Cost effectiveness of epidural steroid injections to manage chronic lower back pain.

BACKGROUND: The efficacy of epidural steroid injections in the management of chronic low back pain is disputed, yet the technique remains popular amongst physicians and patients alike. This study assesses the cost effectiveness of injections administered in a routine outpatient setting in England. METHODS: Patients attending the Nottingham University Hospitals' Pain Clinic received two injections of methylprednisolone plus levobupivacaine at different dosages, separated by at least 12 weeks. Prior to each injection, and every week thereafter for 12 weeks, participants completed the EQ-5D health-related quality of life instrument. For each patient for each injection, total health state utility gain relative to baseline was calculated. The cost of the procedure was modelled from observed clinical practice. Cost effectiveness was calculated as procedure cost relative to utility gain. RESULTS: 39 patients provided records. Over a 13-week period commencing with injection, mean quality adjusted life year (QALY) gains per patient for the two dosages were 0.028 (SD 0.063) and 0.021 (SD 0.057). The difference in QALYs gained by dosage was insignificant (paired t-test, CIs -0.019 - 0.033). Based on modelled resource use and data from other studies, the mean cost of an injection was estimated at £219 (SD 83). The cost utility ratio of the two injections amounted to £8,975 per QALY gained (CIs 5,480 - 22,915). However, at costs equivalent to the tariff price typically paid to providers by health care purchasers, the ratio increased to £27,459 (CIs 16,779 - 70,091). CONCLUSIONS: When provided in an outpatient setting, epidural steroid injections are a short term, but nevertheless cost effective, means of managing chronic low back pain. However, designation of the procedure as a day case requires the National Health Service to reimburse providers at a price which pushes the procedure to the margin of cost effectiveness. TRIAL REGISTRATION: ISRCTN 43299460.

Multi-level computational methods for interdisciplinary research in the HathiTrust Digital Library.

We show how faceted search using a combination of traditional classification systems and mixed-membership topic models can go beyond keyword search to inform resource discovery, hypothesis formulation, and argument extraction for interdisciplinary research. Our test domain is the history and philosophy of scientific work on animal mind and cognition. The methods can be generalized to other research areas and ultimately support a system for semi-automatic identification of argument structures. We provide a case study for the application of the methods to the problem of identifying and extracting arguments about anthropomorphism during a critical period in the development of comparative psychology. We show how a combination of classification systems and mixed-membership models trained over large digital libraries can inform resource discovery in this domain. Through a novel approach of "drill-down" topic modeling-simultaneously reducing both the size of the corpus and the unit of analysis-we are able to reduce a large collection of fulltext volumes to a much smaller set of pages within six focal volumes containing arguments of interest to historians and philosophers of comparative psychology. The volumes identified in this way did not appear among the first ten results of the keyword search in the HathiTrust digital library and the pages bear the kind of "close reading" needed to generate original interpretations that is the heart of scholarly work in the humanities. Zooming back out, we provide a way to place the books onto a map of science originally constructed from very different data and for different purposes. The multilevel approach advances understanding of the intellectual and societal contexts in which writings are interpreted.

A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery.

OBJECTIVE: Our questionnaire study set out to assess the prevalence of chronic pain after thoracic surgery, the contribution of the neuropathic component of chronic pain and the impact of chronic pain on patients' lives. METHODS: A questionnaire was sent to 1152 patients who had undergone thoracic surgery in our department between 7 months and 7 years ago. The questionnaire was designed specifically for the study and included questions on neuropathic symptoms. Responses were correlated with data from our prospectively entered database for analysis. RESULTS: Nine hundred and forty-eight people were included in the study, of which 600 responded (63%). Prevalence of chronic pain is 57% at 7-12 months, 36% at 4-5 years and 21% at 6-7 years. Patient age, consultant and time since the operation all have significant effects. Surgical approach (video-assisted thoracoscopic surgery, thoracotomy) and diagnosis are not significant. Thirty-nine percent of those with pain take analgesia, 46% felt their pain is their worst medical problem and 40% reported it limits their daily activities. The prevalence of each neuropathic symptom is between 35 and 83%. The presence of a neuropathic symptom is associated with significantly more severe pain, more analgesia use and pain more likely to limit daily activity. CONCLUSIONS: Chronic pain has a significant prevalence and impact on patients' lives for several years after thoracic surgery. Nerve dysfunction is associated with more severe pain, a greater impact and tends to persist. The reason for the individual consultant being an important factor in post-thoracotomy pain needs further investigation.

Prescribing opioid analgesics for chronic non-malignant pain in general practice - a survey of attitudes and practice.

BACKGROUND: This study replicates a previous postal survey of general practitioners (GPs) to explore whether attitudes to opioid prescribing have changed at a time when the number of opioid prescriptions issued in primary care has increased. METHODS: With permission, a 57-item survey instrument previously utilised with GPs in the South-west of England was circulated to 214 GPs in city-centre practices in the East Midlands. The survey instrument included items relating to practice context, prescribing patterns and attitudes about analgesic medication, perceived prescribing frequency and reluctance to prescribe. RESULTS: Responses were received from 94 GPs (45%). Almost three-quarters (72.7%) of GPs reported that they sometimes or frequently prescribed strong opioids for chronic non-cancer pain. Over two-thirds (67.8%) reported that they were sometimes or frequently reluctant to prescribe strong opioids for chronic non-cancer pain. No significant relationships were observed between perceived frequency of prescribing and a range of demographic factors; however, concerns about 'physical dependence', 'long-term commitment to prescribing' and 'media reports' were associated with less frequent reported prescribing of, and greater reluctance to prescribe, strong opioids. DISCUSSION: Given the national trend for increased opioid prescriptions, it is unsurprising that more frequent self-reported prescribing is reported here; however, increased frequency does not translate into less reluctance about prescribing. The effectiveness of strong opioids for chronic pain is recognised, but concerns about addiction, dependence and misuse inform a reluctance to use strong opioids. These juxtapositions highlight a continued need for clearer understanding of GPs' perceptions of strong opioids and point to the potential benefit of dedicated guidelines or specialist education and training to address their uncertainties.