The Global Burden of Musculoskeletal Pain-Where to From Here?

To summarize the current understanding of the global burden of musculoskeletal pain-related conditions, consider the process of evidence generation and the steps to generate global pain estimates, identify key gaps in our understanding, and propose an agenda to address these gaps, we performed a narrative review. In the 2010 Global Burden of Disease Study (GBD), which broadened the scope of musculoskeletal conditions that were included over previous rounds, low back pain imposed the highest disability burden of all specific conditions assessed, and subsequent GBD reports further reinforce the size of this burden. Over the past decade, the GBD has produced compelling evidence of the leading contribution of musculoskeletal pain conditions to the global burden of disability, but this has not translated into global health policy initiatives. However, system- and service-level responses to the disease burden persist across high-, middle-, and low-income settings. There is a mismatch between the burden of musculoskeletal pain conditions and appropriate health policy response and planning internationally that can be addressed with an integrated research and policy agenda.

Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice.

Musculoskeletal health conditions such as arthritis, osteoporosis and pain syndromes impart a profound socioeconomic burden worldwide, particularly in developed nations such as Australia. Despite the identified burden, substantial evidence-practice and care disparity gaps remain in service delivery and access that limit the potential for improved consumer outcomes and system efficiencies. Addressing these gaps requires a whole-of-sector response, supported by evidence-informed health policy. Models of care (MoCs) serve as a policy vehicle to embed evidence into health policy and guide practice through changes in service delivery systems and clinician behaviour. In Australia, MoCs for musculoskeletal health have been developed by networks of multidisciplinary stakeholders and are incrementally being implemented across health services, facilitated by dedicated policy units and clinical champions. A web of evidence is now emerging to support this approach to driving evidence into health policy and practice. Understanding the vernacular of MoCs and the development and implementation of MoCs is important to embracing this approach to health policy.

Placing the global burden of low back pain in context.

The latest Global Burden of Disease Study, published at the end of 2012, has highlighted the enormous global burden of low back pain. In contrast to the previous study, when it was ranked 105 out of 136 conditions, low back pain is now the leading cause of disability globally, ahead of 290 other conditions. It was estimated to be responsible for 58.2 million years lived with disability in 1990, increasing to 83 million in 2010. This chapter illustrates the ways that the Global Burden of Disease data can be displayed using the data visualisation tools specifically designed for this purpose. It also considers how best to increase the precision of future global burden of low back pain estimates by identifying limitations in the available data and priorities for further research. Finally, it discusses what should be done at a policy level to militate against the rising burden of this condition.

Associations between drug burden index and falls in older people in residential aged care.

OBJECTIVES: To evaluate the association between the Drug Burden Index (DBI), a measure of a person's total exposure to anticholinergic and sedative medications that includes principles of dose-response and maximal effect and is associated with impaired physical function in community-dwelling older people, and falls in residents of residential aged care facilities (RACFs). DESIGN: Data were drawn from participants in a randomized controlled trial that investigated falls and fractures. SETTING: RACFs in Sydney, Australia. PARTICIPANTS: Study participants (N=602; 70.9% female) were recruited from 51 RACFs. Mean age was 85.7 ± 6.4, and mean DBI was 0.60 ± 0.66. MEASUREMENTS: Medication history was obtained on each participant. Drugs were classified as anticholinergic or sedative and a DBI was calculated. Falls were measured over a 12-month period. Comorbidity, cognitive impairment (Mini-Mental State Examination) and depression (Geriatric Depression Scale) were determined. RESULTS: There were 998 falls in 330 individuals during a follow-up period of 574.2 person-years, equating to an average rate of 1.74 falls per person-year. The univariate negative binomial regression model for falls showed incidence rate ratios of 1.69 (95% confidence interval (CI)=1.22-2.34) for low DBI (<1) and 2.11 (95% CI=1.47-3.04) for high DBI (≥1) when compared with those who had a DBI of 0. After adjusting for age, sex, history of falling, cognitive impairment, depression, use of a walking aid, comorbidities, polypharmacy, and incontinence, incident rate ratios of 1.61 (95% CI=1.17-2.23) for low DBI and 1.90 (95% CI=1.30-2.78) for high DBI were obtained. CONCLUSION: DBI is significantly and independently associated with falls in older people living in RACFs. Interventional studies designed for this population are needed to determine whether reducing DBI, through dose reduction or cessation of anticholinergic and sedative drugs, can prevent falls.

Should response rules be used to decide continued subsidy of very expensive drugs? A checklist for decision makers.

Response rules are increasingly used by the Pharmaceuticals Benefits Scheme (PBS) in Australia and the National Institute of Clinical Excellence (NICE) in the U.K. to limit continued subsidy of very expensive drugs to patients who demonstrate an 'adequate' response. By targeting therapy to patients who appear to benefit most, policy makers aim to increase the cost-effectiveness of therapy. However, the value of response rules in fulfilling this aim is unproven. We present a four-item checklist that may be used to help decision makers identify when a response rule is appropriate. As an example, we apply our checklist to the response rules used for tumour necrosis factor (TNF) inhibitors in rheumatoid arthritis. On the basis of the checklist we find that the response rules in both countries are inadequate and may cause therapy to be inappropriately ceased in some and continued in others. Careful assessment is needed before decision makers adopt a response rule as a way of increasing the cost effectiveness of therapy.

Progress on incorporating the patient perspective in outcome assessment in rheumatology and the emergence of life impact measures at OMERACT 9.

The Patient Perspective Workshop included over 100 researchers and 18 patient participants from 8 countries. Following preconference reading and short plenary presentations, breakout groups considered work undertaken on measurement of sleep, assessing interventions to develop the effective consumer, and assessing psychological and educational interventions. The workshop explored the best way to identify other outcome domains (and instruments) that should be measured in observational or interventional studies with broader intentions than simply altering outcomes captured in the traditional "core set" plus fatigue. Four sleep questionnaires showed promise and will be the subject of further study. The Effective Consumer scale (EC-17) was reviewed and the concept Effective Consumer was well received. Participants thought it worthwhile to measure the skills and attributes of an effective consumer and develop an intervention that would include education in all of the scale's categories. Assessment of educational and psychological interventions requires a wider set of instruments than is currently used; these should relate to the purpose of the intervention. This principle was extended to include wider measures of the impact of disease on life, as indicated in the International Classification of Functioning, Disability and Health. Life impact measure sets covering domains appropriate to different rheumatic conditions and focused on different interventions might be defined by future OMERACT consensus. Measurement instruments within these domains that are valid for use in rheumatic conditions can then be identified and, in the case of psychological and educational interventions, chosen to fit with the purpose of the intervention.

Fracture risk assessment in frail older people using clinical risk factors.

BACKGROUND: this study aims to develop and evaluate a simple fracture risk index for use in frail older people. METHODS: clinical risk factors were assessed at baseline for 2,005 older people (473 males, 1,532 females; mean age 85.7 years, SD 7.1 years) living in aged-care facilities. Fractures were ascertained for 2 years from baseline. Cox regression model was used to identify significant risk factors for fracture. Hazard ratios (HRs) from the model were assigned as weights. The risk index was calculated by multiplying the weights of all risk factors. RESULTS: during a mean follow-up of 1.64 years, 401 fractures occurred in 338 participants. Significant independent clinical risk factors for fracture were institution type, balance, history of previous fracture, cognitive function, number of medications, weight and lower leg length (n = 1,813). The index was capable of identifying higher-risk individuals, with almost an 8-fold increase in the risk of fracture for residents from the lowest 15% to the highest 18% of the score. Among 1-year survivors, a high score (>or=15) indicated approximately a one-in-six chance of fracture, while a low score (<8) indicated only a one-in-forty chance of fracture within a year. The area under the receiver operating characteristic (ROC) curve was 0.69 (95% CI: 0.65-0.72) and 0.68 (95% CI: 0.65-0.71) for identifying someone who would have a fracture in 1 and 2 years respectively. CONCLUSIONS: this risk index could identify individuals at higher fracture risk among institutionalised older people, and thus, could help to rationalise the provision of fracture prevention programs in this population.

Chronic pain and reduced work effectiveness: the hidden cost to Australian employers.

Cost estimates of the impact of chronic pain on work have largely focussed on absenteeism, excluding the hidden contribution of reduced work effectiveness to lost productivity. This paper aims to estimate the cost of lost productivity due to chronic pain in Australia, not only in terms of absenteeism but also reduced work effectiveness. Data on chronic pain in Australia and its impact on work were obtained from the 1997 New South Wales Health Survey (n=17,543) and the Northern Sydney Area Pain Study (n=2,092), both of which were population-based and used random-digit dialing sampling methods. This was combined with relevant Australian population and labour force data obtained from the Australian Bureau of Statistics. From this we estimated annual lost productivity costs arising from both chronic pain-related days absent and 'reduced-effectiveness workdays'. There were estimated to be 9.9 million workdays absent due to chronic pain annually in Australia, equating to a cost of AUD 1.4 billion per annum. Under the assumption that reduced-effectiveness workdays affect productivity costs in the same way as lost work days, the total number of lost workday equivalents was 36.5 million, with the total annual cost of lost productivity due to chronic pain estimated as AUD 5.1 billion per annum. In conclusion, while the impact of reduced work effectiveness on days worked with pain on productivity is uncertain, it has the potential to account for the majority of lost productivity costs associated with chronic pain. Interventions which target working despite pain have the potential to significantly reduce lost productivity costs due to chronic pain.

Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: a comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis.

OBJECTIVES: To analyse the differences in patient health outcomes and out-of-pocket costs following hip and knee joint replacement for osteoarthritis between patients who went home immediately after the acute care hospital stay and those who were admitted to inpatient rehabilitation care before going home. METHODS: One hundred and eighteen patients undergoing total hip or knee replacement in Sydney, Australia completed cost diaries, SF-36 and WOMAC Index, pre-operatively and for one year post-operatively. RESULTS: The health status of all groups improved significantly from before surgery to 12 months post-surgery. No significant difference in health status at 12 months post-surgery was seen between home and rehabilitation patients for either hip or knee replacement. Both hip replacement home and rehabilitation patients and knee replacement home patients reported lower out-of-pocket expenditure from before surgery to 1 year post-surgery. DISCUSSION: The majority of total joint replacement patients can be discharged directly home and achieve excellent outcomes at 12 months post-surgery. We would recommend more focused randomized studies to explore the most suitable patient selection for rehabilitation.

Chronic pain, work performance and litigation.

The overall population impact of chronic pain on work performance has been underestimated as it has often been described in terms of work-related absence, excluding more subtle effects that chronic pain may have on the ability to work effectively. Additionally, most studies have focussed on occupational and/or patient cohorts and treatment seeking, rather than sampling from the general population. We undertook a population-based random digit dialling computer-assisted telephone survey with participants randomly selected within households in order to measure the impact of chronic pain on work performance. In addition, we measured the association between pain-related disability and litigation. The study took place in Northern Sydney Health Area, a geographically defined urban area of New South Wales, Australia, and included 484 adults aged 18 or over with chronic pain. The response rate was 73.4%. Working with pain was more common (on an average 83.8 days in 6 months) than lost work days due to pain (4.5 days) among chronic pain participants in full-time or part-time employment. When both lost work days and reduced-effectiveness work days were summed, an average of 16.4 lost work day equivalents occurred in a 6-month period, approximately three times the average number of lost work days. In multiple logistic regression modelling with pain-related disability as the dependent variable, past or present pain-related litigation had the strongest association (odds ratio (OR)=3.59, P=0.001). In conclusion, chronic pain had a larger impact on work performance than has previously been recognised, related to reduced performance while working with pain. A significant proportion were able to work effectively with pain, suggesting that complete relief of pain may not be an essential therapeutic target. Litigation (principally work-related) for chronic pain was strongly associated with higher levels of pain-related disability, even after taking into account other factors associated with poor functional outcomes.