The NASS lumbar spine outcome assessment instrument: Large sample assessment and sub-scale identification.

BACKGROUND: Accurately assessing patient-reported pain and functional ability is essential to measuring quality of care. PURPOSE: Evaluating the instruments used in assessing quality of care is often overlooked. The North American Spine Society Lumbar Spine Outcome Assessment (NASS-LS) instrument measures patient-reported pain and function in a combined scale. We evaluated the original instrument and assessed separate pain and function subscales based on a set of the items in the original instrument. STUDY DESIGN/SETTING: Data were collected from seven spine clinics in the United States participating in the Spinal Surgery Consortium for Outcomes Research Project. Consenting patients were enrolled in the project and asked to complete the NASS instrument when arriving for a surgical consult. PATIENT SAMPLE: Data from 811 lumbar spine patients were used. METHODS: Analyses were conducted on the original instrument to determine its internal consistency and to determine the structural existence of any underlying scales. Internal consistency of the original and new scales were assessed with Cronbach's coefficient alpha. RESULTS: The original scale was found to be a useful measure of pain and functional ability. Important subscales of pain and functional ability were also identified allowing us to report more meaningful results. CONCLUSION: The original instrument is useful for assessing low-back pain and function as a combined concept. The separate pain and function scales may prove useful assessing varying outcome levels and/or different decisions about subsequent follow-up care.

Sociodemographic differences in the receipt of colorectal cancer surveillance care following treatment with curative intent.

BACKGROUND: Despite limited evidence of its effectiveness, most guidelines recommend colorectal cancer survivors undergo posttreatment surveillance care. This article describes the posttreatment use of colon examinations, carcinoembryonic antigen (CEA) testing, and metastatic disease testing among a managed care population. METHODS: Two hundred fifty-one patients with colorectal cancer enrolled in a managed care organization at diagnosis (1/1/90-12/31/95) and treated with curative intent. Patients were identified via a Cancer Registry maintained by a large group practice. Cumulative incidences of service receipt were estimated using actuarial (Kaplan-Meier) survival analyses. Co- Proportional Hazard Models were used to evaluate the relation of patient sociodemographic and clinical characteristics to service receipt. Average 8-year medical care expenditures were calculated. RESULTS: Within 18 months of treatment, 55% of the cohort received a colon examination, 71% received CEA testing, and 59% received metastatic disease testing. Whites were more likely than minorities to receive CEA testing (RR = 1.47, P = 0.04) and tended to be more likely to receive a colon examination (RR = 1.43, P = 0.09). As the median household income of a patient's zip code of residence increased, so too did the likelihood of colon examination and metastatic disease testing receipt (RR = 1.09, P = 0.03 and RR = 1.12, P <0.01, respectively). Average 8-year medical care expenditures among the cohort were $30,247. CONCLUSIONS: Among a population with financial access to care, differences were found in the receipt of colorectal cancer surveillance care by race and income. Additional investigations are needed to understand why minorities and those residing in low-income areas are less likely to receive surveillance care.

Cost-effectiveness of single-dose methotrexate compared with laparoscopic treatment of ectopic pregnancy.

OBJECTIVE: To evaluate the cost-effectiveness of treatment with intramuscular (IM) methotrexate compared with fallopian tube-sparing laparoscopy for small unruptured ectopic pregnancy. METHODS: A decision-analytic model accounting for varying resolution rates, complication rates, and cost estimates was built to compare the use of methotrexate with laparoscopy. Meta-analysis results of studies identified by a MEDLINE search for IM methotrexate resolution rates and tube-sparing laparoscopy resolution rates were used in model estimation. A similar process was used to generate model complication rates. Data on associated resource use were derived from established clinical guidelines. Estimates of 1998 costs incurred by provider organizations were calculated using data from a large managed care organization. RESULTS: The average methotrexate resolution rate among the studies included was 87% (range 75-90%). The average laparoscopy resolution rate was 91% (range 72-100%). Complication rates for methotrexate ranged from 0% to 22%, with an average of 10% for minor complications, and from 0% to 11% for serious complications, with an average of 7%. Complication rates for laparoscopy ranged from 0% to 8% for intraoperative complications, with an average of 2%, and from 0% to 15% for postoperative complications, with an average of 9%. Baseline model estimates indicated an average cost saving of more than $3000 per resolved ectopic pregnancy with methotrexate treatment compared with laparoscopy. Results of extensive sensitivity analyses supported the finding of a cost saving with methotrexate treatment. CONCLUSION: Single-dose methotrexate is a cost-saving, nonsurgical, fallopian tube-sparing treatment for ectopic pregnancy.