Long-term Outcomes in Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators Compared With Conventional Medical Therapy for Chronic Pain.

Importance: Spinal cord stimulators (SCSs) are increasingly used for the treatment of chronic pain. There is a need for studies with long-term follow-up. Objective: To determine the comparative effectiveness and costs of SCSs compared with conventional medical management (CMM) in a large cohort of patients with chronic pain. Design, Setting, and Participants: This was a 1:5 propensity-matched retrospective comparative effectiveness research analysis of insured individuals from April 1, 2016, to August 31, 2018. This study used administrative claims data, including longitudinal medical and pharmacy claims, from US commercial and Medicare Advantage enrollees 18 years or older in Optum Labs Data Warehouse. Patients with incident diagnosis codes for failed back surgery syndrome, complex regional pain syndrome, chronic pain syndrome, and other chronic postsurgical back and extremity pain were included in this study. Data were analyzed from February 1, 2021, to August 31, 2022. Exposures: SCSs or CMM. Main Outcomes and Measures: Surrogate measures for primary chronic pain treatment modalities, including pharmacologic and nonpharmacologic pain interventions (epidural and facet corticosteroid injections, radiofrequency ablation, and spine surgery), as well as total costs. Results: In the propensity-matched population of 7560 patients, mean (SD) age was 63.5 (12.5) years, 3080 (40.7%) were male, and 4480 (59.3%) were female. Among matched patients, during the first 12 months, patients treated with SCSs had higher odds of chronic opioid use (adjusted odds ratio [aOR], 1.14; 95% CI, 1.01-1.29) compared with patients treated with CMM but lower odds of epidural and facet corticosteroid injections (aOR, 0.44; 95% CI, 0.39-0.51), radiofrequency ablation (aOR, 0.57; 95% CI, 0.44-0.72), and spine surgery (aOR, 0.72; 95% CI, 0.61-0.85). During months 13 to 24, there was no significant difference in chronic opioid use (aOR, 1.06; 95% CI, 0.94-1.20), epidural and facet corticosteroid injections (aOR, 1.00; 95% CI, 0.87-1.14), radiofrequency ablation (aOR, 0.84; 95% CI, 0.66-1.09), or spine surgery (aOR, 0.91; 95% CI, 0.75-1.09) with SCS use compared with CMM. Overall, 226 of 1260 patients (17.9%) treated with SCS experienced SCS-related complications within 2 years, and 279 of 1260 patients (22.1%) had device revisions and/or removals, which were not always for complications. Total costs of care in the first year were $39 000 higher with SCS than CMM and similar between SCS and CMM in the second year. Conclusions and Relevance: In this large, real-world, comparative effectiveness research study comparing SCS and CMM for chronic pain, SCS placement was not associated with a reduction in opioid use or nonpharmacologic pain interventions at 2 years. SCS was associated with higher costs, and SCS-related complications were common.

Health Care Coverage and Access Among Children, Adolescents, and Young Adults, 2010-2016: Implications for Future Health Reforms.

PURPOSE: We examine changes to health insurance coverage and access to health care among children, adolescents, and young adults since the implementation of the Affordable Care Act. METHODS: Using the National Health Interview Survey, bivariate and logistic regression analyses were conducted to compare coverage and access among children, young adolescents, older adolescents, and young adults between 2010 and 2016. RESULTS: We show significant improvements in coverage among children, adolescents, and young adults since 2010. We also find some gains in access during this time, particularly reductions in delayed care due to cost. While we observe few age-group differences in overall trends in coverage and access, our analysis reveals an age-gradient pattern, with incrementally worse coverage and access rates for young adolescents, older adolescents, and young adults. CONCLUSIONS: Prior analyses often group adolescents with younger children, masking important distinctions. Future reforms should consider the increased coverage and access risks of adolescents and young adults, recognizing that approximately 40% are low income, over a third live in the South, where many states have not expanded Medicaid, and over 15% have compromised health.

Inpatient hospital utilization among the uninsured near elderly: data and policy implications for West Virginia.

OBJECTIVE: To inform state policy discussions about the insurance coverage of the near elderly in West Virginia (WV) and the impact of the uninsured near elderly on hospitals in the state. DATA SOURCES: 2003 West Virginia Uniform Bill (UB) hospital discharge data. The data represent all adult inpatient discharges in the state during the year. STUDY DESIGN: We compare the near elderly with other adults and examine differences by insurance status. Key variables include volume of discharges, health insurance coverage, patient characteristics, and charges incurred. FINDINGS: The near elderly constitute the largest group of nonelderly adult inpatient hospital discharges. They are more likely than younger adults to be admitted for emergency conditions; have comorbidities and complications; have longer hospital stays; and incur higher charges on average. Although the near elderly are least likely to be uninsured, they represent the second largest group of uninsured discharges and incur the most in uninsured charges. CONCLUSIONS: The specific needs of the near elderly warrant consideration in WV's (and other states') ongoing development and evaluation of policies aimed at reducing uncompensated care costs, including programs to expand access to health insurance and primary and mental health care among the uninsured.

The implications of cultural orientation for substance use among American Indians.

American Indians were interviewed about their participation in traditional culture and their substance use behaviors. Analyses indicated that cultural orientation differed by age and employment status. Bicultural or less Indian oriented individuals were more likely to misuse alcohol than their more Indian oriented counterparts. The implications of cultural orientation for substance use behaviors are discussed. The need for more precise conceptualization and measurement of acculturation is recommended.