Cost-effectiveness studies of medical and chiropractic care for occupational low back pain: A critical review of the literature

Background context: Back pain is the single most costly work-related injury. Chiropractors and physicians are the main primary care providers for occupational low back pain (OLBP), but there is no consensus regarding the relative cost-effectiveness of these two modes of care. Purpose: To critically appraise and synthesize recent literature on the cost-effectiveness of medical and chiropractic care for OLBP, and to propose a cost-effectiveness methodology that integrates epidemiologic and economic methods for future studies. Study design: Literature review. MEDLINE was searched from 1990 through 1999. Nine articles that met the inclusion criteria were reviewed. The methodological quality of the articles was critically appraised independently by two epidemiologists using standardized review criteria. Two health economists reviewed the studies on cost-effectiveness. Results: The current literature suggests that chiropractors and physicians provide equally effective care for OLBP but that chiropractic patients are more satisfied with their care. Evidence on the relative costs of medical and chiropractic care is conflicting. Several methodological deficiencies limit the validity of the reviewed studies. No studies combine high-quality cost data with adequate sample sizes and controls for confounding factors. Conclusion: Existing studies fail to clarify whether medical or chiropractic care is more cost effective. We suggest that future studies must combine epidemiologic and economic methods to answer the question adequately.