White Coat Underground

I get mail–chiroquacktic edition

A long while back, at the original wordpress incarnation of this blog, I wrote a piece on the reasons that chiropractic is unscientific nonsense. Because it was popular, I moved it over here. Well, a chiropractor has come to bravely defend his field and left us 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

Comments

  1. #1 AgnosticNews
    June 29, 2009

    Hmmm…

    So if I were to charge 50 bucks to have a patient sit down, have me blow a whistle in their face and slap them… Could I conduct a similar “study” comparing the cost of my treatment to chiropractors to demonstrate the superiority of whistle-slap therapy?

    I guess I’ll have to give it a fancy greek/latin based name and publish my own E-journal… but the process sounds pretty simple.

    I’ll call it “Sonoflicotricy”, myself a “Sonoflicotrist”, and publish the “Online Journal of Sonoflicotric Therapy” immediately. Once my study is complete, I’ll be sure to send you the article as proof of just how great this therapy is!

    I’ll only sample from my befuddled patients as well, right after I slap them. I’ll randomize my sample by weekday surveyed.

  2. #2 Zeno
    June 29, 2009

    The whistle therapy proposed by AgnosticNews is just not credible! Significantly better results would come from ringing a small bell (the face slap is optional, depending on whether you like the patient or not). The marketing campaign writes itself! “Sound as a bell!”

    And before anyone suggests it, bagpipes are not a good treatment modality. Anyone who can withstand the skirl of a bagpipe is already too healthy to need treatment. (Wait a minute …)

  3. #3 WcT
    June 30, 2009

    The DC’s are out in force today aren’t they!

    As it happens, I too have been plagued by a chiropractor posting about the usefulness of chiropractic. He cited a paper as well.

    I think DC’s have figured out that if you mention “journal article,” many lay people will be intimidated and back down, and not read the article.

    Great illustration of what happens when you actually read those papers…
    Here’s another one.

  4. #4 Bob O'H
    June 30, 2009

    Anyone who can withstand the skirl of a bagpipe is already too healthy to need treatment.

    Physically healthy perhaps, but clearly not mentally.

  5. #5 Brad
    June 30, 2009

    Hahhaaha. For some reason when I read the comment I thought he was citing a study that measured the cost of treatment of EBM groups vs EBM+sCAM groups. The numbers are interesting, if true, in that regard, but was expecting to see you show how the data was manipulated or fundamentally flawed. When I finally realized the sCAM group wasn’t also receiving EBM treatments my thoughts were something along the lines “lol that’s retarded.”

  6. #6 BB
    June 30, 2009

    DCs can be PCPs? Isn’t the entire premise of the paper false from the get-go?

  7. #7 Russell
    June 30, 2009

    It’s far from clear to me why a healthy person in the middling ages needs a PCP. The blood bank checks my BP every eight weeks when they pull a pint (105/65). I don’t need a PCP to tell me to avoid junk food and to exercise, or to suggest a colonoscopy at 50. I can get a lipids and fasting blood sugar check every few months for $25 at a local pharmacy. Yes, I understand the lab work up a PCP orders is more thorough, including liver enzymes and all sorts of other aspects of blood chemistry. But is that really necessary every year? And yes, I understand a physician can learn a lot from a history. What they would learn from mine is that I don’t have a history of serious health problems. And yes, I know a physician can learn a lot from a physical exam. What I wonder is how often a healthy person should want that? If it’s every five years, you don’t really have a PCP, because he won’t remember you from Adam’s off ox. ;-)

  8. #8 daedalus2u
    June 30, 2009

    This is exactly the kind of analysis that the insurance companies will use to show that CAM is “better”. It is cheaper and results in fewer hospitalizations.

  9. #9 PalMD
    June 30, 2009

    @Russell, the data on how often to have a “complete physical” is not at all clear. I have a post on it in the archives somewhere which I’ll try to dig up, but basically, if you are young without significant health problems you probably don’t need a full physical every year, but you also may (helpful, eh?).

    But while you make a valid point about not knowing how often a physical is needed, you also, I believe, fall prey to the argument of “what use professionals?”

    For example, when you talk about getting your blood sugar checked, what you might not know is that the latest recommendations are to use HbA1C for diabetes diagnosis rather than fasting blood sugar. You may not know what your Framingham risk score is. You may not know that the mole on your lower back is atypical. Etc. Etc. Etc.

  10. #10 Diane
    June 30, 2009

    My beginning A & P (for non-docs) course is being taught by a DC. What a travesty. Especially when he talks endlessly about how useful checking your own poo is. My community college is getting a lengthy complaint from me.

  11. #11 catgirl
    June 30, 2009

    Russell,
    I, like many other women, get a Pap test and gynecological exam every year. It makes sense to do this as part of a routine physical. In the past, I had to have yearly physicals for school. Now my PCP herself insists that I do not need a yearly physical. However, PCPs do more than just give physicals. She’s the doctor I see for minor things like strep throat or unexplained pain rather than going straight to a specialist. If I need to see a specialist for pain, I need my PCP to help me decide which type of specialist to see, since pain can be caused by so many different things. My PCP is also the one who refills my prescriptions for birth control pills and levothyroxine. She orders the tests to see if I need a different dose of levothyroxine, and she advises me on current birth control options in case I want to change. It may be true that some people don’t need a PCP, but they are useful to have even for relatively healthy people like me.

  12. #12 LanceR, JSG
    June 30, 2009

    To echo catgirl, and perhaps expand on her point, the best reason to have a PCP is cost control. People who visit their primary physician regularly tend to be healthier, and spend less on healthcare. Catching even minor things early can lead to vast savings when a minor infection doesn’t go septic. (For an extreme example).

    A relatively healthy person “in the middling ages”? Would that be 30s? 40s? 50s? Healthcare needs change as a person ages. Infections we laugh at in our 30s, we sneeze at in our 40s, and wheeze at in our 50s. That is why most recommendations are for increasing checkups as we age.

  13. #13 Russell
    June 30, 2009

    The websites that calculate Framingham score says mine is 3%. I understand A1C tells time-averaged glucose, and is now the measure of diabetes. Is that now a routine part of physicals?

    The problem with saying that one should have a PCP for various problems that come up is that if those don’t come up any more frequently than every few years, one still doesn’t have a “regular doctor,” but just whoever one happens to see when a problem does come up. No doubt, I’ve been fortunate in that regard.

    Being a hiker and a sailor and living in Texas, I am out in the sun a lot. Every couple of years, I go to a dermatologist to have a visual scan of bumps, moles, etc. If I could find a PCP who would do that, that might be a good route to go. My fortune no doubt will change as the years roll by. The problem is that many physicians work out of a large clinic where it seems they want to work in one fashion. A dermatologist’s office typically knows what I want when I call to schedule that, has a regular charge for that, etc.

  14. #14 David
    June 30, 2009

    Fortunately, we don’t have to rely on uncontrolled poorly defined historical reviews “studies” to address the cost-effectiveness question. It’s been addressed in a randomized prospective controlled trial.

    Kominski et al, 2005 Med Care. v43(5)p428

    The authors randomized 681 patients with low back pain to chiropractic or various other, standard medical care. Chiropractice produced no improvement in outcome but was associated with 50% greater cost.

  15. #15 Chet
    June 30, 2009

    Dear PalMD,
    I do have a question that is not directly related to this blog item, but if you have the time to respond I’d appreciate it. My office is next door to a chiropractor. One day my office manager was having some pain in her lower back so she went across the hall to have it checked out. She came back quite dismayed because she was told to disrobe. The chiro then inserted his finger into her rectum and started manipulating her lower back with the other hand. Needless to say, she was not expecting this and it caught her totally off guard. My question to you is: does this treatment sound legit and possibly part of the chiro’s methodology? Or does it sound suspect to you? She refuses to go back….he wanted her to return for regular adjustments over a 6-month period. She said, “no thanks”. Interested in your thoughts.

  16. #16 Perceval
    July 1, 2009

    Welcome to the UK, Russell. Here, tests are pared down to the cost effective minimum. You see a dermatologist if your PCP is worried. It works, too, but there’s far less emphasis on prevention. It also requires great skill, because the GP is your gate keeper to everything and therefore needs to know just when specialist knowledge is needed. This in turn requires an amazing breadth of knowledge. Exit chiros.

  17. #17 Dr. Severtson
    July 1, 2009

    WOW. Someone supplies research and you cut it down.
    JMPT is a peer reviwed journal having peer reviewers from different disciplines (DC. MD. PhD. PT) and is a journal that stacks up well in comparison to others in its field (like SPINE). It has an impact factor of around .1
    Your critique doesnt hold much merit. Show me the double blind RCT for heart surgery…
    Actually they did a study like that on knee surgery and…..the controls (no SX) got better.
    Numerous medical proceducres have little valid research to support their claims. That can be noted in the constant drug recalls, and scandals where a “researche” skewed all the numbers. Double blind randomized conrol trial studies only lend themselves well to drug testing due to their nature. You should read some of Ian Coulter PhD works on research trials.
    Chiropractic is a clinical science and in that has to do the same thing medicine does. It has to take a clinical case, correlate the information and decide on a treatment program. Medicine does this so well it is now the 3rd leading cause of death in the US (Starfield, JAMA, 2000) Chiropractic does this so well it is the leading “alternative” approach. You dont have to be an MD or even head cashier at Wal-mart to figure out what approach is doing a better job. After all it is about the patient and their outcomes and quality of life…not YOUR pocket book or pride.

  18. #18 bob
    July 1, 2009

    “Dr.” Severtson: You might want to spend a little time here and on the Science-Based Medicine blog. You might learn some things, such as the laughable number of fallacies you employed to make your point.

  19. #19 James Pannozzi
    July 1, 2009

    @Dr. Severtson

    Apparently in this blog, it is considered “politically incorrect” to point out, as you have done, that these supposedly “scientifically” minded posters seem to promptly discard research in perfectly good scientific journals that goes contrary to their innuendo.
    Likewise, they will then smugly point to their own “evidence” based medicine (sic) without noticing that much of the “evidence” is rather illusory.

    What must prove infuriating to them is that as people discover and use, in ever increasing numbers, Complementary and Alternative systems of medicine, their obvious superiority will tend to diminish and, eventually end, the era of assembly line standard medicine in which side effect ridden “drugs” are routinely prescribed as one size fits all. There are a number of rather large corporations and politically well connected special interests who don’t like that idea one bit. Too bad for them. They have earned our contempt.

    The system that “approved” Vioxx with the blessings of the FDA, and the clumsy mechanisms that eventually ordered its recall, are still in place. Somehow, this is not a problem for the “scientism-ists”. Meanwhile, people are going to Chiropractors, Acupuncturists, Homeopaths and avoiding the “standard medicine” mess and that trend is going to continue and increase, as well it should.

    I shall read Ian Coulter’s research articles with great interest.

    Thanks.

  20. #20 Whitecoat Tales
    July 1, 2009

    Severtson (you’ll get the Dr when you prove you’re actually a doctor) :

    Noone suggested that a double blind randomized controlled trial was required here. You’ve missed the biggest point.

    The study said that patients cared for by chiropractic PCPs had less hospitalizations, less surgeries, and used less money. It said nothing about whether or not they recieved good care!
    For example: What does your average chiropractor know about treating hypertension. In a study like this, without measuring outcomes, yea, the patient will save a ton of cash on not getting hypertension meds, and since hypertension is asymptomatic until it’s really too late, they’ll have less hospitalizations, or medication costs to the system. And in 20 years, said patient’s risk for kidney failure, congestive heart failure, and all of the other complications and long term problems associated wtih hypertension skyrocket.

    You can’t compare cost of care, without comparing quality of care.

  21. #21 Howard Boos
    July 2, 2009

    Wow you arrogant members of the Church of Orthodox Medicine must be scared.
    You hide behind the holy shroud of “scientific” research while 2.4 million unnecessary surgeries are performed each year at the cost of 11,900 lives; your approved “scientific” studies of Vioxx alone killed 30 to 50 thousand.
    B.J. Palmer, the developer of Chiropractic once said, “If I could hit someone in the rear with a shovel AND GET RESULTS I’m not too proud to do so.”
    If your supposed “scientific” members had all the answers people wouldn’t continue to flock to doctors of chiropractic.
    Me thinks you protest too loudly.
    Sincerely,
    Dr. Howard Boos
    Proud Doctor of Chiropractic
    Tulsa, OK
    (Stay scared my friends, stay scared.)

  22. #22 PalMD
    July 2, 2009

    An alternative to your current approach that would be more likely to fly, Mr. Boos, would be to give some data to support your assertions.

  23. #23 Bob Crispen
    July 3, 2009

    I love how chiropractors are volunteering to make themselves the spokesmen for alternative medicine. Their businesses must be lousy.

  24. #24 The Blind Watchmaker
    July 3, 2009

    Here’s a little mind exercise.

    I have many patients with complex medical problems. Some of them see chiropractors too and claim that they help their back pain. Fair enough.

    Now, what would happen if we divided them into 2 large groups. One group would have to stop seeing the chiropractor for 12 months. The other group would have to stop all of their medications for 12 months (including antihypertensives, antiarrhythmics, asthma treatments, seizure meds, insulin, etc.

    At the end of the 12 months, which group would have the most emergency room visits, hospitalizations and deaths?
    Which group would save the system the most money?

    Not a study that any sane person would actually do.

  25. #25 Harry
    July 6, 2009

    … she was told to disrobe. The chiro then inserted his finger into her rectum and started manipulating her lower back with the other hand. Needless to say, she was not expecting this and it caught her totally off guard. My question to you is: does this treatment sound legit and possibly part of the chiro’s methodology? Chet

    @Chet,

    I’m a second year Osteopathic Medical Student and what you said (unfortunately) doesn’t sound foreign to me. Some of our more woofull and quacktastic manipulation professors have made comments similar to what that woman experienced. I heard one talking about manipulating the sacrum via the vagina, so a finger in the pooper…. yeah. In short, it maybe part of a quack fringe of manipulative methodology but before my butt gets violated I demand dinner and a movie first!

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