Chiropractic Use Patterns, and Their Antecedents and Consequences in Older Adults

描述（由申请人提供）：2005年IOM关于补充和替代医学的报告指出，尽管CAM疗法在整个历史上一直存在，并且至少有三分之一的美国人使用，但“它只是相对最近的一种疗法。有一个严重的普遍利益...研究和评估这些疗法。事实上，即使是最知名的CAM“脊椎按摩”形式的流行病学也没有得到很好的描述，尽管自2000年以来，老年人对它的使用一直在增加。因此，在这个修订后的R21申请（提交响应PAR 08-213，行为和社会科学的方法和测量），我们建议检查谁使用脊椎治疗服务，随着时间的推移，他们使用脊椎治疗服务的数量和一致性，以及在全国代表性的医疗保险受益人样本中使用脊椎治疗的前因和后果。为了做到这一点，我们成功地将5，511名参与老年人资产和健康动态研究（AHEAD）的自我受访者的数据联系起来，这些人在基线时没有参加管理式医疗保险（7,447名基线时70岁或以上的非机构受试者的原始队列的74%）。这5，511例受试者在进入管理式医疗保险或死亡（以先发生者为准）时进行基线后删失。链接的数据源包括：（a）1993年基线和1995年、1998年、2000年、2002年、2004年和2006年后续AHEAD访谈（B）在每波数据中对每个受试者的地理编码标识符;以及（c）1991-2005日历年的Medicare Part A和B索赔。有了这些数据，我们将解决三个具体的目标：（1）描述老年人中随着时间的推移脊骨神经疗法的使用模式，（2）确定脊骨神经疗法使用模式的前因;（3）评估脊骨神经疗法使用模式对医生就诊，全因住院，门诊护理敏感条件住院，医疗保险支付和死亡率的影响。我们的方法将包括直观的分类规则和算法以及潜在类别分析（目标1），多变量二项和多项逻辑回归分析与模式混合模型（目标2），多变量比例风险，二项和泊松回归分析与非等效因变量（目标3）。我们特别感兴趣的是：（a）评估2000年CMS报销政策的变化如何影响需求和使用模式（即，（B）探讨我们所发现的潜在的报销游戏，以规避在任何12个月期间内12次就诊的任意上限;（c）确定脊椎疗法是否取代基层护理;并且，在本发明中，（d）确定一段时间内的使用模式，然后利用这些模式集中政策干预，或为他们的批准建立客观的指导方针。 公共卫生相关性：正如2005年国际移民组织的报告所指出的那样，在美国，补充和替代医学（CAM）的使用，包括其最容易识别的形式-脊椎按摩疗法-很普遍，但没有得到很好的理解。事实上，在此应用之前，还没有研究过脊椎指压治疗的使用模式，或者它们在美国老年人中的前因和后果。因此，在R21申请中，我们建议完全按照2005年IOM报告的建议进行，对AHEAD中具有全国代表性的老年人样本进行广泛的二次分析，这是一项大型前瞻性队列研究。

DESCRIPTION (provided by applicant): The 2005 IOM report on Complementary and Alternative Medicine notes that although CAM therapies have existed throughout history and are used by at least one-third of all Americans, "it is only relatively recently...that there has been a serious general interest...in investigating and evaluating these therapies." Indeed, even the epidemiology of the most recognizable form of CAM "chiropractic" is not well described, although its use by older adults has been increasing since 2000. Accordingly, in this revised R21 application (submitted in response to PAR 08-213, Methodology and Measurement in the Behavioral and Social Sciences), we propose to examine who uses chiropractic services, the volume and consistency of the chiropractic services that they use over time, and the antecedents and consequences of that chiropractic use among a nationally representative sample of Medicare beneficiaries. To do this, we have successfully linked data for 5,511 self-respondents who participated in the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD) who were not in managed care Medicare at baseline (74% of the original cohort of 7,447 non-institutionalized subjects who were 70 years old or older at baseline). These 5,511 subjects are censored post-baseline at entrance into managed care Medicare or death, whichever comes first. The linked data sources are: (a) their 1993 baseline and 1995, 1998, 2000, 2002, 2004, and 2006 follow-up AHEAD interviews (b) geocode identifiers for each subject at each wave of data; and, (c) Medicare Part A and B claims for calendar years 1991-2005. With these data, we will address three specific aims: (1) to characterize chiropractic use patterns over time among older adults, (2) to identify antecedents of chiropractic use patterns; and, (3) to evaluate the consequences of chiropractic use patterns on physician visits, all-cause hospitalizations, hospitalization for ambulatory care sensitive conditions, Medicare payments, and mortality. Our methods will include intuitive classification rules and algorithms as well as latent class analyses (Aim 1), multivariable binomial and multinomial logistic regression analyses with pattern mixture models (Aim 2), and multivariable proportional hazards, binomial, and Poisson regression analyses with non-equivalent dependent variables (Aim 3). We are especially interested in (a) evaluating how the 2000 CMS reimbursement policy changes affected demand and use patterns (i.e., enduring effects on annual use rates and use patterns over time); (b) exploring the potential reimbursement gaming that we have identified to circumvent the arbitrary CMS cap of 12 visits during any 12-month period; (c) determining whether substitution of chiropractic for primary care occurs; and, (d) identifying patterns of use over time that can then be used to focus policy interventions designed to either shrink the proportion of "chronic high users" or establish objective guidelines for their approval. PUBLIC HEALTH RELEVANCE: As the 2005 IOM report noted, the use of complementary and alternative medicine (CAM) in the United States, including its most readily identifiable form-chiropractic-is widespread but not well understood. Indeed, prior to this application, there have been no studies of chiropractic use patterns over time, or their antecedents and consequences among older Americans. In this R21 application, therefore, we propose to do exactly what the 2005 IOM report recommended-to conduct an extensive, secondary analysis of the nationally representative sample of older adults in the AHEAD, which is a large, prospective cohort study.