Reviewing Trends in Chiropractic, CAM Utilization
By Tina Beychok, Associate Editor
Utilization of complementary and alternative medicine (CAM) has risen steadily in the past 15-plus years. Particularly revealing were the three studies by Dr. David Eisenberg, et al.,1-3 which tracked CAM use over more than a decade.According to those studies, use of CAM rose from 33.8 percent in 1990 to 42.1 percent by 1997, a 47.3 percent increase in total visits to alternative health care providers. This translates to an increase from 427 million CAM users in 1990 to 629 million by 1997.1 By 2002, this represented approximately one in three adults.2
In looking specifically at chiropractic, Eisenberg, et al., found that the majority of those who used CAM chose chiropractic (30.5 percent), which translated into 192 million visits by 1997.1 Another study, the results of which were released in 2006, estimated that 20 percent of the U.S. population has used chiropractic.4 As one might expect, the majority of these visits were for back and neck problems. In fact, one study of 1,275 chiropractic patients found that more than 70 percent of complaints involved back or neck problems.5
Who could put this substantial body of research into perspective? Enter two prominent chiropractic researchers - Dr. William Meeker, president of Palmer College of Chiropractic West and former director of research at the Palmer Center for Chiropractic Research; and Dr. Dana Lawrence, associate professor (clinical research) at the Palmer Center and former editor of the Journal of Manipulative and Physiological Therapeutics (JMPT). In a literature review published earlier this year in Chiropractic & Osteopathy, they examined utilization trends regarding CAM in general and chiropractic.6 This was the second phase of a long-term collaborative project between Palmer College and Palmer College West to develop new evidence-based practices for chiropractic by drawing from current usage and treatment trends.
Drs. Meeker and Lawrence conducted a literature search from 1996 to 2005, using the following keywords: chiropractic, utilization rate, low back pain, use rate, complementary and alternative medicine, and health services. Databases searched were Index Medicus, MANTIS (Manual, Alternative and Natural Therapy Index System), the Index to Chiropractic Literature, and CINAHL (Cumulative Index to Nursing and Allied Health Literature). This yielded a total of 137 papers, which were divided into five thematic groups: back pain, general chiropractic, insurance, CAM, and workers' compensation.
The researchers then organized the data into seven broad categories for purposes of analysis and data presentation: back pain, utilization, geographic population studies, access and insurance, specific conditions, specific settings, and perceptions of CAM. General trends and observations regarding each of the seven categories are noted as follows. For a more complete picture of the study findings and their implications for the chiropractic profession, access the complete text online at www.chiroandosteo.com/content/15/1/2.
In terms of papers that examined back pain, the majority of patients saw a chiropractor for lower back pain (LBP). Rates for LBP care ranged from 68 percent to 87 percent. Patients who sought chiropractic care had, in general, a higher level of pain and lowered mobility, flexibility and overall health status. Variables such as presence of sciatica, longer time to functional recovery, longer duration of pain, and fear of pain interfering with future daily activities indicated a greater likelihood of a visit to a chiropractor for back pain. Two studies in this group also indicated that higher socioeconomic status and being female were indicators for seeking chiropractic care for lower back pain.
Utilization rates varied across the board within the sample. Referral rates from MDs to chiropractors ranged from 2 percent to 83 percent, with an average of 42 percent. Some papers, however, showed that MDs can still be very reluctant to provide referrals to chiropractors. One paper found that 95 percent of MDs would refer patients to physical therapists, while only 14 percent would refer to a chiropractor. At the more positive end of the spectrum was a paper suggesting that 68 percent of MDs believe chiropractic is a valid therapeutic modality, while 82 percent believe it to be a complete therapeutic system.
In examining CAM use among various population groups, the researchers found that anywhere from 7 percent to 17 percent of survey respondents had used chiropractic within the past 12 months, mainly for lower back pain or other associated musculoskeletal conditions. As with the papers on back pain, the majority of chiropractic users in the population papers were white, with a higher socioeconomic status.
Papers in this category suggest that patients utilize chiropractic care as a direct substitute for medical care, not as an add-on; and services by chiropractors yield lower treatment costs, fewer lost workdays and lower compensation payments compared to their medical counterparts.
A number of papers in this group reached a similar conclusion: Cost for medical care is substantially lower with chiropractic than without. One paper in particular found that for patients with musculoskeletal injuries, the average treatment cost for medical care was $3,519 and $663 for chiropractic care. If medical and chiropractic treatment were combined, total costs for the former rose to $4,425, as compared to $748 for the latter.
Two other papers found that CAM coverage resulted in lower health care service utilization. One found that patients whose insurance included chiropractic had lower costs in the fee-for-serve sector, due to lower inpatient utilization of heath care services. Another showed a 43 percent decrease in hospital admissions, outpatient surgeries and drug costs when CAM was combined with conventional medical care.
Several papers looked at CAM and chiropractic use by patients with specific conditions. As could be expected, utilization rates varied widely depending on the condition. One study of HIV patients reported a chiropractic usage rate of 19 percent, and another study of patients with osteoporosis reported a 21 percent utilization rate. Lower rates were reported by patients with cancer (ranging from 3 percent to 13 percent). Patients with psychiatric conditions were least likely to use chiropractic, at less than 1 percent.
In terms of CAM use (not specific to chiropractic), patients suffering with conditions ranging from multiple sclerosis to asthma have utilized some form of CAM, according to the literature. In one study, 42 percent of participants utilized some form of CAM to help treat breathing or nasal symptoms; in another study, more than 25 percent of patients with multiple sclerosis utilized chiropractic. Dissatisfaction with medical care was a strong predictor of CAM use in the MS study.
Perceptions of CAM
Several studies from this group surveyed doctors and medical students regarding their attitudes toward CAM and chiropractic. Interestingly, the general perception was that it was useful for patients. One study found that even though few MDs were likely to use chiropractic themselves (0.6 percent), the attitude toward chiropractic was generally positive. Another study found that 60 percent of doctors had used some form of CAM and would be in favor of a hospital-based CAM center. A study of medical students found that 37 percent had used at least one form of CAM and that chiropractic was seen as the most convincing form of CAM.
"Studies looking at chiropractic utilization demonstrate that the rates vary, but generally fall into a range from around 6% to 12% of the population, most of whom seek chiropractic care for low back pain and not for organic disease or visceral dysfunction. CAM is itself used by people suffering from a variety of conditions, though it is often used not as a primary intervention, but rather as an additional form of care; the literature demonstrates that people usually do not let their primary medical physician know that they are using CAM. CAM and chiropractic often offer lower costs for comparable results compared to conventional medicine. It is apparent that the use of chiropractic is growing, though the impact remains modest; however, CAM as a whole is seeing wholesale increases in utilization."6