Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis.

OBJECTIVES: Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care. METHODS: We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs. RESULTS: We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75 400 per patient. Under base-case assumptions, PSF costs $50 100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL. CONCLUSIONS: In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.

Demographics and patterns of acupuncture use in the Chinese population: the Taiwan experience.

BACKGROUND: The use of complementary and alternative medicine (CAM), including Traditional Chinese Medicine (TCM) and acupuncture, has substantially increased in western countries in the past decade. However, informative data concerning large-scale investigations of acupuncture used in the Chinese society remain rare so far. DESIGN AND OUTCOME MEASURE: The complete datasets of acupuncture outpatient reimbursement claims from 1996 to 2002 were supplied by the National Health Insurance Research Database, Taiwan, and the usage frequencies and characteristics of the acupuncture users, as well as the disease categories that were treated by acupuncture in Taiwan were analyzed. RESULTS: At the end of 2002, among the 21,869,478 total valid beneficiaries of National Health Insurance (NHI), 1,362,351 subjects (6.2%) used acupuncture during this year, but 4,948,464 subjects (22.6%) had used it for the whole 7-year period since 1996. A mean increment of 1,191,164 (53.6%) new users had been involved yearly. Among all those acupuncture users, a female predominance was observed (female:male = 1.12:1), and the age distribution displayed a peak at around the 40s, followed by the 30s and 50s. Private TCM clinics provided more acupuncture usage (82.0%) than did private TCM hospitals (13.7%). The disease categories treated mostly by acupuncture were diseases of the musculoskeletal system (46.2%); injury (41.8%); diseases of the nervous system (3.5%); and symptoms, signs, and ill-defined conditions (2.7%). CONCLUSIONS: Twenty-three percent (23%) of people in Taiwan had used acupuncture during this 7-year period. Musculoskeletoal and neurologic disorders were two major categories commonly treated with acupuncture.

Further analysis of health care costs for chiropractic and medical patients.

OBJECTIVE: To compare the health care costs of patients who have received chiropractic treatment in insurance plans that do not restrict chiropractic or medical benefits with those treated solely by medical and osteopathic physicians. DESIGN: Retrospective statistical analysis of 2 yr of claims data on total insurance payments and total outpatient payments. OUTCOME MEASURES: Total insurance payments and total outpatient payments, each adjusted for sociodemographic characteristics. RESULTS: Patients receiving chiropractic care experienced significantly lower total health care costs as represented by adjusted third-party payments in the fee-for-service sector. Total adjusted cost differences ranged from $291 to $1722 over the 2-yr period. Total adjusted outpatient costs tended to be slightly lower for medical patients but lower hospital utilization for chiropractic patients more than offsets the additional outpatient costs associated with chiropractic care. CONCLUSIONS: The analysis of well-insured patients in plans that do not restrict the chiropractic benefit strengthens results previously reported. In this study, therefore, the favorable cost patterns for chiropractic patients cannot be attributed to insurance restrictions limiting reimbursement for chiropractic services relative to other services. Because adjustments for patient characteristics systematically reduce the cost advantages of chiropractic patients as compared to mean differences derived from unadjusted data, the results also demonstrate that adjusted values should be used for meaningful comparisons between the two groups of patients.

A comparison of health care costs for chiropractic and medical patients.

OBJECTIVE: To compare the health care costs of patients who have received chiropractic treatment for common neuromusculoskeletal disorders with those treated solely by medical and osteopathic physicians. DESIGN: Retrospective statistical analysis of 2 yr of claims data on various categories of utilization and insurance payments for a large national sample of patients. SETTING: Ambulatory and inpatient care. PATIENTS: A total of 395,641 patients with one or more of 493 neuromusculoskeletal ICD-9 codes. OUTCOME MEASURES: Hospital admission rates and 10 categories of insurance payments. RESULTS: Nearly one-fourth of patients were treated by chiropractors. Patients receiving chiropractic care experienced significantly lower health care costs as represented by third party payments in the fee-for-service sector. Total cost differences on the order of $1,000 over the 2-yr period were found in the total sample of patients as well as in subsamples of patients with specific disorders. The lower costs are attributable mainly to lower inpatient utilization. The cost differences remain statistically significant after controlling for patient demographics and insurance plan characteristics. CONCLUSIONS: Although work is in progress to control for possible variations in case mix and to compare outcomes in addition to costs, these preliminary results suggest a significant cost-saving potential for users of chiropractic care. The results also suggest the need to reexamine insurance practices and programs that restrict chiropractic coverage relative to medical coverage.

The growing role of chiropractic in health care delivery.

The number of U.S. chiropractors grew by two-thirds between 1978 and 1988, and new data show that more than 5 percent of Americans used chiropractic during a six-quarter period, spending an annual average of $411. As U.S. policymakers debate creation of standard or minimum benefit packages, these new findings may help to determine whether chiropractic meets the criteria of clinical efficacy and cost-effectiveness.