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BackacheManaging and controlling health care expenditures is a top priority.  Multiple comorbidities in the aging population has become more prevalent likely because of the extended lifespan experienced in the U.S. over the last few decades.  It is estimated that more than sixty percent of Americans over age 65 have multiple chronic conditions, and twenty-three percent of Medicare beneficiaries have 5 or more chronic conditions.

Patients with chronic low back pain (cLBP) have been thought to present to our offices with high prevalence of psychological, somatoform, and musculoskeletal comorbidity. The persistence of LBP may contribute to the development of these disorders and comorbidities have also been associated with poor outcome of LBP. Additionally, patients with comorbidities present with worse physical and psychosocial functioning, poorer response to treatment, and higher rates of health care utilization than other patients suffering from LBP.

The care of individuals with chronic conditions is estimated to account for 78% of US healthcare spending, and Medicare beneficiaries with more than 1 chronic condition account for 95% of all Medicare spending.  Not surprisingly, those with more than 5 chronic conditions account for 66% of Medicare spending. The probability that patients will use expensive health care such as hospital care increases substantially when there are comorbidities.

The rising prevalence of low back pain (LBP) among Medicare beneficiaries, the growing costs of its treatment, and the high use and costs of prescription drugs suggest an essential need to identify suitable, cost-effective, non-drug, non-surgical treatments for older patients with LBP.

Most LBP in older adults can be managed non-surgically.  Randomized controlled clinical trials have shown that chiropractic manipulative treatment (CMT) is an effective, conservative treatment option for LBP. With this in mind, the authors wanted to explore whether older Medicare fee-for service beneficiaries with an episode of LBP and multiple comorbidities who obtained CMT during their episode had lower costs than those who did not.

Methods:

This study was an observational, retrospective study that used Medicare fee-for-service data from 2006 to 2012 to identify older (aged 66 to 99) patients who had a discrete episode of cLBP.  The episode was defined as lasting at least 90 days and was preceded and followed by 180 days in which no LBP diagnosis was noted.  Additionally, each patient also had an additional musculoskeletal disorder diagnosis and a mental health disorder. If a patient had multiple episodes during the study period, only the first episode was included in the analysis.

The study included 4 groups of patients who used: 1) only CMT; 2) conventional medical care followed by CMT; 3) CMT followed by conventional medical care; and 4) only conventional medical care.

For these 4 treatment groups, the authors used un-weighted and propensity-score weighted inflation- and price-adjusted Medicare Part A, B, and D reimbursements during the episode.  Propensity scoring is a powerful tool to strengthen causal inferences drawn from observational studies. Propensity scoring helps in selecting similar patient groups for comparison. Medicare Part A covers hospital, skilled nursing facility, home health and hospice care expenditures. Medicare Part B covers doctors’ services and other outpatient expenditures; and Medicare Part D covers prescription medications. Particular attention was given to Part B reimbursements for chiropractic care, psychiatric care, physical therapy care, and spinal manipulation therapy (SMT) provided by doctors of osteopathy (DOs) as well as to Part D reimbursements for pain medications.

The study also looked at rate of spine surgery within 1 year of the end of the episode as well as compound rates of growth for price and inflation-adjusted Medicare expenditures. In addition, the study examined expenditures for psychiatric visits and pain medications.

Results:

  • Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone
  • CMT only patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode
  • Costs were greatest for patients receiving medical care alone
  • Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories
  • Patients who used only CMT had the lowest Part A and Part B expenditures per episode day, although there was no indication of lower psychiatric or pain medication expenditures associated with CMT

Key Points:

  • Among older, multiply-comorbid Medicare beneficiaries with a chronic low back pain episode, chiropractic manipulative treatment was associated with lower overall episode costs and lower episode costs per day
  • Use of CMT was associated with lower total Part A and Part D Medicare cost growth for multiply-comorbid patients with chronic low back pain episodes over the course of the study period
  • The authors found overall Medicare cost-savings associated with use of chiropractic care
  • There was no evidence of lower psychiatric or pain medication expenditures associated with CMT

Source: Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities. J Manipulative Physiol Ther. 2016 Feb 19. pii: S0161-4754(16)00007-5. doi: 10.1016/j.jmpt.2016.01.006.

Low Back Chiropractic AdjustmentMost low back pain in older adults can be managed non-surgically.  Randomized controlled clinical trials have shown that chiropractic manipulative treatment (CMT) is an effective, conservative treatment option for LBP. With this in mind, the authors of a new analysis wanted to explore whether older Medicare fee-for service beneficiaries with an episode of LBP and multiple comorbidities who obtained CMT during their episode had lower costs than those who did not.

This study was an observational, retrospective study that used Medicare fee-for-service data from 2006 to 2012 to identify older (aged 66 to 99) patients who had a discrete episode of cLBP.  The study included 4 groups of patients who used: 1) only CMT; 2) conventional medical care followed by CMT; 3) CMT followed by conventional medical care; and 4) only conventional medical care.

For these 4 treatment groups, the authors used un-weighted and propensity-score weighted inflation- and price-adjusted Medicare Part A, B, and D reimbursements during the episode.  Propensity scoring is a powerful tool to strengthen causal inferences drawn from observational studies. Propensity scoring helps in selecting similar patient groups for comparison. Medicare Part A covers hospital, skilled nursing facility, home health and hospice care expenditures. Medicare Part B covers doctors’ services and other outpatient expenditures; and Medicare Part D covers prescription medications. Particular attention was given to Part B reimbursements for chiropractic care, psychiatric care, physical therapy care, and spinal manipulation therapy (SMT) provided by doctors of osteopathy (DOs) as well as to Part D reimbursements for pain medications.

The study also looked at rate of spine surgery within 1 year of the end of the episode as well as compound rates of growth for price and inflation-adjusted Medicare expenditures. In addition, the study examined expenditures for psychiatric visits and pain medications.

Results:

  • Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone
  • CMT only patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode
  • Costs were greatest for patients receiving medical care alone
  • Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories
  • Patients who used only CMT had the lowest Part A and Part B expenditures per episode day, although there was no indication of lower psychiatric or pain medication expenditures associated with CMT

Key Points:

  • Among older, multiply-comorbid Medicare beneficiaries with a chronic low back pain episode, chiropractic manipulative treatment was associated with lower overall episode costs and lower episode costs per day
  • Use of CMT was associated with lower total Part A and Part D Medicare cost growth for multiply-comorbid patients with chronic low back pain episodes over the course of the study period
  • The authors found overall Medicare cost-savings associated with use of chiropractic care
  • There was no evidence of lower psychiatric or pain medication expenditures associated with CMT

Reference:

Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities. J Manipulative Physiol Ther. 2016 Feb 19. pii: S0161-4754(16)00007-5.

Aging ChiropracticThere are physiologic changes associated with aging. There are also health conditions that occur more commonly with advancing age. These changes and conditions increase an older adult’s vulnerability to injuries. A recent study investigated risk of injury to Medicare beneficiaries with an office visit for a neuromusculoskeletal problem to chiropractors and primary care physicians.  Specifically, investigators looked at the risk of injury within 7 days of those treated by chiropractic spinal manipulation vs. those evaluated by a primary care physician.  Results showed that 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.

Podcast

Dr. James Whedon

In this episode, Dr. James Whedon and I discuss his research on chiropractic, opioids, adverse events, risk of injury, medicare, and much more.  For instance, his research found 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.  Dr. Jim Whedon is Director of Health Services Research at Southern California University of Health Sciences and adjunct instructor at The Dartmouth Institute for Health Policy and Clinical Practice. He holds a DC degree from Logan College and an MS from Dartmouth College. He has authored 33 peer reviewed publications. He is advisor to the Project for Integrative Health and the Triple Aim, co-chair of the research working group of The Academic Consortium for Integrative Health, charter member of the Academy of Integrative Health & Medicine, and recipient of the Jerome F. McAndrews DC Memorial Research Fund Award from NCMIC Foundation.

Dr. Jim Whedon is a national award-winning, NIH-funded clinical and health services investigator with interests in trauma, integrative medicine, spinal disorders and Medicare health policy. Experience in clinical database development and medical editing. IRB and editorial advisory board member. Licensed chiropractic physician with 25 years clinical experience. Faculty appointment with Geisel School of Medicine at Dartmouth.

Much of his research has focused upon geographic variations in access to chiropractic services under Medicare. He conducts observational research using claims and registry data.

Dr. Whedon’s long-term research goals are to improve access to health services that people need and want, and to improve quality through systematic care of acute problems and conservative upstream care of chronic problems. He has a particular interest in helping to improve access to care for vulnerable populations.

He is also a member of the Advisory Team, Project for Integrative Health and the Triple Aim, and of the Research Working Group, Academic Consortium for Complementary and Alternative Health Care (ACCAHC).

See Dr. Whedon’s list of publications on researchgate.net.

How to cite this episode:
Smith DL. Chiropractic Science: Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon [internet]. Eaton, Ohio; Aug 23, 2018. Podcast: 1:05:21. Available from: https://chiropracticscience.com/podcast/drjameswhedon/

Below is a list of the articles Dr. Whedon discusses in this episode:

1. Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Risk of Adverse Drug Events.
Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
J Manipulative Physiol Ther. 2018 Jun;41(5):383-388. doi: 10.1016/j.jmpt.2018.01.004. Epub 2018 May 26.
PMID: 29843912 [PubMed – in process]
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2. Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids.
Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
J Altern Complement Med. 2018 Jun;24(6):552-556. doi: 10.1089/acm.2017.0131. Epub 2018 Feb 22.
PMID: 29470104 [PubMed – indexed for MEDLINE]
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3. Relevance of Quality Measurement to Integrative Healthcare in the United States.
Whedon JM, Punzo M, Dehen R, Menard MB, Fogel D, Olejownik J.
J Altern Complement Med. 2016 Nov;22(11):853-858. Epub 2016 Sep 23.
PMID: 27660896 [PubMed – indexed for MEDLINE]
Similar articles
4. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities.
Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM.
J Manipulative Physiol Ther. 2016 Feb;39(2):63-75.e1-2. doi: 10.1016/j.jmpt.2016.01.006. Epub 2016 Feb 19.
PMID: 26907615 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
5. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years.
Whedon JM, Mackenzie TA, Phillips RB, Lurie JD.
Spine (Phila Pa 1976). 2015 Feb 15;40(4):264-70. doi: 10.1097/BRS.0000000000000725.
PMID: 25494315 [PubMed – indexed for MEDLINE] Free PMC Article
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6. Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain.
Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD.
J Manipulative Physiol Ther. 2015 Feb;38(2):93-101. doi: 10.1016/j.jmpt.2014.12.001. Epub 2015 Jan 14.
PMID: 25596875 [PubMed – indexed for MEDLINE] Free PMC Article
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7. Comparing Propensity Score Methods for Creating Comparable Cohorts of Chiropractic Users and Nonusers in Older, Multiply Comorbid Medicare Patients With Chronic Low Back Pain.
Weeks WB, Tosteson TD, Whedon JM, Leininger B, Lurie JD, Swenson R, Goertz CM, O’Malley AJ.
J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):620-8. doi: 10.1016/j.jmpt.2015.10.005. Epub 2015 Nov 5.
PMID: 26547763 [PubMed – indexed for MEDLINE] Free PMC Article
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