Spinal Manipulation Cost-Effectiveness Review
Summary provided by Dean L. Smith, D.C., Ph.D.
Michaleff ZA, Lin CW, Maher CG, van Tulder MW. Spinal manipulation epidemiology: Systematic review of cost effectiveness studies. J Electromyogr Kinesiol. 2012 Mar 17. [Epub ahead of print] PubMed PMID: 22429823
Neck and back pain is common in today’s society. It presents major economic burdens due to the high level of chronicity and the resulting long-term disability that are associated with high health-care costs and losses of productivity. As clinicians, we tend to focus on clinical practice guidelines regarding the effectiveness of our care as opposed to the cost-effectiveness of treatment. But, obviously cost-effectiveness is an important consideration in allocating health-care resources.
Economic evaluations are performed frequently alongside randomized controlled trials of treatment effectiveness and typically involve the identification, measurement, valuation and comparison of the costs and benefits of two or more alternative treatments. Economic evaluations are most beneficial when the treatments have been evaluated for efficacy, effectiveness and availability. Economic study of treatments provides us with the information of ‘value for money.’
Spinal Manipulative Therapy (SMT) seems to provide greater improvements for pain and function than a placebo or no treatment but similar improvements to many competing treatments according to some recent research. While there seem to be favorable clinical effectiveness studies of chiropractic compared to other interventions, what about cost-effectiveness? This study aimed to investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration.
Clinical and economic databases were searched for studies evaluating the cost-effectiveness of SMT for spinal pain. Two authors independently screened search results, extracted data and assessed risk of bias using the Consensus on Health Economic Criteria (CHEC-list). The data derived from each study included: a) type and perspective of the economic evaluation, b) subjects, c) treatment comparisons, d) year, study duration, country and currency, e) comprehensive cost evaluation, f) results. The primary outcome used was the relative cost-effectiveness of the interventions – usually reported as an incremental cost-effectiveness or cost-utility ratio (ICER). The ICER indicates the ratio of change in costs to the change in effects of the various treatments. In other words, the ICER represents the incremental difference in costs between the competing treatment alternatives relative to the incremental difference in effects, and can be interpreted as the additional monetary investment needed for an intervention to gain one extra unit of effect compared to the alternative treatment.
The authors performed a systematic review and found six cost-effectiveness studies along with cost-utility analyses. The number of participants in each of the 6 studies ranged from 146 to 1,334. All included studies had a low risk of bias scoring at least 16/19 on the CHEC-List. SMT was delivered by chiropractors, physiotherapists, and osteopaths with treatments involving a combination of manipulation, mobilization, and advice.
• SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP (general practitioner) care, exercise and physiotherapy.
• SMT demonstrated better cost-effectiveness and recovery over GP care for neck pain.
• SMT was found to be a cost-effective treatment option compared to an exercise program in terms of pain, recovery and quality-adjusted life-years (QALYs) gained.
• SMT plus GP care was found to be a cost-effective treatment compared to GP care alone.
• SMT plus GP care was also found to be a cost-effective treatment play compared to GP care plus exercise.
• Annual costs of a combined treatment approach (SMT plus advice and exercise) compared to GP care were lower and with respect to pain and disability outcomes, the data suggested the combined treatment was dominant over GP care.
In conclusion, this systematic review found SMT to be a cost-effective treatment to manage spinal pain. The review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. The evidence was primarily based on single studies conducted in the UK and the Netherlands. More high-quality studies will help determine whether these findings are generalizable in different settings.