How Much of Orthodox Medicine Is Evidence Based?
This is an interesting letter from the British Medical Journal
Scientific heavyweights deplore the NHS money wasted on unproved and disproved treatments used by practitioners of complementary and alternative medicine (CAM), [1, 2] but Lewith, a CAM proponent (see previous letter), is cited elsewhere as saying that the BMJ reckons that 50% of the treatments used in general practice aren’t proved, and 5% are pretty harmful but still being used. [3]
His data were taken from the BMJ Clinical Evidence website. A pie chart (see it below in the Evidence-based Practice posting) indicates that, of about 2500 treatments supported by good evidence, only 15% of treatments were rated as beneficial, 22% as likely to be beneficial, 7% part beneficial and part harmful, 5% unlikely to be beneficial, 4% likely to be ineffective or harmful, and in the remaining 47% the effect of the treatment was “unknown.”
Read more on this topic
Acute low back pain is a common and well investigated condition. BMJ Best Treatments reports that back pain affects 70-85% of all adults, and each year almost half of us get back pain that lasts at least a day. There are 18 treatments for acute low back pain which have been tested by randomized controlled trials (RCTs), of which two (11%) were graded “beneficial” and 13 (72%) “unknown.”
The accompanying table shows all of the 18 treatments for acute low back pain and their rated effect. According to this table, a condition that is extremely common, and for which many treatments have been intensively researched, has an even higher than average proportion of treatments that are labelled “unknown” efficacy, or in other places “need further study.” There must be some mistake.
The solution to the mystery is that the label “unknown” does not mean, “We have no knowledge of the effect of this treatment because it has not been tested in an RCT.”
Astonishingly, it means, “We have tested this treatment in several RCTs, but on balance there is currently no convincing evidence that it is effective for this condition.”
So, the actual efficacy of these 13 other “MEDICAL” treatments for acute back pain are NOT “unknown”… they have just never been demonstrated” in any of the trials that HAVE been conducted. That is vastly different than what this Pie Chart suggests!
Lewith’s interpretation of the pie chart is highly misleading. The research community has been commendably diligent, but of course RCTs often fail to find that certain treatments are effective.
Euphemisms such as “unknown” or “needs more study” for the inefficacy of such treatments may soothe the feelings of proponents of those treatments that have so far failed to show efficacy, but it does an injustice to the researchers who obtained these data, and misleads both practitioners and patients about the extent to which orthodox medicine is evidence based.
John S Garrow vice chairman, HealthWatch, The Dial House, Rickmansworth WD3 7DQ johngarrow@aol.com
Competing interests: None declared.
REFERENCES:
- Kamerow D.
Wham, bang, thank you CAM.
BMJ 2007;335:647. (29 September.) - Colquhoun D.
What to do about CAM?
BMJ 2007;335:736. (13 October.) - Cope J.
The great debate.
Healthwriter 2007 Apr:1-3
The best evidence I see is the MILLIONS of people who EVERYDAY visit their chiropractor for an adjustment. Can anyone argue with those numbers?
Nope…and it’s those numbers that got organized medicine up in arms, in particular, after Eisenberg wrote his first article.
However, those numbers do not count as evidence, in the strictest sense. But it’s sure hard to ignore, isn’t it?
Millions of people took and still take their kids in for antibiotics when they get the flu, kids got better (eventually), doesn’t mean antibiotics were the cure for the flu. The use of a treatment, in large numbers or not, obviously is not evidence of effectiveness.
Children don’t have a say in their health care. I would bet they would choose not to have a needle stuck in them. My point is that those that choose chiropractic day and day out do it because they “feel” it is effective. I guess it would be important to define “effective”
I know patients “feel” that they derive benefit from their chiropractic treatment and feel it is effective for whatever condition(s) they are are seeking treatment. I see this everyday. Effective to the patient is different than that of the insurance company or entity (government) footing the bill. The insurance company would like to know that any given treatment that they are paying for is effective for the diagnosis they are provided. If someone “feels” better after having breast augmentation, does that justify insurance paying for everyone to have plastic surgery? If the patient is paying cash, let them pay for what “feels” good to them and let the buyer beware, but maybe the third party payor should not be on the hook for the bill.
Frank! thanks for that huge boost in my confidence…I didn’t realize I was saving BCBS, Cigna, etc. so much money….wait a minute…I don’t file insurance. wow, that’s some awesome stats though – you’d think most insurance companies would underwrite more chiropractic benefits
Mike I agree. People in general expect their insurance should pay for their sick-care. Insurance is the main reason our country is spending 2x more than anybody else is in the world and getting sicker by the minute
Interesting conversation. Effectiveness, from the 3rd party POV, relates to the success of any treatment to improve on the *natural history* of any complaint. Even with the limited number of funded studies and meta-analyses, chiropractic stacks up well. Many of those studies are available for your review at the Cost-Effectiveness of Chiropractic Page.
The first article says it all:
A new retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management,
demonstrated decreases of 60.2% in-hospital admissions,
59.0% hospital days,
62.0% outpatient surgeries and procedures, and
83% pharmaceutical costs when compared with conventional medicine IPA performance.
This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.
No doubt chiropractic care improves peoples lives and relieves pain faster and less costly than other care with most patients complaining of musculoskeletal complaints. Where we (chiropractors) have gotten into trouble is when a patient comes in for back pain, is better in 4 treatments, but then is told that they need 36 more treatments to “correct” the real problem. Insurance should pay for the 4 visits but not the subsequent 36. At that point, we are not cost effective.
@Frank
I’m interested to know if you have any evidence to show that your spinal stability improves any further after say 20 visits than it does after 4 visits.
RESPONSE from Frank:
Sure, read “Newly Published Study Confirms That “Maintenance Care” Delivers!”
Hi Mike
Anyone who says that “x-number of visits” is required for anything is lying, because none of us can predict the future.
However, pain relief (your 4 visits) is NOT spinal correction….it”s a bandaid. Look at the statistics from BMJ etc…that recurrence is rather common.
Care after the second week should move from pain management to stabilizing care. That can be justified to any carrier by closely monitoring other symptoms like stiffness, ROM, response to ADLs.
I agree that no one can predict the amount of visits required for any diagnosis. as far as 4 visits, I am speaking of the simple subluxation, spinal lesion or crick in the neck, where a pt.(young healthy) should be out of pain in 1-4 treatments. that is correction of that particular patients problem, however, far too often, I have had patients being recommended weeks of care at hundred of dollars far beyond when they are out of pain supposedly to correct something in their spine. We all know this is “revenue enhancement”. I am not talking about a patient that has pain an perhaps need advice and instruction because they have limited range of motion or tight hamstrings, poor posture etc…There are an abundance of chiropractors that, after xray, exam will tell a pt that they need x number of visits, adjustment, decompression to fix their problem, whether or not their pain is relieved in one visit or 5. I hear it all the time. “I went to doctor so and so, paid 6K for 25 decompression sessions and felt the same the second treatment, third and so on. by the way, part of that I blame on the pt, if after the 12 visit they still have excruciating back and leg pain, I would start to question the treatment. I have also had many pt go through the spinal correction package, 6 month 6 grand package and guess what, they still get the recurrences
Obie
I would refer you to Craig Liebenson, D.C.’s textbook Rehabilitation of the Spine for the numerous citations supporting stabilizing care.
Mike
What you are referring to is an acute facet, and yes, those will clear up quickly in a young person. What I am referring to is someone who has had recurrent experiences over years, and that’s most of what I see in this office.
If I *play* the way a managed care outfit wants, I would get them out of pain, then wait 3 or 6 months and then I’d get to see them again.
That’s why I am not on anybody’s managed care panel…I don’t want to do *patch care*. I want to correct people…and just like the orthodontist says about your teeth, remodeling bony and ligamentous tissue takes time. NOT the numbers of visits, but the concerted care over a longer period of time.
I can’t speak for the decompression crowd. I practice McKenzie for disc derangement, and rarely see a disc person more than 9 times the first month. During month 2 it’s between 4-8 visits to resolution. And insurance companies have NO issue with paying for that type of care plan, whereas most of them will not pay for decompression.
@ Frank
The chapter in Liebenson’s book that addresses spinal stability talks only about exercise. In other areas where he talks about manipulation in conjunction with other methods like McKenzie he does not address frequency or duration. The book mentions that Shekelle “thinks” that 12 treatments over a one month period are sufficient for a therapeutic trial for specific conditions.
This does not address the idea chiropractors often present that it takes many treatments to achieve spinal stability (whatever that is) and I am still wondering whether there is any good evidence to show that treatments beyond the elimination of symptoms lead to increased stability and therefore better health and less recurrence.
Hi Obie!
I’m not sure what to say about Liebenson’t text…I loved the classes, and use some of that material, but we do have some philosophical differences about the long-term benefits of the adjustment.
Although our research basis is growing slowly, there’s still a LOT to be funded. Perhaps you could consider tithing some money to FCER so that happens sooner. Our website donates half our income to support research, and have been doing that since 2001.
Please take a look at Ron Rupert’s article
Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II as it reports on some interesting statistics:
• The cost of health care for patients receiving MC in this study was far less than that for patients of similar age in the general population despite the doubling of physician visits (medical plus chiropractic). The greatest difference in health care costs with patients receiving maintenance care was in the areas of nursing care and, especially, hospital care. This reduced need for hospital and nursing home services has recently been corroborated by the research of Coulter et al. [22]
• Chiropractic patients receiving maintenance care, when compared with US citizens of the same age, spent only 31% of the national average for health care services and reported a 50% reduction in medical provider visits. The health habits of patients receiving maintenance care were better overall than the general population, including decreased use of cigarettes and nonprescription drugs. Furthermore, 95.8% believed the care to be either “considerably” or “extremely” valuable.
Mike are you kidding me??? about cost effective?? how is this the cost of 1 count it 1 NCV/EMG pays for 50 you count that too 50 treatments at the medicare reimbursement rate for 98940… dont get me started dumpling I can go on all day.. I work side by side with the the MD’s and PT’s. 36 visits is still less than 1000 dollars. Oh and Cigna pays 20 days for a DC and 90 days for a PT…I have to stop because your out to lunch….. so the number of treatments is irrelevant at the rates we are reimbursed at..Get your head in the right place.
Frank keep up the good work its nice to see someone who has a real handle on things…
warmest regards,
Peter
Dr. Martin, with regards to the 36 visits, I was speaking to a DC who recommends 36 visits for someone who is, many times, almost asymptomatic and wants, not medicare or insurance to pay (which they shouldnt) but the patient to shell out 3-4 grand. Going to a DC or MC or PT for 36 visits with a acute HNP I have no problem with if they are improving with care. Just had a pt. in last week, went to a chiro in his church, took c/s xrays showing mild C5-6 ddd and promptly recommended 100 exact visits at over 3 grand. This is the kind of stuff I see almost weekly. If there were some kind of standards to warrant 100 visits, fine, but where did this DC get 100 visits? from some PM group.
By the way, I want to second the appreciation for the time Dr. Frank gives to the website. It is an excellent source of information and a forum for discussion on various topics.