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

描述(由申请人提供)：国际移民组织2005年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，至少有三分之一的美国人使用，但“直到最近……人们才对调查和评估这些疗法产生了严重的普遍兴趣。”事实上，即使是最知名的CAM“脊椎疗法”的流行病学也没有得到很好的描述，尽管自2000年以来，老年人对它的使用一直在增加。因此，在这份修订的R21申请中(根据PAR 08-213《行为和社会科学中的方法论和测量》提交)，我们建议在具有全国代表性的医疗保险受益人样本中检查谁使用脊椎疗法服务，他们使用的脊椎疗法服务的数量和一致性，以及使用脊椎疗法的前因和后果。为此，我们成功地将5511名自我受访者的数据联系起来，这些受访者参与了基线(7447名初始队列中年龄在70岁或以上的非医疗机构受试者)中未参加管理保健医疗保险的高龄老年人(AHEAD)中资产和健康动态的研究。这5511名受试者在进入管理保健医疗保险或死亡时，无论哪一个先出现，都会在基线后进行审查。相关数据来源是：(A)其1993年的基线和1995、1998、2000、2002、2004和2006年的后续约谈；(B)每波数据中每个受试者的地理编码识别符；(C)1991-2005年历年的联邦医疗保险A部分和B部分索赔。通过这些数据，我们将解决三个具体目标：(1)表征老年人随时间推移的脊椎按摩使用模式；(2)确定脊椎按摩使用模式的先行因素；以及(3)评估脊椎按摩使用模式对医生就诊、全原因住院、门诊敏感情况住院、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)，使用模式混合模型的多变量二项和多项Logistic回归分析(目标2)，以及具有不等价因变量的多变量比例风险、二项和泊松回归分析(目标3)。我们尤其感兴趣的是：(A)评估2000年合作医疗报销政策如何改变对需求和使用模式的影响(即随着时间的推移对年使用率和使用模式产生持久影响)；(B)探索我们确定的潜在报销游戏，以绕过任意12个月期间12次就诊的合作医疗上限；(C)确定是否出现以脊骨疗法取代初级保健的情况；以及(D)确定一段时间内的使用模式，然后可用于集中政策干预措施，旨在减少“慢性高使用率”的比例或为其批准制定客观的指导方针。 与公共卫生相关：正如2005年国际移民组织的报告指出的那样，补充和替代医学(CAM)的使用，包括其最容易识别的形式--脊椎疗法--在美国得到了广泛的应用，但还没有得到很好的理解。事实上，在这项应用之前，还没有关于脊椎疗法随时间的使用模式或其在美国老年人中的前因后果的研究。因此，在这份R21应用程序中，我们建议完全按照国际移民组织2005年报告的建议--对未来全国有代表性的老年人样本进行广泛的二次分析，这是一项大型的前瞻性队列研究。

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.