Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians.

BACKGROUND: Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain. OBJECTIVE: This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome. METHODS: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome. RESULTS: Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study. CONCLUSION: Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.

Computed tomography assessment of sacroiliac screw placement relative to the first sacral neuroforamen.

The radiographic interpretation of sacroiliac screws relative to the S1 neuroforamen is difficult for orthopedic surgeons and radiologists. Computed tomography (CT) with axial images alone or combined with multiplanar reconstructions are often used to assess screw position. The reliability, reproducibility, and accuracy of orthopedist and radiologist interpretations of axial CT images with and without multiplanar reconstructions was determined using 24 cadaveric hemipelves with known sacroiliac screw position. Interobserver reliability of determining screw position was fair for orthopedists and slight for radiologists regardless of imaging modality or screw composition. Intraobserver reproducibility was moderate for orthopedists regardless of imaging modality or screw type. Reproducibility among radiologists was moderate using axial images of titanium screws and substantial with addition of multiplanar reconstructions. Overall accuracy was similar for orthopedists and radiologists. CT images with multiplanar reconstructions improve accuracy in determining sacroiliac screw position, but not significantly. Current imaging modalities are limited by large inaccuracies and by interobserver and intraobserver variation.

Intervention assessment in an Indian health service pharmacy.

OBJECTIVE: To document and evaluate pharmacists' interventions in a setting that has complete and immediate access to patient information. DESIGN: Descriptive report evaluating self-reported interventions made by pharmacists during the conduct of routine dispensing activities. The data collection period was from February 15 to April 1, 1994. SETTING: Ambulatory care facility offering medical and dental care to high school residents, Native Americans, and Alaska Natives in Northwestern Oregon. MAIN OUTCOME MEASURES: Intervention rate per 100 new prescriptions dispensed. Each intervention was evaluated with regard to the information used to initiate it, when during the dispensing process it was initiated, and the intervention type. Outside evaluators determined the clinical significance of the interventions, including potential adverse health consequences, the likelihood of their occurrence, and the level of medical care that would have been required to treat the problem. RESULTS: Of 2,535 orders screened, 104 interventions (4.1%) were collected; 71% of these occurred during chart screening. Pharmacists most often used the medication order itself (60.6%) to detect prescribing problems, followed by other records in the patient's chart (29.8%). Outside evaluators identified 47.1% of the 104 interventions as clinically significant. The most common adverse health consequence prevented was inadequate control of the patient's condition. Outside evaluators also found that the most common level of corrective care that would have been needed if the intervention had not occurred, was a scheduled physician office visit (59.2%). CONCLUSION: This information suggests that pharmacists who have access to patient information may intervene at higher rates and that more of their interventions may be deemed clinically significant. However, larger, double-blinded, case-controlled studies are needed to definitively draw these conclusions.

Managed care and public health departments: who is responsible for the health of the population?

This review examines changes over the past decade in the delivery of health care in the United States, specifically the move toward managed care and capitation. Over 77 million Americans are now enrolled in health maintenance organizations, and the health care delivery system is reorganizing into large group practices and integrated health systems. Examined here are the implications of this shift on the interaction between managed care and public health agencies. How will a population-based system of health care be achieved in light of managed care organizations' responsibility only for their enrolled population, in contrast to the responsibility of the public health service for the entire population? Where does the responsibility of MCOs end and that of public health begin? Should certain public health functions be absorbed by managed care organizations? What are the prospects for partnership between these two systems?

Train accidents involving pedestrians, motor vehicles, and motorcycles.

In the United States, train-related accidents account for more than 18,000 injuries and 1,200 fatalities annually, yet there is a paucity of literature pertaining to this unique injury. We reviewed the medical records of 98 of 135 cases of train-related trauma treated at Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas, from 1990 to 1995. There were 50 train-pedestrian accidents, 47 train-automobile accidents, and 1 train-motorcycle accident, with a mean patient age of 30.1 years (range, 2 to 66 years). Eighteen patients (18%) were pronounced dead on arrival or died shortly after admission. Of the other 80 patients, 27 (34%) were discharged from the emergency department after minor medical treatment, while 53 (66%) were hospitalized, of whom 10 (13%) later expired. The mean Injury Severity Score (ISS) was 11.9 (discharged, 1.8; hospitalized, 14.3; expired, 29.2). Forty-five patients (56%) sustained 57 extremity fractures, and 30 patients (38%) required 40 amputations. Mean Mangled Extremity Severity Score (MESS) for all injured extremities was 5.2 (amputation, 7.7; no amputation, 2.8). On average, the hospitalization cost per patient was greater than $18,698, while the reimbursement from the patients was $2,261, leaving the hospital with a net deficit of approximately 2 million dollars. Surprisingly, train accidents do not always result in serious injury. However, when serious injury is sustained, it is often of high morbidity (amputation) and mortality, which appears to correlate well with the initial MESS and ISS. Extrapolating our cost data to include all train-related accident injuries and deaths indicates that the direct costs to society may exceed 300 million dollars annually. Greater public awareness and preventive measures may reduce the tremendous human and financial costs of train-related accidents.

Imaging assessment of sacroiliac screw placement relative to the neuroforamen.

STUDY DESIGN: Twenty-four cannulated sacroiliac screws were placed bilaterally into 12 cadaveric pelvi (12 titanium screws and 12 stainless-steel screws) and were imaged using conventional and multiplanar reconstructed computed tomography. OBJECTIVES: To determine whether sacroiliac screw position assessment relative to the neuroforamen is enhanced by: 1) computed tomography using multiplanar reconstructions and 2) the use of titanium screws rather than stainless-steel screws. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, there have been no prior studies demonstrating the accuracy of multiplanar computed tomography compared with that of conventional (axial) tomography in determining the position of sacroiliac screws relative to the neuroforamen. Although titanium screws have been shown to have less scatter than stainless-steel screws, the effect of alloy composition on the radiographic accuracy of interpreting the screw position relative to the sacral neuroforamen is unknown. METHODS: Screws were deliberately placed into: position A, in which the screw did not violate the neuroforamen; position B, in which the threads of the screw came within 3 mm of the neuroforamen; and position C, in which the screw clearly was nearly centered in the neuroforamen. The degrees of accuracy in assessing screw position relative to the neuroforamen using conventional (axial) images and using multiplanar reconstructed images were compared. RESULTS: The axial images were accurate in determining screw position relative to the neuroforamen in 50% of cases in which titanium screws were used and in 42% of cases in which stainless-steel screws were used. The corresponding values for multiplanar reconstructions were 92% for cases in which titanium screws were used and 67% for cases in which stainless-steel screws were used. The accuracy of multiplanar reconstructions was statistically better than that of axial images (P < 0.05). Metallic scatter was increased in stainless-steel screws. CONCLUSIONS: The results of this study suggest that the use of computed tomography with multiplanar reconstruction improves accuracy in determining sacroiliac screw position relative to the neuroforamen. The assessment of screw position may be facilitated using titanium screws.

Sonography by the radiologist: self-referral, turf battles, and marketing.

Competition between radiologists and nonradiologists for the performance and billing of radiologic imaging examinations is, perhaps, most pervasive in the field of diagnostic sonography [1-3]. The purpose of this article is to help radiologists understand and deal with turf battles and the self-referral of clinicians and to describe marketing analyses and strategy that can be useful when attempting to decrease competition and increase referrals.

Rehabilitation in the outpatient setting.

A working familiarity with rehabilitation techniques is absent from most primary care settings. Primary care clinicians can benefit greatly from better knowledge of the principles of geriatric rehabilitation. Physiatrists and geriatricians can have a greater impact if future research also explores the practical barriers to providing rehabilitation services outside institutional settings. An active, collaborative search for new models of care is needed. If more elderly citizens are to benefit from effective rehabilitation services, established geriatric rehabilitation programs must learn how to select from the many patients referred for evaluation those who will most benefit from outpatient rehabilitation services. Impending national health care reform creates a window of opportunity to establish rational systems to deliver health services designed for our aging population.

The future of long-term and permanent contraceptive methods. Developments in technology.

The Association for Voluntary Surgical Contraception (AVSC) does not expect dramatic advances in female sterilization during the decade. Minilaparotomy and laparoscopy will endure as the standard surgical approaches, but programs will continue to shift toward the use of local anesthesia for these procedures because of greater safety and lower costs. No-scalpel vasectomy demonstrated by AVSC to be popular, effective, and safe holds greater potential for expanding the vast, and largely ignored, male market. The injection methods of vasectomy now being tested in China and elsewhere may make male sterilization even more acceptable. Markets for IUDs, implants, and injectables will continue to expand as more clients seek safe and effective long term contraception, and as national family planning programs (particularly in Asia) realize the ethical and programmatic importance of offering choices. Norplant is expensive and requires a skilled network of providers to both insert and remove the implants. For these reasons, AVSC expects Norplant to remain a niche method, mostly for urban clients who are not interested in sterilization or who are ill-suited for IUDs or injectables. Injectables, already popular in many parts of the world, will become increasingly available and used now that the US food and Drug Administration has approved Depo-Provera. New types of injectables, currently being developed, will be brought to market. The potential for IUDs is vast, particularly the low-cost, highly-effective Copper T 380A, which is expected to be approved as a 10-year method. However, poor quality service delivery and the high prevalence of sexually transmitted diseases could limit the potential of this method.

Longitudinal assessment of type I procollagen in children with inflammatory bowel disease subjected to surgery.

Using radioimmunoassay we have measured the serum concentrations of the C-terminal propeptide of type I procollagen (pColl-I-C) in 12 Tanner I-II subjects (aged 9-16 years) with severe Crohn's disease (8 patients) or ulcerative colitis (4 patients) and markedly decreased growth velocity who were subjected to surgery and 50 similarly aged children with either ulcerative colitis (20 patients) or Crohn's disease (30 patients) and normal growth. Prior to operation, the mean growth velocity and pColl-I-C concentration in the former group of 12 children were 0.03 +/- 0.02 cm/month (normal greater than or equal to 0.5 cm/month) and 14.1 +/- 1.9 micrograms/dl, respectively. This pColl-I-C concentration is comparable with that previously reported for adults (5-17 micrograms/dl) and significantly lower than found in the 50 normally growing children with inflammatory bowel disease (IBD) (46.9 +/- 2.0 micrograms/dl) (p less than 0.001). All 12 children subjected to surgery had a marked increase in growth velocity and pColl-I-C concentration to 0.73 +/- 0.08 cm/month and 59.1 +/- 5.6 micrograms/dl, respectively (p less than 0.001 compared with preoperative values). Changes in pColl-I-C concentrations antedated measurable changes in linear growth. These data suggest that pColl-I-C concentrations can reflect growth velocity in children with IBD subjected to surgery and may provide a rapidly available measure of current "growth activity."

Breast-feeding attitudes and practices among adolescents.

Breast-feeding attitudes of 128 low-income, pregnant adolescents were assessed using a questionnaire developed for this population. Teens who had been breast-fed as infants had more positive attitudes than bottle-fed teens (p less than 0.002); no differences in attitudes were found by race or age. Pregnant teens who planned to breast-feed their infants had higher attitude scores than those who planned to bottle feed or who were uncertain (p less than 0.001). Of the sample, 32.4% subsequently breast-fed their baby; these teen mothers had more positive attitude scores than the teen mothers who bottle fed (p less than 0.001). The prenatal infant feeding plans of these pregnant teens were significantly related to their postnatal feeding practices (p less than 0.001). Selected implications of these data for health care professionals are discussed.

PIP: Breastfeeding attitudes of 128 low-income, pregnant adolescents were assessed using a questionnaire developed for the urban population attending the Teen Pregnancy Service of Milwaukee, Wisconsin. The sample was between 13 and 20 years of age (mean age = 17.7 years). There were 14 adolescents 15 years of age or less, 81 teens 16-18 years, and 31 19-20 years. 68% were black, 6% hispanic, 24% white and 2% other. 100% were enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC) 84% were receiving Title 19 benefits. Most were having their 1st child (72%); 21 had 1 other child; 6 had 2, and 2 mothers had 4. Teens who had been breastfed as infants had more positive attitudes than bottle-fed teens (p0.002); no differences in attitudes were found by race or age. Pregnant teens who planned to breastfeed their infants had higher attitude scores than those who planned to bottle feed or who were uncertain (p0.001). Of the sample, 32.4% subsequently breastfed their baby; these teen mothers had more positive attitude scores than the teen mothers who bottle fed (p0.001). The prenatal infant feeding plans of these pregnant teens were significantly related to their postnatal feeding practices (p0.001). Health care professionals could use the breastfeeding questionnaire, combined with information about a pregnant teen's plans for infant feeding, to provide baseline data regarding a pregnant adolescent's breastfeeding attitudes. Such information can be efficiently obtained during an early prenatal visit. Subsequent prenatal visits could correct teen misconceptions about breastfeeding (e.g. results in obesity) and emphasize the positive benefits to the infant and mother. It may be useful to invite the teen's boyfriend and mother, given the impact of these individuals on the teen's breastfeeding attitudes. Once a teen decides to breastfeed, significant support is required following delivery to ensure a positive experience. Studies show a "lactation support team" may make significant changes in increasing the use of breastfeeding.

Third-party payor decisions. Doctor, don't dare be intimidated by them!

The case of Wickline v. State forebodes a new tort: malpractice by a physician who unprotestingly complies with a third-party payor's hospitalization restrictions. Medi-Cal granted this patient only half the hospital stay extension requested by her physicians. Following discharge on the appointed date her condition deteriorated, and ensuing complications resulted in the need for leg amputation. The patient subsequently sued the State for injuries, and won. The State appealed and obtained a reversal of the judgment on the verdict. Despite the fact that the premature discharge led to the need for amputation, the decision to discharge the patient had been made by the physicians, not by Medi-Cal. Therefore, Medi-Cal was not liable.

Outpatient therapy of intra-abdominal abscesses following early discharge from the hospital.

Although percutaneous aspiration and drainage of abdominal abscesses will frequently avert an open surgical procedure, patients remain hospitalized during drainage. The authors treated 9 patients for abscesses using percutaneous drainage catheters and sent them home with the catheter in place. All had an uneventful recovery. An average of $12,050 was saved in each case. The authors suggest that outpatient drainage of abdominal abscesses is significantly less expensive than inpatient treatment, yet does not jeopardize patient care.