Low back pain is a distressing, and distressingly common, problem encountered in family medicine. Although this symptom is usually self-limited in otherwise healthy patients, there are few truly effective treatments other than time. Seeking faster relief, many patients visit chiropractors or osteopathic physicians who provide spinal manipulative therapy. Three pro/con editorials in the April 15th issue of AFP debate the effectiveness of spinal maniplation relative to other commonly used treatments for low back pain.
In the first editorial, Drs. James Arnold and Shannon Ehleringer point out that "in two large systematic reviews, manipulation decreased pain and improved range of motion in patients with chronic neck pain and in patients with acute and chronic back pain. Manipulation improved symptoms more effectively than placebo and was as effective as nonsteroidal anti-inflammatory drugs, home exercises, physical therapy, and back school." Dr. Melicien Tettambel concurs in the second editorial, arguing that since "it is unrealistic to expect any single treatment modality to be universally effective across all patients," manipulation has a useful role as an adjunct therapy.
On the other hand, Drs. Peter Cronholm and David Nicklin contend in a third editorial that much of the evidence supporting spinal manipulation for low back pain consists of low-quality studies that demonstrate statistical but not clinical benefit. Since the benefits of manipulation are comparable to watchful waiting, they argue that the latter option should generally be preferred:
Patients in pain are unhappy, and they want relief. The evidence shows that taking acetaminophen or a nonsteroidal anti-inflammatory drug and resting as needed is as effective as spinal manipulation. However, patients attribute pain resolution to active treatment. Although a course of spinal manipulation, or physical therapy, may keep the patient happy (and occupied) while his or her pain spontaneously resolves, the improvement in pain and function is not based on large, quality studies. Whether improved patient satisfaction with spinal manipulation versus watchful waiting is worth the cost of the therapy depends on who pays and how the paying party values satisfaction. As controlling costs becomes more important, incentives make watchful waiting with nonsteroidal anti-inflammatory drugs or acetaminophen the preferred approach.
What do you say when patients ask if seeing a specialist in spinal manipulation will relieve their low back pain?
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Friday, April 20, 2012
Monday, April 9, 2012
Counterintuitive findings on quality incentives and patient satisfaction
They've been repeated so often that many health care quality gurus take them for granted: 1) paying physicians for performance will improve quality of care; 2) increasing patient satisfaction will reduce care costs and improve outcomes.
Not necessarily, two recent studies suggest.
A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of AFP concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes Dr. Elizabeth Salisbury-Afshar, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from AFP readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.
In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:
Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.
Not necessarily, two recent studies suggest.
A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of AFP concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes Dr. Elizabeth Salisbury-Afshar, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from AFP readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.
In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:
Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.