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Research Review By Dr. Ceara Higgins©

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Date Posted:

February 2017

Study Title:

The association between use of chiropractic care and costs of care among older Medicare patients with chronic low back pain and multiple comorbidities

Authors:

Weeks WB, Leininger B, Whedon JM, et al.

Author's Affiliations:

The Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; Health Services and Clinical Research, Palmer College of Chiropractic, Davenport, IA; Integrative Health and Wellbeing Research Program, Centre for Spirituality and Healing, University of Minnesota, Minneapolis, MN; Health Services Research, Southern California University of Health Sciences, Whittier, CA, USA.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2016; 39(2): 63–75.

Background Information:

The growing cost of healthcare is a significant issue in North America. To illustrate, 62% of Americans over 65 have multiple chronic conditions (1) and 23% of individuals on Medicare have 5 or more chronic conditions (2)! Chronic pain – also increasingly common – has been connected to high rates of psychopathology (3), which, when untreated, can interfere with rehabilitation (4) and affect pain levels and all aspects of a healthy life.

Chiropractic manipulative treatment (CMT) has been shown to be an effective treatment for low back pain (LBP) and has been recommended for older adults with back pain (5, 6). This study first explored whether older adults using Medicare fee-for-service benefits with an episode of LBP and multiple comorbidities who received CMT had lower costs than those who did not. Secondly, they explored whether individuals receiving CMT under these circumstances showed reduced costs specifically associated with psychiatric care and/or pain medications.

Pertinent Results:

  • Patients with multiple comorbidities tended to be older, female, less likely to use CMT, more likely to be enrolled in Medicare part D (a drug benefit), had longer episodes of chronic LBP (cLBP), and showed higher Medicare costs (in all areas but CMT).
  • Patients who used CMT tended to be younger, Caucasian, more educated, of higher socioeconomic status, demonstrated less illness burden, generated fewer Medicare expenses in the year prior to their cLBP episode, and lived in regions with a higher per-capita supply of chiropractors (DCs).
  • Patients who only used CMT during their cLBP episodes showed lower overall Medicare costs, shorter episodes, and lower costs per episode day than the other treatment groups, but this group also showed higher rates of treatment for cLBP within the year following the conclusion of the episode. This included an 80% reduction in Medicare Part A (hospital) expenditures, and a 50% reduction in Part B and D expenditures. These individuals showed higher expenditures for CMT but they were offset by the other lower expenditures. This group also showed lower rates of back surgery in the year following their cLBP episode.
  • Individuals who received a combination of CMT and conventional medical care showed lower overall and per episode day costs than patients who did not use any CMT, with most of the cost differences noted in inpatient care costs. When both CMT and conventional medical care were used, the order in which they were received was not associated with large differences in expenditures.
  • Both the CMT only and CMT plus conventional medical care groups showed lower Medicare costs, especially in prescription medication costs, suggesting that DCs could play a significant role in the treatment of cLBP (9).
  • No reductions in psychiatric expenditures were seen with CMT treatment.

Clinical Application & Conclusions:

Older patients with multiple comorbidities who only used CMT during their chronic LBP episodes showed lower overall care costs, shorter episodes, and lower costs of care per episode day than patients in the other treatment groups. In patients using a combination of CMT and conventional medical care, lower overall costs of care and per episode day were seen. This supports the use of CMT as a cost-effective, first line treatment for these patients.

Costs for prescription drugs were also lower in patients receiving CMT, either alone or in conjunction with conventional medical care. This may indicate less need for prescription medications, which may be indicative of better overall health for these patients.

Future research in this area should look at broader and younger patient groups and should also examine patient health outcomes in order to examine if the cost-effectiveness seen in patient groups receiving CMT can be related to better outcomes in other areas.

Study Methods:

This was an observational, retrospective study performed using Medicare fee-for-service files of patients from 66-99 years of age between 2006 and 2012 who experienced a discrete episode of chronic LBP (cLBP). The episode must have lasted at least 90 days (8), be preceded and followed by 180 days with no recorded LBP diagnosis, and during the episode the individual must have had an additional musculoskeletal disorder diagnosis and a mental health disorder diagnosis. If an individual had multiple, discrete episodes of cLBP during this time, only the first one was included.

Patients were categorized for analysis according to treatments received as follows:
  1. only CMT;
  2. conventional medical care followed by CMT;
  3. CMT followed by conventional medical care; or
  4. only conventional medical care.
Medicare Part A, B, and D reimbursements during the episode were considered. Medicare Part A covers hospital, skilled nursing facility, home health, and hospice care expenditures; Medicare Part B covers doctors’ services and other outpatient expenditures (with specific attention paid to CMT, psychiatric care, physical therapy care, and spinal manipulation (SMT) provided by doctors of osteopathy); Medicare Part D covers prescription medications (with special attention paid to pain medications).

Total costs, as well as costs per episode day were calculated. Additionally, healthcare claims for LBP and rates of spinal surgery were considered within one year of the end of the cLBP episode and annual compound rates of growth for price and inflation-adjusted Medicare expenditures were calculated.

Study Strengths / Weaknesses:

Strengths:
  • Multinomial, stepwise logistic regression was used to create equivalent groups for comparison by relatively over-weighting patients who were least likely to be in that treatment group based on their demographics. This made each group more similar, demographically speaking (7).
Weaknesses:
  • Findings may not be generalizable to the larger Medicare fee-for-service population or the general US population.
  • Using Medicare data allowed the researchers to draw conclusions about expenditures, but did not allow them to determine if the care provided was justified or lead to better health outcomes according to the patients.

Additional References:

  1. Partnership for Solutions Chronic Conditions: Making the Case for Ongoing Care. Princeton: Robert Wood Johnson Foundation; 2002.
  2. Richardson W, Nerwick D, Bisgard J, et al. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press; 2001.
  3. Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med 2002; 64: 773-786.
  4. Gatchel RJ. Psychological disorders and chronic pain: cause and effect relationship. In: Gatchel RJ, Turk DC, editors. Psychological approaches to pain management: a practitioner’s handbook. New York: Guilford Publications; 1996. P.33-54.
  5. Rubinstein SM, van Middlekoop M, Assendelft WJ, et al. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev 2011; 2CD008112.
  6. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478-491.
  7. Weeks WB, Tosteson TD, Whedon JM, et al. Comparing Propensity Score Methods for Creating Comparable Cohorts of Chiropractic Users and Nonusers in Older, Multiply Comorbid Patients with Chronic Low Back Pain. J Manipulative Physiol Ther 2015; 38: 620-628.
  8. Rozenberg S. Chronic low back pain: definition and treatment. Rev Prat 2008; 58: 265-272.
  9. Davis MA, Whedon JM, Weeks WB. Complementary and alternative medicine practitioners and Accountable Care Organizations: the train is leaving the station. J Altern Complement Med 2011; 17: 669-674.

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