Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS).

BACKGROUND: The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes. METHODS: The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort. DISCUSSION: This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes.

Health literacy, numeracy, and other characteristics associated with hospitalized patients' preferences for involvement in decision making.

Little research has examined the association of health literacy and numeracy with patients' preferred involvement in the problem-solving and decision-making process in the hospital. Using a sample of 1,249 patients hospitalized with cardiovascular disease from the Vanderbilt Inpatient Cohort Study (VICS), we assessed patients' preferred level of involvement using responses to two scenarios of differing symptom severity from the Problem-Solving Decision-Making Scale. Using multivariable modeling, we determined the relationship of health literacy, subjective numeracy, and other patient characteristics with preferences for involvement in decisions, and how this differed by scenario. The authors found that patients with higher levels of health literacy desired more participation in the problem-solving and decision-making process, as did patients with higher subjective numeracy skills, greater educational attainment, female gender, less perceived social support, or greater health care system distrust (p<.05 for each predictor in multivariable models). Patients also preferred to participate more in the decision-making process when the hypothetical symptom they were experiencing was less severe (i.e., they deferred more to their physician when the hypothetical symptom was more severe). These findings underscore the role that patient characteristics, especially health literacy and numeracy, play in decisional preferences among hospitalized patients.

Time course of arthralgia among women initiating aromatase inhibitor therapy and a postmenopausal comparison group in a prospective cohort.

BACKGROUND: More than 80,000 postmenopausal breast cancer patients in the United States each year are estimated to begin a 5-year course of aromatase inhibitors (AIs) to prevent recurrence. AI-related arthralgia (joint pain and/or stiffness) may contribute to nonadherence, but longitudinal data are needed on arthralgia risk factors, trajectories, and background in postmenopause. This study sought to describe 1-year arthralgia trajectories and baseline covariates among patients with AI and a postmenopausal comparison group. METHODS: Patients initiating AIs (n = 91) were surveyed at the time of AI initiation and at 6 repeated assessments over 1 year. A comparison group of postmenopausal women without breast cancer (n = 177) completed concomitantly timed surveys. Numeric rating scales (0-10) were used to measure pain in 8 joint pair groups (bilateral fingers, wrists, elbows, shoulders, hips, knees, ankles, and toes). Poisson regression models were used to analyze arthralgia trajectories and risk factors. RESULTS: By week 6, the AI-initiating group had more severe arthralgia than did the comparison group (ratio of means = 1.8, 95% confidence interval = 1.24-2.7, P = .002), adjusting for baseline characteristics. Arthralgia then worsened further over 1 year in the AI group. Menopausal symptom severity and existing joint-related comorbidity at baseline among women initiating AI were associated with more severe arthralgia over time. CONCLUSIONS: Patients initiating AI should be told about the timing of arthralgia over the first year of therapy, and advised that it does not appear to resolve over the course of a year. Menopausal symptoms and joint-related comorbidity at AI initiation can help identify patients at risk for developing AI-related arthralgia.

Measuring social health in the patient-reported outcomes measurement information system (PROMIS): item bank development and testing.

PURPOSE: To develop a social health measurement framework, to test items in diverse populations and to develop item response theory (IRT) item banks. METHODS: A literature review guided framework development of Social Function and Social Relationships sub-domains. Items were revised based on patient feedback, and Social Function items were field-tested. Analyses included exploratory factor analysis (EFA), confirmatory factor analysis (CFA), two-parameter IRT modeling and evaluation of differential item functioning (DIF). RESULTS: The analytic sample included 956 general population respondents who answered 56 Ability to Participate and 56 Satisfaction with Participation items. EFA and CFA identified three Ability to Participate sub-domains. However, because of positive and negative wording, and content redundancy, many items did not fit the IRT model, so item banks do not yet exist. EFA, CFA and IRT identified two preliminary Satisfaction item banks. One item exhibited trivial age DIF. CONCLUSION: After extensive item preparation and review, EFA-, CFA- and IRT-guided item banks help provide increased measurement precision and flexibility. Two Satisfaction short forms are available for use in research and clinical practice. This initial validation study resulted in revised item pools that are currently undergoing testing in new clinical samples and populations.

Integration of the National Comprehensive Cancer Network (NCCN) Distress Screening Tool as a Guidepost for Telephonic Oncology Case Management.

PURPOSE OF STUDY: Cigna's oncology case management programs identified the opportunity for case managers to integrate distress screening as recommended by the National Comprehensive Cancer Network (NCCN) in oncology populations. Our purpose in conducting this study was to quantify oncology case management program improvements as a result of using the NCCN Distress Screening Tool to guide telephonic case management. The program improvements we measured comprised more efficient identification of biopsychosocial problems and appropriate resource referrals. PRIMARY PRACTICE SETTING: Case managers in a large commercial health plan piloted integration of distress screening into telephonic case management among U.S. oncology customers experiencing a new diagnosis or care transition from September 2016 to April 2017. METHODOLOGY AND SAMPLE: A retrospective, matched case-control study was conducted among Cigna customers eligible for oncology case management. The pilot group of 317 received distress screening early in the oncology case management assessment. Outcomes included distress severity ranging from 0 to 10 (where 0 = no distress, 1-3 = mild, 4-7 = moderate, and 8-10 = severe), identification and number of biopsychosocial health problems, and percentage of direct resource referrals by case managers to supportive services. RESULTS: More than half (54%) of the screened customers reported mild or greater distress, and there was a strong correlation between degree of distress and average numbers of biopsychosocial health problems or direct resource referrals. Screened customers were 16% more likely to be referred to internal and external resources than customers not screened with the tool (66% vs. 50%, χp < .001). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This study advances evidence-based oncology case management practice during care transitions by providing quantitative evidence for the utility of integrating the NCCN Distress Screening Tool into telephonic oncology case management. Using the tool (thermometer and problem list) to guide telephonic oncology case management and care coordination facilitated more tailored referrals to individuals with cancer enrolled in a large commercial health plan. On the basis of our findings, we integrated distress screening to address unmet biopsychosocial needs in patients with cancer.

Effectiveness of mailed letters to improve medication adherence among Medicare Advantage Plan participants with chronic conditions.

BACKGROUND: Medication adherence is associated with improved health outcomes in multiple chronic diseases. Information is needed on the effectiveness of specific adherence interventions. This study's objectives were to quantify effects of a targeted mailing intervention on adherence among older adults at risk for nonadherence, and to examine associations of individual and plan characteristics with adherence. MATERIALS AND METHODS: Among adults enrolled in a Medicare Advantage Plan with prescription drug coverage from May 2014 to June 2015, those identified as eligible for the mailing intervention had a late refill for oral antidiabetic medication, statin, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker medication and were previously unreachable by telephone. Pharmacy claims data were analyzed with the outcome of 6-month proportion of days covered (PDC) before and after the mailing. The t-test and chi-square analyses were used to evaluate univariate associations. Multivariable linear and logistic regression models were conducted to assess relative covariate effects. A sub-analysis of those with at least one medication fill post-mailing was also performed. RESULTS: A total of 460 non-adherent individuals aged 70±10.5 years, with 50.2% female and 66.7% white individuals, were included. Of those who were mailed a letter, 24.1% became adherent to the specified maintenance medication. Those who received >30-day supplies were more than twice as likely to become adherent after the mailed letter than those who received 30-day supplies or less (P<0.05). Baseline higher PDC was also associated with greater adherence post-mailing (P<0.01). A total of 284 (61.7%) individuals filled their medication at least once after the mailed letter; of those, 39.1% became adherent (mean [SD] change in PDC =0.15 [±0.28]). CONCLUSION: Our findings suggest that a single mailed letter improved medication adherence by 24.1% in adults with chronic conditions. As a health plan seeking to improve its customers' well-being and outcomes, Cigna continues to utilize targeted mail interventions to improve medication adherence.

Hazards for pain severity and pain interference with daily living, with exploration of brief pain inventory cutpoints, among women with metastatic breast cancer.

Few longitudinal studies have assessed risk factors for pain outcomes in tumor-specific populations. Such studies are needed to improve clinical practice guidelines for cancer pain management over the course of treatment. Among patients with metastatic breast cancer, we assessed the impact of baseline clinical and demographic risk factors on patients reaching different pain severity and interference scores. We analyzed data originally collected in a clinical trial of two bisphosphonate therapies. Pain was measured by the Brief Pain Inventory (BPI) severity and interference with daily living 0-10 subscales. We fit univariate (per-cutpoint) and multivariate (cutpoints 3, 4, 5, 6, and 7 on the BPI) proportional hazards models to identify predictors of pain outcomes over 51 weeks among 1,124 women with metastatic breast cancer. Predictors included race, age, education, geographic region, performance status, chemotherapy versus hormonal therapy only, time from first bone metastasis to randomization, and previous skeletal-related event (SRE, e.g., fractures, spinal cord compression). Non-Caucasian women had greater hazards for reaching higher cutpoints (5 and above) on the severity scale than Caucasian women (hazard ratio [HR] for cutpoint 5 interaction term=1.76; 95% confidence interval [CI]=1.37-2.26). For the interference scale, these hazards were greater for those patients with restricted (versus active) baseline Eastern Cooperative Oncology Group (ECOG) performance status (HR for cutpoint 5 interaction term=2.51; 95% CI=2.01-3.13). In the multivariate severity model, other factors associated with higher pain severity were restricted baseline ECOG performance status, previous SRE, and not being employed full-time at baseline (HRs=1.70, 1.23, and 1.33, respectively). Our findings that non-Caucasian race and restricted performance status were associated with greater pain hazards over time confirm previous cross-sectional findings that these characteristics are pain risk factors. Because we found that the most influential demographic and clinical baseline factors had predictive value for worsening outcomes as early as cutpoint 5, we recommend that pain management strategies use cutpoints informed by risk factors for worsening outcomes as cues for earlier intervention, thus delaying or preventing worst pain among women with metastatic disease who are at greatest risk.

Lumbar fusion surgery for degenerative conditions is associated with significant resource and narcotic use 2 years postoperatively in the commercially insured: a medical and pharmacy claims study.

BACKGROUND: Chronic back pain is one of the costliest and most complex medical conditions to manage, involving physiological, psychological, mechanical, social, and environmental factors. An increasing trend of lumbar fusion (LF) surgery for chronic back pain continues despite conflicting evidence for pain relief or improved long-term outcomes. Our goal was to assess medical and pharmacy utilization (including continued use of pain medication) over a 2-year period among patients receiving LF to relieve back pain for degenerative conditions without instability. METHODS: We conducted a 2-year longitudinal cohort study of 1,422 commercially insured patients who received LF from January through September 2009, and who had continuous benefit eligibility through 2011. We assessed resource use among patients with ICD-9-CM diagnostic codes consistent with a degenerative condition, identified from Cigna's national claim database (CPT codes 22612, 22630 and/or 22558). Patients with fracture, tumor, infection, spondylolisthesis, inflammatory arthritis, or deformity diagnostic codes were excluded. RESULTS: Over the 2 years following LF, 992 patients (70%) incurred $9.0 million in additional medical claims payments which averaged $9,383 per patient. These payments included pain management interventions and long term therapy services in 30% of patients. A subset of 850 patients (60%) also had pharmacy benefits and 829 (97.5%) received multiple pain-related classes of medication over the same period. The majority of patients continued on chronic narcotic use (62.5%), and 95% of patients on narcotics preoperatively continued narcotic utilization at two years. This pharmacy benefit subset incurred an additional $2.2 million for pain-related medications at an average cost of $2,600 per patient. Total average payment for patients with combined medical and pharmacy benefits was $12,283. CONCLUSIONS: LF for patients with a degenerative lumbar diagnosis incurred significant resources postoperatively, and was followed by long-term pain and psychotropic medication utilization.

Cost drivers for breast, lung, and colorectal cancer care in a commercially insured population over a 6-month episode: an economic analysis from a health plan perspective.

AIMS: In the absence of clinical data, accurate identification of cost drivers is needed for economic comparison in an alternate payment model. From a health plan perspective using claims data in a commercial population, the objective was to identify and quantify the effects of cost drivers in economic models of breast, lung, and colorectal cancer costs over a 6-month episode following initial chemotherapy. RESEARCH DESIGN AND METHODS: This study analyzed claims data from 9,748 Cigna beneficiaries with diagnosis of breast, lung, and colorectal cancer following initial chemotherapy from January 1, 2014 to December 31, 2015. We used multivariable regression models to quantify the impact of key factors on cost during the initial 6-month cancer care episode. RESULTS: Metastasis, facility provider affiliation, episode risk group (ERG) risk score, and radiation were cost drivers for all three types of cancer (breast, lung, and colorectal). In addition, younger age (p < .0001) and human epidermal growth factor receptor-2 oncogene overexpression (HER2+)-directed therapy (p < .0001) were associated with higher costs in breast cancer. Younger age (p < .0001) and female gender (p < .0001) were also associated with higher costs in colorectal cancer. Metastasis was also associated with 50% more hospital admissions and increased hospital length of stay (p < .001) in all three cancers over the 6-month episode duration. Chemotherapy and supportive drug therapies accounted for the highest proportion (48%) of total medical costs among beneficiaries observed. CONCLUSIONS: Value-based reimbursement models in oncology should appropriately account for key cost drivers. Although claims-based methodologies may be further augmented with clinical data, this study recommends adjusting for the factors identified in these models to predict costs in breast, lung, and colorectal cancers.

Economic and Clinical Outcomes Resulting From the Stage 4 Chronic Kidney Disease Case Management Quality Improvement Initiative.

PURPOSE OF STUDY: Chronic kidney disease (CKD) is a costly and burdensome public health concern. The goal of this study was to evaluate the impact on outcomes and utilization of a pilot program to identify and engage beneficiaries with CKD at risk for progression from Stage 4 to Stage 5. PRIMARY PRACTICE SETTINGS: A quality improvement initiative was conducted to assess the impact of case management on costs and outcomes among 7,720 Cigna commercial medical beneficiaries with Stage 4 CKD enrolled in the United States between January 2012 and October 2012. METHODOLOGY AND SAMPLE: Claims data were analyzed to compare 3,861 beneficiaries randomized to receive condition-focused case management with 3,859 controls, with follow-up through July 2013. After using an algorithm to identify beneficiaries at highest risk of progression, a case management team implemented, among those assigned to the intervention, an evidence-based assessment tool, provided education and follow-up, engaged nephrologists and other providers, and conducted weekly rounds. Primary outcome measures were hospital admissions, emergency department visits, nephrologist visits, dialysis, arteriovenous (AV) fistula creation, and total medical costs. Analysis of variance techniques were used to test group differences. RESULTS: As compared with controls, intervention beneficiaries were 12% more likely to have fistula creation (p = .004). Intervention beneficiaries were observed to have savings of $199 per member per month (PMPM), F = 23.05, p = .04. This difference equated to 6% lower total medical costs in the intervention group. Savings observed were derived half from improved in-network utilization and half from reduced hospital costs. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: .

A Systematic Review and Meta-Analysis of Randomized and Nonrandomized Trials of Clinical Emotional Freedom Techniques (EFT) for the Treatment of Depression.

BACKGROUND: Among a group of therapies collectively known as energy psychology (EP), emotional freedom techniques (EFT) is the most widely practiced. Clinical EFT is an evidence-based practice combining elements of cognitive and exposure therapies with the manual stimulation of acupuncture points (acupoints). Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of outcomes after clinical EFT treatment in reducing depression. METHODS: All studies (2005-2015) evaluating EFT for sufferers of depression were identified by electronic search; these included both outcome studies and randomized controlled trials (RCTs). Our focus was depressive symptoms as measured by a variety of psychometric questionnaires and scales. We used meta-analysis to calculate effect sizes at three time points including posttest, follow-ups less than 90 days, and follow-ups more than 90 days. RESULTS: In total, 20 studies were qualified for inclusion, 12 RCTs and 8 outcome studies. The number of participants treated with EFT included N = 461 in outcome studies and N = 398 in RCTs. Clinical EFT showed a large effect size in the treatment of depression in RCTs. At posttest, Cohen׳s d for RCTs was 1.85 and for outcome studies was 0.70. Effect sizes for follow-ups less than 90 days were 1.21, and for ≥ 90 days were 1.11. EFT were more efficacious than diaphragmatic breathing (DB) and supportive interview (SI) in posttest measurements (P = .06 versus DB, P < .001 versus SI), and sleep hygiene education (SHE) at follow-up (P = .036). No significant treatment effect difference between EFT and eye movement desensitization and reprocessing (EMDR) was found. EFT were superior to treatment as usual (TAU), and efficacious in treatment time frames ranging from 1 to 10 sessions. The mean of symptom reductions across all studies was -41%. CONCLUSIONS: The results show that Clinical EFT were highly effective in reducing depressive symptoms in a variety of populations and settings. EFT were equal or superior to TAU and other active treatment controls. The posttest effect size for EFT (d = 1.31) was larger than that measured in meta-analyses of antidepressant drug trials and psychotherapy studies. EFT produced large treatment effects whether delivered in group or individual format, and participants maintained their gains over time. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of depression improvement subsequent to EFT treatment.

Perceptions of patients and physicians regarding phase I cancer clinical trials: implications for physician-patient communication.

PURPOSE: To describe and compare the perceptions of cancer patients and their physicians regarding phase I clinical trials. METHODS: Eligible patients had been offered phase I trial participation and had decided to participate but had not yet begun treatment. Each patient's physician also served as a study subject. Patients and physicians completed questionnaires with domains including perceptions of potential benefit and harm from treatment (experimental and standard), relative value of quality and length of life, and perceived content of patient-physician consultations. RESULTS: Three hundred twenty-eight patients and 48 physicians completed surveys. Patients had high expectations regarding treatment outcomes (eg, median 60% benefit from experimental therapy), with those choosing to participate in a phase I trial being more optimistic than those declining phase I participation. Patients predicted a higher likelihood of both benefit and adverse reactions from treatment (experimental and standard) than their physicians (P <.0001 for all comparisons). Although 95% of patients reported that quality of life was at least as important as length of life, only 28% reported that changes in quality of life with treatment were discussed with their physicians. In contrast, 73% of physicians reported that this topic was discussed (P <.0001). CONCLUSION: Cancer patients offered phase I trial participation have expectations for treatment benefit that exceed those of their physicians. The discordant perceptions of patients and physicians may possibly be explained by patient optimism and confidence; however, the discrepancies in reports of consultation content, particularly given patients' stated values regarding quality of life, raise the possibility that communication in this context is suboptimal.

Validity and reliability of the Patient-Reported Arthralgia Inventory: validation of a newly-developed survey instrument to measure arthralgia.

BACKGROUND: There is a need for a survey instrument to measure arthralgia (joint pain) that has been psychometrically validated in the context of existing reference instruments. We developed the 16-item Patient-Reported Arthralgia Inventory (PRAI) to measure arthralgia severity in 16 joints, in the context of a longitudinal cohort study to assess aromatase inhibitor-associated arthralgia in breast cancer survivors and arthralgia in postmenopausal women without breast cancer. We sought to evaluate the reliability and validity of the PRAI instrument in these populations, as well as to examine the relationship of patient-reported morning stiffness and arthralgia. METHODS: We administered the PRAI on paper in 294 women (94 initiating aromatase inhibitor therapy and 200 postmenopausal women without breast cancer) at weeks 0, 2, 4, 6, 8, 12, 16, and 52, as well as once in 36 women who had taken but were no longer taking aromatase inhibitor therapy. RESULTS: Cronbach's alpha was 0.9 for internal consistency of the PRAI. Intraclass correlation coefficients of test-retest reliability were in the range of 0.87-0.96 over repeated PRAI administrations; arthralgia severity was higher in the non-cancer group at baseline than at subsequent assessments. Women with joint comorbidities tended to have higher PRAI scores than those without (estimated difference in mean scores: -0.3, 95% confidence interval [CI] -0.5, -0.2; P<0.001). The PRAI was highly correlated with the Functional Assessment of Cancer Therapy-Endocrine Subscale item "I have pain in my joints" (reference instrument; Spearman r range: 0.76-0.82). Greater arthralgia severity on the PRAI was also related to decreased physical function (r=-0.47, 95% CI -0.55, -0.37; P<0.001), higher pain interference (r=0.65, 95% CI 0.57-0.72; P<0.001), less active performance status (estimated difference in location (-0.6, 95% CI -0.9, -0.4; P<0.001), and increased morning stiffness duration (r=0.62, 95% CI 0.54-0.69; P<0.0001). CONCLUSION: We conclude that the psychometric properties of the PRAI are satisfactory for measuring arthralgia severity.

An exploration of relative health stock in advanced cancer patients.

OBJECTIVE: The authors sought to empirically test whether relative health stock, a measure of patients' sense of loss in their health due to illness, influences the treatment decisions of patients facing life-threatening conditions. Specifically, they estimated the effect of relative health stock on advanced cancer patients' decisions to participate in phase I clinical trials. METHOD: A multicenter study was conducted to survey 328 advanced cancer patients who were offered the opportunity to participate in phase I trials. The authors asked patients to estimate the probabilities of therapeutic benefits and toxicity, their relative health stock, risk preference, and the importance of quality of life. RESULTS: Controlling for health-related quality of life, an increase in relative health stock by 10 percentage points reduced the odds of choosing to participate in a phase I trial by 16% (odds ratio = 0.84, 95% confidence interval = 0.72, 0.97). CONCLUSION: Relative health stock affects advanced cancer patients' treatment decisions.

Toward estimating the impact of changes in immigrants' insurance eligibility on hospital expenditures for uncompensated care.

BACKGROUND: The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Our goal was to assess the effect of PRWORA on hospital uncompensated care in the United States. METHODS: We collected the following state-level data for the period from 1994 through 1999: foreign-born, noncitizen population and health uninsurance rates (US Census Current Population Survey); percentage of teaching hospitals (American Hospital Association Annual Survey of Hospitals); and each state's decision whether to implement the PRWORA Medicaid bar for legal permanent residents or to continue offering nonemergency Medicaid coverage using state-only funds (Urban Institute). We modeled uncompensated care expenditures by state (also from the Annual Survey of Hospitals) in both univariate and multivariable regression analyses. RESULTS: When measured at the state level, there was no significant relationship between uncompensated care expenditures and states' percentage of noncitizen immigrants. Uninsurance rates were the only significant factor in predicting uncompensated hospital care expenditures by state. CONCLUSIONS: Reducing the number of uninsured patients would most surely reduce hospital expenditures for uncompensated care. However, data limitations hampered our efforts to obtain a monetary estimate of hospitals' financial losses due specifically to the immigrant eligibility changes in PRWORA. Quantifying the impact of these provisions on hospitals will require better data sources.

Spine and pain clinics serving North Carolina patients with back and neck pain: what do they do, and are they multidisciplinary?

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: Our primary objective was to describe spine and pain clinics serving North Carolina residents with respect to organizational characteristics. Our secondary objective was to assess the multidisciplinary nature of the clinics surveyed. SUMMARY OF BACKGROUND DATA: Pain clinics have become common in the United States, and patients with chronic back pain have increasingly been seeking services at these clinics. Little is known about the organizational characteristics of spine and pain clinics. METHODS: We identified and surveyed spine and pain clinics serving North Carolina residents with chronic back and neck pain. Practice managers at 46 clinics completed a 20-minute questionnaire about the characteristics of their clinic, including providers on staff and services offered. Descriptive and exploratory analyses were conducted to summarize the data. Several variables were constructed to assess the multidisciplinary nature of the clinics. RESULTS: The response rate was 75%. There was marked heterogeneity among the clinics surveyed. Fifty-nine percent of practices were free-standing (n = 27) and 61% were physician-owned (n = 28). Twenty-five clinics (54%) had an anesthesiologist. Other common physician providers were physiatrists and surgeons. Less than one third of sites had mental health providers (n = 12; 26%); only 26% employed physical therapists. Seventy-six percent of sites offered epidural injections, 74% long-term narcotic prescriptions, and 67% antidepressants. The majority of clinics (30 of 33) prescribing narcotics provided monitoring of therapy using periodic urine toxicology testing. Forty-eight percent of sites (n = 22) offered exercise instruction. Few clinics were multidisciplinary in nature. Only 3 (7%) met the criteria of having a medical physician, registered nurse, physical therapist, and mental health specialist. CONCLUSION: Clinics varied widely in their organizational characteristics, including providers and scope of services available. Few clinics were multidisciplinary in nature. This information should be used to determine how pain clinics can better serve patients and improve outcomes.

A long way to go: practice patterns and evidence in chronic low back pain care.

STUDY DESIGN: A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006. OBJECTIVE: The primary objectives of these analyses were to describe health care use (providers, medications, treatments, diagnostic tests) for chronic low back pain (LBP) and relate current patterns of use to current best evidence for care of the condition. SUMMARY OF BACKGROUND DATA: Chronic LBP is common and expensive. Prior research on care utilization often was derived from medical claims databases, reflecting reimbursed health care use, often by one payer. METHODS: Five thousand three hundred fifty-seven households were contacted in 2006 to identify 732 noninstitutionalized adults 21 years and older with chronic LBP. Five hundred ninety individuals sought care. Patient reported health care utilization, comparison with efficacy was demonstrated by current systematic reviews. RESULTS: Individuals with chronic back pain were middle-aged (mean age 53 years), and the majority were women (62%). Provider and treatment use was common and varied. Sixty percent used narcotics in the previous month. The mean number of provider visits was 21, and over one-third had an advanced imaging procedure in the past year. Physical treatments were common, and often not supported by evidence. Only 3% had engaged in a formal spine rehabilitation program. Half of patients not taking antidepressants were positive on a 2-item depression screen. Although this study was population-based, it was conducted in only one state. CONCLUSION: Provider and treatment use for chronic LBP are both very common and varied. Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.

Exercise prescription for chronic back or neck pain: who prescribes it? who gets it? What is prescribed?

OBJECTIVE: To describe exercise prescription in routine clinical practice for individuals with chronic back or neck pain because, although current practice guidelines promote exercise for chronic back and neck pain, little is known about exercise prescription in routine care. METHODS: We conducted a computer-assisted telephone survey of a representative sample of individuals (n = 684) with chronic back or neck pain who saw a physician, chiropractor, and/or physical therapist (PT) in the past 12 months. Individuals were asked about whether they were prescribed exercise, the amount of supervision received, and the type, duration, and frequency of the prescribed exercise. Descriptive and multivariable regression analyses were conducted. RESULTS: Of the 684 subjects, 48% were prescribed exercise. Of those prescribed exercise, 46% received the prescription from a PT, 29% from a physician, 21% from a chiropractor, and 4% from other. In multivariable analyses, seeing a PT or a chiropractor were the strongest predictors of exercise prescription. The likelihood of exercise prescription was increased in women, those with higher education, and those receiving worker's compensation. PTs were more likely to provide supervision and prescribe strengthening exercises compared with physicians and chiropractors, and were more likely to prescribe stretching exercises compared with physicians. CONCLUSION: Our findings suggest that exercise is being underutilized as a treatment for chronic back and neck pain and, to some extent, that the amount of supervision and types of exercises prescribed do not follow current practice guidelines. Exercise prescription provided by PTs appears to be most in line with current guidelines.

The rising prevalence of chronic low back pain.

BACKGROUND: National or state-level estimates on trends in the prevalence of chronic low back pain (LBP) are lacking. The objective of this study was to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care-seeking characteristics of individuals with the condition have changed over the last 14 years. METHODS: A cross-sectional, telephone survey of a representative sample of North Carolina households was conducted in 1992 and repeated in 2006. A total of 4437 households were contacted in 1992 and 5357 households in 2006 to identify noninstitutionalized adults 21 years or older with chronic (>3 months), impairing LBP or neck pain that limits daily activities. These individuals were interviewed in more detail about their health and health care seeking. RESULTS: The prevalence of chronic, impairing LBP rose significantly over the 14-year interval, from 3.9% (95% confidence interval [CI], 3.4%-4.4%) in 1992 to 10.2% (95% CI, 9.3%-11.0%) in 2006. Increases were seen for all adult age strata, in men and women, and in white and black races. Symptom severity and general health were similar for both years. The proportion of individuals who sought care from a health care provider in the past year increased from 73.1% (95% CI, 65.2%-79.8%) to 84.0% (95% CI, 80.8%-86.8%), while the mean number of visits to all health care providers were similar (19.5 [1992] vs 19.4 [2006]). CONCLUSIONS: The prevalence of chronic, impairing LBP has risen significantly in North Carolina, with continuing high levels of disability and health care use. A substantial portion of the rise in LBP care costs over the past 2 decades may be related to this rising prevalence.