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.

What Are the Costs of Cervical Radiculopathy Prior to Surgical Treatment?

STUDY DESIGN: Retrospective, observational study. OBJECTIVE: To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery. METHODS: The Humana claims dataset (2007-2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention. RESULTS: Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193). CONCLUSION: The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step. LEVEL OF EVIDENCE: 3.

Characteristics of chiropractors who manage people aged 65 and older: A nationally representative sample of 1903 chiropractors.

OBJECTIVE: To examine the prevalence and profile of chiropractors who frequently manage people aged 65 years and older. METHODS: A national cross-sectional survey collected practitioner characteristics, practice settings and clinical management characteristics. Multiple logistic regression was conducted on 1903 chiropractors to determine the factors associated with the frequent treatment of people 65 years and older. RESULTS: In total, 73.5% of participants report "often" treating those aged 65 years and older. These chiropractors were associated with treating degenerative spine conditions (OR [odds ratio] 2.25; 95% [confidence interval] CI 1.72-2.94), working in a non-urban area (OR 1.85; 95% CI 1.35-2.54), treating low back pain (referred/radicular) (OR 1.74; 95% CI 1.26-2.40) and lower limb musculoskeletal disorders (OR 1.50; 95% CI 1.15-1.96). CONCLUSIONS: The majority of chiropractors report often providing treatment to older people. Our findings call for more research to better understand older patient complaints that are common to chiropractic practice and the care provided by chiropractors for this patient group.

Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

Objective: To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription. Methods: Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit. Results: We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72-2.03), PTSD (OR = 1.55, 95% CI = 1.41-1.69), depression (OR = 1.40, 95% CI = 1.29-1.53), and current smoking (OR = 1.39, 95% CI = 1.26-1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. Conclusions: Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care.

The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey.

STUDY DESIGN: Secondary analysis of a national survey. OBJECTIVE: The aim of this study was to investigate the prevalence, patterns, and predictors of chiropractic utilization in the US general population. SUMMARY OF BACKGROUND DATA: Chiropractic is one of the largest manual therapy professions in the United States and internationally. Very few details have been reported about the use of chiropractic care in the United States in recent years. METHODS: Cross-sectional data from the 2012 National Health Interview Survey (n = 34,525) were analyzed to examine the lifetime and 12-month prevalence and utilization patterns of chiropractic use, profile of chiropractic users, and health-related predictors of chiropractic consultations. RESULTS: Lifetime and 12-month prevalence of chiropractic use were 24.0% and 8.4%, respectively. There is a growing trend of chiropractic use among US adults from 2002 to 2012. Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being. A substantial number of chiropractic users had received prescription (23.0%) and/or over-the-counter medications (35.0%) for the same health problem for which chiropractic was sought and 63.8% reported chiropractic care combined with medical treatment as helpful. Both adults older than 30 years (compared to younger adults), and those diagnosed with spinal pain (compared to those without spinal pain) were more likely to have consulted a chiropractor in the past 12 months. CONCLUSION: A substantial proportion of US adults utilized chiropractic services during the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common. Studies on the current patient integration of chiropractic and conventional health services are warranted. LEVEL OF EVIDENCE: 3.

Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs.

OBJECTIVES: The purpose of this study was to analyze national trends and key features of the Department of Veterans Affairs' (VA's) chiropractic service delivery and chiropractic provider workforce since their initial inception. METHODS: This was a serial cross-sectional analysis of the VA administrative data sampled from the first record of chiropractic services in VA through September 30, 2015. Data were obtained from VA's Corporate Data Warehouse and analyzed with descriptive statistics. RESULTS: From October 1, 2004, through September 30, 2015, the annual number of patients seen in VA chiropractic clinics increased from 4052 to 37349 (821.7%), and the annual number of chiropractic visits increased from 20072 to 159366 (693.9%). The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation and evaluation and management services. The total number of VA chiropractic clinics grew from 27 to 65 (9.4% annually), and the number of chiropractor employees grew from 13 to 86 (21.3% annually). The typical VA chiropractor employee is a 45.9-year-old man, has worked in VA for 4.5 years, and receives annual compensation of $97860. VA also purchased care from private sector chiropractors starting in 2000, growing to 159533 chiropractic visits for 19435 patients at a cost of $11155654 annually. CONCLUSIONS: Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.

Low back pain patients in Sweden, Denmark and the UK share similar characteristics and outcomes: a cross-national comparison of prospective cohort studies.

BACKGROUND: Low back pain (LBP) is the world's leading cause of disability and yet poorly understood. Cross-national comparisons may motivate hypotheses about outcomes being condition-specific or related to cultural differences and can inform whether observations from one country may be generalised to another. This analysis of data from three cohort studies explored whether characteristics and outcomes differed between LBP patients visiting chiropractors in Sweden, Denmark and the UK. METHODS: LBP patients completed a baseline questionnaire and were followed up after 3, 5, 12 and 26 weeks. Outcomes were LBP intensity (0-10 scales) and LBP frequency (0-7 days the previous week). Cohort differences were tested in mixed models accounting for repeated measures. It was investigated if any differences were explained by different baseline characteristics, and interaction terms between baseline factors and nations tested if strength of prognostic factors differed across countries. RESULTS: The study sample consisted of 262, 947 and 453 patients from Sweden, Denmark and the UK respectively. Patient characteristics were largely similar across cohorts although some statistically significant differences were observed. The clinical course followed almost identical patterns across nations and small observed differences were not present after adjusting for baseline factors. The associations of LBP intensity and episode duration with outcome differed in strength between countries. CONCLUSIONS: Chiropractic patients with low back pain had similar characteristics and clinical course across three Northern European countries. It is unlikely that culture have substantially different impacts on the course of LBP in these countries and the results support knowledge transfer between the investigated countries.

Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B.

BACKGROUND CONTEXT: Concern about improper payments to chiropractic physicians prompted the US Department of Health and Human Services to describe chiropractic services as a "significant vulnerability" for Medicare, but little is known about trends in the use and cost of chiropractic spinal manipulation provided under Medicare. PURPOSE: To quantify the volume and cost of chiropractic spinal manipulation services for older adults under Medicare Part B and identify longitudinal trends. STUDY DESIGN/SETTING: Serial cross-sectional design for retrospective analysis of administrative data. PATIENT SAMPLE: Annualized nationally representative samples of 5.0 to 5.4 million beneficiaries. OUTCOME MEASURES: Chiropractic users, allowed services, allowed charges, and payments. METHODS: Descriptive statistics were generated by analysis of Medicare administrative data on chiropractic spinal manipulation provided in the United States from 2002 to 2008. A 20% nationally representative sample of allowed Medicare Part B fee-for-service claims was merged, based on beneficiary identifier, with patient demographic data. The data sample was restricted to adults aged 65 to 99 years, and duplicate claims were excluded. Annualized estimates of outcome measures were extrapolated, per beneficiary and per user rates were estimated, and volumes were stratified by current procedural terminology code. RESULTS: The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services. CONCLUSIONS: Chiropractic claims account for less than 1/10th of 1% of overall Medicare expenditures. Allowed services, allowed charges, and fee-for-service payments for chiropractic spinal manipulation under Medicare Part B generally increased from 2002, peaked in 2005 and 2006, and then declined through 2008. Per user spending for chiropractic spinal manipulation also declined by 18% from 2006 to 2008, in contrast to 10% growth in total spending per beneficiary and 16% growth in overall Medicare spending.

Shared decision making through informed consent in chiropractic management of low back pain.

OBJECTIVE: The purpose of this study was to propose questions that may be helpful to educate patients considering treatment approaches to manage low back pain (LBP) and to determine if the information currently presented in informed consent (IC) documents at chiropractic colleges is sufficient to help a patient considering chiropractic management of LBP make a fully informed decision. METHODS: Questions to inform decision making for a patient contemplating any intervention for LBP were developed by the authors based on their clinical and research experience. Answers to the questions were suggested based on findings from recent clinical practice guidelines and systematic reviews. Institutions that are members of the Association of Chiropractic Colleges (ACC) were surveyed and asked to provide a copy of the IC documents currently used in their outpatient educational clinics. The IC documents were analyzed to determine if they stated (or implied) information that may be helpful in addressing each of the proposed questions. RESULTS: The list of 20 questions included 4 questions on each of the following 5 topics: condition, proposed treatment, potential benefits, potential harms, and possible alternatives. A total of 21 ACC institutions were contacted, of which 20 responded. The number of questions that could potentially be answered with information provided in the IC documents ranged from 2 to 13, with a mean of 6.5, including a mean of 3.6 stated answers and 2.9 implied answers. CONCLUSIONS: Some information to help patients consider chiropractic management of LBP is currently included in the IC documents used in clinics of ACC institutions. However, many of the questions that could help achieve shared decision making are not included. Modifying IC documents may help patients understand the nature, benefits, harms, costs, and alternatives to LBP care.

Manipulative therapy for lower extremity conditions: update of a literature review.

OBJECTIVE: The purpose of this study is to update a systematic review on manipulative therapy (MT) for lower extremity conditions. METHODS: A review of literature was conducted using MEDLINE, MANTIS, Science Direct, Index to Chiropractic Literature, and PEDro from March 2008 to May 2011. Inclusion criteria required peripheral diagnosis and MT with or without adjunctive care. Clinical trials were assessed for quality using a modified Scottish Intercollegiate Guidelines Network (SIGN) ranking system. RESULTS: In addition to the citations used in a 2009 systematic review, an additional 399 new citations were accessed: 175 citations in Medline, 30 citations in MANTIS, 98 through Science Direct, 54 from Index to Chiropractic Literature, and 42 from the PEDro database. Forty-eight clinical trials were assessed for quality. CONCLUSIONS: Regarding MT for common lower extremity disorders, there is a level of B (fair evidence) for short-term and C (limited evidence) for long-term treatment of hip osteoarthritis. There is a level of B for short-term and C for long-term treatment of knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is a level of B for short-term treatment of plantar fasciitis but C for short-term treatment of metatarsalgia and hallux limitus/rigidus and for loss of foot and/or ankle proprioception and balance. Finally, there is a level of I (insufficient evidence) for treatment of hallux abducto valgus. Further research is needed on MT as a treatment of lower extremity conditions, specifically larger trials with improved methodology.

Measures in chiropractic research: choosing patient-based outcome assessments.

OBJECTIVE: Outcome assessment normally used in research can support the therapeutic process by tracking patient symptoms and function and offering a common language to clinicians and researchers. This study's objectives were to (1) identify patient-based outcomes assessments used in published chiropractic studies, (2) describe a framework for identifying appropriate sets of measures, and (3) address the challenges associated with these measures relevant to chiropractic. METHODS: This literature review identified and evaluated the most commonly used to outcome measures in chiropractic research. Instruments were evaluated in terms of feasibility, practicality, economy, reliability, validity, and responsiveness to clinical change. A search of PubMed and Index to Chiropractic Literature (from inception to June 2006) was performed. RESULTS: A total of 1166 citations were identified. Of these, 629 were selected as relevant. The most common patient-based outcomes assessments instruments identified were the Oswestry Pain/Disability Index, Visual Analog Scale, and Short Form 36. CONCLUSIONS: The integration of outcome measures is consistent with current national initiatives to enhance health care quality through performance measurement and can also be used to further the field of chiropractic health care research. Outcome measures are both a research tool and a means by which providers can consistently measure health care quality. Based upon this review, there is a wide range of outcome measures available for use in chiropractic care. Those most commonly cited in the literature are the numeric rating scale, Visual Analog Scale, Oswestry Pain/Disability Index, Roland-Morris Low Back Pain and Disability Questionnaire, and Short Form 36.