Spinal disorders are the most common reason patients visit their primary care provider. When they do, the hope is that they will receive first-line, nonpharmacological and noninterventional, guideline-concordant care, which of course, includes chiropractic. Unfortunately, this is not usually the case for patients in low-income, non-Hispanic white (NHW) zip codes.
A retrospective cohort study in preprint examines the experiences of more than a million insured adults from 29,318 zip codes with 1,534,280 episodes of a spinal disorder involving 500,000-plus health care providers (HCPs). Overall, these experiences cost $2,022,124,695 in care. This study follows two previous studies conducted by a research team affiliated with UnitedHealth Group and Optum Labs that examined effective care for low back pain and neck pain, respectively.1-3
In all three studies, care is grouped according to how it aligns with clinical practice guidelines. First-line services are the most guidelines concordant, and include chiropractic and osteopathic manipulation, active care, manual therapy, and acupuncture. Second-line services include prescription NSAIDs and skeletal muscle relaxants, radiography, and MRI studies. Least concordant with clinical practice guidelines are third-line services: prescription opioids, spinal injections and surgery, and CT scans.
Compared to individuals in primarily white, middle-income zip codes, individuals in NHW, disadvantaged zip codes were more likely to initially contact an emergency medicine physician (Relative Risk 2.23, 95% CI 2.11-2.36) or primary care provider (RR 1.40, 95% CI 1.38-1.42) and less likely to contact a chiropractor (RR 0.36, 95% CI 0.34-0.37).
These individuals had higher exposure to prescription NSAIDs (RR 1.99, 95% CI 1.95-2.02), skeletal muscle relaxants (RR 1.57, 95% CI 1.52-1.59), opioids (RR 1.18, 95% CI 1.15-1.20), and CT scans (RR 1.94, 95% CI 1.84-2.04). They were also more likely to receive other second- and third-line services, and less likely to receive first-line services.
Individuals in lower NHW, disadvantaged zip codes "had lower total cost associated with higher rates of pharmacological services, lower rates of first line non-pharmacological services, and lower rates of spinal surgery." Individuals in primarily white, middle-income zip codes "had higher total cost associated with lower rates of pharmacological services, higher rates of first-line non-pharmacological services, higher rates of MRI and spinal injection."
In addition, more chiropractors per 100 population was associated with a lower rate of opioid use, while more pain management physicians per 100 population was associated with a higher rate of opioid use. The type of health care provider initially contacted by patients with spinal disorders made a significant difference in the rate of opioid exposure.
Among the many important points made in this study, the impact of doctors of chiropractic on the reduction of the use of opioids and other drugs is clear. The question is, how to get chiropractic care to more disadvantaged, lower-income people?
Editor's Note: The research papers referenced in this article are preprints and have not been certified by peer review as of press time. They report new medical research that has yet to be evaluated and thus should not be used yet to guide clinical practice.
References
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