Relationship of American Spinal Injury Association Impairment Scale Grade to Post-injury Hospitalization and Costs in Thoracic Spinal Cord Injury.

BACKGROUND: The lifetime economic burden of thoracic spinal cord injury (SCI) is known to be high, but evidence of variability of costs in relation to the American Spinal Injury Association Impairment Scale (AIS) grade is limited. OBJECTIVE: To estimate lifetime economic costs of hospitalization by AIS grade in thoracic SCI. METHODS: Using SCI Model Systems data from January 2000 to March 2016 from the National Spinal Cord Injury Statistical Center, we estimated mean total annual days of all-cause hospitalization by AIS grade among persons with thoracic SCI, based on assessments 1, 5, and 10 yr post-injury. We combined this information with secondary cost data and projections of life expectancy to estimate lifetime economic costs of hospitalization by AIS grade in persons aged 35 yr at time of thoracic SCI. Future costs were discounted to present value at 3% annually. RESULTS: One year post-injury, mean total annual days of hospitalization ranged from 2.1 for persons with AIS-D injuries to 5.9 for those who were AIS-A. Similar differences were noted 5 and 10 yr post-SCI. The estimated net present value of expected lifetime costs of hospitalization following thoracic SCI at age 35 yr was $321 534, $249 514, $188 989, and $68 120 (2015 US$) for AIS-A, AIS-B, AIS-C, and AIS-D injuries, respectively. CONCLUSION: Persons with less severe thoracic SCI, as reflected in AIS grade, spend fewer days in hospital over their lifetimes, leading to lower costs of inpatient care. Therapies improving AIS grade following thoracic SCI may provide cost savings in addition to addressing substantial unmet need.

The burden of neuropathic pain: results from a cross-sectional survey.

BACKGROUND: There are few published data on the treatment patterns and burden of neuropathic pain. We have investigated this in a large, observational, cross-sectional survey. METHODS: We surveyed 602 patients with neuropathic pain recruited from general practitioners in six European countries. Physicians recorded demographic and treatment information, including prescription medications. Patients completed Brief Pain Inventory (BPI) severity and interference questions, the EuroQol (EQ-5D), and questions about their productivity, non-prescription treatments, and frequency of physician visits. The BPI Pain Severity score (range: 0-10) is the mean of worst, least, average, and current pain ratings, with scores of 4-6 and 7-10 considered moderate and severe, respectively. We evaluated the impact of pain severity on functioning using analysis of variance models and chi2 tests. RESULTS: Mean (SD) age was 62.9 (14.4) years (50% female). Most patients reported moderate (54%) or severe (25%) pain. Nearly all patients (93%) were prescribed medications for their neuropathic pain: analgesics (71%); anti-epileptics (51%); antidepressants (29%); sedatives/hypnotics (15%). Seventy-six percent visited their physician at least once in the past month. Employment status was affected in 43% of patients; those employed missed a mean (SD) of 5.5 (9.8) workdays during the past month. Pain severity was associated significantly (P<0.001) with poorer EQ-5D scores (mild=0.67, moderate=0.46, severe=0.16), greater disruption of employment status (mild=24%, moderate=48%, severe=54%), and more frequent physician visits (% with one or more visits: mild=66%, moderate=79%, severe=83%). CONCLUSIONS: Patients with neuropathic pain visit their physician frequently and report substantial pain that interferes with daily functioning despite receiving treatment.

Development of a metric for a day of manageable pain control: derivation of pain severity cut-points for low back pain and osteoarthritis.

The objective of this study was to adapt the concept of 'episode-free day', a metric for measuring symptom relief in daily units, to the clinical outcome literature for persistent pain. The episode-free day metric is widely used in other medical literature, but no analogous measure exists in pain literature. Prior focus groups with this population suggested that a 'Day of Manageable Pain Control' was an appropriate name for the metric. In the present study, in order to derive a statistical criterion for 'Manageable Day', we used Serlin et al.'s (Pain 61 (1995) 277) cut-point derivation method to derive a single cut-point on a 0-10 scale of average pain that divided groups with significant persistent pain optimally on pain-related functional interference. Participants were 194 patients with moderate-severe low back pain (n=96) or osteoarthritis (n=98). For both patient samples, '5' was the cut-point that optimally distinguished groups on pain-related interference. '5-8' and '5-7' were double cut-point solutions that optimally divided LBP and OA samples into three categories (e.g. lowest, medium and highest average pain), respectively. Derived cut-points were confirmed using a variety of measures of functional disability. Together with research that showed that average pain ratings of approximately 5 and below permit increased function and quality of life in patients with moderate to severe low back pain and osteoarthritis, our findings provide support for the use of 0-5 on a 0-10 numeric average pain severity scale as one possible criterion for a Manageable Day.

Clinical characteristics and economic costs of patients with painful neuropathic disorders.

UNLABELLED: Using a large US health insurance claims database, we identified all persons aged 18 years or older with 2 or more medical encounters in calendar year 2000 for painful neuropathic disorders (PNDs). We also identified an age- and gender-matched group of patients without PNDs (matched control subjects). We then compared the clinical characteristics and economic costs of PND patients with those of matched control subjects. There were a total of 55,686 patients with PNDs in the study database. The most frequently noted PNDs were back and neck pain with neuropathic involvement (62.3% of PND patients), causalgia (12.1%), and diabetic neuropathy (10.8%). In comparison with matched control subjects, PND patients were more likely to have other pain-related conditions, including fibromyalgia (6.0% vs 0.6% for control subjects), osteoarthritis (13.6% vs 3.6%), and other chronic comorbidities, such as coronary heart disease (13.6% vs 6.5%) and depression (6.4% vs 2.3%). Total calendar year 2000 health care charges were 3-fold higher for PND patients than matched control subjects ($17,355 vs $5,715, respectively). Our results suggest that patients with PNDs are generally in poorer health and have higher health care costs than their peers without these conditions. PERSPECTIVE: Use of nonsteroidal anti-inflammatory agents and opioids was widespread in patients with PNDs, while relatively few received antiepileptic drugs and tricyclic antidepressants, both of which are often more effective against neuropathic pain. Our study raises questions about the optimality of PND treatment in clinical practice.

How do changes in pain severity levels correspond to changes in health status and function in patients with painful diabetic peripheral neuropathy?

The current analysis compares changes in pain with changes in function and health status in individuals with painful diabetic peripheral neuropathy (DPN). The post hoc analysis is based on a 12week, multinational, placebo-controlled trial of pregabalin in which 401 patients were randomized to treatment. Study measures included the Brief Pain Inventory short-form (BPI-sf), EQ-5D and other patient-reported outcomes. Cutpoints were derived on the BPI-sf 0-10 average pain numeric rating scale [NRS] to classify pain grades of "mild" (1-3), moderate (4-6) and severe (7-10), adjusting for geographical regions where data were collected. Two different metrics were used to classify the importance of change in pain severity from baseline to 12weeks: changes in pain severity grades (defined by cutpoint categories) and percent reduction in the NRS (categories ranging from 0-9% to 50%). An improvement in one pain grade or a 30% reduction in the NRS served as determinants of a clinically important difference. Patients with a one-grade reduction in pain severity, either from "severe-to-moderate" or "moderate-to-mild," had a 3-point improvement the BPI-sf Pain Interference Index (PII; a composite measure of function); a reduction from "severe-to-mild" pain corresponded to a 6-point improvement in the PII. Similarly, a reduction in the NRS of 30% and 50% corresponded to a 3-point and a 5-point improvement in the PII, respectively. Changes in pain were also associated with changes in health status. Results suggest that patients whose pain is not reduced to a mild level of severity can still experience clinically important changes in function and health status.

Patterns of healthcare utilization and cost in patients with newly diagnosed fibromyalgia.

OBJECTIVES: To compare healthcare utilization and costs in the year preceding and following initial diagnosis of fibromyalgia (FM). METHODS: Using a large US health insurance claims database, we identified all persons with newly diagnosed FM (International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 729.1) between January 1, 2003, and December 31, 2005 ("FM patients"). Each patient's first-noted claim with a diagnosis of FM was designated the "index date," and all pharmacy, outpatient, and inpatient claims were compiled over the 12-month periods preceding and following this date ("prediagnosis" and "postdiagnosis," respectively). Patients with incomplete pre- or postdiagnosis data were excluded. Healthcare utilization and costs were compared between the 2 periods. RESULTS: A total of 1803 patients met all study inclusion criteria; mean (SD) age was 50.4 (9.4) years; 91% were women. Comorbidities were common, including arthritis (21% of study subjects), back pain (20%), and painful neuropathic disorders (16%). The percentage of study subjects receiving various pain-related medications increased from pre- to postdiagnosis, including opioids (51.3% vs 55.9%), antiepileptics (22.6% vs 28.6%), and tricyclic antidepressants (15.5% vs 21.2%) (all P <.01). Mean total healthcare costs also increased by $1725 between these periods (mean [95% confidence interval]: $9324 [$8655, $10,092] vs $11,049 [$10,245, $11,973], respectively; P <.01). CONCLUSIONS: Patients with FM are often seen for other medical problems prior to initial diagnosis. Levels of healthcare utilization and costs are high during both the pre- and postdiagnosis periods.

The economic burden of fibromyalgia: comparative analysis with rheumatoid arthritis.

OBJECTIVE: To quantify and compare direct costs, utilization, and the rate of comorbidities in a sample of patients with fibromyalgia (FM), a poorly understood illness associated with chronic widespread pain that is commonly treated by rheumatologists, to patients with rheumatoid arthritis (RA), a well studied rheumatologic illness associated with inflammatory joint pain. Patients with both illnesses were isolated and reported as a third group. A secondary analysis of work loss was performed for an employed subset of these patients. RESEARCH DESIGN AND METHODS: Retrospective cohort analysis of Thomson Reuters MarketScan administrative healthcare claims and employer-collected absence and disability data for adult patients with a diagnosis of FM (ICD-9-CM 729.1) and/or RA (ICD-9-CM 714.0x,-714.3x) on at least one inpatient or two outpatient claims during 2001-2004. MAIN OUTCOME MEASURES: The 12-month healthcare utilization, expenditures, and rates of comorbidities were quantified for all study-eligible patients; absence and short-term disability days and costs were quantified for an employed subset. RESULTS: The sample included 14034 FM, 7965 RA, and 331 FM+RA patients. Patients with FM had a higher prevalence of several comorbidities and greater emergency department (ED) utilization than those with RA. Mean annual expenditures for FM patients were $10911 (SD=$16075). RA patient annual expenditures were similar to FM: $10716 (SD= $16860). Annual expenditures were almost double in patients with FM+RA ($19395, SD= $25440). A greater proportion of patients with FM had any short-term disability days than those with RA (20 vs. 15%); and a greater proportion of patients with RA had any absence days (65 vs. 80%). Mean costs for absence from work and short-term disability in the FM and RA groups were substantial and similar. The FM+RA group was of insufficient sample size to report on work loss. LIMITATIONS: The availability of newer and more expensive FDA-approved medications since 2004 is not reflected in our findings. This analysis was restricted to commercially insured patients and therefore may not be generalizable to the entire U.S. population. CONCLUSIONS: The burden of illness in FM is substantial and comparable to RA. Patients with FM incurred direct costs approximately equal to RA patients. Patients with FM had more ED, physician, and physical therapy visits than RA patients. Patients in both groups had several comorbidities. Patients with FM+RA incurred direct costs almost double those of the patients with either diagnosis alone. FM and RA patients incurred similar overall absence and short-term disability costs.

Human and economic burden of generalized anxiety disorder.

The goal of the current work is to provide a comprehensive review and interpretation of the literature on the human and economic burden of generalized anxiety disorder (GAD) and how it compares with that of other mental disorders. The term "human burden" is used to describe quantified impairments in role functioning and quality of life (QOL). "Economic burden" describes costs related to health care resource utilization and lost work. A review of 34 studies reporting original quantitative data on associations between GAD and role functioning, QOL, and/or economic costs was undertaken. GAD was defined by DMS-III-R, DSM-IV, or ICD-10 DCR. Persons with GAD (both with and without a comorbid mental disorder) described significant impairments due to both physical and emotional problems. Studies typically showed that role and QOL impairments of GAD were at least comparable in magnitude to those of other anxiety disorders, somatoform disorders, and physical conditions, and greater than those of substance use disorders. Large representative studies showed that role impairments of pure GAD were similar in magnitude to those of pure MDD. Studies of DSM-IV disorders showed that QOL impairments of GAD were at least comparable in magnitude to those of MDD; studies of DSM-III-R disorders showed the opposite pattern. GAD was associated with considerable economic costs owing to lost work productivity and high medical resource use. Quality of care initiatives that have been implemented to increase recognition and improve treatment outcomes for persons with MDD should be extended to the effective management of GAD.

Use of tricyclic antidepressants in older patients with painful neuropathies.

OBJECTIVE: To describe patterns of use of tricyclic antidepressants (TCAs) (e.g., amitriptyline, nortriptyline) in older patients with painful neuropathies. RESEARCH DESIGN AND METHODS: Using a large US health insurance claims database, we identified all persons who: (1) received a TCA between 1 January 1999 and 30 June 2001, (2) were aged > or =65 years as of the date of their first prescription for a TCA during this period, and (3) had one or more health care encounters for the treatment of a painful neuropathy in the 30-day period immediately preceding their initial receipt of a TCA. We then examined the prevalence of selected comorbidities and/or concurrent use of medications that might render the prescribing of a TCA inappropriate, based on a listing of contraindications, warnings, and precautions found in the package inserts for these agents. Patterns of TCA use also were examined, based on information on paid claims. RESULTS: A total of 1,732 patients met all inclusion and exclusion criteria for the study. Their mean age was 74.6 years; 60.3% were women. Amitriptyline was the most frequently prescribed TCA (79.4% of patients). Forty-one percent of study subjects receiving TCAs had conditions--primarily cardiovascular--that render the use of such agents potentially inappropriate. The mean daily dose of TCAs was universally low (about 23 mg). CONCLUSIONS: The high prevalence of conditions rendering the use of TCAs potentially inappropriate, along with relatively low daily dosages, suggest that many older patients with painful neuropathies who are prescribed these agents may be suboptimally treated.