Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence

Center for Disability Research at the Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine (Impact Factor: 1.63). 03/2011; 53(4):396-404. DOI: 10.1097/JOM.0b013e31820f3863
Source: PubMed


To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP).
A total of 894 cases followed 1 year using workers' compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.
Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8).
In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.

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    • "The literature search yielded a total of 129 articles. Based upon abstract reviews, we excluded 100 articles because of duplication or failure to meet inclusion criteria, leaving 29 peer-reviewed articles for full-text review, including 13 articles related to chiropractic under Medicare20-32 and 16 articles on chiropractic maintenance care.33-48 In addition, we reviewed 7 government reports issued on the provision of chiropractic services under Medicare, which included 5 reports on chiropractic under Medicare prepared by the Office of Inspector General (OIG; US Department of Health and Human Services) and corresponding official responses,18,19,49-51 a report of the Comprehensive Error Rate Testing (CERT) program,52 and the report to Congress on the Demonstration of Expanded Coverage of Chiropractic Services Under Medicare.17 "
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    ABSTRACT: Objectives Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services? Methods A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage. Results The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health. Conclusions The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.
    Journal of Chiropractic Humanities 12/2013; 20(1):9–18. DOI:10.1016/j.echu.2013.07.001
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    • "Maintenance care (MC) is used by chiropractors to treat patients who are no longer in an acute state of pain; the purpose being to prevent recurrence of episodic conditions (secondary prevention) and/or maintain a desired level of function (tertiary prevention). The concept is frequently used among chiropractors [1,2] and limited evidence suggests that, among workers with work-related back pain, MC in chiropractic practice appears to decrease the recurrence rate [3]. However, according to two literature reviews, very limited evidence regarding the definitions, purpose and content of MC is currently available [4,5]. "
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    ABSTRACT: To describe and interpret Danish Chiropractors' perspectives regarding the purpose and rationale for using MC (maintenance care), its content, course and patient characteristics. Semi-structured interviews were conducted with 10 chiropractors identified using a stratified, theoretical sampling framework. Interviews covered four domains relating to MC, namely: purpose, patient characteristics, content, and course and development. Data was analysed thematically. Practitioners regard MC primarily as a means of providing secondary or tertiary care and they primarily recommend it to patients with a history of recurrence. Initiating MC is often a shared decision between clinician and patient. The core elements of MC are examination and manipulation, but exercise and general lifestyle advice are often included. Typically, treatment intervals lie between 2 and 4 months. Clinician MC practices seem to evolve over time and are informed by individual practice experiences.Chiropractors are more likely to offer MC to patients whose complaints include a significant muscular component. Furthermore, a successful transition to MC appears dependent on correctly matching complaint with management. A positive relationship between chiropractor and patient facilitates the initiation of MC. Finally; MC appears grounded in a patient-oriented approach to care rather than a market-oriented one. MC is perceived as both a secondary and tertiary preventative measure and its practice appears grounded in the tenet of patient-oriented care. A positive personal relationship between chiropractor and patient facilitates the initiation of MC. The results from this and previous studies should be considered in the design of studies of efficacy.
    Chiropractic and Manual Therapies 08/2013; 21(1):27. DOI:10.1186/2045-709X-21-27
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    ABSTRACT: After work-related injury or disease, multiple spells of work absences and unsuccessful return to work (RTW) are common. The purpose of this study was to identify predictors of sustained RTW and work disability recurrences. Australian WorkSafe Victoria claims containing income compensation payments starting between January 1st, 2001 and December 31st, 2004 (n = 59,526) were analysed over a 2-year observation window. Time until first RTW and final RTW, and 'recurrences' (cessations of payments of >7 days), were derived from claims payments data. Regression models were used relating demographic, occupational, workplace and injury characteristics to RTW outcomes. Although 94% of claimants had at least one RTW, only 79% achieved sustained RTW during follow-up. Median time until first RTW was 50 days; median time until final RTW was 91 days. Independent predictors of delayed final RTW were older age, afflictions involving the neck or multiple locations, and working in manufacturing. Of those who returned to work, 37% had at least one recurrence: risk factors were ages 35-55, female sex, working as a labourer, working in manufacturing, traumatic joint/ligament or muscle/tendon injury and musculoskeletal and connective tissue diseases, and afflictions involving the neck or multiple locations. Work disability recurrences are common and have considerable impact on sustained RTW outcomes. A policy focus on education about secondary prevention may help improve long-term RTW outcomes, particularly for persons with musculoskeletal disorders and those working in manufacturing.
    Journal of Occupational Rehabilitation 12/2011; 22(3):283-91. DOI:10.1007/s10926-011-9344-y · 2.80 Impact Factor
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