Chiropractic use in the Medicare population: prevalence, patterns, and associations with 1-year changes in health and satisfaction with care.

OBJECTIVE: The purpose of this study was to examine how chiropractic care compares to medical treatments on 1-year changes in self-reported function, health, and satisfaction with care measures in a representative sample of Medicare beneficiaries. METHODS: Logistic regression using generalized estimating equations is used to model the effect of chiropractic relative to medical care on decline in 5 functional measures and 2 measures of self-rated health among 12170 person-year observations. The same method is used to estimate the comparative effect of chiropractic on 6 satisfaction with care measures. Two analytic approaches are used, the first assuming no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models. RESULTS: The unadjusted models show that chiropractic is significantly protective against 1-year decline in activities of daily living, lifting, stooping, walking, self-rated health, and worsening health after 1 year. Persons using chiropractic are more satisfied with their follow-up care and with the information provided to them. In addition to the protective effects of chiropractic in the unadjusted model, the propensity score results indicate a significant protective effect of chiropractic against decline in reaching. CONCLUSION: This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

The comparative effect of episodes of chiropractic and medical treatment on the health of older adults.

OBJECTIVES: The comparative effect of chiropractic vs medical care on health, as used in everyday practice settings by older adults, is not well understood. The purpose of this study is to examine how chiropractic compares to medical treatment in episodes of care for uncomplicated back conditions. Episodes of care patterns between treatment groups are described, and effects on health outcomes among an older group of Medicare beneficiaries over a 2-year period are estimated. METHODS: Survey data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old were linked to participants' Medicare Part B claims under a restricted Data Use Agreement with the Centers for Medicare and Medicaid Services. Logistic regression was used to model the effect of chiropractic use in an episode of care relative to medical treatment on declines in function and well-being among a clinically homogenous older adult population. Two analytic approaches were used, the first assumed no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models. RESULTS: Episodes of care between treatment groups varied in duration and provider visit pattern. Among the unadjusted models, there was no significant difference between chiropractic and medical episodes of care. The propensity score results indicate a significant protective effect of chiropractic against declines in activities of daily living (ADLs), instrumental ADLs, and self-rated health (adjusted odds ratio [AOR], 0.49; AOR, 0.62; and AOR, 0.59, respectively). There was no difference between treatment types on declines in lower body function or depressive symptoms. CONCLUSION: The findings from this study suggest that chiropractic use in episodes of care for uncomplicated back conditions has protective effects against declines in ADLs, instrumental ADLs, and self-rated health for older Medicare beneficiaries over a 2-year period.

Chiropractic episodes and the co-occurrence of chiropractic and health services use among older Medicare beneficiaries.

OBJECTIVE: The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine. METHODS: Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample. RESULTS: There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period. CONCLUSION: Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries.

BACKGROUND: Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines. METHODS: The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop. RESULTS: The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline. CONCLUSIONS: Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries.

BACKGROUND: Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function. METHODS: We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests. RESULTS: Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status. CONCLUSIONS: In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

Paediatric tele-emergency care: A study of two delivery models.

INTRODUCTION: Tele-emergency models have been utilized for decades, with growing evidence of their effectiveness. Due to the variety of tele-emergency department (tele-ED) models used in practice, however, it is challenging to build standardized metrics for ongoing evaluation. This study describes two tele-ED programs, one specialized and one general, that provide care to paediatric populations. Through an examination of model structures and patient populations, we gain insight into how evaluative measures should reflect tele-ED model design and purpose. METHODS: Qualitative descriptions of the two tele-ED models are presented. We show a retrospective cohort analysis describing paediatric patients' key characteristics, reasons for visit, and disposition status by case/control status. Case/control patient encounter data were collected October 2015 through December 2017, from 15 spoke hospitals within each tele-ED program. RESULTS: The two tele-ED models serve distinct paediatric populations, and measures of tele-ED utilization and disposition reflect those differences. In the specialized University of California (UC) Davis Health program, tele-ED was utilized in 36% of paediatric critical care encounters and 78% of those were transferred. In the Avera eCARE program, tele-ED was activated in 1.7% of paediatric encounters and 50.6% of those were transferred. When Avera eCARE paediatric encounters were stratified by severity, measures of tele-ED use and disposition status among high-severity encounters were more similar to UC Davis Health. DISCUSSION: This study describes how design choices of tele-ED models have implications for evaluative measures. Measures of tele-ED model success need to reflect model purpose, populations served, and for whom tele-ED service use is appropriate.

Rural Bypass of Critical Access Hospitals in Iowa: Do Visiting Surgical Specialists Make a Difference?

PURPOSE: Rural bypass for elective surgical procedures is a challenge for critical access hospitals, yet there are opportunities for rural hospitals to improve local retention of surgical candidates through alternative approaches to developing surgery lines of business. In this study we examine the effect of visiting surgical specialists on the odds of rural bypass. METHODS: Discharge data from the 2011 State Inpatient Databases and State Ambulatory Surgery Databases for Iowa were linked to outreach data from the Office of Statewide Clinical Education Programs and Iowa Physician Information System to model the effect of surgeon specialist supply on rural patients' decision to bypass rural critical access hospitals. FINDINGS: Patients in rural communities with a local general surgeon were more likely to be retained in a community than to bypass. Those in communities with visiting general surgeons were more likely to bypass, as were those in communities with visiting urologists and obstetricians. Patients in communities with visiting ophthalmologists and orthopedic surgeons were at higher odds of being retained for their elective surgeries. CONCLUSION: In addition to known patient and local hospital factors that have an influence on bypass behavior among rural patients seeking elective surgery, availability of surgeon specialists also plays an important role in whether patients bypass or not. Visiting ophthalmologists and orthopedic surgeons were associated with less bypass, as was having local general surgeons. Visiting general surgeons, urologists, and obstetricians were associated with greater odds of bypass.

Rural Bypass for Elective Surgeries.

PURPOSE: Rural bypass of Critical Access Hospitals (CAHs) for elective inpatient and outpatient surgical procedures has not been studied. Residents choosing to have their elective surgeries elsewhere, when the local CAH provides those surgical services, erode their rural hospital's financial base. The purpose of this research is to describe the elective surgical bypass rate, the procedures most commonly bypassed by rural residents, the distribution of volume among CAHs that offer elective surgical services, and factors predictive of bypass. METHODS: A sample of elective surgery discharges was created from the 2011 Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery Databases for Colorado, North Carolina, Vermont, and Wisconsin. Frequencies of procedures bypassed and CAH volume distribution were performed. Logistic regression was used to model factors associated with rural bypass for elective surgical care. FINDINGS: The rural bypass rate for elective surgical procedures is 48.4%. Procedures bypassed most are operations on the musculoskeletal system, eye, and digestive system. Annual volume distribution for elective surgical procedures among CAHs varied widely. Patients who are younger, medically complex, at higher surgical risk, and have private insurance are at higher odds of bypass. Patients are also more likely to bypass low-volume hospitals. CONCLUSION: Rural hospitals should consider developing surgical services that are performed electively and on an outpatient basis that are attractive to a broader rural population. CAHs that already offer elective surgical procedures and yet who are still bypassed must examine the mutable factors that drive bypass behavior.

Variation in Primary Care Service Patterns by Rural-Urban Location.

BACKGROUND: Rural communities have disproportionately faced primary care shortages for decades in spite of policy efforts to prepare and attract primary care health professionals to practice in rural locales. Insight into how primary care physicians' service patterns in rural areas differ from those in less rural places is important to better inform recruitment strategies that target primary care providers and rural communities. OBJECTIVES: The purpose of this research is to describe how primary care physician service patterns vary by rural-urban location for a large, privately insured population. We discuss implications of service pattern variation on policy efforts to attract primary care providers to underserved rural areas. METHODS: Claims data from fully insured commercial health insurance beneficiaries were used to develop service pattern profiles for primary care providers located in 1 of 4 types of rural-urban areas in Iowa in 2009. The 4 area types are metropolitan, micropolitan, noncore area adjacent to a metro area, and noncore/nonadjacent rural area. RESULTS: There were differences in primary care physicians' service patterns by rural-urban area type. Physicians in nonmetropolitan areas provided relatively more care on a per physician basis than those in the metropolitan area type, as well as more surgery, maternity, emergency, and nursing facility services than metropolitan physicians. CONCLUSION: Primary care physicians who value practicing a relatively diverse range of services may find locating in rural areas an appealing choice. Health systems and policy makers seeking to attract primary care physicians to rural areas can incorporate this reality into a recruitment strategy.

Postoperative complications and patient satisfaction: does payer status have an impact?

BACKGROUND: Patient demographics and outcomes may influence patient satisfaction. We aim to investigate the relationship between postoperative complications and survey-based satisfaction in the context of payer status. METHODS: Institutional data were used to identify major complication occurrence and linked to patient satisfaction surveys. The impact of complication occurrence on satisfaction was investigated and stratified by payer status. RESULTS: In all, 1,597 encounters were identified with an 18% major complication rate. Satisfaction scores in specific domains were significantly more likely to be above the median for patients without complications (P < .01) and for payer status Medicaid/low income (P < .05). In sensitivity analyses, we found no significant interactions among payer status, complications, and satisfaction scores. CONCLUSIONS: Significant differences exist for individual satisfaction survey domains between patients with and without major postoperative complications and by payer status. Payer status was not found to have an impact on the intersection of major complications and patient satisfaction.