continued...
Safety concerns should be paramount in interpreting the results of future cost-effectiveness analyses. A systematic review of the available prospective data on the safety of chiropractic indicates that adverse events, albeit common, seem to be mild and transient.14 Local discomfort or pain, radiating pain, headaches, neck stiffness, fatigue, nausea, and dizziness have been reported.15 Serious complications such as cerebrovascular accidents, spinal cord compression, vertebral fracture, tracheal rupture, and carotid dissection have been described, especially with cervical manipulation, but are thought to be rare.14, 16-17 Careful scrutiny should be applied in future research toward defining the subset of patients who would be at higher risk for major complications from chiropractic and in whom the intervention would cease to be appropriate, let alone cost-effective. On the other hand, chiropractic manipulation may prove to be a safer alternative when compared with the use of nonsteroidal anti-inflammatory agents or opiates in frail patients who are highly susceptible to the development of devastating medication adverse effects.
Could the actual implementation of expanded or universal chiropractic coverage affect cost savings adversely? The inclusion of sicker patients in the chiropractically insured group could paradoxically lead to a higher degree of resource utilization by chiropractors, attenuating the expected cost reduction and decreasing the expense gap between chiropractors and other specialists caring for back pain.
The role of chiropractic in the delivery of health care has exhibited some fluidity in the recent past. Advocates from within the chiropractic profession argue for the right of chiropractors to be perceived and acknowledged as primary care providers, diagnosing and treating the myriad problems that characterize ambulatory care and not restricting their practice to the management of musculoskeletal conditions.18 Legorreta et al13 identify potential cost-savings related mostly to the management of back pain and related neuromuscular ailments but do not assess the economic feasibility of a more comprehensive model of chiropractic "primary" care. Extensive research in this area is warranted as chiropractic moves toward novel and/or broader roles in health care delivery.
The study published in this issue of ARCHIVES offers a tantalizing glimpse into possible large-scale economic benefits obtained through access to chiropractic coverage by large groups of insured patients. Nevertheless, critical questions remain regarding which subsets of patients could derive the most benefit from chiropractic care and yet incur fewer health expenditures. Once these questions are answered, we will have moved one step closer to success in the daunting task of managing back pain.
AUTHOR INFORMATION
Correspondence: Dr Ness, Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242 (
[email protected]).
We thank Patsy McAtee for her efforts in the development of this editorial.
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