The Effect of Reduced Access to Chiropractic Care on Medical Service Use for Spine Conditions Among Older Adults.

OBJECTIVE: The purpose of this study was to examine the extent to which access to chiropractic care affects medical service use among older adults with spine conditions. METHODS: We used Medicare claims data to identify a cohort of 39,278 older adult chiropractic care users who relocated during 2010-2014 and thus experienced a change in geographic access to chiropractic care. National Plan and Provider Enumeration System data were used to determine chiropractor per population ratios across the United States. A reduction in access to chiropractic care was defined as decreasing 1 quintile or more in chiropractor per population ratio after relocation. Using a difference-in-difference analysis (before versus after relocation), we compared the use of medical services among those who experienced a reduction in access to chiropractic care versus those who did not. RESULTS: Among those who experienced a reduction in access to chiropractic care (versus those who did not), we observed an increase in the rate of visits to primary care physicians for spine conditions (an annual increase of 32.3 visits, 95% CI: 1.4-63.1 per 1,000) and rate of spine surgeries (an annual increase of 5.5 surgeries, 95% CI: 1.3-9.8 per 1,000). Considering the mean cost of a visit to a primary care physician and spine surgery, a reduction in access to chiropractic care was associated with an additional cost of $114,967 per 1,000 beneficiaries on medical services ($391 million nationally). CONCLUSIONS: Among older adults, reduced access to chiropractic care is associated with an increase in the use of some medical services for spine conditions.

Access to chiropractic care and the cost of spine conditions among older adults.

OBJECTIVES: Chiropractic care is a service that operates outside of the conventional medical system and is reimbursed by Medicare. Our objective was to examine the extent to which accessibility of chiropractic care affects spending on medical spine care among Medicare beneficiaries. STUDY DESIGN: Retrospective cohort study that used beneficiary relocation as a quasi-experiment. METHODS: We used a combination of national data on provider location and Medicare claims to perform a quasi-experimental study to examine the effect of chiropractic care accessibility on healthcare spending. We identified 84,679 older adults enrolled in Medicare with a spine condition who relocated once between 2010 and 2014. For each year, we measured accessibility using the variable-distance enhanced 2-step floating catchment area method. Using data for the years before and after relocation, we estimated the effect of moving to an area of lower or higher chiropractic accessibility on spine-related spending adjusted for access to medical physicians. RESULTS: There are approximately 45,000 active chiropractors in the United States, and local accessibility varies considerably. A negative dose-response relationship was observed for spine-related spending on medical evaluation and management as well as diagnostic imaging and testing (mean differences, $20 and $40, respectively, among those exposed to increasingly higher chiropractic accessibility; P <.05 for both). Associations with other types of spine-related spending were not significant. CONCLUSIONS: Among older adults, access to chiropractic care may reduce medical spending on services for spine conditions.

Development and Validation of a Deep Learning Algorithm for Mortality Prediction in Selecting Patients With Dementia for Earlier Palliative Care Interventions.

Importance: Early palliative care interventions drive high-value care but currently are underused. Health care professionals face challenges in identifying patients who may benefit from palliative care. Objective: To develop a deep learning algorithm using longitudinal electronic health records to predict mortality risk as a proxy indicator for identifying patients with dementia who may benefit from palliative care. Design, Setting, and Participants: In this retrospective cohort study, 6-month, 1-year, and 2-year mortality prediction models with recurrent neural networks used patient demographic information and topics generated from clinical notes within Partners HealthCare System, an integrated health care delivery system in Boston, Massachusetts. This study included 26 921 adult patients with dementia who visited the health care system from January 1, 2011, through December 31, 2017. The models were trained using a data set of 24 229 patients and validated using another data set of 2692 patients. Data were analyzed from September 18, 2018, to May 15, 2019. Main Outcomes and Measures: The area under the receiver operating characteristic curve (AUC) for 6-month and 1- and 2-year mortality prediction models and the factors contributing to the predictions. Results: The study cohort included 26 921 patients (16 263 women [60.4%]; mean [SD] age, 74.6 [13.5] years). For the 24 229 patients in the training data set, mean (SD) age was 74.8 (13.2) years and 14 632 (60.4%) were women. For the 2692 patients in the validation data set, mean (SD) age was 75.0 (12.6) years and 1631 (60.6%) were women. The 6-month model reached an AUC of 0.978 (95% CI, 0.977-0.978); the 1-year model, 0.956 (95% CI, 0.955-0.956); and the 2-year model, 0.943 (95% CI, 0.942-0.944). The top-ranked latent topics associated with 6-month and 1- and 2-year mortality in patients with dementia include palliative and end-of-life care, cognitive function, delirium, testing of cholesterol levels, cancer, pain, use of health care services, arthritis, nutritional status, skin care, family meeting, shock, respiratory failure, and swallowing function. Conclusions and Relevance: A deep learning algorithm based on patient demographic information and longitudinal clinical notes appeared to show promising results in predicting mortality among patients with dementia in different time frames. Further research is necessary to determine the feasibility of applying this algorithm in clinical settings for identifying unmet palliative care needs earlier.

High-Cost Dual Eligibles' Service Use Demonstrates The Need For Supportive And Palliative Models Of Care.

Health care spending is generally highest among people who need both complex medical care and long-term services and supports, such as adults dually eligible for Medicare and Medicaid. Understanding how different types of complex patients use services over time can inform policies that target this population. High combined Medicare and Medicaid spending are found in two distinct groups of high-cost dual eligibles: older beneficiaries who are nearing the end of life, and younger beneficiaries with sustained need for functional supports. However, both groups have high hospitalization costs. Among high-cost dual eligibles living in the community, those who are older spend less on home and community-based services than those who are younger. Greater use of such services might provide stable support in the last year or two of life, when illness and functional decline accelerate. Tailored approaches to each population's distinct needs could yield care of increased value to patients and their families, with the potential to lower costs if patients' needs can be met with fewer stays in short-term inpatient facilities.

Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain.

BACKGROUND: Whether availability of chiropractic care affects use of primary care physician (PCP) services is unknown. METHODS: We performed a cross-sectional study of 17.7 million older adults who were enrolled in Medicare from 2010 to 2011. We examined the relationship between regional supply of chiropractic care and PCP services using Spearman correlation. Generalized linear models were used to examine the association between regional supply of chiropractic care and number of annual visits to PCPs for back and/or neck pain. RESULTS: We found a positive association between regional supply of chiropractic care and PCP services (rs = 0.52; P <.001). An inverse association between supply of chiropractic care and the number of annual visits to PCPs for back and/or neck pain was apparent. The number of PCP visits for back and/or neck pain was 8% lower (rate ratio, 0.92; 95% confidence interval, 0.91-0.92) in the quintile with the highest supply of chiropractic care compared to the lowest quintile. We estimate chiropractic care is associated with a reduction of 0.37 million visits to PCPs nationally, at a cost of $83.5 million. CONCLUSIONS: Greater availability of chiropractic care in some areas may be offsetting PCP services for back and/or neck pain among older adults.

Fewer hospitalizations result when primary care is highly integrated into a continuing care retirement community.

Meeting the medical and social needs of elderly people is likely to be costly, disruptive, and at odds with personal preferences if efforts to do so are not well coordinated. We compared two different models of primary care in four different continuing care retirement communities. In the first model, used in one community, the physicians and two part-time nurse practitioners delivered clinical care only at that site, covered all settings within it, and provided all after-hours coverage. In the second model, used in three communities, on-site primary care physician hours were limited; the same physicians also had independent practices outside the retirement community; and after-hours calls were covered by all members of the practices, including physicians who did not practice on site. We found that residents in the first model had two to three times fewer hospitalizations and emergency department visits. Only 5 percent of those who died did so in a hospital, compared to 15 percent at the other sites and 27 percent nationally. These findings provide insight into what is possible when medical care is highly integrated into a residential retirement setting.

Higher health care quality and bigger savings found at large multispecialty medical groups.

The belief that integrated delivery systems offer better care at lower cost has contributed to growing interest in accountable care organizations. These provider-led delivery systems would accept responsibility for their primary care populations and would have financial incentives for improving care and reducing costs. We investigated this belief by comparing the costs and quality of care provided to Medicare beneficiaries in twenty-two health care markets by physicians who did and did not work within large multispecialty group practices affiliated with the Council of Accountable Physician Practices. In most markets, and after adjustment for patient factors, group physicians affiliated with the council provided higher-quality care at a 3.6 percent lower annual cost ($272 per patient).