The life impact of burns: the perspective from burn persons in Brazil during their rehabilitation phase.

PURPOSE: By using a combination of qualitative and quantitative methods, the focus of this study was to describe the changes associated with burns on the lives of Brazilian burn victims during the rehabilitation phase, and to investigate possible associations between the changes in work reported by the participants and the percentage of total body surface area burnt, and the body areas affected by the injury. METHOD: Participants were 18 years of age or older, who had been discharged from hospitalisation between 6 months and 1 year before the interview, or who underwent reconstructive surgery during the previous year, or who were under outpatient follow-up awaiting reconstructive surgery. Data were collected by means of semi-structured interviews. RESULTS: Thirty-eight of the 44 participants (86.4%) reported some type of changes associated with the burn injury, the treatment, or both, regarding the following aspects: work, leisure, relationships, religious ties, educational activities and habits (smoking, using alcohol and drugs and dressing style). The data showed a statistically significant association between burns on at least one of the upper limbs (with or without hands) and changes in work. CONCLUSIONS: Some of the aspects mentioned by the participants, such as work and leisure activities, need to be further researched in order to improve our understanding of the impact that these changes causes in the person's life.

A randomized trial to examine the mechanisms of cognitive, behavioral and mindfulness-based psychosocial treatments for chronic pain: Study protocol.

This randomized trial will evaluate the mechanisms of three chronic pain treatments: cognitive therapy (CT), mindfulness meditation (MM), and activation skills (AS). We will determine the extent to which late-treatment improvement in primary outcome (pain interference) is predicted by early-treatment changes in cognitive content, cognitive process, and/or activity level. The shared versus specific role of these mechanisms across the three treatments will be evaluated during treatment (Primary Aim), and immediately post-treatment to examine relapse mechanisms (Secondary Aim). We will enroll 300 individuals with chronic pain (with low back pain as a primary or secondary condition), with 240 projected to complete the study. Participants will be randomly assigned to eight, 1.5 h telehealth group sessions of CT, MM, or AS. Mechanisms and outcomes will be assessed twice daily during 2-week baseline, 4-week treatment period, and 4-week post-treatment epoch via random cue-elicited ecological momentary assessment (EMA); activity level will be monitored during these time epochs via daily monitoring with ActiGraph technology. The primary outcome will be measured by the PROMIS 5-item Pain Interference scale. Structural equation modeling (SEM) will be used to test the primary aims. This study is pre-registered on clinicaltrials.gov (Identifier: NCT03687762). This study will determine the temporal sequence of lagged mediation effects to evaluate rates of change in outcome as a function of change in mediators. The findings will provide an empirical basis for enhancing and streamlining psychosocial chronic pain interventions. Further, results will guide future efforts towards optimizing maintenance of gains to effectively reduce relapse risk.

Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.

Administrative databases are increasingly used for studying outcomes of medical care. Valid inferences from such data require the ability to account for disease severity and comorbid conditions. We adapted a clinical comorbidity index, designed for use with medical records, for research relying on International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes. The association of this adapted index with health outcomes and resource use was then examined with a sample of Medicare beneficiaries who underwent lumbar spine surgery in 1985 (n = 27,111). The index was associated in the expected direction with postoperative complications, mortality, blood transfusion, discharge to nursing home, length of hospital stay, and hospital charges. These associations were observed whether the index incorporated data from multiple hospitalizations over a year's time, or just from the index surgical admission. They also persisted after controlling for patient age. We conclude that the adapted comorbidity index will be useful in studies of disease outcome and resource use employing administrative databases.

An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations.

OBJECTIVE: To study temporal trends and geographic variations in the use of surgery for spinal stenosis, estimate short-term morbidity and mortality of the procedure, and examine the likelihood of repeat back surgery after surgical repair. DESIGN: Cohort study based on Medicare claims. SETTING: Hospital care. SUBJECTS: All Medicare beneficiaries 65 years of age or older who received a lumbar spine operation for spinal stenosis in 1985 or 1989 were followed through 1991 (10,260 patients from the 1985 cohort and 18,655 from the 1989 cohort). MAIN OUTCOME MEASURES: Two outcomes were measured: (1) rates of operation for spinal stenosis by state and (2) on an individual level, operative complications (cardiopulmonary, vascular, or infectious), postoperative mortality, and time between first operation and any subsequent reoperation. RESULTS: Rates of surgery for spinal stenosis increased eightfold from 1979 to 1992 for patients aged 65 and older and varied almost fivefold among US states. Mortality and operative complications increased with age and comorbidity. Complications were more likely for men and for individuals receiving spinal fusions. The 1989 cohort experienced a slightly higher probability of reoperation than the 1985 cohort for the first 3 years of follow-up. CONCLUSIONS: A rapid increase in surgery rates for spinal stenosis was identified over a 14-year period. The wide geographic variations and substantial complication rate from this elective surgical procedure (partly related to patient age) suggest a need for more information on the relative efficacy of surgical and nonsurgical treatments for this condition. The risks and benefits of particular surgical procedures for specific clinical and demographic subgroups as well as individual patient preferences regarding surgical risks and possible outcomes should also be evaluated further. These issues are likely to become increasingly important with the aging of the US population.

Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure.

We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patient's age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.

Characteristics in Medicare beneficiaries associated with reoperation after lumbar spine surgery.

STUDY DESIGN: A cohort study was undertaken using medical claims of Medicare beneficiaries. OBJECTIVES: Factors associated with reoperation after lumbar spine surgery were identified. SUMMARY OF BACKGROUND DATA: Repeat spine surgery is one outcome measure of surgical success, but little is known about clinical or demographic factors associated with repeat surgery. METHODS: Medicare beneficiaries who had surgery in 1985 were included in follow-up through 1989. Time between the first operation and a lumbar spine reoperation, death, or end of follow-up period was recorded. Survival analysis (time-to-event) techniques were used to test the association of baseline characteristics with reoperation. RESULTS: Higher reoperation rates were associated (P < 0.05) with previous back surgery, younger age, recent hospitalization, white race, and diagnosis of herniated disc (compared with other diagnoses). Fusion alone or combined with other procedures did not lower the reoperation rate. CONCLUSION: Reoperation rates are affected not only by technical factors, but also by demographic and clinical characteristics that are often omitted from reports of surgical case series.

Why does geographic variation in health care practices matter? (And seven questions to ask in evaluating studies on geographic variation).

One of the most active fields in health services research is the study of "geographic variation," or disparities in rates of certain types of health care practices among large areas (such as countries or regions of a country) or small areas (such as countries or hospital market areas); "small area analysis" in particular has received much attention in journals and the popular press. Increasingly, data upon which to base studies of geographic variation are becoming available. This article poses questions to ask in applying studies on geographic variation to health care settings. Because findings from these studies may ultimately affect patient care, the questions are important for physicians as well as health services researchers. The questions are: 1) What events are to be analyzed? 2) What geographic units are to be analyzed? 3) How good are the data? 4) Are differences in rates due to chance alone? 5) Are high rates too high? 6) How is geographic variation to be explained? 7) What is the role of "presentation style" in explaining geographic variation?

Physician views about treating low back pain. The results of a national survey.

STUDY DESIGN: Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain. OBJECTIVE: To document physician beliefs about the efficacy of specific treatments and the extent to which these beliefs correspond to current knowledge. SUMMARY OF BACKGROUND DATA: Little is known about physician beliefs regarding the efficacy of specific back pain treatments. METHODS: A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders. RESULTS: Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acute or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorities of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use. CONCLUSIONS: The lack of consensus among physicians could be attributable to the absence of clear evidence-based clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy, or a tendency to discount the efficacy of competing treatments.

Meta-analysis. A useful tool for the spine researcher.

Meta-analysis is a systematic and objective methodology for synthesizing research literature. The authors present the history and definition of meta-analysis, discuss the generic framework for design and implementation of a meta-analysis, and review the problems and pitfalls that can accompany meta-analyses. Their discussion draws on practical experience with several meta-analyses of the low back pain literature. Meta-analysis can be used to help answer the questions about various options for diagnosis and treatment of low back problems and also to point out gaps in our knowledge base that may have a high priority for research. Meta-analytic methods are an informative means of addressing health care controversies with major patient management and cost implications.

Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population.

Regional variations in lumbar spinal fusion rates suggest a poor consensus on surgical indications. Therefore, complications, costs, and reoperation rates were compared for elderly patients undergoing surgery with or without spinal fusion. Subjects were Medicare recipients who underwent surgery in 1985, with 4 years of subsequent follow-up. There were 27,111 eligible patients, of whom 5.6% had fusions. Mean age was 72 years. Patients undergoing fusion had a complication rate 1.9 times greater than those who had surgery without fusion. The blood transfusion rate was 5.8 times greater, nursing home placement rate 2.2 times greater, and hospital charges 1.5 times higher (all P < 0.0005). Six-week mortality was 2.0 times greater for patients undergoing fusions (P = 0.025). Reoperation rates at 4 years were no lower for patients who had fusion surgery and results were similar in most diagnostic subgroups. Indications for fusion among older patients require better definition, preferably based on outcomes from prospective controlled studies.

Helping patients decide about back surgery: a randomized trial of an interactive video program.

STUDY DESIGN: A randomized trial of 100 patients with low back pain who were potential surgical candidates. OBJECTIVES: To determine whether an interactive videodisc with a booklet is superior to a booklet alone for informing patients about back surgery. SUMMARY OF BACKGROUND DATA: Substantial geographic variation has been observed in lumbar spine surgery. Informed patient preferences should play an important role in decisions about surgery. However, little is known about optimal strategies for informing patients. METHODS: Subjects were randomized to receive an interactive videodisc (with a booklet) or a booklet alone. A knowledge test administered at baseline and follow-up was used to measure improvement in knowledge about treatment options for lumbar spine problems. Patients' reactions to the videodisc and booklet and preferences for treatment were also assessed. RESULTS: The patients' knowledge improved after exposure to either intervention. Multivariate analyses adjusted for baseline score, age, education, gender, and diagnosis showed a significant advantage for the videodisc with booklet over the booklet alone. The videodisc-booklet group showed significantly greater gains in knowledge among subjects with the worst baseline knowledge scores. A larger proportion of subjects in the videodisc-booklet group rated the materials easy to understand (93% vs.- 72%,P = 0.04), containing the right amount of information (93% vs.- 80%,P = 0.3), and adequate to assist in choice of treatment (75% vs.- 51%,P = 0.2). Those who viewed the videodisc expressed a somewhat lower preference for surgery than those who received the booklet alone (23% vs.- 42%,P = 0.4). CONCLUSIONS: Both the booklet alone and the combination of videodisc and booklet improved knowledge. The combination produced greater knowledge gains than the booklet alone for the subgroup with the least knowledge at baseline. Patients preferred the combination and had a slightly lower preference for surgery if they had viewed the video presentation. For some patients, the video may enhance involvement in clinical decisions.

Managing low back pain: attitudes and treatment preferences of physical therapists.

BACKGROUND AND PURPOSE: We surveyed physical therapists about their attitudes, beliefs, and treatment preferences in caring for patients with different types of low back pain problems. SUBJECTS AND METHODS: Questionnaires were mailed to all 71 therapists employed by a large health maintenance organization in western Washington and to a random sample of 331 other therapists licensed in the state of Washington. RESULTS: Responses were received from 293 (74%) of the therapists surveyed, and 186 of these claimed to be practicing in settings in which they treat patients who have back pain. Back pain was estimated to account for 45% of patient visits. The McKenzie method was deemed the most useful approach for managing patients with back pain, and education in body mechanics, stretching, strengthening exercises, and aerobic exercises were among the most common treatment preferences. There were significant variations among therapists in private practice, hospital-operated, and health maintenance organization settings with respect to treatment preferences, willingness to take advantage of the placebo effect, and mean number of visits for patients with back pain. CONCLUSIONS AND DISCUSSION: These variations emphasize the need for more outcomes research to identify the most effective treatment approaches and to guide clinical practice.

Impact of a worker's compensation practice guideline on lumbar spine fusion in Washington State.

OBJECTIVES: In the face of escalating medical costs for injured workers, the Washington State Department of Labor and Industries (L&I), which pays for most workers' compensation costs in the state, established guidelines for elective lumbar fusion as part of its inpatient utilization review program. The guidelines were tied to reimbursement strictures. The authors attempt to assess the effects of these guidelines, which were introduced in November 1988, upon subsequent L&I fusion procedures. METHODS: Discharge data from the Comprehensive Hospital Abstract Reporting System and algorithms using International Classification of Diseases, Version 9, Clinical Modification diagnosis and procedure codes were used to identify lumbar surgical cases. Population estimates were from the 1990 US Census Bureau. RESULTS: During the period of years 1987 through 1992, the lumbar fusion rate for the state showed a 26% decline compared with a 3% decrease for all lumbar operations. After November 1988, when the guidelines went into effect, the state fusion rate declined 33%, whereas rates for nonfusion operations essentially were unchanged. The sharpest decline corresponded in time to implementation of the guidelines. Prior to the initiation of L&I guidelines, the proportion of fusions among L&I patients was higher than among non-L&I patients. The opposite was true by the end of 1992, and the L&I proportion decreased more rapidly than the non-L&I proportion. Time series analysis revealed that both the decline in Washington state lumbar fusion rates and the decline in the proportion of lumbar fusion among L&I patients were statistically significant. CONCLUSIONS: The data suggest that the L&I lumbar fusion surgery criteria and reimbursement standards implemented in 1988 contributed to a decline in rates of performing that procedure. The utilization review aspect of the guidelines as well as the process of involving surgeons in the preparation and dissemination of guidelines also may have been contributory.

Physician variation in diagnostic testing for low back pain. Who you see is what you get.

OBJECTIVE: This study examined patterns of diagnostic test use for patients with low back pain. Three specific questions were addressed: 1) What tests do physicians recommend for patients with 3 common types of low back pain? 2) Do physicians in various specialties differ in the tests they would order? and 3) How appropriate are physicians' choices of tests, based on current medical knowledge and expert recommendations? METHODS: A stratified national random sample of 2,604 physicians in 8 specialties was mailed questionnaires asking about the tests they would order for hypothetical patients with acute back pain, sciatica, or chronic low back pain. Physicians were also asked which procedures they generally used to evaluate suspected lumbar nerve root compression. These responses were compared with guidelines that have been suggested by the Quebec Task Force on Spinal Disorders, based on comprehensive evaluation of the scientific literature. RESULTS: Approximately 1,100 physicians responded to the survey (43% response rate). Magnetic resonance imaging was the most frequently used procedure for evaluating suspected lumbar nerve root compression, although a majority of neurosurgeons would still use myelography. Neurosurgeons and neurologists were twice as likely as other specialists to order an imaging study for patients with acute nonradiating pain or chronic back pain. Physiatrists and neurologists were more than 3 times as likely as other specialists to order electromyograms for acute back pain with sciatica or chronic back pain. Rheumatologists were almost twice as likely as other specialists to order laboratory tests for both acute and chronic back pain. The reported use of imaging and electrodiagnostic tests was generally premature and more extensive than that recommended by the Quebec Task Force. CONCLUSION: There is little consensus, either within or among specialties, on the use of diagnostic tests for patients with back pain. Thus, the diagnostic evaluation depends heavily on the individual physician and his or her specialty, and not just the patient's symptoms and findings. Furthermore, many physicians may be ordering imaging studies too early and for patients who do not have the appropriate clinical indications. These results suggest a need for additional clinical guidelines as well as better adherence to existing guidelines.

Patient outcomes after lumbar spinal fusions.

OBJECTIVES: To determine success and complication rates for lumbar spinal fusion surgery, predictors of good outcomes, and whether fusion improves success rates of laminectomy for specific low back disorders. DATA SOURCES: English-language journal articles published from 1966 through April 1991, identified through MEDLINE searching (spinal fusion plus limiting terms), bibliography review, and expert consultation. STUDY SELECTION: Articles were selected only if they reported at least 1 year of follow-up data enabling the classification of clinical outcomes as satisfactory or unsatisfactory for at least 30 patients. DATA EXTRACTION: Two reviewers independently extracted data on patient characteristics, surgical methods, patient outcomes, and quality of study methods. DATA SYNTHESIS: Of 47 articles, there were no randomized trials. Four nonrandomized studies compared surgery with and without fusion for herniated disks; three found no advantage for fusion. On average, 68% of patients had a satisfactory outcome after fusion, but the range was wide (16% to 95%), and the satisfactory outcome rate was lower in prospective than in retrospective studies. The most frequently reported complications were pseudarthrosis (14%) and chronic pain at the bone graft donor site (9%). Clinical outcomes did not differ by diagnosis or fusion technique, but were worse in studies with a greater number of previously operated patients. CONCLUSIONS: For several low back disorders no advantage has been demonstrated for fusion over surgery without fusion, and complications of fusions are common. Randomized controlled trials are needed to compare fusion, surgery without fusion, and nonsurgical treatments in rigorously defined patient groups.