October 2006


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Study Shows Increased Utilization of Chiropractic

A study published in the July 2006 issue of the American Journal of Managed Care showed an increase in the number of people using insurance benefits for what the authors termed, complementary and alternative medicine (CAM), with chiropractic leading the way. This study was a review of usage of CAM (complementary and alternative medicine) by more than 600,000 people enrolled in various healthcare plans in the state of Washington. 

The study notes that the State of Washington  has a law that requires private health insurance to cover complementary and alternative medicine (CAM) when delivered by licensed providers.  The results of the study showed that of the more than 600 000 enrollees in private insurance in Washington, 13.7% made CAM claims. The breakdown of these claims showed that 1.3% of enrollees made claims for acupuncture, 1.6% for naturopathy, 2.4% for massage, and by far the largest segment was for chiropractic at 10.9% of claims.

The study reviewed claims in the year 2002. What was also interesting was that they noted the increased insurance claims had no real additive effect on the total health expenditures.  They discovered that the median per-visit expenditures for CAM were $39.00 while the per visit average for conventional medical care was considerably more at $74.40. They tabulated that the total cost of the plans per person in a plan were $2589, of which only $75 (2.9%) was spent on CAM. This makes non-medical care a very affordable option.

The study also showed that enrollees made some 3,246,793 visits to medical practitioners in 2002 and during that same period they made 481,553 visits to chiropractors.  The authors noted in their conclusion, "The number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest."

In their conclusion the researchers made a bold statement for insurance companies as to the costs of including chiropractic and other services they called CAM.  They stated, "Payers have resisted covering CAM providers in part because of a fear that coverage would result in large, steadily increasing, and unpredictable expenditures for CAM services, not unlike the history of prescription drug coverage. Our study performed 6 years after the mandated inclusion of CAM benefits in Washington state suggests that this is not going to be the case."



Antibiotics Not Needed for Most Ear Infections

A study published in the September 13, 2006 Journal of the American Medical Association (JAMA) shows that "watchful waiting" is better than using antibiotics for the treatment of ear infections known as Acute Otitis Media (AOM).  The study starts off by noting that AOM is the most common diagnosis for which antibiotics are prescribed to children.

In this study 283 children ages 6 months to 12 years seen in a hospital emergency department, with acute ear infections were divided into two groups.  One group was treated only by the "wait-and-see prescription", known as the WASP group.  The second group was known as the SP group which stood for "standard prescription".  The authors noted that previous studies did not include severe cases as would be seen in the emergency room as with these cases.

The "wait-and-see prescription" group of children did get a prescription for antibiotics, but their parents were advised to wait and see for 48 hours before considering filling the prescription.  These parents were  asked not to fill the prescription they were given unless the child either is no better or is worse in 48 hours.  The "standard prescription" group got a prescription for antibiotics and were not given any instructions to wait and see. 

The results showed that 62% of the prescriptions in the WASP group were never filled. Conversely, about 90% of the children in the "standard prescription" group whose parents were not asked to wait and see wound up taking the antibiotics. Even more interesting is that the researchers found that, "There was no statistically significant difference between the groups in the frequency of subsequent fever, otalgia (pain), or unscheduled visits for medical care."  In essence the group that did not take antibiotics did just as good as the group that took the medication.

Lead researcher, David M. Spiro, MD, commented in a WebMD article by saying, "In this country, 96% to 98% of physicians treat ear infections immediately with antibiotics, even though most cases will resolve on their own without treatment."  In the conclusion of the study, Spiro and co-authors stated, "The WASP (wait-and-see-prescription) approach substantially reduced unnecessary use of antibiotics in children with AOM (acute otitis media) seen in an emergency department and may be an alternative to routine use of antimicrobials for treatment of such children.

It should be noted that in 2004 the American Academy of Pediatrics gave their approval to the wait-and-see approach and stated that 80% of children whose ear infections are not treated immediately with antibiotics get better on their own.



Malpractice Study Links Doctors' Basic Errors to Wrong Diagnoses

A study published in the October 3, 2006 issue of the Annals of Internal Medicine shows a correlation between doctor errors and incorrect diagnoses that lead to patient harm. This study differs from others in that it does not focus on errors in treatment, but rather errors in diagnosis that then lead to wrong care and harm.

Also covering this study is an article from the October 2, 2006 Associated Press that appeared in many news outlets.  Researchers in this study reviewed 307 completed malpractice cases, of which 181 were reported to involve errors in the diagnosis that then resulted in harm to the patient.  A high majority of these cases were cancer patients.  The reviews were from malpractice insurance companies files.

The results of the reviews showed  that of the 307 total claims 59 percent involved a diagnostic error that harmed patients. Of these 181 cases another 59 percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) were of such a serious nature that they resulted in the death of the patient.

The results showed that some of the more common errors involved "failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%])."

According to the researchers, the causes for these errors as stated in the study were, "failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%])."

Dr. Tejal K. Gandhi, lead author and director of patient safety at Brigham and Women's Hospital in Boston stated that he felt doctors could use more help.  He commented, "I don't want to say that it's not the physician's responsibility. We think there could be tools to help physicians make these decisions better."

At the end of the published study in the Annals of Internal Medicine, there was an editors context note that stated, "Efforts to reduce medical errors and improve patient safety have not generally addressed errors in diagnosis. As with treatment, diagnosis involves complex, fragmented processes within health care systems that are vulnerable to failures and breakdowns."



Behavioral Changes and Chiropractic Care, A Case Study

A documented case study published in the October 4, 2006 issue of the peer reviewed publication, the Journal of Vertebral Subluxation Research (JVSR), describes the results of chiropractic care on an 8-year-old boy with many learning and behavioral disorders.  Additionally, his mother reported that the boy also suffered from, severe headaches, neck pain, constant “blood shot” eyes, stomach pains, an inability to sit still, incoordination, behavioral problems and learning difficulties. She noted that the child's medical doctor had no explanation for these problems.

It was noted that the majority of the boy's problems started after a fall he had 18 months earlier. The mother also noted that her son had normal development, activity and learning skills until the accident.  Finally the mother brought the boy to a chiropractor. The chiropractor performed an examination and x-rays.  It was noted that there was a restriction in neck movement and tenderness over certain neck vertebrae. After review of all the findings it was determined that vertebral subluxations were present. 

Care was initiated for corrections of subluxations with visits initially starting at once per week for the first two months. However, as documented in this case, positive changes started occurring quickly.  After the third adjustment the boy's mother brought in the spelling tests the child had taken.  The tests prior to care showed severe problems as the child could only get two or three correct out of ten.  After the second adjustment, the child scored a 100% and his tests continued to show drastic improvement.  His teacher even noted that the boy was able to, "sit still and concentrate without disturbing the other children."

The child continued to receive reports from school commenting on his academic improvement as well as his social interactivity.  The authors of the case study noted that there were many possible explanations for the results seen in this case.  However, they noted that other than the usage of  “over the counter” medications  reported by the mother, the young boy did not take any prescribed medication.  The only change that directly correlated with the improvement in this young boy was the introduction of chiropractic care.



Drug Effects on Kids Uncertain

A study published in the September 13, 2006 issue of the Journal of the American Medical Association (JAMA) starts off with a chilling statement. "Much of pediatric drug use is off-label because appropriate pediatric studies have not been conducted and the drugs have not been labeled by the US Food and Drug Administration (FDA) for use in children."  In other words, according to the authors in JAMA, most of the drugs being sold for children have not been approved by the FDA for use in children.

The study, also reported on in a September 13, 2006 Associated Press story, notes that very little of the research that is done gets published in scientific journals.  This then makes it hard for doctors to know about the medications or the study results.  Dr. Danny Benjamin, an associate professor at Duke University who led the study and also works for the U.S. Food and Drug Administration commented, "Ironically, some of the times when drugs do work (in children), they're still not getting published."

Dr. Benjamin noted that many of the studies that do get done are never submitted for publication in journals. Dr. Catherine DeAngelis, JAMA editor-in-chief noted in the AP story that few studies submitted to JAMA involve the effects of medication on children. 

It is not known if the reason for these lack of submissions is the change in 2004 by many of the scientific journals that now require drug tests be pre-registered before the testing in order to be considered for publication after the tests are complete.  The reason the publications did this was because drug companies were running multiple studies on some drugs then only publishing the best results from drug trials while hiding the ones that may not have been so successful.  Gregory D. Curfman, executive editor of the New England Journal of Medicine explains the rationale by stating, "When a pharmaceutical company sponsors a clinical trial and the results turn out not to be in the best financial interests of the company, it has been our experience these results are never made public."

By not submitting the pediatric drug tests for publication in the journals, the drug companies could conceivably bury those tests that were not favorable, while distributing only those that seemed to work.  In response, Scott Lassman of Pharmaceutical Research and Manufacturers of America, noted that drug companies often present data at medical conferences and or post them on an online industry database.  This type of dissemination does not undergo the same scrutiny as publication in a peer reviewed scientific journal.



Growing Pains and Chiropractic

In the September 26, 2006 Research Update of the International Chiropractic Pediatric Association (ICPA) comes a preliminary case study that reviews the process of a young boy with growing pains under chiropractic care.  In this case a 3 year old boy was suffering from complaints of leg pain and lower back pain. In addition, he experienced pain in both feet, headaches and recent bed wetting. He had received no prior treatment except for his parents massaging his legs.

The case study notes that the term growing pain has been used for approximately 150 years. The term was first coined by Duchamp in 1832 in his treatise, “Maladies de la Croissance.” Studies indicate that what is termed as "growing pains" occur in approximately 20% of children and may be as high as 37% and is slightly more prevalent in girls compared to boys.

The study notes that growing pains may begin in infancy with the greatest discomfort between the ages of 3-5 years and generally seem to disappear as the child matures. A number of conditions have been implicated (though not fully substantiated) as possible factors in growing pains such as rapid growth, overexertion, rheumatic conditions, infection, sacroiliac joint dysfunction, orthopedic defects, vague ill health, and psychological factors.

The diagnosis of this condition is usually made by excluding other conditions and therefore leaving only the idea that the pains are "growing pains". In the case of this young boy, a chiropractic examination revealed the presence of subluxations and a course of care was initiated.

The care consisted of 15 visits over a 13 week period. After the first adjustment, the patient did not complain of leg pain for three days. After 7 visits, the mother reported that her son was sleeping through the night without leg pains. By the 15th visit, the child had become and remained symptom-free for almost 3 weeks.  The author's conclusion of this study was, "This case report provides supporting evidence of the effectiveness of chiropractic care in children with growing pains."



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