Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review.

BACKGROUND: The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain. METHODS: A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators. RESULTS: The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures. CONCLUSION: Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

The antiretroviral-experienced patient.

There are many considerations for stopping and changing antiretroviral (ARV) therapy in the ARV-experienced individual. Given the potential for possible long-term toxicities and the shift to initiating ARV therapy later, it may be reasonable to stop ARV therapy among asymptomatic patients with high CD4 cell counts and low viral loads and carefully monitor them. Ongoing studies are currently evaluating this strategy. Treatment regimen failure may be due to problems with tolerability, adherence, pharmacokinetic issues, or emergence of resistance. Clinicians can utilize two types of resistance testing-genotype and phenotype assays. Generally, continuation of an optimized regimen in the patient with a multidrug resistant (MDR) virus is the best strategy. Structured treatment interruption among patients with an MDR virus is not recommended. New drugs, either recently licensed, such as enfuvirtide, or under investigation, may offer hope to patients with an MDR virus.