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，尽管辅助医学疗法在历史上一直存在，并且至少有三分之一的美国人使用，“它只是相对最近的……大家都很关心……研究和评估这些疗法。”事实上，即使是最知名的CAM形式“脊椎指压疗法”的流行病学也没有得到很好的描述，尽管自2000年以来，老年人对其的使用一直在增加。因此，在修订后的R21申请（响应PAR 08-213，行为和社会科学的方法论和测量）中，我们建议在全国代表性的医疗保险受益人样本中检查谁使用脊椎指压治疗服务，他们使用脊椎指压治疗服务的数量和一致性，以及脊椎指压治疗使用的前因和后果。为了做到这一点，我们成功地将5,511名参与资产和健康动态研究（AHEAD）的自我调查者的数据联系起来，这些人在基线时没有参加管理式医疗保险（占原始队列7,447名非机构受试者的74%，他们在基线时年龄在70岁或以上）。这5511名受试者在进入管理式医疗保险或死亡时（以先发生者为准）在基线后进行审查。关联的数据源是：(a) 1993年的基线和1995年、1998年、2000年、2002年、2004年和2006年的后续AHEAD访谈；(b)每波数据中每个受试者的地理编码标识符；(c) 1991-2005日历年的医疗保险A部分和B部分索赔。有了这些数据，我们将有三个具体的目的：(1)表征老年人脊椎指压疗法使用模式随时间的变化，(2)确定脊椎指压疗法使用模式的前因；(3)评估捏脊疗法使用模式对医生就诊、全因住院、门诊敏感疾病住院、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分析（Aim 1），使用模式混合模型的多变量二项和多项逻辑回归分析（Aim 2），以及使用非等效因变量的多变量比例风险，二项和泊松回归分析（Aim 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，随着时间的推移，对年使用率和使用模式的持久影响）；(b)探讨我们已确定的可能的报销机制，以规避任意12个月内就诊12次的医保上限；(c)确定是否出现了脊椎指压疗法取代初级保健的情况；(d)确定长期的使用模式，然后可以用来集中政策干预，旨在缩小“长期高使用者”的比例或建立批准这些使用者的客观准则。

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.