Articles

I get mail–chiroquacktic edition

A long while back, at the original wordpress incarnation of my usual blog, I wrote a piece on the reasons that chiropractic is unscientific nonsense. Because it was popular, I resurrected it. Well, a chiropractor has come to bravely defend his field and left me a comment.

A study in the May 2007 issue of the Journal of Manipulative and Physiological Therapeutics reports health plans that use Chiropractors as Primary Care Providers (PCPs) reduce their health care utilization costs significantly.

The study covers the seven-year period from 1999 to 2005. Researchers compared costs and utilization data from an Independent Physicians Association (IPA) that uses Chiropractors as PCPs and a traditional HMO that doesn’t.

The Chiropractic PCPs had 59 percent fewer hospitalizations, 62 percent fewer outpatient surgical cases and 85 percent lower drug costs compared with the HMO plans.

The patients in the Chiropractic PCP group also reported higher satisfaction with their care than the HMO group. Over the seven-year period, Chiropractic patients consistently demonstrated a high degree of satisfaction with their care that ranged from 89 percent to 100 percent.

Study co-author James Winterstein, D.C. says that patients using Chiropractic PCP health care groups “experienced fewer hospitalizations, underwent fewer surgeries and used considerably fewer pharmaceuticals than HMO patients who received traditional medical care.”

Hmmm…interesting assertions. Let’s examine these assertions and the “article” they come from.

ResearchBlogging.orgWe will set aside for a moment that the Journal of Manipulative and Physiological Therapeutics is not well-regarded in the science-based medicine community, and examine the article on its merits alone. Once we’ve dealt with that, we’ll examine the chiropractors comment.

The “study”

“Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update,” is a bit of a confusing piece of writing, but I’ll do my best to parse it out for you. The goal of the study is quite clearly set out:

In this article, we are not taking a position on the efficacy of any CAM treatment. Rather, we are interested in the current use of CAM modalities and cost effects of such use, regardless of treatment outcome. These clinical utilization and cost outcomes are compared with previously published results.

In other words, they are looking at alternative medicine vs. real medicine to see which is cheaper, not whether it actually works. Unsurprisingly, I have a problem with this.

I could do a much quicker study asking the same question. If I were to forbid people from seeing the doctor or going to the emergency room, I would undoubtedly find that they spent fewer health care dollars. But why would I ask such a thing? There is no point to seeing how much something costs without addressing whether or not it even works.

Anyway, what the original study and this one did was look at patients cared for by a group of “alternative” doctors and compare them to a group of patients cared for by a group of real doctors. In the study, they equate CAM-oriented physicians with chiropractors, which confused me, so I went back to the original study(2) to investigate this issue (emphasis mine):

At the project’s inception, personal interviews were conducted with all categories of physicians, including MDs/DOs and DCs whose style of medical practice qualified them as potential CAM-oriented PCPs. For a variety of professional, personal, political, and economic reasons, only the Doctors of Chiropractic were willing to undertake the project.

Res ipsa loquitor

Anyway, let’s skip straight to the outcomes. I think we can safely ignore for now the patient satisfaction outcomes, since patients self-selected into the chiropractic group. Moving on to the reduced utilization, it’s important to point out a few facts. First, as noted, the patients self-selected into the altmed group so may be less inclined to utilize medications and procedures. Second, chiropractors aren’t really allowed to do very much, and their religion philosophy is biased against accepted theories of disease, so they are not likely to go to their physician overseers and ask them to order tests and prescribe medications. Third, cost is irrelevant if the care isn’t known to be effective. Finally, in the words of the authors themselves:

The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.

Now, about that comment from my old piece. The commenter completely passed over the issue of whether or not chiropractic makes sense, and quoted from a study that explicitly avoids evaluating the efficacy of chiropractic.

Chiropractors have a long way to go if they wish to justify their practices, and this study doesn’t move them any further down that road.

__________________________

References

1) SARNAT, R., WINTERSTEIN, J., & CAMBRON, J. (2007). Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update Journal of Manipulative and Physiological Therapeutics, 30 (4), 263-269 DOI: 10.1016/j.jmpt.2007.03.004

2) SARNAT, R., & WINTERSTEIN, J. (2004). Clinical and Cost Outcomes of an Integrative Medicine IPA Journal of Manipulative and Physiological Therapeutics, 27 (5), 336-347 DOI: 10.1016/j.jmpt.2004.04.007

Posted in: Science and Medicine

Leave a Comment (18) ↓

18 thoughts on “I get mail–chiroquacktic edition

  1. zeno says:

    Excellent! They just don’t seem to understand that tricky word ‘evidence’! Keep up the good work.

  2. Fred Dagg says:

    At the recent World Federation of Chiropractic Conference in Montreal, one keynote speaker was Dr. David Eisenberg of Harvard. He spoke of the integration of chiropractic and other complimentary services (e.g. acupuncture and massage), with medical care at Harvard, and a pilot trial showing greatly improved outcomes for chronic back pain patients as a result. Dr. Eisenberg was apparently impressed at the calibre and depth of chiropractic research.

  3. David Gorski says:

    Of course he would. After all, he’s the director of Harvard’s CAM program at the Osher Institute at Harvard:

    http://www.osher.hms.harvard.edu/people.asp

  4. Canucklehead says:

    Trouble is, that evidence stuff is just so hard to produce and you can’t always guarantee the ‘proper’ outcome. Best bet is keep producing junk, tout it as good quality research and eventually some one, somewhere, might be persuaded by it.

  5. Fred Dagg says:

    “Patients do not see complementary and conventional medicine as being mutually exclusive. This pattern will probably continue and may even expand as evidence of effectiveness accumulates”

    - The Institute of Medicine
    “The market for complementary and integrative medicine is vast and shows no sign of diminishing. This trend must be guided by scientific inquiry, clinical judgment, regulatory authority, and shared decision-making.”

    - Dr. David Eisenberg

    http://www.osher.hms.harvard.edu/default.asp

  6. Dr Atwood did a whoolle series on Harvard, discussing Dr Eisenberg quite a bit. Starts here.

  7. Fred Dagg says:

    I suggest everybody who views this site review the following site for a really good impression on how there is a meeting of minds on how to acheive the best for patients. They are the ones who are important.

    http://www.osher.hms.harvard.edu/default.asp

  8. pmoran says:

    Fred “He spoke of the integration of chiropractic and other complimentary services (e.g. acupuncture and massage), with medical care at Harvard, and a pilot trial showing greatly improved outcomes for chronic back pain patients as a result. ”

    The critical thing is whether more objective measures of benefit were looked at, such as percentage of patients getting back to work, If so, and this proved to be a consistent and reasonably cost-effective outcome then I do not see how we could refuse to support such programs on a purely pragmatic basis. Chronic back pain is a very difficult condition to help.

    From the point of view of the science of it, as opposed to the pressures of practical medicine, such presumably non-randomised studies provide NO support for any unique medical activity of chiropractic, acupuncture or massage. Any benefits may be simply due to the extra attention and support.

    I’ll bet Eisenberg suspects this himself.

  9. Fred Dagg says:

    Pmoran
    your query is answered with this reswearch.

    Low Back Pain, Predictors of Chronic Disability.

    One risk factor/predictor of chronic disability is the choice of healthcare provider.
    “Workers whose first health visit for the injury was to a chiropractor had substantially better outcomes.”
    The percentage of workers diasled after one year was 5% with chiropractic care, 12% with primary care, 26% occupational medicine, 23% others.
    The authors of the study offer two possibilities for the better outcomes of those who consulted the chiropractor first.
    1) “….it is possible that workers who saw chiropractors differed in prognostically favourable ways.”
    2) “It is also possible that chiropractic care was more effective in improving pain/and or promoting return to work”.
    They conclude that more research is needed to investigate the effects of early care on work disabilty.

    Turner JA, Franklin G et al. (2008) ISSLS Prize Winner: Early Predictors of Chronic Work Disabilty: A Prospective, PopulatioBased Study of Workers with Back Injuries, Spine, 33(25):2809-2818).

  10. pmoran says:

    That was a non-randomised study, Fred. Hence the auther’s comment 1) above.

    Eisenberg’s pilot study had to have involved outcomes in two comparable starting groups to have any validity at all.

  11. Fred Dagg says:

    Pmoran

    No, it is sour grapes from you.

  12. pmoran says:

    Oh, I realise my error. I said “presumably non-randomised studies” when I meant “presumably uncontrolled studies” (i.e. randomised but lacking a placebo “control” — necessary if looking for unique effects from a treatment method ).

  13. psamathos says:

    Okay, so spinal manipulation may have unique beneficial effects for chronic back pain. But if that’s true, there’s no need to continue to call it “alternative medicine.” This in no way lends credence to the pre-scientific mythology surrounding chiropractic, nor does the coincidental efficacy of spinal manipulation for chronic back pain give reason to accept any other alternative therapy. This is why people like Dr. Eisenberg are really taking an entirely backwards approach, and this is why straight chiropractors who are operating from an understanding of the “innate intelligence” mythology are still dangerously ignorant.

  14. OZDigger says:

    Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation

    We found consistency for concurrent hypoalgesia, sympathetic nervous system excitation and changes in motor function. Pooling of data suggested that joint mobilisation improved outcomes by approximately 20% relative to controls. This specific pattern suggests that descending pathways might play a key role in manual therapy induced hypoalgesia. Our review supports the existence of an alternative neurophysiological model, in which passive joint mobilisation stimulates areas within the central nervous system.
    Man Ther. 2008 Oct;13(5):387-96. Epub 2008 Mar 3

    Something from the physiotherapists. Probably wasted on most of you, but it does talk about the neurophysiological effects of joint mobilisation.
    I put this in another blog, but it seemed to be needed here also.

  15. Mobilisation is NOT SMT or chiropractic manipulation.
    Noone is disputing the utility of mobilisation, which is one of the core modalities used by the physiotherapists.

    Your comment shows a misunderstanding of the basic terms involved in this discussion.

  16. OZDigger says:

    Well Whitec… that just shows how ignorant you are on the topic of spinal manual therapy .

  17. pmoran says:

    “Pooling of data suggested that joint mobilisation improved outcomes by approximately 20% relative to controls. ”

    There are innumerable problems with trying to deduce physiology or pathology from subjective clinical outcomes.

    It is not even stated in the abstract whether placebo controls were used in the selected studies. This at minimum suggests the authors are not aware of the critical importance of that to the meaning of the data.

    I can’t access the whole article but I suspect this is an example of the considerable substandard “quasi-science” going on these days within “alternative”, and even some conventional medical disciplines. seeking more vindication of their practices.

    It has the appearance and jargon of science without the substance.

  18. dt says:

    Fred, regarding the study you mentioned, surely you can appreciate what a major selection bias is introduced when the patient chooses the healthcare provider, rather than this being a randomised process?

Comments are closed.