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Leggett CG, Schmidt RO, Skinner J, Lurie JD, Luan WP. Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients. Mil Med 2024; 189:e2170-e2176. [PMID: 38491995 DOI: 10.1093/milmed/usae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/16/2024] [Accepted: 02/19/2024] [Indexed: 03/18/2024] Open
Abstract
INTRODUCTION There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers. MATERIALS AND METHODS A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument. RESULTS Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10). CONCLUSION This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.
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Affiliation(s)
- Christopher G Leggett
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Rachel O Schmidt
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Jonathan Skinner
- Department of Economics, Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and the National Bureau of Economic Research, Hanover, NH 03755, USA
| | - Jon D Lurie
- Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - William Patrick Luan
- Cost Analysis and Research Division, Institute for Defense Analyses, Alexandria, VA 22305-3086, USA
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Keaney L, Kilding A, Fordy G, Kilding H. Why are we doing this Staff? Justification and implications of aerobic fitness testing in the military. Work 2024:WOR240137. [PMID: 39213123 DOI: 10.3233/wor-240137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Physical fitness is a key tenet of military organisations worldwide. Specifically, many consider aerobic fitness (AF) an essential physical attribute for ensuring optimal military performance and readiness. However, the intricate relationship between AF and various facets of military job performance necessitates comprehensive review to ascertain the appropriateness and effectiveness of its assessment. OBJECTIVE This narrative review aims to describe the relationship between AF and factors influencing individual military performance and readiness, and explores the implications of the enforcement of in-service, generic AF test standards in military populations. METHODS Databases (PubMed and Google Scholar) were searched for all relevant published peer-reviewed literature as at August 2023. RESULTS Inconsistent associations were found between AF and outcomes influencing individual military performance (physical capabilities, cognitive capabilities, presenteeism and productivity, resilience, and technical/tactical capabilities) and readiness (mental health and wellbeing and physical health). Consequently, the level of AF needed for acceptable or optimal military performance remains uncertain. CONCLUSIONS AF is a cornerstone of health and performance, yet linking generic AF test standards to job performance is complex, with multiple factors interacting to influence outcomes. From existing literatures, there does not appear to be a specific level of AF at, and/or above, which acceptable military performance is achieved. As such, the enforcement of and emphasis on in-service, pass/fail, generic AF test standards in military populations is questionable and requires thoughtful re-evaluation. Role/task-specific AF should be assessed through evidence-based PES and the use of generic AF tests limited to the monitoring and benchmarking of health-related fitness.
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Affiliation(s)
- Lauren Keaney
- Human Sciences, Defence Science & Technology, New Zealand Defence Force, Auckland, New Zealand
| | - Andrew Kilding
- Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand
| | - Graham Fordy
- Australian Defence Apparel (ADA) New Zealand Ltd
| | - Helen Kilding
- Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand
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Candon M, Nielsen A, Dusek JA, Spataro Solorzano S, Cheatle M, Neuman MD, Samitt C, Shen S, Werner RM, Mandell D. Utilization of Reimbursed Acupuncture Therapy for Low Back Pain. JAMA Netw Open 2024; 7:e2430906. [PMID: 39207752 PMCID: PMC11362866 DOI: 10.1001/jamanetworkopen.2024.30906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/07/2024] [Indexed: 09/04/2024] Open
Abstract
Importance Treating low back pain (LBP) often involves a combination of pharmacologic, nonpharmacologic, and interventional treatments; one approach is acupuncture therapy, which is safe, effective, and cost-effective. How acupuncture is used within pain care regimens for LBP has not been widely studied. Objective To document trends in reimbursed acupuncture between 2010 and 2019 among a large sample of patients with LBP, focusing on demographic, socioeconomic, and clinical characteristics associated with acupuncture use and the nonpharmacologic, pharmacologic, and interventional treatments used by patients who utilize acupuncture. Design, Setting, and Participants This cross-sectional study included insurance claims of US adults in a deidentified database. The study sample included patients diagnosed with LBP between 2010 and 2019. Data were analyzed between September 2023 and June 2024. Main Outcomes and Measures Changes in rates of reimbursed acupuncture utilization between 2010 and 2019, including electroacupuncture use, which involves the electrical stimulation of acupuncture needles. Covariates included age, sex, race and ethnicity, income, educational attainment, region, and a chronic LBP indicator. Secondary analyses tracked other nonpharmacologic treatments (eg, physical therapy, chiropractic care), pharmacologic treatments (eg, opioids, gabapentinoids), and interventional treatments (eg, epidural steroid injections). Results The total sample included 6 840 497 adults with LBP (mean [SD] age, 54.6 [17.8] years; 3 916 766 female [57.3%]; 802 579 Hispanic [11.7%], 258 087 non-Hispanic Asian [3.8%], 804 975 non-Hispanic Black [11.8%], 4 974 856 non-Hispanic White [72.7%]). Overall, 106 485 (1.6%) had 1 or more acupuncture claim, while 61 503 (0.9%) had 1 or more electroacupuncture claim. The rate of acupuncture utilization increased consistently, from 0.9% in 2010 to 1.6% in 2019; electroacupuncture rates were relatively stable. Patients who were female (male: odds ratio [OR], 0.68; 99% CI, 0.67-0.70), Asian (OR, 3.26; 99% CI, 3.18-3.35), residing in the Pacific region (New England: OR, 0.26; 99% CI, 0.25-0.28), earning incomes of over $100 000 (incomes less than $40 000: OR, 0.59; 99% CI, 0.57-0.61), college educated (high school or less: OR, 0.32; 99% CI, 0.27-0.35), and with chronic LBP (OR, 2.39; 99% CI, 2.35-2.43) were more likely to utilize acupuncture. Acupuncture users were more likely to engage in other nonpharmacologic pain care like physical therapy (39.2%; 99% CI, 38.9%-39.5% vs 29.3%; 99% CI, 29.3%-29.3%) and less likely to utilize prescription drugs, including opioids (41.4%; 99% CI, 41.1%-41.8% vs 52.5%; 99% CI, 52.4%-52.5%), compared with nonusers. Conclusions and Relevance In this cross-sectional study, we found that acupuncture utilization among patients with LBP was rare but increased over time. Demographic, socioeconomic, and clinical characteristics were associated with acupuncture utilization, and acupuncture users were more likely to utilize other nonpharmacologic treatments and less likely to utilize pharmacologic treatments.
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Affiliation(s)
- Molly Candon
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffery A. Dusek
- Susan Samueli Integrative Health Institute, University of California, Irvine
- Division of General Internal Medicine, Department of Medicine, University of California, Irvine
| | - Sebastian Spataro Solorzano
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Rice University, Houston, Texas
| | - Martin Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Siyuan Shen
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Tefera YG, Gray S, Nielsen S, Gelaw A, Collie A. Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review. JOURNAL OF OCCUPATIONAL REHABILITATION 2024; 34:398-414. [PMID: 37934329 PMCID: PMC11180015 DOI: 10.1007/s10926-023-10138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/10/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes. METHODS We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible. RESULTS From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes. CONCLUSION Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.
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Affiliation(s)
- Yonas Getaye Tefera
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Shannon Gray
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, 47-49 Moorooduc Hwy, Frankston, 3199, Australia
| | - Asmare Gelaw
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Alex Collie
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
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Bauer MR, Richard P, Ritter G, Yoon J, Larson MJ. Clinician approaches to new spine pain cases in primary care: Balance of opioid prescribing and early linkage to exercise therapy and spinal manipulation. J Eval Clin Pract 2024; 30:355-366. [PMID: 38062882 PMCID: PMC11023770 DOI: 10.1111/jep.13944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/29/2023] [Accepted: 10/26/2023] [Indexed: 02/28/2024]
Abstract
RATIONALE, AIMS AND OBJECTIVES Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation). METHOD The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016. RESULTS The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates. CONCLUSION Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.
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Affiliation(s)
- Mark R. Bauer
- Heller School for Social Policy and Management, Brandeis University, Waltham MA
| | - Patrick Richard
- Preventive Medicine & Biostatistics, Uniformed Services University, Bethesda MD
| | - Grant Ritter
- Heller School for Social Policy and Management, Brandeis University, Waltham MA
| | - Jangho Yoon
- Preventive Medicine & Biostatistics, Uniformed Services University, Bethesda MD
| | - Mary Jo Larson
- Heller School for Social Policy and Management, Brandeis University, Waltham MA
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Nghiem VT, Larson MJ, Adams RS, Moresco N, Highland KB. Opioid Prescription Clusters Associated With Early or Unplanned Military Separation. Mil Med 2024; 189:e748-e757. [PMID: 37646783 PMCID: PMC10898939 DOI: 10.1093/milmed/usad339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/27/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Early/unplanned military separation in Active Component U.S. service members can result in reduced readiness during periods of high-tempo combat and increased demand for health care services within the Military Health System and Veterans Administration. Although current assessment tools leverage prescription data to determine deployment-limiting medication receipt and the need for interventions or waivers, there is a lack of understanding regarding opioid prescription patterns and subsequent early/unplanned military separation after return from deployment. As such, understanding these relationships could support future tool development and strategic resourcing. Therefore, the goal of the present study was to identify unique 12-month opioid prescription patterns and evaluate their relationship with early/unplanned military separation in Active Component service members who returned from deployment. MATERIALS AND METHODS This retrospective, IRB-approved cohort study included data from 137,654 Active Component Army service members who returned from deployment between 2007 and 2013, received a post-deployment (index) opioid prescription, and had at least 1 year of Active Component service post-opioid initiation. A k-means clustering analysis identified clusters using opioid prescription frequency, median dose, median days supply, and prescription breaks (≥30 days) over the 12-month post-initiation (monitoring) period. A generalized additive model examined whether cluster membership and additional covariates were associated with early/unplanned separation. RESULTS In addition to the single opioid prescription (38%), the cluster analysis identified five clusters: brief/moderate dose (25%), recurrent breaks (16%), brief/high dose (11%), long/few prescriptions (8%), and high prescription frequency (2%). In the generalized additive model, the probability of early/unplanned military separation was higher for the high prescription frequency cluster (74%), followed by recurrent breaks (45%), long/few prescriptions (37%), brief/moderate dose (30%), and brief/high dose (29%) clusters, relative to the single prescription (21%) cluster. The probability of early/unplanned separation was significantly higher for service members with documented substance use disorders, mental health conditions, or traumatic brain injuries during the monitoring periods. Service members assigned male were more likely to have an early/unplanned separation relative to service members assigned female. Latinx service members and service members whose race was listed as Other were less likely to experience early/unplanned separation relative to white service members. Relative to Junior Officers, Junior Enlisted and Senior Enlisted service members were more likely to experience early/unplanned separation, but Senior Officers were less likely. CONCLUSIONS Further evaluation to support the integration of longitudinal opioid prescription patterns into existing tools (e.g., a screening tool for deployment-limiting prescriptions) may enable more timely intervention and support service delivery to mitigate the probability and impact of early/unplanned separation.
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Affiliation(s)
- Vi T Nghiem
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Mary Jo Larson
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
| | - Rachel Sayko Adams
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, USA
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO 80045, USA
| | - Natalie Moresco
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 201814, USA
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Lurie JD, Leggett CG, Skinner J, Carragee E, Austin AM, Luan WP. A Regional Analysis of Low Back Pain Treatments in the Military Health System. Spine (Phila Pa 1976) 2024; 49:278-284. [PMID: 36972139 DOI: 10.1097/brs.0000000000004639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/15/2022] [Indexed: 06/18/2023]
Abstract
STUDY DESIGN Claims-based analysis of cohorts of TRICARE Prime beneficiaries. OBJECTIVE To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP. SUMMARY OF BACKGROUND Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System. PATIENTS AND METHODS Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis. RESULTS Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97). CONCLUSIONS We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.
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Affiliation(s)
| | | | | | - Eugene Carragee
- Department of Orthopedic Surgery, Stanford University, Redwood City, CA
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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Midboe AM, Javier SJ, Salsbury SA, Katsovich L, Burgess DJ, King HA, Taylor SL, Martino S, Mayer JM, Wallace RB, Der-Martirosian C, Kerns RD. Impact of COVID-19 pandemic on nonpharmacological pain management trials in military and veteran healthcare settings: an evaluation informed by implementation science. Transl Behav Med 2023; 13:601-611. [PMID: 37030012 PMCID: PMC10415731 DOI: 10.1093/tbm/ibad015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2023] Open
Abstract
The coronavirus disease (COVID-19) pandemic disrupted healthcare and clinical research, including a suite of 11 pragmatic clinical trials (PCTs), across clinics within the Department of Veterans Affairs (VA) and the Department of Defense (DOD). These PCTs were designed to evaluate an array of nonpharmacological treatments and models of care for treatment of patients with pain and co-occurring conditions. The aims of the study are to (a) describe modifications to PCTs and interventions to address the evolving pandemic and (b) describe the application of implementation science methods for evaluation of those PCT modifications. The project used a two-phase, sequential, mixed-methods design. In Phase I, we captured PCT disruptions and modifications via a Research Electronic Data Capture questionnaire, using Periodic Reflections methods as a guide. In Phase II, we utilized the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) taxonomy to develop a focus group interview guide and checklist that would provide more in-depth data than Phase I. Data were analyzed using directed content analysis. Phase I revealed that all PCTs made between two and six trial modifications. Phase II, FRAME-guided analyses showed that the key goals for modifying interventions were increasing treatment feasibility and decreasing patient exposure to COVID-19, while preserving intervention core elements. Context (format) modifications led eight PCTs to modify parts of the interventions for virtual delivery. Content modifications added elements to enhance patient safety; tailored interventions for virtual delivery (counseling, exercise, mindfulness); and modified interventions involving manual therapies. Implementation science methods identified near-real-time disruptions and modifications to PCTs focused on pain management in veteran and military healthcare settings.
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Affiliation(s)
- Amanda M Midboe
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Public Health Sciences, School of Medicine, University of California, Davis, CA 95616, USA
| | - Sarah J Javier
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Public Health Sciences, School of Medicine, University of California, Davis, CA 95616, USA
| | - Stacie A Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA 52803, USA
| | - Lily Katsovich
- Department of Psychiatry, Yale University, New Haven, CT 06511, USA
- Departments of Neurology, Yale University, New Haven, CT 06511, USA
- Departments of Psychology, Yale University, New Haven, CT 06511, USA
| | - Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, MN 55417, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Heather A King
- VA HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC 27701, USA
| | - Stephanie L Taylor
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, Los Angeles, CA 90073, USA
- Department of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Health Policy and Management, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Steve Martino
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06511, USA
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - John M Mayer
- The Vert Mooney Research (DBA US Spine & Sport Foundation), San Diego, CA 92111, USA
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA
| | - Claudia Der-Martirosian
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, Los Angeles, CA 90073, USA
| | - Robert D Kerns
- Department of Psychiatry, Yale University, New Haven, CT 06511, USA
- Departments of Neurology, Yale University, New Haven, CT 06511, USA
- Departments of Psychology, Yale University, New Haven, CT 06511, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA
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Meerwijk EL, Adams RS, Larson MJ, Highland KB, Harris AHS. Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration. Mil Med 2022; 188:usac074. [PMID: 35311994 PMCID: PMC10363012 DOI: 10.1093/milmed/usac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/09/2022] [Accepted: 03/04/2022] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy. MATERIALS AND METHODS We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020. RESULTS Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83). CONCLUSIONS Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.
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Affiliation(s)
- Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
| | - Rachel Sayko Adams
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, Aurora, CO 80045, USA
| | - Mary Jo Larson
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethe-sda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Surgery, Stanford University, Stanford, CA 94305, USA
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10
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Bolton R, Ritter G, Highland K, Larson MJ. The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System. BMC Health Serv Res 2022; 22:312. [PMID: 35255912 PMCID: PMC8900315 DOI: 10.1186/s12913-022-07700-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain – Army soldiers returning from deployment. Methods Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008–2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. Results In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. Conclusions Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07700-4.
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Affiliation(s)
- Rendelle Bolton
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA. .,US Department of Veterans Affairs, VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, 200 Springs Road, Bedford, MA, 01730, USA.
| | - Grant Ritter
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
| | - Krista Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA.,Henry M. Jackson Foundation, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA
| | - Mary Jo Larson
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
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11
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Kim SJ, Park SM, Cho HJ, Park JW. The Relationship Between Primary Sleep Disorders and Temporomandibular Disorders: An 8-Year Nationwide Cohort Study in South Korea. Int J Gen Med 2021; 14:7121-7131. [PMID: 34729021 PMCID: PMC8555531 DOI: 10.2147/ijgm.s331387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background While evidence is accumulating to propose a specific contribution of sleep disorders and low quality sleep in the pathogenesis of temporomandibular disorders (TMD), management of primary sleep disorders in the process of preventing and treating TMD still remains scientifically unsupported. Objective To investigate the association of primary sleep disorders with TMD risk in South Korea. Patients and Methods This study was based on the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) of South Korea with 468,882 participants. After excluding participants diagnosed in 2002, those with a diagnosis of a primary sleep disorder in 2003–2005 were recruited. All participants diagnosed with TMD between January 1, 2006 and December 31, 2013 received follow-up. Cox proportional hazards regression was performed to determine the adjusted hazard ratios (aHR) and 95% confidence interval (CI) for TMD according to the presence or absence of a primary sleep disorder diagnosis. Results After adjusting for all covariates, primary sleep disorder patients had a 44% higher risk for TMD compared with non-sleep disorder participants (aHR 1.44, 95% CI 1.02–2.04). The incidence rate of TMD was nearly twice as high in participants with sleep disorders compared with those without (6.08 vs 3.27, per 104 person-years). In subgroup analysis, an association was observed with those over 60 years old or who frequently exercised physically. Conclusion Primary sleep disorders could be an important independent risk factor for the initiation and maintenance of TMD. Patients with sleep disorders should be monitored for possible co-occurrence of TMD-related symptoms that could aggravate sleep disorders in turn.
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Affiliation(s)
- Seon-Jip Kim
- Department of Preventive Dentistry and Public Oral Health, School of Dentistry, Seoul National University, Seoul, Republic of Korea.,Dental Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sang Min Park
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Hyun-Jae Cho
- Department of Preventive Dentistry and Public Oral Health, School of Dentistry, Seoul National University, Seoul, Republic of Korea.,Dental Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Ji Woon Park
- Dental Research Institute, Seoul National University, Seoul, Republic of Korea.,Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea.,Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
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12
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Richard P, Patel N, Gedeon D, Hyppolite R, Younis M. Common Symptoms of Mild Traumatic Brain Injury and Work Functioning of Active-Duty Service Members with a History of Deployment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18158079. [PMID: 34360372 PMCID: PMC8345698 DOI: 10.3390/ijerph18158079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/16/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022]
Abstract
This study used data from the Military Health System Data Repository to examine the association between mild traumatic brain injuries (mTBI) and work functioning such as work duty limitations, hospital emergency room visits and inpatient admissions for active-duty service members (ADSMs). Further, this study assessed the role that common symptoms of mTBI play in work functioning. Multivariate results showed that having a mTBI diagnosis is not a major factor that results in being "released with work duty limitations". However, findings from these regression models also showed that the interaction of mTBI with cognitive and linguistic symptoms resulted in odds of 3.63 (CI: 1.40-9.36, p < 0.01) for being "released with work duty limitations" and odds of 4.98 (CI: 1.16-21.39, p < 0.05) for having any emergency department visits compared to those with no diagnosis of mTBI and none of these symptoms. Additionally, the interaction of mTBI with sleep disturbance and chronic pain showed odds of 2.72 (CI: 1.31-5.65, p < 0.01) and odds of 11.56 (CI: 2.65-50.44, p < 0.01) for being "released with work duty limitations" compared to those with no diagnosis of TBI and none of these symptoms, respectively. Further research is needed to investigate the association between mTBI and duration of time off work to provide a comprehensive understanding of the effect of mTBI on work functioning in the Military Health System.
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Affiliation(s)
- Patrick Richard
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Correspondence: ; Tel.: +1-301-295-9770
| | - Nilam Patel
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20814, USA; (N.P.); (D.G.); (R.H.)
| | - Daniel Gedeon
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20814, USA; (N.P.); (D.G.); (R.H.)
| | - Regine Hyppolite
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20814, USA; (N.P.); (D.G.); (R.H.)
| | - Mustafa Younis
- Department of Health Policy and Management, School of Public Health, Jackson State University, Jackson, MS 39217, USA;
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13
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Adams RS, Meerwijk EL, Larson MJ, Harris AHS. Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System. BMC Health Serv Res 2021; 21:494. [PMID: 34030684 PMCID: PMC8145830 DOI: 10.1186/s12913-021-06536-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. METHODS Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008-2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. RESULTS The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. CONCLUSIONS The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.
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Affiliation(s)
- Rachel Sayko Adams
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA.
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, 1700 N. Wheeling Street, Aurora, CO, 80045, USA.
| | - Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
| | - Mary Jo Larson
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
- Department of Surgery, Stanford University, Stanford, CA, 94305, USA
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14
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Hodgkin D, Adams RS, Ritter G, Lee S, Highland KB, Larson MJ. Do nonpharmacological services offset opioids in pain treatment for soldiers? Health Serv Res 2021; 56:1222-1232. [PMID: 33997971 DOI: 10.1111/1475-6773.13664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To examine the relationships between nonpharmacological treatment (NPT) utilization and opioid prescriptions and doses and whether these relationships vary according to the type of NPT service received. DATA SOURCE Secondary data from the US Military Health System, nationwide. STUDY DESIGN Patterns of NPT utilization and opioid prescriptions were analyzed over the 23 months after initial pain treatment (index visit). Regression models were used to examine the relationship between opioid prescription use in a given month and NPT service utilization in the three preceding months, using person fixed effects to control for time-invariant patient characteristics, as well as time fixed effects. Analyses were stratified by whether the patient filled an opioid prescription in the first 30 days post index visit. DATA EXTRACTION METHODS Administrative data on health care utilization were extracted from the US Military Health System Data Repository for Army service members who returned from deployments in Afghanistan and Iraq that ended in fiscal years 2008 to 2014 and had at least one outpatient visit with a primary diagnosis of musculoskeletal pain in the subsequent year. PRINCIPAL FINDINGS Utilization of any NPT service in the past 3 months was positively associated with filling an opioid prescription in the given month, regardless of whether the patient was initially prescribed opioids (percentage point difference [PP] =2.87, P < 0.01) or not (PP = 0.83, P < 0.01). However, for those not initially prescribed opioids, use of any NPT service in the past 3 months was negatively associated with mean daily opioid dose in the given month (morphine milligram equivalent dose = -0.4017, P < 0.01). For those initially prescribed opioids, NPT was not associated with opioid dose. CONCLUSIONS NPT only reduced the prescription opioid daily dose for some patients, whereas the probability of receiving an opioid prescription was positively associated with NPT. Future research should assess whether recent system-level policies and program changes influence referral and opioid prescribing patterns.
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Affiliation(s)
- Dominic Hodgkin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA.,Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
| | - Grant Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Sue Lee
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Krista Beth Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Rockville, Maryland, USA.,The Henry M. Jackson Foundation, Rockville, Maryland, USA
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
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15
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Saadoun M, Bauer MR, Adams RS, Highland KB, Larson MJ. Opioid and Nonpharmacologic Treatments Among Soldiers With Chronic Pain and Posttraumatic Stress Disorder. Psychiatr Serv 2021; 72:264-272. [PMID: 33467870 PMCID: PMC8127998 DOI: 10.1176/appi.ps.201900303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study examined the prevalence of chronic pain alone, posttraumatic stress disorder (PTSD) alone, and both chronic pain and PTSD among U.S. Army soldiers during the postdeployment year. METHODS The sample was 576,425 active duty soldiers returning from deployment in Afghanistan or Iraq between October 1, 2008, and September 30, 2014. Bivariate statistics were used to compare health care utilization among subgroups. Multivariate logistic regression with additional covariates was used to identify predictors of receiving an opioid days' supply of >30 days in the postdeployment year among soldiers with chronic pain, focusing on the effect of PTSD alone and on an interaction of PTSD with nonpharmacologic treatments (including therapeutic exercise, chiropractic treatment, acupuncture, and biofeedback). RESULTS In total, 12.2% of the soldiers received a chronic pain diagnosis, 5.1% a PTSD diagnosis, and 1.8% had both. Among soldiers with both conditions, 80.3% received nonpharmacologic treatment, and 31.4% received an opioid days' supply of >30 days. Among soldiers with chronic pain, comorbid PTSD and lack of nonpharmacologic treatment was associated with increased odds of receiving an opioid days' supply of >30 days (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.3-1.6). PTSD combined with specific nonpharmacologic treatment modalities had a variable relationship with opioid receipt, and only PTSD with acupuncture or biofeedback was associated with reduced odds (OR=0.8, 95% CI=0.7-0.9). CONCLUSIONS Soldiers having both chronic pain and PTSD have significant health care needs. Although these soldiers accessed mental health care and received nonpharmacologic treatment, additional interventions are needed to mitigate protracted opioid utilization.
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Affiliation(s)
- Mayada Saadoun
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Mark R Bauer
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Rachel Sayko Adams
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Krista Beth Highland
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Mary Jo Larson
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
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16
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Qu H, Yu LJ, Wu JT, Liu G, Liu SH, Teng P, Ding L, Zhao Y. Spine system changes in soldiers after load carriage training in a plateau environment: a prediction model research. Mil Med Res 2020; 7:63. [PMID: 33349256 PMCID: PMC7751100 DOI: 10.1186/s40779-020-00293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Low back pain is the most common spinal disorder among soldiers, and load carriage training (LCT) is considered the main cause. We aimed to investigate changes in the spine system of soldiers after LCT at high altitudes and the change trend of the lumbar spine and surrounding soft tissues under different load conditions. METHODS Magnetic resonance imaging scans of the lumbar spines of nine soldiers from plateau troops were collected and processed. We used ImageJ and Surgimap software to analyze changes in the lumbar paraspinal muscles, intervertebral discs (IVDs), intervertebral foramina, and curvature. Furthermore, the multiple linear regression equation for spine injury owing to LCT at high altitudes was established as the mathematical prediction model using SPSS Statistics version 23.0 software. RESULTS In the paraspinal muscles, the cross-sectional area (CSA) increased significantly from 9126.4 ± 691.6 mm2 to 9862.7 ± 456.4 mm2, and the functional CSA (FCSA) increased significantly from 8089.6 ± 707.7 mm2 to 8747.9 ± 426.2 mm2 after LCT (P < 0.05); however, the FCSA/CSA was not significantly different. Regarding IVD, the total lumbar spine showed a decreasing trend after LCT with a significant difference (P < 0.05). Regarding the lumbar intervertebral foramen, the percentage of the effective intervertebral foraminal area of L3/4 significantly decreased from 91.6 ± 2.0 to 88.1% ± 2.9% (P < 0.05). For curvature, the lumbosacral angle after LCT (32.4° ± 6.8°) was significantly higher (P < 0.05) than that before LCT (26.6° ± 5.3°), while the lumbar lordosis angle increased significantly from 24.0° ± 7.1° to 30.6° ± 7.4° (P < 0.05). The linear regression equation of the change rate, △FCSA% = - 0.718 + 23.085 × load weight, was successfully established as a prediction model of spinal injury after LCT at high altitudes. CONCLUSION The spinal system encountered increased muscle volume, muscle congestion, tissue edema, IVD compression, decreased effective intervertebral foramen area, and increased lumbar curvature after LCT, which revealed important pathophysiological mechanisms of lumbar spinal disorders in soldiers following short-term and high-load weight training. The injury prediction model of the spinal system confirmed that a load weight < 60% of soldiers' weight cannot cause acute pathological injury after short-term LCT, providing a reference supporting the formulation of the load weight standard for LCT.
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Affiliation(s)
- Hao Qu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ling-Jia Yu
- Department of Orthopaedics, Beijing Friendship Hospital, Beijing, 100050, China
| | - Ju-Tai Wu
- Department of Orthopaedics, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, China
| | - Gang Liu
- Department of Radiology, Qinghai Red Cross Hospital, Xining, 810000, Qinghai, China
| | - Sheng-Hui Liu
- School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China
| | - Peng Teng
- National Laboratory of Human Factors Engineering, China Astronaut Research and Training Center, Beijing, 100094, China
| | - Li Ding
- School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China.
| | - Yu Zhao
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Adams RS, Larson MJ, Meerwijk EL, Williams TV, Harris AHS. Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments. J Head Trauma Rehabil 2020; 34:167-175. [PMID: 31058759 PMCID: PMC6546163 DOI: 10.1097/htr.0000000000000481] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization. SETTING VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma. PARTICIPANTS Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011. DESIGN Population-based cohort study. MAIN MEASURES Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization. RESULTS In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization. CONCLUSION CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Drs Adams and Larson); Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California (Drs Meerwijk and Harris); and NORC at the University of Chicago, Bethesda, Maryland (Dr Williams)
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18
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Meerwijk EL, Larson MJ, Schmidt EM, Adams RS, Bauer MR, Ritter GA, Buckenmaier C, Harris AHS. Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration. J Gen Intern Med 2020; 35:775-783. [PMID: 31659663 PMCID: PMC7080907 DOI: 10.1007/s11606-019-05450-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.
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Affiliation(s)
- Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Eric M Schmidt
- Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Mark R Bauer
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Chester Buckenmaier
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, MD, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Department of Surgery, Stanford University, Stanford, CA, USA
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Kazis LE, Ameli O, Rothendler J, Garrity B, Cabral H, McDonough C, Carey K, Stein M, Sanghavi D, Elton D, Fritz J, Saper R. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019; 9:e028633. [PMID: 31542740 PMCID: PMC6756340 DOI: 10.1136/bmjopen-2018-028633] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/24/2019] [Accepted: 09/02/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP). DESIGN A retrospective cohort study of patients with new-onset LBP from 2008 to 2013. SETTING The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP. PARTICIPANTS 216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance. EXPOSURES The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists). MAIN OUTCOME MEASURES Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months). RESULTS Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively). CONCLUSIONS Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.
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Affiliation(s)
- Lewis E Kazis
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Omid Ameli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- OptumLabs, Cambridge, Massachusetts, USA
| | - James Rothendler
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Brigid Garrity
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christine McDonough
- University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, USA
| | - Kathleen Carey
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michael Stein
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | | | - Julie Fritz
- Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Robert Saper
- Boston University Medical Campus, Boston, Massachusetts, USA
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