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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.

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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

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