Pg. Shekelle et al., CONGRUENCE BETWEEN DECISIONS TO INITIATE CHIROPRACTIC SPINAL MANIPULATION FOR LOW-BACK-PAIN AND APPROPRIATENESS CRITERIA IN NORTH-AMERICA, Annals of internal medicine, 129(1), 1998, pp. 9
Background: Recent U.S. practice guidelines recommend spinal manipulat
ion for some patients with low back pain. If followed, these guideline
s are likely to increase the number of persons referred for chiropract
ic care. Concerns have been raised about the appropriate use of chirop
ractic care, but systematic data are lacking. Objective: To determine
the appropriateness of chiropractors' decisions to use spinal manipula
tion for patients with low back pain. Design: Retrospective review of
chiropractic office records against preset criteria for appropriatenes
s that were developed from a systematic review of the literature and a
nine-member panel of chiropractic and medical specialists. Appropriat
eness criteria reflect the expected balance between risk and benefit.
Setting: 131 of 185 (71%) chiropractic offices randomly sampled from s
ites in the United States and Canada. Patients: 10 randomly selected r
ecords of patients presenting with low back pain from each office (131
0 patients total). Measurements: Sociodemographic data on patients and
chiropractors; use of health care services by patients; assessment of
the decision to initiate spinal manipulation as appropriate, uncertai
n, or inappropriate. Results: Of the 1310 patients who sought chiropra
ctic care for low back pain, 1088 (83%) had spinal manipulation. For 8
59 of these patients (79%), records contained data sufficient to deter
mine whether care was congruent with appropriateness criteria. Care wa
s classified as appropriate in 46% of cases, uncertain in 25% of cases
, and inappropriate in 29% of cases. Patients who did not undergo spin
al manipulation were less likely to have a presentation judged appropr
iate and were more likely to have a presentation judged inappropriate
than were patients who did undergo spinal manipulation (P = 0.01). Con
clusions: The proportion of chiropractic spinal manipulation judged to
be congruent with appropriateness criteria is similar to proportions
previously described for medical procedures; thus, the findings provid
e some reassurance about the appropriate application of chiropractic c
are. However, more than one quarter of patients were treated for indic
ations that were judged inappropriate. The number of inappropriate dec
isions to use chiropractic spinal manipulation should be decreased.