To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion.
The 2007 National Health Interview Survey (NHIS).
We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n = 973), for health promotion (n = 3,281), or for both purposes (n = 3,031). We used complex survey design methods to make national estimates and examine respondents' self-reported health status, health behaviors, and conventional health services utilization.
Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion.
This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.
Complementary and alternative medicine; health services; preventive health services
The three major human apoE isoforms (apoE2, apoE3, and apoE4) are encoded by distinct alleles (ε2, ε3, and ε4). Compared to ε3, ε4 is associated with increased risk to develop Alzheimer’s disease (AD), cognitive impairments in Parkinson’s disease (PD), and other conditions. In contrast, a recent study indicated an increased susceptibility to the recurring and re-experiencing symptom cluster of Post Traumatic Stress Disorder (PTSD), as well as related memory impairments, in patients carrying at least one ε2 allele. Contextual fear conditioning and extinction are used in human and animal models to study this symptom cluster. In this study, acquisition (day 1, training), consolidation (day 2, first day of re- exposure) and extinction (days 2–5) of conditioned contextual fear in human apo 2, apo 3, and apo 4 targeted replacement (TR) and C57BL/6J wild-type (WT) mice was investigated. Male and female apo 2 mice showed acquisition and retrieval of conditioned fear, but failed to exhibit extinction. In contrast, WT, apoE3 and apoE4 mice showed extinction. While apoE2 mice exhibited lower freezing in response to the context on day 2 than apoE3 and apoE4 mice, this cannot explain their extinction deficit as WT mice exhibited similar freezing levels as apoE2 mice on day 2 but still exhibited extinction. Elevating freezing through extended training preserved extinction in controls, but failed to ameliorate extinction deficits in apoE2 animals. These data along with clinical data showing an association of apoE2 with susceptibility to specific symptom clusters in PTSD supports an important role for apoE isoform in the extinction of conditioned fear.
apoE; PTSD; extinction; acquisition
Retrospective cross-sectional analysis of administrative data.
To examine the relationship between regional chiropractic supply and both use and utilization intensity of chiropractic services among Medicare beneficiaries.
Summary of Background Data
Numerous studies have documented trends and patterns in the utilization of chiropractic services in the United States, but little is known about geographic variation in the relationship between chiropractic supply and utilization.
We analyzed Medicare claims data for services provided by chiropractic physicians in 2008. We aggregated the data to the hospital referral region level and employed small area analysis techniques to generate descriptive statistics. We mapped geographic variations in chiropractic supply, use and utilization intensity (treatments per user) and quantified the variation by coefficient of variation and extremal ratio. We employed Spearman’s rank correlation coefficient to correlate use with supply. We employed a logistic regression model for chiropractic use and a multiple linear regression model for chiropractic utilization intensity.
The average regional supply of chiropractic physicians was 21.5 per 100,000 adult capita. The average percentage of beneficiaries who used chiropractic was approximately 7.6 (SD 3.9). The average utilization intensity was 10.6 (SD 1.8). Regional chiropractic supply varied more than 14 fold, and chiropractic use varied more than 17 fold. Chiropractic supply and use were positively correlated (Spearman’s rho 0.68; p<.001). A low back or cervical spine problem was strongly associated with chiropractic use (OR 21.6 and 14.3, respectively). Increased chiropractic supply was associated with increased chiropractic use (OR 1.04), but not with increased chiropractic utilization intensity.
Both the supply of chiropractors and the utilization of chiropractic by older US adults varied widely by region. Increased chiropractic supply was associated with increased chiropractic use, but not with increased chiropractic utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference.
Chiropractic; Spinal Manipulation; Medicare
Serial, cross-sectional, nationally representative surveys of non-institutionalized adults.
To examine expenditures on common ambulatory health services for the management of back and neck conditions.
Summary of Background Data
Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population.
We used the Medical Expenditure Panel Survey (MEPS) to examine adult (age ≥ 18 years) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions.
Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. Over the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; while physical therapy was the most costly service overall, in recent years those costs have contracted.
Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.
Medical Expenditure Panel Survey (MEPS); Spine Expenditures; Back Pain; Neck Pain
National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed. Proposals to teach residents to provide value-based care have come from the Medicare Payment Advisory Commission (MedPAC), the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Physicians (ACP). Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care. In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than 20 opportunities for residency programs to incorporate training in value-based care.
medical education; residency training; graduate medical education; value; health care value; value-based care
Biologically salient sounds, including speech, are rarely heard in isolation. Our brains must therefore organize the input arising from multiple sources into separate “streams” and, in the case of speech, map the acoustic components of the target signal onto meaning. These auditory and linguistic processes have traditionally been considered to occur sequentially and are typically studied independently [1, 2]. However, evidence that streaming is modified or reset by attention , and that lexical knowledge can affect reports of speech sound identity [4, 5], suggests that higher-level factors may influence perceptual organization. In two experiments, listeners heard sequences of repeated words or acoustically matched nonwords. After several presentations, they reported that the initial /s/ sound in each syllable formed a separate stream; the percept then fluctuated between the streamed and fused states in a bistable manner. In addition to measuring these verbal transformations, we assessed streaming objectively by requiring listeners to detect occasional targets—syllables containing a gap after the initial /s/. Performance was better when streaming caused the syllables preceding the target to transform from words into nonwords, rather than from nonwords into words. Our results show that auditory stream formation is influenced not only by the acoustic properties of speech sounds, but also by higher-level processes involved in recognizing familiar words.
•Linguistic processing affects perceptual organization•The acoustic elements of words fuse more readily than those of nonwords•Bistable speech sounds share dynamics with other ambiguous perceptual objects
The contrasting distribution of species diversity across the major lineages of cichlids makes them an ideal group for investigating macroevolutionary processes. In this study, we investigate whether different rates of diversification may explain the disparity in species richness across cichlid lineages globally. We present the most taxonomically robust time-calibrated hypothesis of cichlid evolutionary relationships to date. We then utilize this temporal framework to investigate whether both species-rich and depauperate lineages are associated with rapid shifts in diversification rates and if exceptional species richness can be explained by clade age alone. A single significant rapid rate shift increase is detected within the evolutionary history of the African subfamily Pseudocrenilabrinae, which includes the haplochromins of the East African Great Lakes. Several lineages from the subfamilies Pseudocrenilabrinae (Australotilapiini, Oreochromini) and Cichlinae (Heroini) exhibit exceptional species richness given their clade age, a net rate of diversification, and relative rates of extinction, indicating that clade age alone is not a sufficient explanation for their increased diversity. Our results indicate that the Neotropical Cichlinae includes lineages that have not experienced a significant rapid burst in diversification when compared to certain African lineages (rift lake). Neotropical cichlids have remained comparatively understudied with regard to macroevolutionary patterns relative to African lineages, and our results indicate that of Neotropical lineages, the tribe Heroini may have an elevated rate of diversification in contrast to other Neotropical cichlids. These findings provide insight into our understanding of the diversification patterns across taxonomically disparate lineages in this diverse clade of freshwater fishes and one of the most species-rich families of vertebrates.
We aimed to characterize patterns in the timing of initial emergency procedures for patients with open tibia fracture and examine the relationship between initial procedure timing and in-hospital amputation.
Data were analyzed from the Nationwide Inpatient Sample, 2003–2009. Adult patients were included if they had a primary diagnosis code of open tibia fracture. Patients were excluded for the following: transferred from or to another hospital, an immediate amputation was performed, more than one amputation was performed, no emergency procedure was documented, or treated at a facility that did not perform any amputations. We evaluated the association between timing of the first procedure and the outcome of amputation using multiple logistic regression, controlled for patient risk factors and hospital characteristics.
Of 7,560 patients included in the analysis, 1.3% (n=99 patients) underwent amputation on hospital day 2 or later. The majority of patients (52.6%) underwent first operative procedure on day 0 or 1. In adjusted analyses, timing of first operative procedure beyond the day of admission is associated with more than three times greater odds of amputation (day 1 OR 3.81, 95% CI 1.80–8.07).
Delay of first operative procedure beyond the day of admission appears to be associated with a significantly increased probability of amputation in patients with open tibia fracture. All practitioners involved in the management of patients with open tibia fracture should seek a solution for any barrier, other than medical stability of the patient, of achieving early operative intervention.
amputation; debridement; emergent procedures; lower extremity reconstruction; lower extremity trauma; open tibial fracture
Metabotropic glutamate receptors (mGluRs) are coupled to second messenger pathways via G proteins and modulate synaptic transmission. Of the eight different types of mGluRs (mGluR1-mGluR8), mGluR4, mGluR6, mGluR7, and mGluR8 are members of group III. Group III receptors are generally located presynaptically, where they regulate neurotransmitter release. Because of their role in modulating neurotransmission, mGluRs are attractive targets for therapies aimed at treating anxiety disorders. Previously we showed that the mGluR4-selective allosteric agonist VU 0155041 reduces anxiety-like behavior in wild-type male mice. Here, we explore the role of mGluR4 in adult (6-month-old) and middle-aged (12-month-old) male and female mice lacking this receptor. Compared to age- and sex-matched wild-type mice, middle-aged mGluR4-/- male mice showed increased measures of anxiety in the open field and elevated zero maze and impaired sensorimotor function on the rotarod. These changes were not seen in adult 6-month old male mice. In contrast to the male mice, mGluR4-/- female mice showed reduced measures of anxiety in the open field and elevated zero maze and enhanced rotarod performance. During the hidden platform training sessions of the water maze, mGluR4-/-mice swam father away from the platform than wild-type mice at 6, but not at 12, months of age. mGluR4-/- mice also showed enhanced amygdala-dependent cued fear conditioning. No genotype differences were seen in hippocampus-dependent contextual fear conditioning. These data indicate that effects of mGluR4 on sensorimotor function and measures of anxiety, but not cued fear conditioning, are critically modulated by sex and age.
mGluR4; anxiety; Group-III mGluR; learning; memory
To determine whether hospital discharges for intussusception in children younger than 1 year have changed since the reintroduction of rotavirus vaccine in the United States.
Serial cross-sectional analysis.
Children younger than 1 year with a discharge diagnosis of intussusception identified in the Kids’ Inpatient Database, a series of nationally representative data sets of pediatric hospital discharges in the United States with 4 available years prior to vaccine reintroduction (1997, 2000, 2003, and 2006) and 1 year after (2009).
Hospital discharge before vs after rotavirus vaccine reintroduction.
Total number and rate of hospital discharges for infants younger than 1 year with a diagnosis of intussusception (International Classification of Diseases, Ninth Revision, Clinical Modification code 560.0).
From 1997 to 2006, there was no change in the total number of hospital discharges for intussusception, with a small decrease in the rate of intussusception discharges (41.6 [95% CI, 36.7–46.5] to 36.5 [95% CI, 31.7–41.2] per 100 000 infants). Based on the trend, the predicted rate of discharges for intussusception in 2009 was 36.0 (95% CI, 30.2–41.8) per 100 000 infants. The measured rate of hospital discharges for intussusception in 2009 was 33.3 (95% CI, 29.0–37.6) per 100 000 infants.
The reintroduction of rotavirus vaccine since 2006 has not resulted in a detectable increase in the number of hospital discharges for intussusception among US infants.
The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children’s Health, estimating the prevalence of parents’ report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33–63 % and 57–76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public–private difference: 5–34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents’ report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.
Medical home; Public insurance; Disparities; Health policy; National Survey of Children’s Health
The protein kinase B-Raf is a critical component of the Ras/MAPK signaling pathway. An oncogenic B-Raf mutation that constitutively activates the kinase was identified in z50% of melanoma patients and in other cancers. A structure-guided drug discovery approach enabled the development of Zelboraf, a targeted inhibitor of oncogenic B-Raf. This drug has been used successfully in the clinic to treat metastatic melanoma patients harboring B-Raf mutations.
The purposes of this study were to analyze data from the longitudinal Medical Expenditures Panel Survey (MEPS) to evaluate the impact of an aging population on secular trends in back pain and chronicity and to provide estimates of treatment costs for patients who used only ambulatory services.
Using the MEPS 2-year longitudinal data for years 2000 to 2007, we analyzed data from all adult respondents. Of the total number of MEPS respondent records analyzed (N = 71 838), we identified 12 104 respondents with back pain and further categorized 3842 as chronic cases and 8262 as nonchronic cases.
Secular trends from the MEPS data indicate that the prevalence of back pain has increased by 29%, whereas chronic back pain increased by 64%. The average age among all adults with back pain increased from 45.9 to 48.2 years; the average age among adults with chronic back pain increased from 48.5 to 52.2 years. Inflation-adjusted (to 2010 dollars) biennial expenditures on ambulatory services for chronic back pain increased by 129% over the same period, from $15.6 billion in 2000 to 2001 to $35.7 billion in 2006 to 2007.
The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.
Back pain; Costs and cost analysis; Aging; Spine; Economics; Chronic disease
Two recent studies that examined National Health Interview Survey data reported divergent findings regarding the propensity of adult chiropractic users to receive seasonal influenza immunization. Although one study found a statistically significant negative association between chiropractic use and influenza vaccination, another found that chiropractic users were significantly more likely to be vaccinated. The purpose of this study is to extend previous works by delving more deeply into recent data to identify adult chiropractic users at high risk and high priority for vaccination against influenza and pneumococcal disease.
We used data from the 2007 National Health Interview Survey in an attempt to replicate previous methodologies and further examine vaccination among adult chiropractic users (age ≥18 years) who, according to the Center for Disease Control and Prevention guidelines, should receive influenza and/or pneumococcal vaccination. We used complex survey design methods to make national estimates and used logistic regression to determine if having used chiropractic care predicted vaccination.
We found major methodological differences between the prior studies. In our analyses, we found that chiropractic users were significantly less likely than nonusers to have received the pneumococcal vaccine, and we found no significant difference between chiropractic users and nonusers relative to having received the seasonal flu vaccine.
Methodological differences in previous studies that investigated the association between chiropractic care and adult vaccination likely explain divergent findings reported in the literature. Future studies should consider these differences.
Chiropractic; Vaccination; Health Surveys; Preventive Health Services
We characterized the mutational landscape of melanoma, the form of skin cancer with the highest mortality rate, by sequencing the exomes of 147 melanomas. Sun-exposed melanomas had markedly more ultraviolet (UV)-like C>T somatic mutations compared to sun-shielded acral, mucosal and uveal melanomas. Among the newly identified cancer genes was PPP6C, encoding a serine/threonine phosphatase, which harbored mutations that clustered in the active site in 12% of sun-exposed melanomas, exclusively in tumors with mutations in BRAF or NRAS. Notably, we identified a recurrent UV-signature, an activating mutation in RAC1 in 9.2% of sun-exposed melanomas. This activating mutation, the third most frequent in our cohort of sun-exposed melanoma after those of BRAF and NRAS, changes Pro29 to serine (RAC1P29S) in the highly conserved switch I domain. Crystal structures, and biochemical and functional studies of RAC1P29S showed that the alteration releases the conformational restraint conferred by the conserved proline, causes an increased binding of the protein to downstream effectors, and promotes melanocyte proliferation and migration. These findings raise the possibility that pharmacological inhibition of downstream effectors of RAC1 signaling could be of therapeutic benefit.
Acetyl coenzyme A carboxylase B gene (ACACB) single nucleotide polymorphism (SNP) rs2268388 is reproducibly associated with type 2 diabetes (T2DM)-associated nephropathy (DN). ACACB knock-out mice are also protected from obesity. This study assessed relationships between rs2268388, body mass index (BMI) and gene expression in multiple populations, with and without T2DM. Among subjects without T2DM, rs2268388 DN risk allele (T) associated with higher BMI in Pima Indian children (n = 2021; p-additive = 0.029) and African Americans (AAs) (n = 177; p-additive = 0.05), with a trend in European Americans (EAs) (n = 512; p-additive = 0.09), but not Germans (n = 858; p-additive = 0.765). Association with BMI was seen in a meta-analysis including all non-T2DM subjects (n = 3568; p-additive = 0.02). Among subjects with T2DM, rs2268388 was not associated with BMI in Japanese (n = 2912) or EAs (n = 1149); however, the T allele associated with higher BMI in the subset with BMI≥30 kg/m2 (n = 568 EAs; p-additive = 0.049, n = 196 Japanese; p-additive = 0.049). Association with BMI was strengthened in a T2DM meta-analysis that included an additional 756 AAs (p-additive = 0.080) and 48 Hong Kong Chinese (p-additive = 0.81) with BMI≥30 kg/m2 (n = 1575; p-additive = 0.0033). The effect of rs2268388 on gene expression revealed that the T risk allele associated with higher ACACB messenger levels in adipose tissue (41 EAs and 20 AAs with BMI>30 kg/m2; p-additive = 0.018) and ACACB protein levels in the liver tissue (mixed model p-additive = 0.03, in 25 EA bariatric surgery patients with BMI>30 kg/m2 for 75 exams). The T allele also associated with higher hepatic triglyceride levels. These data support a role for ACACB in obesity and potential roles for altered lipid metabolism in susceptibility to DN.
There has been a considerable increase in studies investigating rates of diversification and character evolution, with one of the promising techniques being the BiSSE method (binary state speciation and extinction). This study uses simulations under a variety of different sample sizes (number of tips) and asymmetries of rate (speciation, extinction, character change) to determine BiSSE’s ability to test hypotheses, and investigate whether the method is susceptible to confounding effects.
We found that the power of the BiSSE method is severely affected by both sample size and high tip ratio bias (one character state dominates among observed tips). Sample size and high tip ratio bias also reduced accuracy and precision of parameter estimation, and resulted in the inability to infer which rate asymmetry caused the excess of a character state. In low tip ratio bias scenarios with appropriate tip sample size, BiSSE accurately estimated the rate asymmetry causing character state excess, avoiding the issue of confounding effects.
Based on our findings, we recommend that future studies utilizing BiSSE that have fewer than 300 terminals and/or have datasets where high tip ratio bias is observed (i.e., fewer than 10% of species are of one character state) should be extremely cautious with the interpretation of hypothesis testing results.
Key innovations; Character evolution; Systematics
Mutations of comparative gene identification 58 (CGI-58) in humans cause Chanarin-Dorfman syndrome, a rare autosomal recessive disease in which excess triacylglycerol (TAG) accumulates in multiple tissues. CGI-58 recently has been ascribed two distinct biochemical activities, including coactivation of adipose triglyceride lipase and acylation of lysophosphatidic acid (LPA). It is noteworthy that both the substrate (LPA) and the product (phosphatidic acid) of the LPA acyltransferase reaction are well-known signaling lipids. Therefore, we hypothesized that CGI-58 is involved in generating lipid mediators that regulate TAG metabolism and insulin sensitivity. Here, we show that CGI-58 is required for the generation of signaling lipids in response to inflammatory stimuli and that lipid second messengers generated by CGI-58 play a critical role in maintaining the balance between inflammation and insulin action. Furthermore, we show that CGI-58 is necessary for maximal TH1 cytokine signaling in the liver. This novel role for CGI-58 in cytokine signaling may explain why diminished CGI-58 expression causes severe hepatic lipid accumulation yet paradoxically improves hepatic insulin action. Collectively, these findings establish that CGI-58 provides a novel source of signaling lipids. These findings contribute insight into the basic mechanisms linking TH1 cytokine signaling to nutrient metabolism.
Previous studies suggest a possible association between using chiropractic care and lower influenza vaccination rates. We examined adult influenza vaccination rates for chiropractic patients to determine if they are different than those for users of other complementary and alternative medicine(CAM).
We used the 2007 National Health Interview Survey to examine influenza vaccination rates among adult respondents who were considered high priority for the influenza vaccine(n=12,164). We separated respondents into clinically meaningful categories according to age and whether or not they had recently used chiropractic care, some other type of CAM, or neither. We used adjusted logistic regression to determine whether user status predicted influenza vaccination.
Only 33% of younger and 64% of older high priority Chiropractic Users were vaccinated in 2007; these rates approximated those of Non-CAM Users. However, younger Non-Chiropractic CAM Users were more likely than Non-CAM Users to have been vaccinated (p-value=0.05). In adjusted logistic regressions, we found statistically insignificant differences when comparing Chiropractic Users to Non-CAM Users for younger adults (OR=0.93(95% CI:0.76–1.13), or for older adults OR=0.90(95% CI:0.64–1.20).
Chiropractic Users appear no less likely to be vaccinated for influenza; whereas, younger Non-chiropractic CAM Users are more likely than Non-CAM Users to be vaccinated.
Knowledge of “actionable” somatic genomic alterations present in each tumor (e.g., point mutations, small insertions/deletions, and copy number alterations that direct therapeutic options) should facilitate individualized approaches to cancer treatment. However, clinical implementation of systematic genomic profiling has rarely been achieved beyond limited numbers of oncogene point mutations. To address this challenge, we utilized a targeted, massively parallel sequencing approach to detect tumor genomic alterations in formalin-fixed, paraffin embedded (FFPE) tumor samples. Nearly 400-fold mean sequence coverage was achieved, and single nucleotide sequence variants, small insertions/deletions, and chromosomal copy number alterations were detected simultaneously with high accuracy compared to other methods in clinical use. Putatively actionable genomic alterations, including those that predict sensitivity or resistance to established and experimental therapies, were detected in each tumor sample tested. Thus, targeted deep sequencing of clinical tumor material may enable mutation-driven clinical trials and, ultimately, ”personalized” cancer treatment.
The most intense spenders on health services are considerably less healthy—49% report fair or poor health status compared to 15% of the general adult population— and are elderly. Such findings have important implications for addressing national health-care spending because interventions targeting those people who are in poor health could theoretically generate dramatic cost savings. Although the popularity of complementary and alternative medicine (CAM) in the US is well recognized, little is known about the distribution of out-of-pocket expenditures on CAM services.
This study examined the distribution of out-of-pocket expenditures on CAM health services in the US.
The research team used data from the 2007 National Health Interview Survey to examine the distribution in the US of out-of-pocket expenditures on CAM services and the characteristics of adult (age ≥ 18 years) CAM users (n = 2972) according to spending.
Using complex survey-design methods, the research team generated national estimates of expenditures on CAM services and used linear regression adjusted for covariates to determine whether self-reported health status predicted CAM spending.
According to our estimates, in 2007, over 30 million adults reported out-of-pocket expenditures on CAM services, and of these individuals, 7.2 million were heavy CAM spenders with a mean annual expenditure of $1385. The highest quartile of CAM spenders accounted for $10 billion of the $13.9 billion spent nationally on CAM in 2007. Self-reported health status did not differ among groups with differing levels of CAM spending, β̂ = 1.00 (95% CI, 0.8–1.2).
Out-of-pocket spending on CAM is concentrated. Just a quarter of CAM users account for over 70% of all expenditures on CAM services, and health status does not appear to be associated with level of CAM spending.
Describe the underlying principles used to develop a web-based algorithm that incorporated intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment for diabetic macular edema (DME) in a Diabetic Retinopathy Clinical Research Network (DRCR.net) randomized clinical trial.
Discussion of treatment protocol for DME.
Subjects with vision loss from DME involving the center of the macula.
The DRCR.net created an algorithm incorporating anti-VEGF injections in a comparative effectiveness randomized clinical trial evaluating intravitreal ranibizumab with prompt or deferred (≥24 weeks) focal/grid laser in eyes with vision loss from center-involved DME. Results confirmed that intravitreal ranibizumab with prompt or deferred laser provides superior visual acuity outcomes, compared with prompt laser alone through at least 2 years. Duplication of this algorithm may not be practical for clinical practice. In order to share their opinion on how ophthalmologists might emulate the study protocol, participating DRCR.net investigators developed guidelines based on the algorithm's underlying rationale.
Main Outcome Measures
Clinical guidelines based on a DRCR.net protocol.
The treatment protocol required real time feedback from a web-based data entry system for intravitreal injections, focal/grid laser, and follow-up intervals. Guidance from this system indicated whether treatment was required or given at investigator discretion and when follow-up should be scheduled. Clinical treatment guidelines, based on the underlying clinical rationale of the DRCR.net protocol, include repeating treatment monthly as long as there is improvement in edema compared with the previous month, or until the retina is no longer thickened. If thickening recurs or worsens after discontinuing treatment, treatment is resumed.
Duplication of the approach used in the DRCR.net randomized clinical trial to treat DME involving the center of the macula with intravitreal ranibizumab may not be practical in clinical practice, but likely can be emulated based on an understanding of the underlying rationale for the study protocol. Inherent differences between a web-based treatment algorithm and a clinical approach may lead to differences in outcomes that are impossible to predict. The closer the clinical approach is to the algorithm used in the study, the more likely the outcomes will be similar to those published.
In the United States (US) a shortage of primary care physicians has become evident. Other health care providers such as chiropractors might help address some of the nation’s primary care needs simply by being located in areas of lesser primary care resources. Therefore, the purpose of this study was to examine the distribution of the chiropractic workforce across the country and compare it to that of primary care physicians.
We used nationally representative data to estimate the per 100,000 capita supply of chiropractors and primary care physicians according to the 306 predefined Hospital Referral Regions. Multiple variable Poisson regression was used to examine the influence of population characteristics on the supply of both practitioner-types.
According to these data, there are 74,623 US chiropractors and the per capita supply of chiropractors varies more than 10-fold across the nation. Chiropractors practice in areas with greater supply of primary care physicians (Pearson’s correlation 0.17, p-value < 0.001) and appear to be more responsive to market conditions (i.e. more heavily influenced by population characteristics) in regards to practice location than primary care physicians.
These findings suggest that chiropractors practice in areas of greater primary care physician supply. Therefore chiropractors may be functioning in more complementary roles to primary care as opposed to an alternative point of access.
Chiropractic; Supply; Distribution; Health resources; Manpower
In the United States, therapeutic vaccines may provide considerable benefit to cancer patients. Yet, there has been no assessment of whether vaccines currently in the research and development pipeline reflect the burden of disease and current survival patterns for different malignancies. The authors used data from the National Cancer Institute, Surveillance Epidemiology and End Results (SEER) database, and clinicaltrials.gov registry to characterize the vaccine development pipeline with respect to 5 measures of disease burden and treatment effectiveness for cancer: annual incidence, annual mortality, five-year survival rate, recent change in five-year survival (1999-2006 vs 1990-1992), and five-year mortality estimate (=annual incidence*[1 - 5-yr survival rate]). In 2011, the authors identified 231 active clinical trials for therapeutic cancer vaccines. Of these trials, 81 vaccines are currently in Phase I, 140 in Phase II, and 10 vaccines in Phase III. Vaccine trials for melanoma are most common (n=40), followed by breast cancer (34), lung cancer (30), and prostate cancer (22). Correlation analyses revealed that only annual cancer incidence is significantly associated with current therapeutic cancer vaccine trial activity (r=.60; p=.003). Annual mortality, 5-year survival rate and 5-year mortality estimates were not associated with vaccine trial activity. The authors conclude that therapeutic cancer vaccine clinical trials correspond with disease incidence in the U.S., but not with measures of mortality and survival that reflect the effectiveness of currently available treatment modalities. Future development of therapeutic vaccines for cancer may benefit patients more if there is stronger complementarity with other therapeutic options.
cancer; clinical trials; immunotherapy; incidence; mortality; vaccine
As the prevalence and severity of obesity among adolescents has increased, so has the number seeking bariatric surgery. Little is known about the opinions and referral behaviors of primary care physicians regarding bariatric surgery among adolescents. Therefore, the objective of this study was to assess primary care physicians’ opinions regarding referral of obese adolescents for bariatric surgery.
In spring of 2007, a two-page survey was fielded to a national randomsample of physicians (375 pediatricians and 375 family physicians). The survey explored physicians’ opinions about: (1) whether they would ever refer an adolescent for bariatric surgery, (2) the minimum age at which bariatric surgery should be considered, and (3) prerequisites to bariatric surgery. Chi-square tests were used to examine associations in responses.
The response rate was 67%. Nearly one-half of physicians (48%) would not ever refer an obese adolescent for bariatric surgery. The most frequently endorsed minimum age at which physicians would make a referral for bariatric surgery was 18 years (46%). Almost all respondents endorsed the need for participation in a monitored weight management program prior to bariatric surgery (99%). However, the recommended duration of treatment varied from 3 months to over 5 years, with almost half recommending 12 months of monitored treatment prior to surgery.
Some severely obese adolescents may desire and potentially benefit from bariatric surgery, but referral for the procedure may depend heavily on the attitudes of their primary care physicians.
Obesity; Adolescents; Bariatric surgery; Referrals; Primary care physicians