 28,160 MC beneficiaries with cLBP diagnosis | SMT vs OAT | Frequency of escalated care: hospitalizations, ED visits, advanced imaging, specialist visits, | 5 years | Hospitalization: |
| surgery, interventional pain med, | DC 1.4% MD 4.8% | |||||||
| and encounters | Injections: | |||||||
| DC 17%; MD 48% | ||||||||
| Adv imaging: | ||||||||
| DC 21%; MD 44% | ||||||||
| Specialist visit: | ||||||||
| DC 28%; MD 77% | ||||||||
| ED visit: | ||||||||
| DC 7%; MD 22%. Escalated care > 2.5 X higher for OAT vs SMT group | ||||||||
| Whedon [46] | 2022 | CO | Medicare claims 2012–2016 | 55,949 MC beneficiaries | DC vs MD | Filling opioid prescription | 1 year from initial visit | Risk for filling opioid prescription 56% lower for DC (hazard ratio 0.44) |
| with spinal pain | ||||||||
| Anderson [27] | 2021 | CO | Insurance claims | 10,372 unique back pain initial episodes | Initial SMT vs delayed SMT vs no SMT (medical care only) | Imaging, injections or back surgery | 6 years | Initial SMT: 30% decrease in risk of imaging, injections or back surgery vs no SMT; risk with delayed SMT was higher than those with no SMT (22% Increase risk of escalation). I |
| 2012–2018 | ||||||||
| Anderson [28] | 2021 | CO | Insurance claims | 7951 unique neck pain initial episodes | SMT vs any care without SMT (PT included as “other care”) | Imaging, injections, emergency room, or surgery | 6 years | Using SMT as reference (1.0), risks for other care: |
| 2012–2018 | Imaging 1.8; injection 6.5; ED 16.9; surgery 7.3. Risk of escalation 2.1 for any group that did not receive SMT | |||||||
| Davis [30] | 2021 | CO | Medicare claims | 39,278 MC chiropractic users | Use of medical services among chiropractic users who relocated and had decreased access to chiropractic vs those who did not | # of visits to PC MDs, surgeries, and overall costs for spine conditions | 2 years before versus 2 years after relocation | Reduced DC access: |
| Increased rate of PCMD visits for spine conditions | ||||||||
| Increased rate of spine surgeries | ||||||||
| Overall additional costs of medical services = $114,967 per 1,000 beneficiaries | ||||||||
| Whedon [43] | 2021 | CO | Medicare claims | 28,160 MC beneficiaries with long-term management of cLBP with SMT or OAT | SMT vs OAT | Adverse drug events (2) | 12 months | Any ADE: |
| 2012–2016 | SMT 0.9%; OAT 18.3% | |||||||
| Opioid dependence/abuse: | ||||||||
| SMT 0.3%; OAT 14.3% | ||||||||
| ADE 51% lower in an outpatient setting with SMT. Long term care was 5X higher in OAT | ||||||||
| Whedon [42] | 2021 | CO | Medicare Claims 2012–2016 | 28,160 MC with long-term care of cLBP with SMT or OAT | SMT vs OAT; Medical general and specialty practices, PM&R, DC, PT and Pain Management | Long-term total healthcare costs and LBP care costs | 5 years | Mean LBP care long-term costs with OAT 58% lower than SMT |
| Total long-term costs 1.87 times higher for OAT | ||||||||
| Louis [39] | 2020 | CO | Marketscan research databases 2010–2014 | 427,966) patients with new-onset neck pain | Conservative (AC, DC, PT) vs PCP vs specialists (EM, Ortho, neurologists, PM&R, other) | Opioid prescriptions | Short term = 30 days after index visit; long term = 4 continuous quarters after index visit | AC had the lowest OR for opioid use; DCs had the lowest OR for opioid use at all time points compared to PT, PCP, Ortho, EM, PM&R, neurologist, and other. EM highest up to 90 days |
| Whedon [45] | 2020 | CO | Insurance claims 2012–2017 | 101,221 patients with spinal pain | SMT + PC MD vs no SMT, PC MD only | Opioid prescriptions | 6 years | 1.55 and 2.03 times more non-SMT patients filled an opioid prescription |
| Davis [31] | 2019 | CO | Medicare claims 2010–2014 | 84,679 MC chiropractic users who relocated | Use of medical services among chiropractic users with and/or neck pain who had decreased access to chiropractic vs those who did not | Cost of annual spine-related spending | 1 year | Higher spine-related spending on medical evaluation, management/procedures and diagnostic imaging and testing was associated with decreased access to chiropractic |
| Kazis [37] | 2019 | CO | OptumLabs Data Warehouse 2006–2015 | 216,504 new-onset LBP patients | Conservative (AC, DC, PT) vs specialist (PCP, Ortho, EM PM&R, MD-Other, neurosurgeon) | Opioid prescriptions | Short term = 30 days after index visit; long term = 4 continuous quarters after index visit | For both short and long -term prescriptions: Specialists had the highest OR and conservative (DC, PT, AC) the lowest |
| Rhon [12] | 2019 | CO | Military Health System (MHS) MHS Management and Reporting | 7,566 patients with spine or shoulder pain | MT only vs MT + opioids; MT provided by PT, DO, or DC | total outpatient healthcare visits and costs, spine- and shoulder-related visits and costs, opioid prescriptions | 1 year after index visit | All costs were lower for MT first |
| Tool (M2) database | Costs, visits, and opioid prescriptions lower with: | |||||||
| MT only | ||||||||
| MT early intervention before opioids (< 30 days from index) | ||||||||
| Elder [24] | 2018 | PCO | EHR from Kaiser Permanente Northwest HMO | Sample size: 70 referred, 139 nonreferred patients | Standard care vs standard care + chiropractic | Clinical outcomes and costs of pain-related healthcare | 2 years (2013–2015); patients followed up for 6 months | No statistically significant differences in either patient-reported |
| or economic outcomes | ||||||||
| Whedon [44] | 2018 | CO | NH administrative claims database 2013–2014 | 13,384 patients with primary LBP diagnosis | DC care vs non-DC care | Likelihood of opioid prescription fill; rate of prescription fill and associated costs | 2 years | OR for opioid prescription fill was 0.45 for DC care with a 55% lower likelihood of filling an opioid prescription; opioid prescription costs were also significantly lower |
Study designs: CO Retrospective/cross-sectional cohort study; CS Cost study/economic evaluation; PCO prospective cohort study
AC Acupuncturist; ADE Adverse drug event; APRN Advanced practice registered nurse; cLBP Chronic low back pain; CT Computed tomography; DC Chiropractor; DO Osteopathic physician; ED Emergency department; EHR Electronic healtth record; EM Emergency room medical physician; LBP Low back pain; MC Medicare; MD Medical doctor; MRI Magnetic resonance imaging; MT Manual therapy; OAT Opioid analgesic therapy; OR Odds ratio; Ortho Orthopedist/orthopedic surgeon; PCP/PCMD Primary care medical physician; PM&R Physical medicine and rehabilitation medical physician; PT Physical therapist; RN Registered nurse; SMT Spinal manipulative therapy