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Access to Chiropractic Care and the Cost of Spine Conditions Among Older Adults

Matthew A. Davis, PhD, DC, MPH; Olga Yakusheva, PhD; Haiyin Liu, MA; Joshua Tootoo, MS; Marita G. Titler, PhD, RN; and Julie P.W. Bynum, MD, MPH
Among older adults who have a spine condition, access to chiropractic care may reduce medical spending on diagnostic services.
The end point for all analyses was the change in spine-related spending (eg, spending on inpatient care, ambulatory care), which was normally distributed. Across baseline accessibility of chiropractic care, age and sex differed very little; however, race and health status varied (eAppendix Table 1). Therefore, we adjusted for differences in our analyses using linear regression. Specifically, our models adjusted for baseline chiropractic care accessibility, beneficiary characteristics (age, sex, race, baseline comorbidities, and change in comorbidities), and access to primary care physicians (at baseline and a change in access). Analyses were based on complete case analysis and we assumed any missing values to be missing completely at random. A 2-sided P value of less than .05 was considered statistically significant. Geospatial analyses were conducted using ArcGIS version 10.5 (Esri; Redlands, California) and analyses of claims data were conducted using SAS version 9.4 (SAS Institute; Cary, North Carolina).

Our analyses were restricted to beneficiaries who had evidence of a back and/or neck condition in the baseline year. In a subanalysis we repeated all analyses on a subset of 57,807 older adults who also had spine claims in the postrelocation year.


Characteristics of Study Population

Among the 84,679 older adults enrolled in Medicare with a spine condition prior to relocating, 9.5%, 18.0%, 22.9%, 26.7%, and 22.9% resided in quintiles 1 through 5 of chiropractic care accessibility, respectively. The mean (SD) age of older adults with a spine condition who moved once was 77.0 (7.2) years; 68.4% were female, and 3.9% were black.

Accessibility of Chiropractic Care

The total number of active chiropractors varied little from 2010 to 2014—from a high of 45,264 in 2012 to a low of 44,040 in 2014. Across the country, local accessibility varied considerably, with a higher concentration of chiropractors observed in the upper Midwest and a relatively lower concentration in the South (coefficient of variation = 93%) (Figure 1; eAppendix Figure 3). Across US ZCTAs in 2014, the mean (SD) ratio of chiropractors per 100,000 population was 15.6 (14.4). Ratios for quintile 1 were 0.0 to 4.6; quintile 2, 4.7 to 9.4; quintile 3, 9.5 to 15.0; quintile 4, 15.1 to 23.6; and quintile 5, 23.7 to 445.5. The several ZCTAs with very high chiropractor to population ratios were in the upper Midwest, where the profession originated and a large chiropractic school is located (in Davenport, Iowa).

Chiropractic Care Accessibility and Spine-Related Spending

When examining whether the beneficiaries relocated to an area with higher or lower chiropractic care accessibility relative to where they started, we found few differences in mean spending on total, inpatient, and ambulatory spine care (Table 1). The only marginally statistically significant differences in spending were mean increases of $513 in total spine-related spending (P = .05) and $434 in inpatient spine-related spending (P = .06) among older adults who resided in quintile 3 and who moved to an area of lower chiropractic care accessibility. Although attenuated, some small differences were observed by category of ambulatory care spine spending (Table 2).

Among residents of quintile 5 who moved to an area of lower chiropractic care accessibility, mean spending on medical procedures decreased by $53 (P = .04). Residents of quintile 2 who moved to an area of higher chiropractic care accessibility had a decrease of $30 (P <.001) in mean spending on spine diagnostic imaging and tests.

We found more consistent changes when examining the association of spending with the magnitude of the change in chiropractic care accessibility (Figures 2 and 3). In general, increases in spending were observed among older adults who moved to areas with lower accessibility of chiropractic care—however, the only statistically significant increase was for inpatient spending among those who moved to areas with chiropractic accessibility 2 quintiles higher than where they started (mean difference in spending of $291; P = .05). In addition, a small dose–response relationship was observed for ambulatory care spine spending on “evaluation and management” and “imaging and testing” (Figure 3). For both, decreases of 3 and 4 quintiles of chiropractic accessibility were associated with approximate mean increases in spending of $20 (P <.05) and $40 (P <.01), respectively.

The inverse association between accessibility of chiropractic care and spending on spine imaging and testing persisted when restricted to the subset of older adults who had a spine condition in the postrelocation year.

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