Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis.

BACKGROUND: Cervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation. METHODS: We evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007-2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6-7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event. RESULTS: The odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar. CONCLUSION: Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.

Validation of Resting Energy Expenditure Equations in Older Adults with Obesity.

It is unclear which energy expenditure prediction equation should guide weight loss interventions in older adults with obesity. We ascertained the validity of four equations commonly used in practice in a series of weight loss studies of adults aged ≥65 with a body mass index ≥30kg/m2 using indirect calorimetry data. Diagnostic accuracy was defined as <10% discrepancy between predicted and measured resting metabolic rate (RMR). Mean was 73.4 years. RMR using the ReeVue was 1,643 kCal. With 59.0% accuracy, the WHO equation demonstrated the highest accuracy while the Harris-Benedict yielded 53.5% accuracy. The Owens equation demonstrated the least variability (21.5% overprediction, 27.8% underprediction) with 50.7% accuracy. A SECA bioimpedance analyzer noted the second lowest accuracy of 49.6%. Only 43.1% of measurements were within 10% of the gold-standard indirect calorimetry value using the Mifflin equation. All equations demonstrated <60% accuracy suggesting a great need for estimating energy needs.

Usability Assessment of a Bluetooth-Enabled Resistance Exercise Band Among Young Adults.

BACKGROUND: Resistance-based exercises effectively enhance muscle strength, which is especially important in older populations as it reduces the risk of disability. Our group developed a Bluetooth-enabled handle for resistance exercise bands that wirelessly transmits relative force data through low-energy Bluetooth to a local smartphone or similar device. We present a usability assessment that evaluates an exercise system featuring a novel Bluetooth-enabled resistance exercise band, ultimately intended to expand the accessibility of resistance training through technology-enhanced home-based exercise programs for older adults. Although our target population is older adults, we assess the user experience among younger adults as a convenient and meaningful starting point in the testing and development of our device. METHODS: There were 32 young adults participating in three exercise sessions with the exercise band, after which each completed an adapted version of the Usefulness, Satisfaction, and Ease (USE) questionnaire to characterize the exercise system's strengths and weaknesses in usability. RESULTS: Questionnaire data reflected a positive and consistent user experience, with all 20 items receiving mean scores greater than 5.0 on a seven-point Likert scale. There were no specific areas of significant weakness in the device's user experience. CONCLUSIONS: The positive reception among young adults is a promising indication that the device can be successfully incorporated into exercise interventions and that the system can be further developed and tested for the target population of older adults.

Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study.

OBJECTIVE: Spinal manipulation (SM) is recommended for first-line treatment of patients with low back pain. Inadequate access to SM may result in inequitable spine care for older US adults, but the supply of clinicians who provide SM under Medicare is uncertain. The purpose of this study was to measure temporal trends and geographic variations in the supply of clinicians who provide SM to Medicare beneficiaries. METHODS: Medicare is a US government-administered health insurance program that provides coverage primarily for older adults and people with disabilities. We used a serial cross-sectional design to examine Medicare administrative data from 2007 to 2015 for SM services identified by procedure code. We identified unique providers by National Provider Identifier and distinguished between chiropractors and other specialties by Physician Specialty Code. We calculated supply as the number of providers per 100 000 beneficiaries, stratified by geographic location and year. RESULTS: Of all clinicians who provide SM to Medicare beneficiaries, 97% to 98% are doctors of chiropractic. The geographic supply of doctors of chiropractic providing SM services in 2015 ranged from 20/100 000 in the District of Columbia to 260/100 000 in North Dakota. The supply of other specialists performing the same services ranged from fewer than 1/100 000 in 11 states to 8/100 000 in Colorado. Nationally, the number of Medicare-active chiropractors declined from 47 102 in 2007 to 45 543 in 2015. The count of other clinicians providing SM rose from 700 in 2007 to 1441 in 2015. CONCLUSION: Chiropractors constitute the vast majority of clinicians who bill for SM services to Medicare beneficiaries. The supply of Medicare-active SM providers varies widely by state. The overall supply of SM providers under Medicare is declining, while the supply of nonchiropractors who provide SM is growing.

Varying Levels of Food Insecurity Associated with Clinically Relevant Depressive Symptoms in U.S. Adults Aged 60 Years and Over: Results from the 2005-2014 National Health and Nutrition Survey.

Food insecurity refers to restricted or uncertain access to and ineffective utilization of nutritious and safe foods. Although food insecurity is linked to poorer physical health consequences among older adults, national estimates are not well known on food insecurity and depression. Using the 2005-2014 National Health and Nutrition Examination Survey, this study examines the associations between varying food insecurity levels and clinically relevant depressive symptoms (defined by PHQ-9 ≥ 10) among adults ≥60 years old (n = 7969). Rates of clinically relevant depressive symptoms in marginal, low, and very low food security were 12.3, 16.3, and 25.2%, respectively. Marginal, low, and very low food security were significantly associated with clinically relevant depressive symptoms: odds ratio (OR) = 1.12 (95% confidence intervals [CI] 1.07-1.18), OR = 1.07 (95% CI 1.03-1.12), and OR = 1.24 (95% CI 1.16-1.32), respectively. Given the intersection of food insecurity and depression, geriatric health professionals should work to improve health and nutrition programs for older adults at risk for or experiencing both public health concerns.

Development and Implementation of a Person-Centered, Technology-Enhanced Care Model For Managing Chronic Conditions: Cohort Study.

BACKGROUND: Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this support model unsustainably burdensome on health care systems globally. Mobile health technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being used to their full extent within US health care systems. OBJECTIVE: The purpose of this study was to examine the use of staff and costs of a remote monitoring care model in persons with and without a chronic condition. METHODS: At Dartmouth-Hitchcock Health, 2894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a mobile phone app that facilitated digital communication with nursing and health behavior change staff. Health data were collected and automatically analyzed, and behavioral support communications were generated based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per capita expenditures. RESULTS: Participants averaged 41 years of age; 72.70% (2104/2894) were female and 12.99% (376/2894) had at least one chronic condition. On average each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 39.74% (8587/21,607) of all staff conversations, with higher per capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 and 0.19 per capita conversations, respectively, P<.001). When compared to the same period in the prior year, per capita health care expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls. CONCLUSIONS: The technology-based chronic condition management care model was frequently used and demonstrated potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.