Despite Practice Guidelines for Back Pain, Prescriptions for Narcotics Rise While Those for NSAIDs Fall

Medical practice guidelines are voluntary. Sometimes, this leads to clearly dysfunctional outcomes.

This interview with the author of a new article in JAMA Internal Medicine underscores the conclusions reached in the 2010 study by Bishop and colleagues at the National Spine Center in Canada, published in Spine Journal, which found management of low by pain by primary care medical physicians (PCPs) to be highly “guideline-discordant” with regard to medications. (Bishop’s article also found that for low back pain, guideline-based care that includes spinal manipulation by chiropractors is significantly more effective than usual care by PCPs).

The new JAMA Internal Medicine article’s lead author is John N. Mafi, MD, chief medical resident and fellow in general medicine at Beth Israel Deaconess Medical Center in Boston:

We saw a decline in use of NSAIDs that was discordant with the guidelines. The guidelines recommend it as a first-line treatment. What we are seeing instead is a rise in narcotic prescriptions. The guidelines are cautious about narcotics and say to be cautious and recommend them only as second- or third-line therapies.

There is also discordance between the guidelines and physician use of imaging. In patients with new-onset back pain, ordering an MRI or CT scan is not indicated in most cases. Finally, we saw a rise in referrals to specialists, though primary care clinicians are usually able to manage patients with routine cases of back pain themselves with minimal treatment.

news@JAMA: What do you think is driving physicians to pursue these more aggressive treatment approaches?

Dr Mafi: We are a society that demands instant solutions, but back pain doesn’t play by these rules. It takes time, and unfortunately, the fancier treatments haven’t been shown to decrease patient’s pain or increase their quality of life. That’s why we have to rely on the less-is-more approach.

news@JAMA: What do you think is driving the shift from NSAIDs to narcotics?

Dr Mafi: It is in part patient expectations and a sentiment that emerged in the 1990s physicians weren’t paying enough attention to patient pain. The Joint Commission made pain the fifth vital sign. In response, there has been an overcorrection and now narcotics are reached for first. Since that time, there has been a 300% increase in narcotic prescriptions and rise in narcotic overdoses and deaths. In 2008 almost 15000 people died—more than for cocaine and heroin overdoses combined. There are huge public health implications.

References:

1. Mafi JN, McCarthy EP, Davis RB, Landon BE. WOrsening trends in the management and treatment of back pain. JAMA Internal Medicine. 2013 (epub before print).

2. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal. 2010;10(12):1055-1064.

JAMA’s Low Back Pain Patient Page

To chiropractic students today, it may seem altogether ordinary (and certainly evidence-based) to recommend chiropractic care for low back pain. The evidence supporting this has been quite strong since at least the mid-1990s. Yet for those of us who remember the days of the boycott and the ethical proscriptions against medical physicians who cooperated in any way with chiropractors, seeing this recommendation in the pages of the Journal of the American Medical Association is a milestone moment.

From my editorial in the current issue of Health Insights Today: 

So why is this news? Ask any chiropractor who’s been in the field for more than a decade or two and they’ll know. When we became chiropractors, and in some cases for long after that, it was taken for granted that JAMA, the official voice of the medical profession, would never publish a handout recommending chiropractic care for any condition. Long after research had demonstrated the effectiveness of spinal adjustments for low back pain (as recognized, for example, by the federal Agency for Healthcare Policy and Research report in 1994), such a recommendation never appeared in the pages of JAMA.

Why now? It’s hard for an outsider to say with certainty, but after a certain point, the consistent  conclusions of all major practice guidelines (including the influential 2007 Low Back Pain Guidelines jointly prepared by the American College of Physicians and American Pain Society) probably became impossible to ignore while seeking to maintain an aura of integrity. In addition, this likely represents a generational change in the medical profession. More and more medical doctors in leadership positions came of age professionally at a time when a fair reading of available research clearly led to the conclusion that spinal manual care (what the new JAMA Patient Page calls “chiropractic therapy”) is in fact helpful for acute, subacute and chronic low back pain.

Provider Nondiscrimination Update

My editorial on the Affordable Care Act’s section that prohibits insurance companies from discriminating against classes of health care providers is now posted at Health Insights Today.

When fully implemented, this federal nondiscrimination policy will for the first time forbid any American health insurance company from refusing to cover services legally provided by a class of licensed health care practitioners (e.g., chiropractors, acupuncturists or clinical social workers) acting within the scope of their state licenses, if it covers those services when provided by a different class of practitioners (e.g., medical or osteopathic physicians). While the Affordable Care Act does not mandate equal payment for equal work (i.e., paying a chiropractor providing a service the same rate as an MD providing the same service), friend and foe alike understand that Section 2706 would make it illegal for insurers to cover any health service for one class of providers licensed to perform it while rejecting coverage for another also licensed to do so. (This nondiscrimination policy does not apply to the two largest government insurance plans—Medicare, which offers partial chiropractic coverage nationwide, and Medicaid, where coverage varies from state to state.)

This part of  the law goes into effect on January 1, 2014. Because it applies to all services that a practitioner is licensed to provide under state law, the implications are quite broad. I’ll be writing more about this in the near future, and presenting on the prevention and health promotion part of this equation at the March ACC-RAC conference in Washington, DC. (ACC-RAC is the annual Association of Chiropractic Colleges Research Agenda Conference).

The Supreme Court Speaks, Health Reform Continues

My editorial on the health reform law has been posted as part of the new issue of Health Insights Today, here. There’s a focus on the potential effects of the law for chiropractic and CAM, along with broader societal effects that will come with implementation (or repeal).

I hope you all click through to the full editorial. Here’s an excerpt.

First, the landmark provider nondiscrimination rule, Section 2706:

Since most readers of Health Insights Today have a strong interest in chiropractic and complementary and alternative medicine (CAM), let’s begin with the provisions directly related to those fields. First and foremost, the Affordable Care Act’s Section 2706 enacts for the first time a nationwide provider nondiscrimination policy, prohibiting insurance companies from denying coverage based on provider type for services provided by licensed health care practitioners. For example, this policy appears to indicate that if spinal manipulation or acupuncture (or any other service within a practitioner’s scope of practice) is covered when performed by a medical or osteopathic physician, insurers cannot have a policy denying such coverage when the service is performed by a chiropractor or acupuncturist. In the past, such discriminatory policies have had the effect of routing patients away from DCs, LAcs and other non-MD/DO practitioners.

The nondiscrimination rule is a landmark step forward and marks the first time that legislation applies such a policy across the entire nation. However, it does not bar all forms of discrimination. Importantly, insurers are not barred from paying some types of practitioners more than others for the same services. Chiropractors and a variety of other non-MD/DO practitioners sought such a ban but did not achieve it in this legislation. Success on that front will have to wait until later.

The full ramifications of Section 2706 will become clearer over time, as uncertainties are resolved through state and/or federal regulatory actions or litigation. For now, it is seen by chiropractic and CAM leaders and attorneys as the most significant piece of federal legislation in many years. The American Medical Association House of Delegates approved a resolution at its June 2012 national meeting that calls for the repeal of the nondiscrimination policy. While vigilance on the part of chiropractic and CAM organizations remains necessary, this AMA repeal effort faces a steep uphill climb unless the November 2012 election brings a president, House, and Senate that repeals the entire Affordable Care Act. Senate Republican Leader Mitch McConnell and House Speaker John Boehner have pledged to seek full repeal in early 2013. 

I ask each of our readers … please familiarize yourself with what is in the law, so that you will be able to evaluate all claims — pro or con — based on facts rather than distortions.  

 

 

 

Congressional Committee Calls Chiropractic “Key Benefit” Within DoD Health Care System, Urges Pay Equity System

Over the past decade and a half, chiropractic has increasingly become an integral part of the health care systems serving America’s active duty military and its veterans. DCs now work at 45 VA hospitals and outpatient facilities as well as 60 Department of Defense treatment centers.

This news release from the American Chiropractic Association just arrived:

Congressional Committee Calls Chiropractic “Key Benefit” Within DoD Health Care System, Urges Pay Equity System      

Arlington, Va.- Members of the House Armed Services Committee have approved the inclusion of a strong, pro-chiropractic directive in their official committee report accompanying the FY 2013 National Defense Authorization Act. The committee language asserts that services provided by doctors of chiropractic (DCs) for our nation’s men and women in uniform is of “high quality” and has become a “key” benefit within the military health care system. Read relevant pages from the committee report here.

According to the American Chiropractic Association (ACA) and Association of Chiropractic Colleges (ACC), the language is significant for several reasons. “What we have here–and this is very important–is an official statement from one of the House’s oversight committees with authority over the Pentagon that directly links the services of DCs to the treatment of conditions experienced as a result of combat operations. This is a huge validation that chiropractic services are of significant, direct value to a combat fighting force,” said ACA President Keith Overland, DC.

Equally significant, the thrust of the language is aimed at ensuring that DCs within the military achieve “pay equality” and appropriate “job classifications” that are on par with other health care providers with similar training, education and scopes of practice. Regarding that language, Dr. Overland noted, “Our advocacy efforts have not only been aimed at getting DCs into federal health care programs such as the DoD’s, and expanding their presence there, but they also have been aimed at ensuring that DCs are provided with appropriate status, authority, salaries and other benefits equal to those enjoyed by comparable-level providers. This is a major step forward in this advocacy process. It demonstrates that Congress is not just interested in simple DC inclusion, but inclusion in the right way which fully recognizes the status, training and professional capabilities of a DC. Part of the ACA’s mission is to level the playing field down to every last detail.”

Inclusion of the language follows a bi-partisan letter sent last year to the Assistant Secretary of Defense for Health Affairs, signed by 15 members of the House Armed Services Committee, requesting the Department of Defense take action to correct the wage rate disparity experienced by doctors of chiropractic within the DoD. Full congressional action on the Defense Authorization bill that includes the House committee language has not yet taken place, but enactment is expected later this year, according to ACA officials, and will be a positive indicator that Congress continues to support a robust chiropractic program within the Department of Defense.

“The Association of Chiropractic Colleges is gratified that the extensive education and training that doctors of chiropractic receive has been recognized and that appropriate compensation is vital,” said ACC President Dr. Richard Brassard. Dr. Overland added, “I want to thank House Armed Services Committee Chairman Buck McKeon, Ranking Member Adam Smith and especially Congressmen Mike Rogers of Alabama and Dave Loebsack of Iowa for moving this issue forward.”

For further information on chiropractic inclusion in the military, or to learn more about ACA’s ongoing legislative efforts, go to ACA’s Advocacy webpage at www.ACAToday.org

 

Doctors Urge Their Colleagues to Quit Doing Worthless Tests

This is a very difficult policy to implement as long as doctors and hospitals continue to be paid more when they perform more procedures. Radiology departments are major profit centers for hospitals and other health care facilities.

To see major medical groups such as the American Board of Internal Medicine endorse this policy is heartening. I would add that my profession, chiropractic, has made major changes along these lines within our educational institutions over the last decade. Student interns cannot routinely x-ray patients; for imaging studies to be approved, specific guidelines (such as the Canadian Cervical Spine Rule) must be followed.

Nine national medical groups are launching a campaign called Choosing Wisely to get U.S. doctors to back off on 45 diagnostic tests, procedures and treatments that often may do patients no good.

Many involve imaging tests such as CT scans, MRIs and X-rays. Stop doing them, the groups say, for most cases of back pain, or on patients who come into the emergency room with a headache or after a fainting spell, or just because somebody’s about to undergo surgery.

The Choosing Wisely project was launched last year by the foundation of the American Board of Internal Medicine. It recruited nine medical specialty societies representing more than 376,000 physicians to come up with five common tests or procedures “whose necessity … should be questioned and discussed.”

The groups represent family physicians, cardiologists, radiologists, gastroenterologists, oncologists, kidney specialists and specialists in allergy, asthma and immunology and nuclear cardiology.

Eight more specialty groups will join the campaign this fall, representing hospice doctors, head and neck specialists, arthritis doctors, geriatricians, pathologists, hospital practitioners, nuclear medicine specialist and those who perform a heart test called echocardiography.

Consumer groups are involved, too. Led by Consumer Reports, they include the AARP, National Business Coalition on Health, the Wikipedia community and eight others.

The effort represents a growing sense that there’s a lot of waste in U.S. health care, and that many tests and treatments are not only unnecessary but harmful.

Harvard economist David Cutler estimates that a third of what this country spends on health care could safely be dispensed with.

h/t Stephen Perle