The 2008 prevalence of chiropractic use in the US adult population.

OBJECTIVE: The purpose of this study was to produce prevalence estimates and identify determinants of variability in chiropractic use in the US adult population. METHODS: The Medical Expenditure Panel Survey was used to estimate prevalence for the adult population and subpopulations according to several sociodemographic, geographic, and health characteristics. Multivariable logistic regression model was used to explore the effects of the independent predictors on chiropractic use. RESULTS: The 2008 chiropractic prevalence of use was estimated to be 5.2% (95% confidence interval, 4.7-5.6). The adjusted odds of using chiropractic services were approximately 46% less for Asians, 63% less for Hispanics, and 73% less for blacks compared with whites; 21% less for men than women; and 68% higher for those with arthritis compared with those without. Persons from high-income families have greater odds of using chiropractic services compared with those from middle-income (42%) and low-income (67%) families. There was a significant interaction between Census region and urban-rural location. The results showed the prevalence of chiropractic use to be highest in small metro areas in the Midwest (10.5%) and Northeast (10.4%) as well as micropolitan/noncore areas in the West (10.8%) and Midwest (10.1%). CONCLUSIONS: This study validates previous findings showing the prevalence of use is higher for whites, women, and persons with higher family income or reported arthritis. The results of this study also indicate that chiropractic use varies across the urban-rural landscape depending on the region of the country, suggesting that the effect of geographic location may be more complex than previously reported.

Clinical, demographic, and geographic determinants of variation in chiropractic episodes of care for adults using the 2005-2008 Medical Expenditure Panel Survey.

OBJECTIVE: The primary aim of this study was to report nationally representative estimates of the visit utilization, per visit expenditures, and total expenditures for chiropractic episodes of care in the US adult population. The secondary aim was to identify clinical, demographic, geographic, and payment factors associated with variation in the levels of utilization and expenditures. METHODS: Data from the 2005-2008 Medical Expenditure Panel Survey were used to construct complete episodes of chiropractic care (n = 1639) for the civilian, noninstitutionalized adult population. Bivariate descriptive statistics were calculated for visit utilization, per visit expenditures, and total expenditures per episode of care by several clinical, demographic, geographic, and payment variables. Multivariable regression models were used to evaluate the effects of the independent variables on each of the 3 dependent variables. RESULTS: The unadjusted mean number of visits per episode was 5.8 (95% confidence interval [CI], 5.3-6.4] and varied significantly by race/ethnicity, perceived mental health, urban-rural location, and source of payment. The mean total expenditures per visit per episode were estimated to be $69 (95% CI, $65-$73). There was variation associated with the census region, urban-rural location, and source of payment variables. Total expenditures for an episode of care were estimated to be $424 (95% CI, $371-$477] with variation according to urban-rural location and source of payment. During 29% of the episodes all expenditures were paid with out-of-pocket funds. CONCLUSIONS: Variation in the utilization and expenditures during chiropractic episodes of care is primarily associated with payment source and geographic factors.

Implications of the accuracy of MEPS prescription drug data for health services research.

This paper assesses the quality of the Medical Expenditure Panel Survey (MEPS) drug data and the impact that misreporting prescription drug data has on descriptive and behavioral analyses. It does this by matching MEPS participants with Medicare Part D coverage during the period 2006-2007 to their Part D claims data. In the validation sample, the number of drug fills and total expenditures are reasonably accurate compared with claims. Household respondents tended to underreport the number of different drugs taken, but tended to overreport the number of fills of each drug. Behavioral analyses of the determinants of medication use and expenditures were largely unaffected because underreporting cut across most sociodemographic groups.

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by a county level of urban influence.

OBJECTIVE: To examine child and hospital demographics and children's health care coverage, use, expenditures, and quality by a county-level measure of urban influence. METHODS: Two national health care databases serve as the sources of data for this report: the 2002 Medical Expenditure Panel Survey (MEPS) and the 2002 Nationwide Inpatient Sample (NIS) and State Inpatient Databases (SID) from the Healthcare Cost and Utilization Project (HCUP). In both data sets, county urbanicity is defined by use of a collapsed version of the 2003 Urban Influence Codes, to distinguish among children residing in and hospitals located in large metropolitan (metro) counties, small metro counties, micropolitan counties, and noncore counties. RESULTS: Demographics. In large metro counties, greater percentages of the child population are Hispanic or black non-Hispanic than in small metro, micropolitan, and noncore counties; in micropolitan and noncore counties, higher proportions of children are below 200% of the federal poverty level than in large metro and small metro counties. Noncore areas have a greater percentage of children in fair or poor health compared with those in small metro and micropolitan counties. Most hospitals are located in large and small metro areas, and large metro areas have a higher proportion of teaching hospitals compared with other areas. Health care. In general, there were no overall differences by place of residence in the proportion of children with and without insurance, although differences emerged in subpopulations within Urban Influence Code types. Hispanic children residing in large metro counties were more likely to be uninsured than those in small metro counties. Overall, the proportion of children with at least one dental visit was larger in small metro areas compared with both large metro and noncore areas. The proportion of children with medicines prescribed was generally lower in large metro areas compared with all other areas both overall and among subpopulations of children. Children in noncore areas were more likely to have a hospital inpatient stay and any emergency department use compared with children in large metro areas. Children in large metro counties had longer average inpatient stays and a higher hospital inpatient charge per day compared with children in all other counties. Although most hospitalizations for children from large metro areas occurred in large metro areas, over half of hospitalizations for noncore children occurred outside of noncore counties. Further, children from noncore counties appear to be hospitalized for ambulatory sensitive conditions more than children from all other areas. CONCLUSIONS: County-level data analyses performed using a collapsed version of the Urban Influence Codes with MEPS and HCUP data shed additional light on the health care patterns for children that were not previously evident when only the dichotomous metropolitan/nonmetropolitan geographic schema was used.

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

OBJECTIVES: To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States. METHODS: Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations. RESULTS: Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children. CONCLUSIONS: While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Health-related quality of life improves with treatment-related GERD symptom resolution after adjusting for baseline severity.

Severity and frequency of gastroesophageal reflux disease (GERD) related symptoms are associated with impaired health-related quality of life (HRQL). This study evaluated the association between baseline heartburn severity and endpoint HRQL of patients treated for heartburn and the relationship between complete resolution of heartburn symptoms and HRQL outcomes after controlling for baseline severity. We completed a secondary analysis of clinical symptom and HRQL data from three clinical trials in adult patients receiving either omeprazole or ranitidine treatment for GERD. HRQL was assessed using the Psychological General Well-Being Index (PGWB) in each of the three clinical trials, and two of the trials also included the Medical Outcomes Study Sleep disturbance scale. Gastrointestinal symptoms were evaluated using either the Gastrointestinal Symptom Rating Scale or a modified version of the scale. Baseline heartburn severity (none/minor, mild, moderate or severe) was defined based on patient-reported symptoms. Analysis of covariance (ANCOVA) models were used to compare mean HRQL scores by baseline level of heartburn symptom severity and whether or not patients experienced complete heartburn resolution. At baseline, PGWB scores were significantly worse (p < 0.05) for patients with more severe heartburn symptoms. There were no statistically significant baseline severity by symptom resolution interactions in any of the ANCOVA models. For all three trials and across all follow-up assessments, mean PGWB scores were statistically significantly higher for patients with completely resolved heartburn symptoms versus those whose symptoms were unresolved (all p-values < 0.05). Few significant effects were observed for sleep disturbance scores. While the severity of heartburn symptoms at the start of medical treatment for GERD is not associated with improvements in HRQL in subsequent weeks of treatment, complete resolution of symptoms is associated with improvements in psychological well-being.

Health care for children and youth in the United States: 2002 report on trends in access, utilization, quality, and expenditures.

OBJECTIVE: To examine changes in insurance coverage, health care utilization, perceived quality of care, and expenditures for children and youth in the United States using data from 1987-2001. METHODS: Three national health care databases serve as the sources of data for this report. The Medical Expenditure Panel Survey (1996-2001) provides data on insurance coverage, utilization, expenditures, and perceived quality of care. The National Medical Expenditure Survey (1987) provides additional data on utilization and expenditures. The Nationwide Inpatient Sample (1995-2000) from the Healthcare Cost and Utilization Project provides information on hospitalizations. RESULTS: The percent of children uninsured for an entire year declined from 10.4% in 1996 to 7.7% in 1999. Most changes in children's health care occurred between 1987 and the late 1990s. Overall utilization of hospital-based services has declined significantly since 1987, especially for inpatient hospitalization. Several of the observed changes from 1987 varied significantly by type of health insurance coverage, poverty status, and geographic region. Quality of care data indicate some improvement between 2000 and 2001, which varies by insurance coverage. Overall, mean length of stay of hospitalizations did not change significantly from 1995 to 2000, but changes in the prevalence of hospitalizations and the length of stay associated with age-specific diagnoses were evident during this time period. CONCLUSIONS: Health care for children and youth has changed significantly since 1987, with most of the changes occurring between 1987 and 1996. Insurance coverage has improved, the site of care has shifted toward ambulatory sites, hospital utilization has declined, and expenditures on children as a proportion of total expenditures have decreased. Variation in these changes is evident by insurance status, poverty, and region.

Health care for children and youth in the United States: 2001 annual report on access, utilization, quality, and expenditures.

OBJECTIVES: To provide an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States and new information on parents' perceived quality of care for their children and to provide information on variation in hospitalizations for children from a 24-state hospital discharge data source. METHODS: The data on insurance coverage, utilization, expenditures, and perceived quality of care come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Nationwide Inpatient Sample, which is part of the Healthcare Cost and Utilization Project. Both data sets are maintained by the Agency for Healthcare Research and Quality. RESULTS: In 2000, 64.5% of children were privately insured, 21.6% were insured through public sources, and 13.9% were uninsured. Children aged 15-17 years were more likely to be uninsured than children 1-4 years old. Children without health insurance coverage were less likely to use health care services, and when they did, their rates of utilization and expenditures were lower than insured children. Publicly insured children were the most likely to use hospital inpatient and emergency department (ED) care. Being black or Hispanic and living in families with incomes below 200% of the poverty line were associated with lower utilization and expenditures. A small proportion of children account for the bulk of health care expenditures: approximately 80% of all children's health care expenditures are attributable to 20% of children who used medical services. Although most parents report that their experiences with health care for their children are good, there are significant variations by type of insurance coverage. There are substantial differences in average length of hospitalization across the United States, ranging from 2.9-4.1 days, and rates of hospital admission through the ED, which vary across states from 10%-25%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10- to 17-year age group, more than 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy. The top 10 most common conditions treated in the hospital account for 40%-60% of all hospital stays. CONCLUSION: Children's use of health care services varies considerably by the type of health insurance coverage, race/ethnicity, and family income. Quality of care, as measured by parents' experiences of care, also varies by type of coverage. There is substantial variation in use of hospital services across states.

Validity of reported Medicare Part D enrollment in the Medical Expenditure Panel Survey.

The authors validate reported Part D coverage in the Medical Expenditure Panel Survey (MEPS) and assess the impact of misreporting on descriptive and behavioral analyses. MEPS participants with Medicare coverage during 2006 to 2007 were matched to Medicare administrative data. A summary measure of Part D coverage based on several questions has substantial validity (κ = .70) and an agreement rate of 85.1%. Some beneficiaries confused Part D and private drug coverage, leading to both under- and overreported Part D coverage. Accuracy varies little by sociodemographic group. Standard regression models of the determinants of Part D enrollment were estimated with both MEPS-based and administrative data-based measures of Part D enrollment. In this analysis, the signs of the marginal effects were the same, the magnitudes were similar, and mostly the same variables had statistically significant effects in both regressions. Thus, behavioral analyses are largely unaffected by misreporting.

Determinants of utilization and expenditures for episodes of ambulatory physical therapy among adults.

BACKGROUND: Comprehensive information on determinants and patterns of use and spending for ambulatory physical therapy services is needed to inform health planning and policy decisions. Most research in the literature on this topic is limited to specific payers, age groups, and conditions. OBJECTIVE: The purpose of this study was to examine factors associated with the resource intensity of physical therapy episodes for adults in the United States as measured by number of visits and expenses per visit. DESIGN: This study was a secondary analysis of longitudinal survey data from the Medical Expenditure Panel Survey (MEPS) panels 9, 10, and 11. METHODS: An analytic file was created based on data from the longitudinal data files for 3 MEPS panels and the annual office-based and hospital outpatient event files. A total of 1,377 episodes of physical therapy care were identified. Variation in both the total number of visits per episode and expenses per visit was examined by fitting regression models to evaluate the effects of selected independent variables classified into 4 categories: episode-level variables, demographic characteristics, geographic variables, and health status indicators. RESULTS: Average total expenses per episode (in 2007 dollars) were $1,184 (median=$651), with an average number of visits per episode of 9.6 (median=6.0) and average expenses per visit of $130 (median=$95). Significant variation by geographic characteristics, sex, and one comorbid condition (high blood pressure) was found in the number of visits model. In the expenditures model, expenses per visit were associated with age/insurance coverage, setting (hospital outpatient versus office based), primary condition category, and mental health status. Limitations Limitations include limited sample sizes of physical therapy users and lack of detailed clinical information. CONCLUSIONS: Variability in the resource intensity of physical therapy episodes is influenced to some degree by nonclinical variables.

Annual report on health care for children and youth in the United States: focus on injury-related emergency department utilization and expenditures.

OBJECTIVE: To examine state differences in children's utilization of injury-related emergency department (ED) care across 14 states, benchmarking aggregate state estimates against national expenditure estimates for outpatient injury-related ED care. METHODS: A retrospective analysis was performed using the 2003 State Emergency Department Databases and State Inpatient Databases from the Healthcare Cost and Utilization Project and data from the Medical Expenditure Panel Survey. Pediatric ED visits with any injury International Classification of Diseases Ninth Version Clinical Modification (ICD-9-CM) diagnosis code were selected. The Barell Injury Diagnosis Matrix, ICDMAP-90 software, and the Trauma Information Exchange Program data were used to classify injuries, produce injury severity scores, and examine utilization in trauma centers. Aggregate and state-specific descriptive analyses compared differences in patient and injury characteristics and admission status by age, severity of injury, and expected payer. RESULTS: Over 1.5 million or nearly one-third of ED visits were for pediatric injuries in the 14 states studied. Nationally, 5.4% of children had an injury-related ED visit, and approximately $2.3 billion was spent on outpatient injury-related ED visits in 2003. The pattern of injury-related ED visit care varied considerably by state. For example, injury-related ED visit rates ranged from 63.3 to 164.4 per 1000 children. Infants, adolescents, children from very low income communities, and children from nonmetropolitan and nonmicropolitan areas were more likely to have an injury-related ED visit than their peers. Although patient characteristics were fairly consistent across states, admission rates and expected source of payment for injury-related ED visits varied considerably by state. Hospital admission rates ranged from 1.5% to 4.4% of injury-related ED visits and expected payer estimates ranged from 37.1% to 71.0% of visits billed to private insurance, 17.9% to 47.0% billed to Medicaid, and 2.1% to 10.4% billed as uninsured. CONCLUSIONS: This study suggests that injuries account for a significant portion of pediatric ED visits. There is substantial variation in ED use and hospital admissions for injured children across states and payers. This variation suggests that there are several opportunities for improvement in emergency care for children. To better understand the underlying reason for the variation, multivariate and hypothesis-driven research should focus on the nature and outcomes of injury-related ED care in the context of small area practice patterns and state programs, policies, and care system characteristics.