Story Source

By Dr Daniel Redwood, DC

The Patient Protection and Affordable Care Act includes transparency provisions requiring the federal government to publicly disclose data on all payments by Medicare to healthcare providers. On April 9, 2014, the Center for Medicare and Medicaid Services (CMS) released a massive data set containing information on more than 880,000 distinct health care providers who collectively received $77 billion in Medicare payments in 2012, under the Medicare Part B Fee-for-Service program. According to CMS, “With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual healthcare providers.”

This Medicare payment data set has provided investigative journalists and other writers with a treasure trove of ideas for stories and commentaries. Among the many dramatic articles published in the wake of the initial Medicare data release, a few have targeted perceived waste or abuse of the system by chiropractors.

Earlier this year, the finance publication Forbes published an opinion piece 1 by Steven Salzberg, PhD, a professor of medicine and biostatistics in the Institute of Genetic Medicine at Johns Hopkins University School of Medicine, in which the author asserted that the entire $496 million paid by Medicare for chiropractic services (which accounts for .006 percent of total Medicare payments to healthcare providers) is an example of wasteful government spending. Salzberg urged policymakers to zero out the chiropractic portion of the Medicare budget as a starting point in new legislative efforts to cut federal health spending.

Salzberg is no stranger to attacks on chiropractic and other alternatives to conventional allopathic medicine. His group, Science-Based Medicine, may be best understood as a modern-day successor to the infamous Quackbusters organization, which for decades sought to undermine chiropractic and other alternatives to allopathic medicine at every opportunity. Quackbusters may be dead but its spirit unfortunately lives on.

How to Respond to Attacks

The best way for doctors of chiropractic (DCs) to respond to extremist broadsides like the Forbes article is with facts, context and research.2,3 Anthony Hamm, DC, president of the American Chiropractic Association, set precisely the right tone in his letter to the editor of Forbes in which he noted that “DCs are the highest rated healthcare practitioners for low-back pain treatments — treating nearly 27 million Americans annually — above physical therapists, specialist physicians/ MDs (e.g., neurosurgeons, neurologists, orthopedic surgeons) and primary care physicians/MDs (e.g., family or internal medicine).” Citing a study by the Washington State Department of Labor and Industry,4 Dr. Hamm noted, “This is not surprising when you consider that injured workers are 28 times less likely to undergo spinal surgery if their first point of contact is a DC rather than a surgeon (MD), and that treatment for low-back pain initiated by a chiropractic physician costs up to 20 percent less than treatment started by a MD.” Dr. Hamm added that “unnecessary spinal fusion surgery (a procedure that has seen a 500 percent increase in the last decade) has resulted in an estimated $200 million in improper billing to Medicare in 2011 alone. It is noteworthy that Medicare deemed the surgeries medically unnecessary because more conservative treatment hadn’t been tried first.”

Know the Research

When responding to attacks on the value of chiropractic care for Medicare patients and older adults specifically, DCs should be particularly conversant on two recent randomized trials: one on chronic low-back pain5 by Maria Hondras, DC, PhD, and colleagues and the other on chronic neck pain6 by a team led by Michele Maiers, DC, MPH. These were the first, and remain the only, randomized clinical trials on chiropractic care for older people. In light of the demographic bulge of the baby boomer generation now entering the Medicare rolls, these studies should be seen as an essential part of our outreach toolkit.

Chronic Low-Back Pain in People Over 55

The first-ever randomized clinical trial of chiropractic care for geriatric patients was published in 2009 in theJournal of Manipulative and Physiological Therapeutics (JMPT) by a team of investigators at Palmer College of Chiropractic led by veteran chiropractic researcher Maria Hondras. Artfully crafted, this trial compared results of two biomechanically distinct chiropractic methods (e.g., diversified and flexion-distraction) and also included a group that was treated with minimal conservative medical care (i.e., consisting of medication, usually acetaminophen). Patients in all groups also received home exercise instruction. All participants were at least 55 years old with subacute or chronic nonradicular low-back pain.

The primary outcome variable was low-backrelated disability assessed with the 24-item Roland Morris Disability questionnaire at 3, 6, 12 and 24 weeks. The results were quite favorable to chiropractic, with people receiving the two different forms of chiropractic manual manipulation achieving the same levels of improvement, which exceeded the progress achieved by the group receiving medical care.

Describing this important study five years after its 2009 publication, Dr. Hondras, now a PhD fellow at the University of Southern Denmark’s Institute of Sports Science and Clinical Biomechanics, says, “As with most randomized controlled trials examining chiropractic interventions, we found small advantages of our manual therapy treatments over minimal conservative medical care in the areas of pain and functional status. These changes may have great value for individual patients who are 55 and older.” She also points out that there were no serious side effects from either low- or high-velocity spinal manipulation, “and in this sense older adults may be more confident about choosing chiropractic as an effective and safe option for their back pain. Given that participants in our trial had relatively uncomplicated low back pain, it will be important to replicate similar work in older adults with co-morbid conditions.”

Chronic Neck Pain in People Over 65

The first randomized clinical trial on chiropractic treatment of chronic mechanical neck pain in seniors was published by Maiers et al. in Spine Journal in 2013. This study was funded by the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services. Unlike the Hondras low-back pain study, Maiers’ neck pain trial involved a single method of spinal manipulation, with the researchers assessing the relative effectiveness of manipulation and supervised rehabilitative exercise, both in combination with, and compared to home exercise alone for neck pain in 241 individuals age 65 years or older.

Patient self-report outcomes were collected at baseline and 4, 12, 26 and 52 weeks after randomization. The primary outcome was pain, measured by an 11-box numerical rating scale. Secondary outcomes included disability (Neck Disability Index), general health status (Medical Outcomes Study Short Form-36), satisfaction (7-point scale), improvement (9-point scale) and medication use (days per week).

After 12 weeks of treatment, the manipulationplus- home-exercise group demonstrated a 10 percent greater decrease in pain compared with the home-exercise-only group, and five percent change over supervised-plus-home exercise. Analysis incorporating primary and secondary patient-rated outcomes showed that the manipulation plus home exercise group was superior to the home-exercise-alone group in both the short and long term.

Geriatric Chiropractic Best Practices

Doctors of chiropractic base clinical care decisions on the best available research evidence combined with their own clinical experience and that of others, applying these in a context that respects the values and preferences of individual patients. DCs, like members of other health professions, can benefit greatly from “best practices” consensus documents prepared by representative groups of their peers in a Delphi process, following the rigorous RAND-UCLA (University of California, Los Angeles) methodology. Proposed consensus statements on geriatric care by DCs were circulated electronically to the Delphi panel until consensus was reached. Consensus was defined as agreement by at least 80 percent of the panelists. There were 28 panelists from 17 U.S. states and Canada, including 24 doctors of chiropractic, i.e., physical therapist, nurse, psychologist, and acupuncturist.

The chiropractic best practices document7 developed in accordance with these methods was published in theJMPT in 2010, and its conclusions (with the references on which they are based) can be accessed on the website8 of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), a broad-based organization whose mission includes generating, updating and providing web access to evidence-based clinical guidelines and reports through the CCGPP Rapid Response Resource Center (R3C). It is important to note that the recommendations on geriatric care by chiropractors reflect an understanding that chiropractic practice involves far more than delivery of spinal adjustments. (For more on CCGPP, see May 2014 ACA News, p. 10)

The best practices document includes recommendations for practicing DCs to consider when evaluating, treating and managing geriatric cases (see Box, Page 14.)

Why Best Practices Matter

As aptly described by Louis Sportelli, DC, in an accompanying article (see Page 18), the development and deployment of best-practice documents is a critical component of the chiropractic profession’s efforts to maximally legitimize the use of chiropractic care for older adults, particularly in light of the fact that rigorous chiropractic geriatric research is minimal. The best-practice document on pediatrics9 has demonstrated the ability of such chiropractic consensus documents to influence medical physicians to view chiropractic more favorably, (see interview10 by Jay Greenstein, DC, with Stephen Lazoritz, MD, in the August 2014 ACA News, p. 22). In geriatrics and all other areas where consensus processes have been completed, DCs have the opportunity to apply these in encounters with insurers, policymakers and others. Their impact can be substantial.

Cheryl Hawk, DC, PhD, associate vice president of Research and Health Policy at Logan University, has been involved in eight consensus projects that resulted in published best-practices or clinical guidelines, as well as the development of internal care pathways for Logan, based on a similar methodology. Reflecting on her experiences with these consensus projects, Dr. Hawk says, “Evidence can be used as a tool or a weapon, and providers need to know how to use it safely and for their patients’ best interests. I see guidelines simply as a way to help them do that.”

References

1. www.forbes.com/sites/stevensalzberg/2014/04/20/new-medicare-data-reveal-startling-496-million-wasted-on-chiropractors/.

2. Lawrence D, Goertz C. How to Respond When the Media Criticizes Chiropractic: Do’s and Don’ts. Dynamic Chiropractic. July 1, 2014, Vol. 32, Issue 13.

3. Rosner A. Dynamic Chiropractic. July 1, 2014, Vol. 32, Issue 13.

4. Keeney, B. J., et al. (2013). “Early Predictors of Lumbar Spine Surgery After Occupational Back Injury: Results From a Prospective Study of Workers in Washington State.” Spine (Phila Pa 1976) 38(11): 953-964.

5. Hondras, M. A., et al. (2009). “A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain.” J Manipulative Physiol Ther 32(5): 330-343.

6. Maiers, M., et al. (2013). “Spinal manipulative therapy and exercise for seniors with chronic neck pain.”Spine J. [ePub ahead of print].

7. Hawk, C., et al. (2010). “Best practices recommendations for chiropractic care for older adults: results of a consensus process.” J Manipulative Physiol Ther 33(6): 464-473.

8. http://clinicalcompass.org/wp-content/uploads/2013/09/Special-populations-Geriatric.pdf.

9. Hawk, C., et al. (2009). “Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process.” J Manipulative Physiol Ther 32(8): 639-647.

10. “ Integrative Issues: Chiropractic, Preventing Child Abuse and Medicaid,” Aug.2014 ACA News, p. 20.

Evidence-Based Recommendations for Chiropractic Care of Older Adults (With References)

• Strength training and balance exercises improve function and reduce impairment

• Strong evidence to support1

§ Counseling for physical activity and exercise1

§ Counseling for general health1

§ Counseling for fall prevention1

• Screen for fall risk factors

§ Medication use (including polypharmacy)1

§ Blood pressure1

§ Balance and gait1

§ Heart health1

§ Home safety1

• Tables included in the article

§ Outline geriatric red flags for immediate referral and those requiring co-management or appropriate referral1

§ Agency for Healthcare Research and Quality (AHRQ) recommendations for screening and counseling for adults aged 65 and older 1

• Hawk et al. article provides “a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of older adults.”1

• Dougherty et al. article focuses on SMT, acupuncture, physical activity/exercise, nutritional counseling and fall prevention2

• Observational studies and RCTs have reported improvement of spinal pain (acute, subacute and chronic) among seniors using SMT, BioEnergetic Synchronization Technique and Cox Flexion-Distraction technique. 2

A 2010 UK Report of Manual Therapies indicates chiropractic’s effectiveness in adults for:

§ SMT for acute, subacute and chronic LBP; headaches (migraine and cervicogenic) and cervicogenic dizziness2,3

§ SMT or mobilization for some extremity joint conditions2,3

§ SMT or mobilization of thoracic spine for both acute and subacute neck pain2,3

• Limited evidence for SMT for COPD, constipation, depression (associated with back pain), Parkinson ’s disease, MS, pneumonia, spinal stenosis, urinary incontinence, and OA pain and dysfunction, especially of the knee 2

• Acupuncture and chronic MSK pain

§ Insufficient experimental evidence showing its benefit over other modalities2

• Evidence for supplement use affecting health outcomes

A 2011 systematic review and meta-analysis found that vitamin D (800 to1000 IU/day) improves strength and balance.4

A 2010 systematic review found that vitamin D supplementation reduces risk of falls:5

§ Most beneficial: vitamin D and calcium as an “adjunct to pharmacologic regimen in treatment of osteoporosis and in the prevention of hip fractures and other non-vertebral fractures”2

§ Recommended 1,200 mg calcium; 1,000 IU of vitamin D2

§ Other supplements have inadequate evidence or evidence of significant side effects 2

• Positive effects of aerobic exercise and strength training (strength, balance and physical functioning)2

§ Modest beneficial effect of resistive training on strength outcomes2

§ Strong evidence for improving gait speed and chair stands2

§ Decreased levels of arthritic knee pain with resistive training2

• DCs should collect falls history information, and provide treatment and exercises for musculoskeletal conditions 2

References

1. Hawk C, Schneider M, Dougherty P, Gleberzon BJ, Killinger LZ. Best practices recommendations for chiropractic care for older adults: results of a consensus process. J Manipulative Physiol Ther. Jul-Aug 2010;33(6):464-473.

2. Dougherty PE, Hawk C, Weiner DK, Gleberzon B, Andrew K, Killinger L. The role of chiropractic care in older adults. Chiropr Man Therap. 2012;20(1):3. FREE FULL TEXT.

3. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3. FREE FULL TEXT.

4. Muir SW, Montero-Odasso M. Effect of vitamin D supplementation on muscle strength, gait and balance in older adults: a systematic review and meta-analysis. Journal of the American Geriatrics Society. Dec 2011;59(12):2291-2300.

5. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. Dec 21 2010;153(12):815-825

Published in the September ACA News