Research Review By Dr. Ceara Higgins©

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Date Posted:

February 2017

Study Title:

Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain

Authors:

Stochkendahl MJ, Sorensen J, Vach W et al.

Author's Affiliations:

Nordic Institute of Chiropractic and Clinical Biomechanics, Denmark; Department of Public Health, University of Southern Denmark; Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Germany; Odense University Hospital, Denmark.

Publication Information:

Open Heart 2016; 3(1): e000334. doi: 10.1136/openhrt-2015-000334.

Background Information:

Over the last 25 years, an increase in hospital admissions due to suspected acute coronary syndrome has been seen in many countries (1), with the majority of these individuals being diagnosed with angina pectoris or non-specific chest pain (NSCP).

NSCP has been estimated to account for up to 80% of visits to rapid access chest pain clinics due to new episodes of chest pain (2). In 2013, the average annual societal cost per NSCP patient was estimated at €10,000 (3). This estimate includes hospital admission costs, decreased quality of life, sick leave, and lost productivity.

Roughly 10-30% of NSCP cases can be attributed to musculoskeletal problems (4). A 2012 study looked at the efficacy of chiropractic care compared to self-management in the treatment of NSCP diagnosed as having a musculoskeletal cause (5), with the chiropractic group showing significantly better results at 4 and 12 weeks, but no significant difference after 52 weeks (we reviewed that paper in 2012 and it can be found, with this Review, in the Clinical – Non-Cardiac Chest Pain section of the database). The current study looked into the 1-year cost effectiveness of these two approaches in terms of healthcare utilization, medication, and quality of life in patients with non-specific (non-cardiac) chest pain.

Pertinent Results:

59 patients were randomized to chiropractic care and 56 to self-management. Of those, 17 from the chiropractic group and 33 from the self-management group failed to complete the study. Data from the national registry was collected on all 115 for 1 year.

Both groups showed an increase in health related quality of life (HRQoL) with no significant difference seen between the groups at any time point. Fewer chiropractic care patients used healthcare services (including GP-after hours service, admissions to cardiology departments, cardiology ambulatory visits, and other ambulatory visits), and those who did used fewer visits. Chiropractic care patients had more visits to chiropractors than the self-management group (obviously), but fewer visits to physiotherapists. Both groups showed similar prescription and non-prescription medication usage, with the chiropractic group showing higher use of non-prescription mild analgesics and herbal medicines and the self-management group showing higher use of prescription opioids and lipid-modifying drugs.

The average cost of chiropractic care (€403.7) was higher than the cost of self-management (€44.8). However, other primary care costs were similar between the groups (€409.4 vs €502.9) and the costs of hospital care were lower in the chiropractic care group (€1919.5 vs €4305.8). In addition, the total 1-year costs for the chiropractic care group were €2183 lower than the self-management group, but this difference did not reach statistical significance.

Clinical Application & Conclusions:

While statistical significance was not obtained, similar improvements in HRQoL and Quality-adjusted life years (QALYs) were found in both groups, with lower total healthcare costs in the chiropractic care group in the first year after enrolling in the study. This suggests that offering patients presenting with acute non-specific chest pain (NSCP) the opportunity to consult with a musculoskeletal health care provider (a chiropractor!) is more cost-effective than leaving them to manage their condition themselves.

The results of this study must, however, be interpreted with consideration to the high attrition (drop-out) rate in both treatment groups (29% in the chiropractic group and 59% from the self-management group failed to complete the study).

Study Methods:

All patients presenting at a Danish emergency cardiology department between August 6th, 2006 and March 31st, 2008 with acute chest pain underwent routine diagnostic procedures. Any patients discharged had their records screened for inclusion.

Inclusion Criteria:
  • Primary complaint of acute chest pain of < 7 days’ duration
  • No diagnosis of acute coronary syndrome or another definite cardiac or medical diagnosis
  • Age between 18-75 years
  • Resident of the local country
  • Able to read and understand Danish
  • Have undergone diagnostic procedures to rule out acute coronary syndrome
  • No significant comorbidity or contraindications for spinal manipulative therapy
Exclusion Criteria:
  • Previous acute coronary syndrome
  • Prior percutaneous coronary intervention or coronary artery bypass grafting
  • Inflammatory joint disease, insulin-dependent diabetes, fibromyalgia, malignant disease, major osseous anomaly, osteoporosis, apoplexy, or dementia
  • Inability to cooperate
  • Pregnancy
All participants were assessed at baseline by the study clinician who obtained patient self-report questionnaires, a detailed case history, a general health examination, and systematic palpation of the chest wall and spine. Patients identified as having pain caused by mechanical joint and muscle dysfunction related to C4-T8 somatic structures, found via palpation, were classified as having musculoskeletal chest pain (6).

Both groups received usual care (typically, a 5 minute consultation with the attending cardiologist) and were then split into chiropractic care and self-management groups. Individuals in the chiropractic care group were assigned to one of eight experienced chiropractors in their local area and received individualized treatment for their condition (consisting of a variety of manual therapies and exercises). Time was also dedicated to provide advice and address any concerns the patient may have. A maximum of 10 treatment sessions (20 minutes each), one to three times per week for 4 weeks were allowed, with the clinician given the option of discharging the patient earlier if the patient became pain-free. Chiropractic patients received average of 7 treatments and 32% of those patients had an x-ray performed. Those in the self-management group received a 15-minute consultation with the study clinician, which included reassurance and advice. Patients were told that their chest pain was benign and self-limiting and were given two to three exercises to perform at home.

Information on resource use was collected from the national registries. This is uniquely possible in Denmark, as all citizens are given a unique identification number that is used to access health care. Additional data on clinical outcomes and resource use was collected from the patient self-report questionnaires collected at baseline, 4, 12, and 52 weeks. On these questionnaires, patients were asked to describe their use of complementary and alternative medicine (CAM) and non-prescriptive drugs over the previous three months. Costs considered included hospital costs (based on the Danish National Health Service standards), prescription and non-prescription drugs (based on the price charged by pharmacies), chiropractic care, self-management sessions (valued at the same cost as a single chiropractic treatment), additional visits to mainstream healthcare, and additional visits to CAM providers.

General health status was evaluated using the Medical Outcomes Study Short Form 36-item Health Survey (SF-36, v1US). This evaluates health in six dimensions: physical functioning, role limitations, social functioning, pain, mental health, and vitality. A Danish scoring algorithm was applied to calculate an index score from 0 (death) to 1 (perfect health) (7).

Study Strengths / Weaknesses:

Strengths:
  • A standardized and previously validated examination protocol was utilized (6).
  • Utilizing the unique personal identification number assigned to Danish residents allowed the researchers to track all hospital and public primary care utilization and medication use over the 1-year follow-up of all subjects, which helped to (at least partially) atone for the high drop-out rate they reported.
  • The external validity of the study was strengthened by utilizing the real-life context of a large university hospital and community based chiropractic clinics.
Weaknesses:
  • A high number of subjects in both groups failed to complete the study.
  • For individuals lost to follow-up, use of primary care covered by private insurance plans was not able to be obtained but was considered to be negligible when compared to hospital costs and unlikely to impact the outcomes significantly.
  • Indirect costs such as sick leave and lost productivity were not taken into account.
  • The 1-year follow up did not allow for observation of any potential long-term adverse (or positive) effects.

Additional References:

  1. Fagring AJ, Lappas G, Kjellgren, et al. Twenty-year trends in incidence and 1-year mortality in Swedish patients hospitalized with non-AMI chest pain. Data from 1987-2006 from the Swedish hospital and death registries. Heart 2010; 96: 1043-1049.
  2. Marks EM, Chambers JB, Russell V, et al. The rapid access chest pain clinic: unmet distress and disability. QJM 2014; 107: 429-434.
  3. Mourad G, Alwin J, Stromberg A, et al. Societal costs of non-cardiac chest pain compared with ischemic heart disease – a longitudinal study. BMC Health Serv Res 2013; 13: 403.
  4. Parkash O, Almas A, Hameed A, et al. Comparison of non cardiac chest pain (NCCP) and acute coronary syndrome (ACS) patients presenting to a tertiary care centre. J Pak Mad Assoc 2009; 59: 667-671.
  5. Stochkendahl MJ, Christensen HW, Vach W, et al. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial pf patients without acute coronary syndrome. J Manipulative Physiol Ther 2012; 35: 7-17.
  6. Stochkendahl MJ, Christensen HW, Vach W, et al. Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial. BMC Musculoskeletal Disord 2008; 9: 40.
  7. Oppe M, Devlin NJ, Szende A. EQ-5D value sets: inventory, comparative review and user guide. Dordrecht, The Netherlands: Springer, 2007.