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RESEARCHERS VIEW RESULTS AS BOTH REASSURING AND CHALLENGING
REPORT IS FIRST ON QUALITY OF CHIROPRACTIC CARE FOR INDIVIDUAL PATIENTS
SANTA MONICA, Calif., July 1--In results that provide "some reassurance" about the quality of chiropractic care but that also challenge the profession to improve its performance, a RAND study finds that 46 percent of a sample of patients who had spinal manipulation for low back pain received appropriate care. Care was classified as inappropriate in another 29 percent of the cases and as uncertain in the remaining 25 percent.
The study, appearing in today's Annals of Internal Medicine, represents the first rigorous analysis of the quality of chiropractic care provided to individual patients. Earlier RAND research projects broke ground by bringing together medical doctors and chiropractic practitioners to establish the benefits of chiropractic therapy for some problems, notably certain types of low back pain.
"The message of our new study is a mixed one," observes lead researcher Dr. Paul G. Shekelle, an internist based at RAND and the West Los Angeles Veterans Affairs Medical Center. Shekelle also led the previous projects. "First, everybody needs to stop treating chiropractors as if they are quacks. An appropriateness rate of roughly half is in the same ballpark as the findings for certain medical procedures when appropriateness measures were introduced a dozen years ago. Chiropractors are appropriately treating some patients, and those patients are likely to benefit as a result of their care.
"At the same time, chiropractors need to recognize that one of the missions of a health profession is to pursue and incorporate research on quality. Clearly, a 29 percent inappropriateness rate is too high and should be decreased."
Systematic data on the quality of chiropractic care is particularly timely today. Low back pain is not only one of the most common symptoms afflicting adult Americans but, with direct and indirect costs estimated at $60 billion annually, one of the most economically burdensome. Recently, federal government practice guidelines began to recommend spinal manipulation as a treatment for those with an uncomplicated acute case of low back pain. Chiropractors provide most of the manipulative therapy delivered in the United States, and that recommendation is expected to significantly increase their caseloads.
The study focused on retrospective analysis of the records of 1310 patients who sought care for low back pain between 1985 and 1991 in 131 randomly sampled chiropractic offices located in five metropolitan sites in the United States and one in Canada.
The research team, including two medical doctors, three chiropractors and a psychologist, first developed a comprehensive array of indications -- specific clinical situations -- for which spinal manipulation might be considered. A multispecialty panel of nationally--recognized back experts, again including both medical doctors and chiropractors, then rated the indications on a nine-point scale of potential risks and benefits, with 1 being extremely inappropriate for the procedure and 9 being extremely appropriate. Ratings that fell between 4 and 6 were categorized as uncertain. Finally, the researchers applied those ratings to the information in the patient records.
The study rated only the appropriateness of a decision to initiate spinal manipulation, not the number of sessions provided.
The work was funded by grants from the Consortium for Chiropractic Research, the Chiropractic Foundation for Spinal Research, and the Foundation for Chiropractic Education and Research.
The study is the subject of an editorial in the current issue of Annals. Both the paper and the editorial are available from the American College of Physicians on the Internet (www.acponline.org) or by calling Mary Bernard at 800-523- 1546, ext. 2656. For interviews with Dr. Shekelle, call RAND's Public Information Office (310-451-6913).
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