A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain

by

Pran Manga, Ph.D. 1
Douglas E. Angus, M.A. 2
Costa Papadopoulos, MHA 3
William R. Swan, B.Comm. 4

August 1993

1. Professor and Director, Masters in Health Administration Program. University of Ottawa; and President, Pran Manga and Associates Inc., Ottawa.
2. Adjunct Professor, University of Ottawa and Project Director, The Cost-Effectiveness of the Canadian Health Care System, Queen s - University of Ottawa Economic Projects.
3. Health Care Consultant and Associate of Pran Manga and Associates, Inc.
4. Consultant in Health Care Economics.

Our recommendations for reform include the following:

1. Current policy discourages the utilization of chiropractic services for the management of LBP (Lower Back Pain). There should be a shift in policy to encourage and prefer chiropractic services for most patients with LBP.
2. Chiropractic services should be fully insured under the Ontario Health Insurance Plan, removing the economic disincentive for patients and referring health providers. This one step will bring a shift from medical to chiropractic management that can be expected to lead to very significant savings in health care expenditure, and even larger savings if a more comprehensive view of the economic costs of low-back pain is taken.
3. Chiropractic services should be fully integrated into the health care system. Because of the high incidence and cost of LBP, hospitals, managed health care groups (community health centres, comprehensive health organizations, and health service organizations) and long-term care facilities should employ chiropractors on a full-time and/or part-time basis. Additionally such organizations should be encouraged to refer patients to chiropractors.
4. Chiropractors should be employed by tertiary hospitals in Ontario. Hospitals already employ chiropractic in the United States with good effect. Similar recommendations have been made recently by government inquiries in Australia and Sweden, and following government funded research in the U.K. and other countries. Unnecessary or failed surgery is not only costly but also represents low quality care. The opportunity for consultation, second opinion and wider treatment options are significant advantages we foresee from this initiative which has been employed with success in a clinical research setting at the University Hospital, Saskatoon.
5. Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients needs.
6. Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients. Access should be given upon the request of chiropractors or their patients.
7. Since low-back pain is of such significant concern to workers compensation, chiropractors should be engaged at a senior level by Workers Compensation Board to assess policy, procedures and treatment of workers with back injuries. This should be on an interdisciplinary basis with other professional, technical and managerial staff so that there is early development of more constructive relationships between chiropractors, physicians, physiotherapists and Board staff and consultants. A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the workers compensation system in Ontario.
8. The government should make the requisite research funds and resources available for further clinical evaluation of chiropractic management of LBP, and for further socioeconomic and policy research concerning the management of LBP generally. Such research should include surveys to obtain a better understanding of patients choices, attitudes and knowledge of treatments with respect to LBP. The objective of these surveys should be better information for health policy, programme planning and consumer education purposes.
9. Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public funding. Chiropractic is the only regulated health profession in Ontario without public funding for education at present, and it works against the best interests of the health care system for chiropractors to be educated in relative isolation from other health science students.
10. Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions. Lack of cooperation has been a major factor in the current inefficient management of LBP. Better cooperation is important if the government is to capture the large potential savings in question and, it should be noted, is desired by an increasing number of individuals within each of the professions.