1 Professor and Director, Masters in Health Administration Program, University of Ottawa; and President, Pran Manga and Associates Inc., Ottawa.

2 Adjunct Professor, University of Ottawa and Project Director, The Cost-Effectiveness of the Canadian Healthcare System, Queen's - University of Ottawa Economic Projects.

3 Healthcare Consultant and Associate of Pran Manga and Associates, Inc.

4 Consultant in Healthcare Economics.

The support of the Ministry of Health, Government of Ontario, which solely funded the project, is gratefully acknowledged. The views and opinions expressed in this report are those of the authors only, and should not be attributed to the MHA Program, University of Ottawa, the Ministry of Health or the Ontario Chiropractic Association .

Introduction

The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce healthcare 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 healthcare services.

The area of low-back pain (LBP) offers governments and the private sector an excellent opportunity to attain the twin goals of greater cost-effectiveness and a major reduction in healthcare costs. 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 government circles in Canada. Studies on the prevalence and incidence of LBP suggest that it is ubiquitous, probably the leading cause of disability and morbidity in middle-aged persons, and by far the most expensive source of workers' compensation costs in Ontario - as indeed in most other jurisdictions.

Much of the treatment of LBP appears to be inefficient. Evidence from Canada, the USA, the UK and elsewhere shows that there are conflicting methods of treatment, many with little - if any scientific evidence of effectiveness, and very high costs of treatment. Despite this, levels of disability from LBP are increasing.

In the Province of Ontario LBP is managed mostly by physicians and chiropractors, with physiotherapists also playing a significant role. While medical services are fully insured under Medicare, chiropractic care services are only partially covered. LBP patients incur the highest out-of-pocket expenses for chiropractic services. Virtually no out-of-pocket expenses are incurred for medical treatment, with the exception of drugs, and out-of-pocket expenses incurred for physiotherapy services fall somewhere in between the two.

Medical physicians, chiropractors, physiotherapists and an assortment of other professionals together offer about thirty-six therapeutic modalities for the treatment of LBP. In this study we focused principally on the effectiveness and cost effectiveness of chiropractic and medical management of LBP.

F1.
On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. Many medical therapies are of questionable validity or are clearly inadequate.

F2.
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. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic complications for LBP patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low-back pain.

F3.
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 also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by non-chiropractic professionals.

F4.
There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management. We reviewed numerous studies that range from very persuasive to convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must be noted and is significant to us in forming our conclusions and recommendations. The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care.

F5.
There would be highly significant cost savings if more management of LBP was transferred from medical physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually. The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, much fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability. Workers' compensation studies report that injured workers with the same specific diagnosis of LBP returned to work much sooner when treated by chiropractic physicians than by medical physicians. This leads to very significant reductions in direct and indirect costs.

F6.
There is good empirical evidence that patients are very satisfied with chiropractic management of LBP and considerably less satisfied with physician management. Patient satisfaction is an important health outcome indicator and adds further weight to the clinical and health economic results favoring chiropractic management of LBP.

F7.
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. Chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians.

F8.