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Background The burden of spinal pain can be aggravated by the hazards of opioid analgesics, which are still widely prescribed for spinal pain despite evidence-based clinical guidelines that identify non-pharmacological therapies as the preferred first-line approach. Previous studies have found that chiropractic care is associated with decreased use of opioids, but have not focused on older Medicare beneficiaries, a vulnerable population with high rates of co-morbidity and polypharmacy. The purpose of this investigation was to evaluate the association between chiropractic utilization and use of prescription opioids among older adults with spinal pain. Methods We conducted a retrospective observational study in which we examined a nationally representative multi-year sample of Medicare claims data, 2012–2016. The study sample included 55,949 Medicare beneficiaries diagnosed with spinal pain, of whom 9,356 were recipients of chiropractic care and 46,593 were non-recipients. We measured the adjusted risk of filling a prescription for an opioid analgesic for up to 365 days following diagnosis of spinal pain. Using Cox proportional hazards modeling and inverse weighted propensity scoring to account for selection bias, we compared recipients of both primary care and chiropractic to recipients of primary care alone regarding the risk of filling a prescription. Results The adjusted risk of filling an opioid prescription within 365 days of initial visit was 56% lower among recipients of chiropractic care as compared to non-recipients (hazard ratio 0.44; 95% confidence interval 0.40–0.49). Conclusions Among older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.

BackgroundLow back pain (LBP) imposes a costly burden upon patients, healthcare insurers, and society overall. Spinal manipulation as practiced by chiropractors has been found be cost-effective for treatment of LBP, but there is wide variation among chiropractors in their approach to clinical care, and the most cost-effective approach to chiropractic care is uncertain. To date, little has been published regarding the cost effectiveness of different approaches to chiropractic care. Thus, the current study presents a cost comparison between chiropractic approaches for patients with acute or subacute care episodes for low back pain.MethodsWe employed a retrospective cohort design to examine costs of chiropractic care among patients diagnosed with acute or subacute low back pain. The study time period ranged between 07/01/2016 and 12/22/2017. We compared cost outcomes for patients of two cohorts of chiropractors within health care system: Cohort 1) a general network of providers, and Cohort 2) a network providing conservative evidence-based care for rapid resolution of pain. We used generalized linear regression modeling to estimate the comparative influence of demographic and clinical factors on expenditures.ResultsA total of 25,621 unique patients were included in the analyses. The average cost per patient for Cohort 2 (mean allowed amount $252) was lower compared to Cohort 1 (mean allowed amount $326; 0.77, 95% CI 0.75–0.79,p ConclusionsThis study comprehensively analyzed cost data associated with the chiropractic care of adults with acute or sub-acute low back pain cared by two cohorts of chiropractic physicians. In general, providers in Cohort 2 were found to be significantly associated with lower costs for patient care as compared to Cohort 1. Utilization of a clinical model characterized by a patient-centered clinic approach and standardized, best-practice clinical protocols may offer lower cost when compared to non-standardized clinical approaches to chiropractic care.

Introduction: Complementary health care professionals deliver a substantial component of clinical services in the United States, but insurance coverage for many such services may be inadequate. The...

Objective Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. Design and Setting We employed a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012–2017. Subjects We included adults aged 18–84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. We identified two cohorts of subjects: Recipients received both primary care and chiropractic care, and nonrecipients received primary care but not chiropractic care. Methods We performed adjusted time-to-event analyses to compare recipients and nonrecipients with regard to the risk of filling an opioid prescription. We stratified the recipient populations as: acute (first chiropractic encounter within 30 days of diagnosis) and nonacute (all other patients). Results The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients filled an opioid prescription, as compared with recipients (in Connecticut: hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.11–2.17, P = 0.010; in New Hampshire: HR = 2.03, 95% CI = 1.92–2.14, P Conclusions Patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.

Objective The occurrence of cervical vertebral erosion due to vertebral artery (VA) abnormalities such as tortuosity/loop formation and pseudoaneurysm is rare, but both abnormalities are potentially fatal. There are few reports of cervical vertebral body erosion due to VA abnormality. We report a case of a 92-year-old woman who presented to her primary care physician with neck pain and was referred for chiropractic care. Clinical Features The patient complained of headaches, left-sided neck pain, limited range of motion with radiating pain, and bilateral weakness of the upper extremities. On examination, cervical ranges of motion were decreased with moderate pain, along with sensory, motor, and deep tendon reflex deficits. The initial magnetic resonance imaging report obtained was nonconclusive. Axial T2, sagittal T1, sagittal T2, coronal T2, sagittal STIR, and axial GE sequences of the cervical spine were obtained for a reread. A reread of the magnetic resonance images suggested a diagnosis of a tortuosity of the VA, resulting in a chronic erosion of the C5 vertebral body; however, a pseudoaneurysm of the VA would be considered a possible differential cause for the vertebral body erosion Intervention and Outcome Management of cervical vertebral body erosion due to VA abnormality is often complicated and must be tailored to each patient's individual clinical presentation and symptoms. The patient in this case was managed with anticoagulant medication, close monitoring, and acupuncture treatment, which resulted in a reduction in pain intensity. Conclusion Vertebral artery abnormality and subsequent erosion of the vertebral body is a rare occurrence and can mimic symptoms of musculoskeletal neck pain and cervical radiculopathy. It is important to recognize features of VA abnormalities on magnetic resonance imaging.

Study design We combined elements of cohort and crossover-cohort design. Objective The objective of this study was to compare long-term outcomes for Spinal Manipulative Therapy (SMT) and Opioid Analgesic Therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). Summary of background data Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. Methods We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. Results SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% CI 2.64-2.69, p Conclusions Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

Study design Retrospective observational study. Objective Opioid Analgesic Therapy (OAT) and Spinal Manipulative Therapy (SMT) are evidence-based strategies for treatment of chronic low back pain (cLBP), but the long-term safety of these therapies is uncertain. The objective of this study was to compare OAT versus SMT with regard to risk of adverse drug events (ADEs) among older adults with cLBP. Summary of background data We examined Medicare claims data spanning a 5-year period on fee-for-service beneficiaries aged 65 to 84 years, continuously enrolled under Medicare Parts A, B, and D for a 60-month study period, and with an episode of cLBP in 2013. We excluded patients with a diagnosis of cancer or use of hospice care. Methods All included patients received long-term management of cLBP with SMT or OAT. We assembled cohorts of patients who received SMT or OAT only, and cohorts of patients who crossed over from OAT to SMT or from SMT to OAT. We used Poisson regression to estimate the adjusted incidence rate ratio for outpatient ADE among patients who initially chose OAT as compared with SMT. Results With controlling for patient characteristics, health status, and propensity score, the adjusted rate of ADE was more than 42 times higher for initial choice of OAT versus initial choice of SMT (rate ratio 42.85, 95% CI 34.16-53.76, P Conclusion Among older Medicare beneficiaries who received long-term care for cLBP the adjusted rate of ADE for patients who initially chose OAT was substantially higher than those who initially chose SMT.Level of Evidence: 2.

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

The objective of this study was to compare patients' perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment.Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data: SMT, PDT, and 2 crossover cohorts (where participants experienced both types of treatments). A total of 195 Medicare beneficiaries responded to the survey. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short Form Health Survey to measure HRQoL.Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort's reported concern about PDT (P = .03).Among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.

OBJECTIVES: The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT). METHODS: We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias. RESULTS: The study sample totaled 28,160 subjects, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT as compared to those initiated care with SMT (95% CI 1.65-2.11; p

Objective The purpose of this study was to examine experiences and attitudes toward care offered by chiropractors and prescription drug therapy offered by medical physicians for patients who have back pain. Methods A cross-sectional survey measured patients with back pain (n = 150) seeking care within an academic primary care setting. A survey assessed patient experiences, beliefs, and attitudes regarding chiropractic care and prescription drug therapy. Two samples of patients in the New Hampshire region included 75 patients treated by a doctor of chiropractic (DC) and 75 treated by a medical primary care physician (PCP). The 30-item survey was sent to existing and new patients between February 2019 and January 2020. Between-group comparisons were examined to test rates of reporting and to determine the mean difference in the total number of office visits between the 2 samples. Results Patients treated by both DCs and PCPs reported high overall satisfaction with chiropractic care received for low back pain with no significant differences between groups. The majority in both groups reported that seeing a DC for back pain made sense to them (95% of patients treated by a DC and 75% of patients treated by a PCP) whereas the minority reported that taking prescription drugs for back pain made sense (25% of patients treated by a DC and 41% of patients treated by a PCP). There was no statistical difference between groups when patients were asked if seeing a chiropractor changed their beliefs or behaviors about taking pain medication. Significant differences were found between groups for agreement that chiropractic care would be a suitable treatment for back pain (79% of patients treated by a DC and 45% of patients treated by a PCP). There were 7% of patients treated by PCP and 23% of the patients treated by DC who agreed that a DC would be the first health care provider they would like to see for their general health needs. Conclusions In this sample of patients, patient satisfaction regarding chiropractic care received for back pain was high. There were differences between patient groups about preferences for treatment for back pain. Our results indicate that patients reported that seeing a DC for back pain did not change their beliefs or behaviors regarding prescription drug therapy provided by their medical PCP.

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.

Objective The purpose of this study was to examine the feasibility of developing and administering a patient adherence survey to assess self-reported adherence to treatment recommendations from a chiropractic doctor within an academic health center. Methods The survey items were developed by the authors and vetted by the university's students and faculty, who serve as health care practitioners at an academic health center. Adult patients with spine pain who were seen by a doctor of chiropractic at an academic health center were included in this survey study. A 32-item survey was administered between October 2019 and March 2020. Results A total of 62 respondents completed the anonymous survey. We found that 89% of respondents adhered to their clinic appointments. Although 82% of respondents said that their doctor's recommendation made sense, only 44% reported completely following treatment recommendations for at-home stretching and exercise. Conclusion This study determined that it is feasible to assess patient self-reported adherence to chiropractic treatment within an academic health center setting. In our sample we found that although patient adherence to clinic appointments was high, adherence to treatments was not.

Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects. The objective of this investigation was to evaluate the association between utilization of chiropractic services and the use of prescription opioid medications.The authors used a retrospective cohort design to analyze health insurance claims data.The data source was the all payer claims database administered by the State of New Hampshire. The authors chose New Hampshire because health claims data were readily available for research, and in 2015, New Hampshire had the second-highest age-adjusted rate of drug overdose deaths in the United States.The study population comprised New Hampshire residents aged 18-99 years, enrolled in a health plan, and with at least two clinical office visits within 90 days for a primary diagnosis of low-back pain. The authors excluded subjects with a diagnosis of cancer.The authors measured likelihood of opioid prescription fill among recipients of services delivered by doctors of chiropractic compared with nonrecipients. They also compared the cohorts with regard to rates of prescription fills for opioids and associated charges.The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among recipients compared with nonrecipients (odds ratio 0.45; 95% confidence interval 0.40-0.47; p 0.0001). Average charges per person for opioid prescriptions were also significantly lower among recipients.Among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients. The underlying cause of this correlation remains unknown, indicating the need for further investigation.

Proponents of bioidentical estrogens claim that they are superior for treating menopausal symptoms, including depressive symptoms. Small trials examining the effects of bioidentical estrogens on depressive symptoms show conflicting results. We conducted a systematic review to assess the effectiveness and safety of bioidentical estrogens for treatment of depressive symptoms in peri- and postmenopausal women.We searched the scientific literature for randomized controlled trials of at least 4 weeks duration, comparing bioidentical estrogen with placebo for depressive symptoms in menopausal women. The main outcome measure was improvement in depressive symptoms on a validated scale.We found 12 clinical trials that met inclusion criteria, two of which contained insufficient data for quantitative analysis. In the 10 studies (inclusive of 1208 subjects) for which complete data were available for inclusion in the meta-analysis, bioidentical estrogen had no clinically significant effect on depressive symptoms (standardized mean difference [SMD] -0.02; confidence interval [95% CI] -0.41 to +0.38). Pooled studies were highly heterogeneous, and numerous approaches to reducing heterogeneity were unsuccessful. Subgroup analyses showed no significant difference in effect for women treated with adjunctive progestogen, women treated with unopposed estrogen, perimenopausal, or postmenopausal and mixed populations. A possible benefit in perimenopausal women treated with unopposed estradiol may have been diluted by studies including older postmenopausal women whose depressive symptoms were unrelated to menopause.In this first systematic review of bioidentical hormone replacement therapy, we found that bioidentical estrogen has no clear benefit in treating depressive symptoms in menopausal women, but heterogeneity of available studies limits the potential for definitive conclusions. Future research should compare bioidentical estrogen with nonbioidentical estrogen for treatment of depressive symptoms in perimenopausal women.

Objective The objective of this investigation was to compare the value of primary spine care (PSC) with usual care for management of patients with spine-related disorders (SRDs) within a primary care setting. Methods We retrospectively examined existing patient encounter data at 3 primary care sites within a multi-clinic health system. Designated clinicians serve in the role as PSC as the initial point of contact for spine patients, coordinate, and follow up for the duration of the episode of care. A PSC may be a chiropractor, physical therapist, or medical or osteopathic physician who has been trained to provide primary care for patients with SRDs. The PSC model of care had been introduced at site I (Lebanon, New Hampshire); sites II (Bedford, New Hampshire) and III (Nashua, New Hampshire) served as control sites where patients received usual care. To evaluate cost outcomes, we employed a controlled quasi-experimental design for analysis of health claims data. For analysis of clinical outcomes, we compared clinical records for PSC at site I and usual care at sites II and III, all with reference to usual care at site I. We examined clinical encounters occurring over a 24-month period, from February 1, 2016 through January 31, 2018. Results Primary spine care was associated with reduced total expenditures compared with usual care for SRDs. At site I, average per-patient expenditure was $162 in year 1 and $186 in year 2, compared with site II ($332 in year 1; $306 in year 2) and site III ($467 in year 1; $323 in year 2). Conclusion Among patients with SRDs included in this study, implementation of the PSC model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.

Objectives The purpose of this study was to assess the status, supply, demographics, and characteristics of chiropractic practice in the continent of Africa. Methods A survey consisting of questions on demographics, clinical practice, and patient profile was administered to 608 chiropractors practicing in the different countries of the African continent. Chiropractic association officers of each country were contacted via e-mail for assistance in the distribution of the survey link to chiropractors in their country. The initial questionnaire was pretested with a small group of chiropractors from 2 African countries—4 from Ethiopia and 6 from Botswana—to assess the validity of the questions. The legal status of the chiropractic practice was obtained from online resources. Descriptive statistics were conducted in Microsoft Excel. Results Of the 54 countries in the continent of Africa, 23 countries were identified to have chiropractors. One hundred twenty-four surveys were returned from 15 countries with an overall response rate of 20.3% by clinicians with varying years in clinical practice. Nearly 84% of the chiropractors were between ages 26 and 50. More than 69% reported being a graduate of 1 of the 2 academic institutions located in Africa. Most chiropractors practice in South Africa. Most chiropractors practice in privately owned clinics, and 38% practice in multidisciplinary clinics. Nearly 92% reported using diversified technique and 27% used McKenzie exercises for treatment. Patients presented with a variety of conditions, predominantly chronic pain (59%). Conclusions This study provides a general overview on the status, supply, demographics, and characteristics of chiropractic practice in the continent of Africa. The supply of chiropractors in Africa is scarce and unevenly distributed. Although in the early stages of recognition, chiropractors in Africa are contributing to the care of people with musculoskeletal and spine-related disorders. Considering the high burden of spine pain, there appears to be potential for growth for chiropractic in the continent of Africa.

With the advent of new models for payment and delivery of healthcare services, the use of quality measures for continual improvement of clinical healthcare is now an integral feature of medical practice in the United States. However, quality measurement and quality improvement activities are not common practice among integrative health providers. This article discusses the import and application of quality measurement to the practice of integrative healthcare. It reviews developments in the healthcare quality improvement movement, explores the relevance of quality measures to integrative healthcare, describes examples of the current use of quality measures in integrative health practice, discusses discriminatory policies that may prevent participation in quality improvement by integrative health practitioners, and makes recommendations for practice and policy.

In the article, “Insurance Reimbursement for Complementary Healthcare Services,” we reported that the likelihood of reimbursement for complementary health care services in New Hampshire was significantly lower as compared with services of primary care physicians. The relatively low likelihood of reimbursement for integrative health care suggests that many patients who want such services must pay for them out of pocket. Affordable access to these services may be similarly limited in other states; certainly the utilization of integrative health care services varies significantly across the US states, and such variation may be tied to likelihood of reimbursement. Unwarranted geographic variation in reimbursement for integrative health care services is likely to compound inequities in access to health care in general, particularly for people of lower socioeconomic status. The aspirational value of Health Justice asserts the obligation of societies to attend to the basic health needs of all, with particular attention to the disadvantaged. A new project under development, The Atlas of Integrative Healthcare, is intended to support the advancement of health justice. The Atlas project is expected to support the policy goals of the integrative health care community with regard to helping patients access the high-value integrative health care services that they need and want.

Objective Patients who use complementary and integrative health services like chiropractic manipulative treatment (CMT) often have different characteristics than do patients who do not, and these differences can confound attempts to compare outcomes across treatment groups, particularly in observational studies when selection bias may occur. The purposes of this study were to provide an overview on how propensity scoring methods can be used to address selection bias by balancing treatment groups on key variables and to use Medicare data to compare different methods for doing so. Methods We described 2 propensity score methods (matching and weighting). Then we used Medicare data from 2006 to 2012 on older, multiply comorbid patients who had a chronic low back pain episode to demonstrate the impact of applying methods on the balance of demographics of patients between 2 treatment groups (those who received only CMT and those who received no CMT during their episodes). Results Before application of propensity score methods, patients who used only CMT had different characteristics from those who did not. Propensity score matching diminished observed differences across the treatment groups at the expense of reduced sample size. However, propensity score weighting achieved balance in patient characteristics between the groups and allowed us to keep the entire sample. Conclusions Although propensity score matching and weighting have similar effects in terms of balancing covariates, weighting has the advantage of maintaining sample size, preserving external validity, and generalizing more naturally to comparisons of 3 or more treatment groups. Researchers should carefully consider which propensity score method to use, as using different methods can generate different results.

Racial and ethnic disparities in utilization of chiropractic services have been described at the state level, but little is known about such local disparities. We analyzed Medicare data for the year 2008 to evaluate by ZIP code for utilization of chiropractic services among older adults in Los Angeles County, California. We evaluated for availability and use of chiropractic services by racial/ethnic category, quantified geographic variations by coefficient of variation, and mapped utilization by selected racial/ethnic categories. Among 7502 beneficiaries who used chiropractic services, 72% were white, 12% Asian, 1% black, 1% Hispanic, and 14% other/unknown. Variation in the number of beneficiaries per ZIP code who used chiropractic services was highest among Hispanics, blacks, and Asians. We found evidence of racial disparities in use of chiropractic services at the local level in Los Angeles County. Older blacks and Hispanics in Los Angeles County may be underserved with regard to chiropractic care.

Objectives Mortality rates due to adverse drug events (ADEs) are escalating in the United States. Analgesics are among the drug classes most often associated with occurrence of an ADE. Utilization of nonpharmacologic chiropractic services for treatment of low back pain could lead to reduced risk of an ADE. The objective of this investigation was to evaluate the association between utilization of chiropractic services and likelihood of an ADE. Methods We employed a retrospective cohort design to analyze health insurance claims data from the state of New Hampshire. After inversely weighting each participant by their propensity to be in their cohort, we employed logistic regression to compare recipients of chiropractic services to nonrecipients with regard to likelihood of occurrence of an ADE in an outpatient setting. Results The risk of an ADE was significantly lower among recipients of chiropractic services as compared with nonrecipients. The adjusted likelihood of an ADE occurring in an outpatient setting within 12 months was 51% lower among recipients of chiropractic services as compared to nonrecipients (OR 0.49; P = .0002). The reported ADEs were nonspecific with regard to drug category in the majority of incidents that occurred in both cohorts. Conclusions Among New Hampshire adults with office visits for low back pain, the adjusted likelihood of an ADE was significantly lower for recipients of chiropractic services as compared to nonrecipients. No causal relationship was established between utilization of chiropractic care and risk of an ADE. Future research should employ larger databases, rigorous methods to reduce risk of bias, and more sensitive means of identifying ADEs.

Insurance reimbursement for clinical services provided by complementary healthcare professionals in the United States likely differs by provider specialty. It is hypothesized that a lower likelihood of insurance reimbursement demonstrates that complementary healthcare services are not utilized to an optimal level and are not financially accessible to all who may need or want these services. The purpose of this project was to evaluate the likelihood of insurance reimbursement for complementary healthcare services compared with other complementary services and with conventional primary care medical services in New Hampshire.The authors studied health claims for services provided in a nonemergent outpatient setting in New Hampshire in 2014. The study population consisted of New Hampshire residents aged 18-99 years with claims for selected clinical services commonly provided by complementary healthcare providers. The authors modeled the proportion of reimbursed claims by specialty of complementary healthcare service provider, compared with the reimbursement rate for primary care physicians' claims. The authors modeled first for the proportion of reimbursement for any selected clinical service, next for any evaluation and management (EM) service, and finally for the most commonly used EM procedure code, current procedural terminology (CPT) 99213 (reevaluation of established patient).Compared with primary care physicians, the likelihood of reimbursement for any service was 69% lower for acupuncturists, 71% lower for doctors of chiropractic medicine, and 62% lower for doctors of naturopathic medicine. For any EM service, likelihood of reimbursement was 69% lower for acupuncturists, 78% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. With further restriction to CPT 99213 only, likelihood of reimbursement was 34% lower for acupuncturists, 77% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine.In New Hampshire, the likelihood of health insurance reimbursement for certain clinical services differs significantly by provider specialty. More research is needed to evaluate the extent and cause of such differences and the effect of such differences on the utilization of complementary healthcare services in the United States.

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.

Objective The purposes of this study were to examine the direct costs associated with Medicare's 2005-2007 “Demonstration of Expanded Coverage of Chiropractic Services” (Demonstration) and their drivers, to explore practice pattern variation during the Demonstration, and to describe scenarios of cost implications had provider behavior and benefit coverage been different. Methods Using Medicare Part B data from April 1, 2005, and March 31, 2007, and 2004 Rural Urban Continuum Codes, we conducted a retrospective analysis of traditionally reimbursed and expanded chiropractic services provided to patients aged 65 to 99 years who had a neuromusculoskeletal condition. We compared chiropractic care costs, supply, and utilization patterns for the 2-year periods before, during, and after the Demonstration for 5 Chicago area counties that participated in the Demonstration to those for 6 other county aggregations—urban or rural counties that participated in the Demonstration; were designated comparison counties during the Demonstration; or were neither participating nor comparison counties during the Demonstration. Results When compared with other groups, doctors of chiropractic in 1 region (Chicago area counties) billed more aggressively for expanded services and were reimbursed significantly more for traditionally reimbursed chiropractic services provided before, during, and after the Demonstration. Costs would have been substantially lower had doctors of chiropractic in this 1 region had responded similarly to those in other demonstration counties. Conclusion We found widespread geographic variation in practice behavior and patterns. Our findings suggest that Medicare might reduce the risk of accelerated costs associated with the introduction of a new benefit by applying appropriate limits to the frequency of use and overall costs of those benefits, particularly in highly competitive markets.

We report the case of a woman with posttraumatic stress disorder secondary to childhood sexual assault who attempted withdrawal from long-term use of antidepressant medication and experimented with a plethora of different therapies. The complex case history illustrates the potential difficulty of withdrawal from chronic antidepressant medication and the role of integrative therapies for posttraumatic stress disorder.

The purpose of this study was to measure geographic variations in the availability and use of chiropractic under Medicare.A cross-sectional design was used to analyze a large nationally representative sample of Medicare data. Data from a 20% representative sample of all paid Medicare Part B fee-for-service claims for 2007 were merged with files containing beneficiary and provider data. The sample was restricted to adults aged 65 to 99 years. Measures of chiropractic availability and use were described and selectively mapped by state. Geographic variations were quantified. Spearman test was used to evaluate for correlation between chiropractic availability and use.The average number of doctors of chiropractic (DC) by state was 1135; average DC per 1000 beneficiaries was 2.5 (SD, 1.1). The average number of chiropractic users by state was 34,502 (SD, 30,844); average chiropractic users per 1000 beneficiaries was 76 (SD, 41). Chiropractic availability by state varied 6-fold, and chiropractic use varied nearly 30-fold. Availability was strongly correlated with use (Spearman ρ, 0.86; P.001). Expenditures per DC were highest in the upper Midwest and lowest in the far West; expenditures per user were highest in New England and New York, and lowest in the West.Chiropractic availability and use by older adults under Medicare predominated in rural states in the North Central United States. Expenditures were higher in the East and Midwest and lower in the far West. Chiropractic availability and use by state were highly correlated. Future analyses should use small-area analysis and statistical modeling to identify factors predictive of chiropractic use.

Objective The appropriate role for chiropractic in US health care has not been established, but third-party payors and public policy makers must make decisions about the appropriate role for chiropractors in health care systems and for the services that chiropractors provide. Appropriateness studies for chiropractic may inform those decisions. The purpose of this article is to discuss the implications and limitations of appropriateness studies for chiropractic. Discussion We reviewed the general context for assessment of the appropriateness and the application of appropriateness studies to chiropractic in particular. We evaluated the implications and limitations for chiropractic of methods of small area analysis and the RAND-UCLA Appropriateness Method. The RAND-UCLA Appropriateness Method has been applied to the evaluation of spinal manipulation. Regional variations in chiropractic utilization have yet to be described through small area analysis, but these methods appear to hold some potential for assessing the appropriateness of chiropractic care. Both small area analysis and the RAND-UCLA method offer limited possibilities for the assessment of chiropractic appropriateness. Conclusion Future assessment of the appropriate role for chiropractic in US health care will raise issues beyond the scope of previous appropriateness studies. Studying the appropriate role for chiropractic will require consideration of the clinical discipline in its entirety, rather than individual consideration of specific interventions. A fair assessment of chiropractic appropriateness will require new evidence and perhaps new research methodologies.

Background—Trauma registries may contain records without a codable trauma diagnosis, creating a “data gap” that multiplies the number of invalid registry data fields. We designed an investigation intended to determine the incidence of registry records with non-codable trauma diagnoses, characterize those records, and determine the reasons for inadequate diagnosis data. Methods—We utilized a retrospective cohort design. A query of trauma registry records spanning a five-year period yielded 129 records with no injury severity score. Each patient’s medical record was reviewed, sources of diagnostic information were noted and diagnoses were categorized. Results—In 57% of cases, we found documentation that the patient had sustained an injury, but the injury was inadequately documented in the discharge summary. In 19% of cases, although the registry record was valid, the diagnosis was not codable as trauma. In 17% of cases, clinical documentation was adequate, but the diagnosis was inadequately recorded in the trauma registry. In 13% of cases, no traumatic injury was sustained, although the registry record was valid. In 2% of cases, the trauma registry record itself was invalid. In 1% of cases, a coding error occurred. Conclusions—Particularly prominent among records with inadequate discharge documentation were cases of head and spine injury for which there was no radiographic evidence. The incidence of records with uncodable diagnoses might best be reduced through improved physician documentation, revision of trauma registry inclusion criteria, increased attention by trauma registrars to key sources of documentation, and direct communication with the attending physician when necessary.

Objective The purpose of this study was to determine whether use of chiropractic manipulative treatment (CMT) was associated with lower healthcare costs among multiply-comorbid Medicare beneficiaries with an episode of chronic low back pain (cLBP). Methods We conducted an observational, retrospective study of 2006 to 2012 Medicare fee-for-service reimbursements for 72326 multiply-comorbid patients aged 66 and older with cLBP episodes and 1 of 4 treatment exposures: chiropractic manipulative treatment (CMT) alone, CMT followed or preceded by conventional medical care, or conventional medical care alone. We used propensity score weighting to address selection bias. Results After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided. Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories. While patients who used only CMT had the lowest Part A and Part B expenditures per episode day, we found no indication of lower psychiatric or pain medication expenditures associated with CMT. Conclusions This study found that older multiply-comorbid patients who used only CMT during their cLBP episodes had lower overall costs of care, shorter episodes, and lower cost of care per episode day than patients in the other treatment groups. Further, costs of care for the episode and per episode day were lower for patients who used a combination of CMT and conventional medical care than for patients who did not use any CMT. These findings support initial CMT use in the treatment of, and possibly broader chiropractic management of, older multiply-comorbid cLBP patients.

Objective We report on the case of a patient with spinal epidural hematoma (SEH) after spinal manipulative therapy and review features of reported cases of a similar nature. Clinical Features The patient was undergoing Coumadin anticoagulant therapy for atrial fibrillation and presented to the chiropractor complaining of a stiff neck. After cervical manipulation, he developed paresthesia in both feet, progressing to motor deficits in all 4 extremities. He required a laminectomy and evacuation of a clot indenting the spinal cord. Results Review of the literature revealed 7 reported cases of SEH after manipulation; 5 patients underwent cervical manipulation and 1 patient received Coumadin therapy. Conclusion Practitioners of spinal manipulative therapy should be aware of SEH as a possible complication of manipulation in patients at risk and should exercise caution in the care of patients undergoing anticoagulant therapy.

Study Design. Retrospective cohort studyObjective. In older adults with a neuromusculoskeletal complaint, to evaluate risk of injury to the head, neck or trunk following an office visit for chiropractic spinal manipulation, as compared to office visit for evaluation by primary care physicianSummary of Background Data. The risk of physical injury due to spinal manipulation has not been rigorously evaluated for older adults, a population particularly vulnerable to traumatic injury in general.METHODS. We analyzed Medicare administrative data on Medicare B beneficiaries aged 66-99 with an office visit in 2007 for a neuromusculoskeletal complaint. Using a Cox proportional hazards model, we evaluated for adjusted risk of injury within 7 days, comparing two cohorts: those treated by chiropractic spinal manipulation vs. those evaluated by a primary care physician. We used direct adjusted survival curves to estimate the cumulative probability of injury. In the chiropractic cohort only, we used logistic regression to evaluate the effect of specific chronic conditions on likelihood of injury.RESULTS. The adjusted risk of injury in the chiropractic cohort was lower as compared to the primary care cohort (hazard ratio 0.24; 95% CI 0.23-0.25). The cumulative probability of injury in the chiropractic cohort was 40 injury incidents per 100,000 subjects, as compared to 153 incidents per 100,000 subjects in the primary care cohort. Among subjects who saw a chiropractic physician, the likelihood of injury was increased in those with a chronic coagulation defect, inflammatory spondylopathy, osteoporosis, aortic aneurysm and dissection, or long-term use of anticoagulant therapy.CONCLUSIONS. Among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician. Language: en

Objective The purpose of this study was to quantify risk of stroke after chiropractic spinal manipulation, as compared to evaluation by a primary care physician, for Medicare beneficiaries aged 66 to 99 years with neck pain. Methods This is a retrospective cohort analysis of a 100% sample of annualized Medicare claims data on 1 157 475 beneficiaries aged 66 to 99 years with an office visit to either a chiropractor or primary care physician for neck pain. We compared hazard of vertebrobasilar stroke and any stroke at 7 and 30 days after office visit using a Cox proportional hazards model. We used direct adjusted survival curves to estimate cumulative probability of stroke up to 30 days for the 2 cohorts. Results The proportion of subjects with stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33-0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01-1.19). Conclusions Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

Objectives Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services? Methods A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage. Results The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health. Conclusions The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.

Medicare covers chiropractic care, but the health-care community knows little about the demographic characteristics of older adults who use chiropractic services under the Medicare program. Researchers do not know the demographic composition of chiropractic users under Medicare, how the demographics of chiropractic use and rates of use have changed over time, and how users' characteristics vary geographically across the United States. An understanding of the demographics of chiropractic users can help chiropractic organizations, policy makers, and other stakeholders plan for an equitable allocation of resources to meet the chiropractic health-care needs of all of Medicare's beneficiaries.The study intended to evaluate Medicare administrative data to determine (1) longitudinal trends in the demographic composition of the population that used chiropractic services, (2) longitudinal trends in rates of chiropractic use by demographic group, and (3) geographic variations in chiropractic use among minorities.The research team used a serial cross-sectional design to analyze administrative data for beneficiaries of Medicare during the years 2002 to 2008, using a 20% random sample that provided those beneficiaries' racial and geographical characteristics. The team restricted the study's actual sample to adults aged 65 to 99 and defined chiropractic users as beneficiaries who had at least one paid claim for chiropractic care on a date of service in an analyzed calendar year.For each state in the United States and the District of Columbia for each of the 7 years studied, the team determined the number of chiropractic users in total and the number of users in selected demographic categories and calculated percentage estimates and averages for each category. The team analyzed 2008 data for rates of use within racial groups and for geographic variations in those rates and quantified variations in rates by state using the coeffcient of variation (CV). The team mapped race-specific rates for selected minorities, categorized by quintiles, to illustrate geographic variations by state.Analysis by beneficiary's race showed that the proportion of chiropractic users who were white hovered at 96% to 97% throughout the time period studied, while 1% to 2% were black. Each of the other racial categories comprised 1% or less of users, and the percentages showed little change over time. Rates among racial minorities showed greater geographic variation than did rates for whites. The greatest geographic variations in use by specific racial minorities occurred among Hispanics, Asians, and Native Americans.The research team's results showed little longitudinal variation in the demographics of chiropractic use under Medicare but a striking difference in rates of use between whites and minorities, and substantial geographic variations in user rates among racial minorities. The research team's findings suggest the possibility that barriers may exist for minorities' access to chiropractic care. As minority populations in the United States continue to grow, the health-care community can expect that any impact on population health that these barriers cause will grow as well.

Background In the United States (US) a shortage of primary care physicians has become evident. Other health care providers such as chiropractors might help address some of the nation’s primary care needs simply by being located in areas of lesser primary care resources. Therefore, the purpose of this study was to examine the distribution of the chiropractic workforce across the country and compare it to that of primary care physicians. Methods We used nationally representative data to estimate the per 100,000 capita supply of chiropractors and primary care physicians according to the 306 predefined Hospital Referral Regions. Multiple variable Poisson regression was used to examine the influence of population characteristics on the supply of both practitioner-types. Results According to these data, there are 74,623 US chiropractors and the per capita supply of chiropractors varies more than 10-fold across the nation. Chiropractors practice in areas with greater supply of primary care physicians (Pearson’s correlation 0.17, p-value Conclusion These findings suggest that chiropractors practice in areas of greater primary care physician supply. Therefore chiropractors may be functioning in more complementary roles to primary care as opposed to an alternative point of access.

The purposes of this study were to analyze data from the longitudinal Medical Expenditures Panel Survey (MEPS) to evaluate the impact of an aging population on secular trends in back pain and chronicity and to provide estimates of treatment costs for patients who used only ambulatory services.Using the MEPS 2-year longitudinal data for years 2000 to 2007, we analyzed data from all adult respondents. Of the total number of MEPS respondent records analyzed (N = 71,838), we identified 12,104 respondents with back pain and further categorized 3842 as chronic cases and 8262 as nonchronic cases.Secular trends from the MEPS data indicate that the prevalence of back pain has increased by 29%, whereas chronic back pain increased by 64%. The average age among all adults with back pain increased from 45.9 to 48.2 years; the average age among adults with chronic back pain increased from 48.5 to 52.2 years. Inflation-adjusted (to 2010 dollars) biennial expenditures on ambulatory services for chronic back pain increased by 129% over the same period, from $15.6 billion in 2000 to 2001 to $35.7 billion in 2006 to 2007.The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.

STUDY DESIGN Retrospective cross-sectional analysis of administrative data. OBJECTIVE To examine the relationship between regional chiropractic supply and both use and utilization intensity of chiropractic services among Medicare beneficiaries. SUMMARY OF BACKGROUND DATA Numerous studies have documented trends and patterns in the utilization of chiropractic services in the United States, but little is known about geographic variation in the relationship between chiropractic supply and utilization. METHODS We analyzed Medicare claims data for services provided by chiropractic physicians in 2008. We aggregated the data to the hospital referral region level and used small area analysis techniques to generate descriptive statistics. We mapped geographic variations in chiropractic supply, use and utilization intensity (treatments per user), and quantified the variation by coefficient of variation and extremal ratio. We used Spearman rank correlation coefficient to correlate use with supply. We used a logistic regression model for chiropractic use and a multiple linear regression model for chiropractic utilization intensity. RESULTS The average regional supply of chiropractic physicians was 21.5 per 100,000 adult capita. The average percentage of beneficiaries who used chiropractic was approximately 7.6 (SD, 3.9). The average utilization intensity was 10.6 (SD, 1.8). Regional chiropractic supply varied more than 14-fold, and chiropractic use varied more than 17-fold. Chiropractic supply and use were positively correlated (Spearman ρ, 0.68; P < 0.001). A low back or cervical spine problem was strongly associated with chiropractic use (odds ratios, 21.6 and 14.3, respectively). Increased chiropractic supply was associated with increased chiropractic use (odds ratio, 1.04) but not with increased chiropractic utilization intensity. CONCLUSION Both the supply of chiropractors and the utilization of chiropractic by older US adults varied widely by region. Increased chiropractic supply was associated with increased chiropractic use but not with increased chiropractic utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference.

Legislation that supports the establishment of Accountable Care Organizations (ACOs) was recently enacted into law as part of the Patient Protection and Affordable Care Act, and in 2012 the Centers for Medicare and Medicaid Services will begin contracting with ACOs. Although ACOs will play a significant role in reform of the U.S. health care delivery system, thus far, discussions have focused exclusively on the coordination of conventional health services. This article discusses the potential engagement of the complementary and alternative (CAM) workforce in ACOs and the foreseeable impacts of ACO legislation on the future of U.S. CAM services.

Objective The objective of this study was to examine the volume and rate of Medicare Part B claims for chiropractic spinal manipulation longitudinally from 1998 to 2004. Methods A descriptive retrospective analysis was performed on Medicare part B claims from 1998 to 2004 using the Medicare Part B Standard Analytical Variable Length File . Using a 5% random sample of Medicare part B claims, the total number of claims were determined for chiropractic spinal manipulation procedures, and the rate of chiropractic spinal manipulation procedures per 1000 beneficiaries. Results From 1998 through 2003, the number of chiropractic spinal manipulation claims increased by 38% (from 824 249 total claims in 1998 to 1 133 872 in 2003) followed by a 24% decline from 2003 to 2004. The rate of total chiropractic spinal manipulation claims rose 29% from 649 claims per 1000 beneficiaries per year in 1998 to a high of 839 claims per 1000 beneficiaries per year in 2003 and then declined by 25% to 632 claims per 1000 beneficiaries per year in 2004. Conclusion Medicare Part B claims for chiropractic spinal manipulation increased significantly from 1998 to 2003 and then abruptly declined from 2003 to 2004. Estimates for 2004 are at variance with earlier published estimates.