The Ministry of Health of the Ontario has just released its commissioned report. The principal authors are two independent health economists: Professor Pran Manga, MA, PhD, director of the Health Administration program at the University of Ottawa, and Douglas Angus, adjunct professor of Health Economics at the University of Ottawa.
The executive summary of the report sets the tone of the study.
The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce health care costs. It has brought a new and unprecedented emphasis on evidence-based allocation of resources, with an overriding objective of improving the cost-effectiveness of health care services. Today, LBP has become one of the most costly causes of illness and disability in Canada; a phenomenon which does not appear to be generally appreciated or understood in medical and governmental circles in Canada. Much of the treatment of LBP appears to be inefficient. In this study we focused principally on the effectiveness and cost effectiveness of chiropractic and medical management of LBP.
The executive summary lists nine findings:
- On evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP.
- There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain.
- While it is prudent to call for even further clinical evidence of the effectiveness and efficacy of chiropractic management of LBP, what the literature revealed to us is the much greater need for clinical evidence of the validity of medical management of LBP. Indeed, several existing medical therapies of LBP are generally contraindicated on the basis of the existing clinical trials.
- There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management.
- There would be highly significant cost savings if more management of LBP was transferred from physicians to chiropractors.
- There is good empirical evidence that patients are very satisfied with chiropractic management of LBP and considerably less satisfied with physician management.
- Despite official medical disapproval and economic disincentive to patients (higher private, out-of-pocket cost), the use of chiropractic has grown steadily over the years.
- In our view, the constellation of the evidence of:
(a) the effectiveness and cost-effectiveness of chiropractic management of low back pain;
(b) the untested, questionable or harmful nature of many current medical therapies;
(c) thee economic efficiency of chiropractic care for low back pain compared with medical care;
(d) the safety of chiropractic care;
(e) the higher satisfaction levels expressed by patients of chiropractors, together offers and overwhelming case in favor of much greater use of chiropractic services in the management of low back pain; The government will have to instigate and monitor the reform called for by our overall conclusions, and take appropriate steps to see that the savings are captured. The greater use of chiropractic services in the health care delivery system will not occur by itself, by accommodation between the professions, or by actions on the part of the workers' compensation board or the private sector generally.
The summary concludes with 10 recommendations:
- Current policy discourages the utilization of chiropractic services for the management of LBP.
- Chiropractic services should be fully insured under the Ontario Health Insurance Plan, removing the economic disincentive for patients and referring health providers.
- Chiropractic services should be fully integrated into the health care system.
- Chiropractors should be employed by tertiary hospitals in Ontario.
- Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs.
- Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients.
- Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with back injuries.
- The government should make the requisite research funds and resources available for further clinical evaluation of chiropractic management of LBP, and for further socio-economic and policy research concerning the management of LBP generally.
- Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public funding.
- Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.
The significance of the findings and recommendations are clear. This was not a study by chiropractors, but an independent, government-funded study conducted by respected health economists. The conclusions of these investigators were inescapable, given the current literature on LBP.
