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Bise CG, Schneider M, Freburger J, Fitzgerald GK, Switzer G, Smyda G, Peele P, Delitto A. First Provider Seen for an Acute Episode of Low Back Pain Influences Subsequent Health Care Utilization. Phys Ther 2023; 103:pzad067. [PMID: 37379349 DOI: 10.1093/ptj/pzad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/03/2022] [Accepted: 03/23/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Costs associated with low back pain (LBP) continue to rise. Despite numerous clinical practice guidelines, the evaluation and treatments for LBP are variable and largely depend on the individual provider. As yet, little attention has been given to the first choice of provider. Early research indicates that the choice of first provider and the timing of interventions for LBP appear to influence utilization. We sought to examine the association between the first provider seen and health care utilization. METHODS Using 2015-2018 data from a large insurer, this retrospective analysis focused on patients (29,806) seeking care for a new episode of LBP. The study identified the first provider chosen and examined the following year of medical utilization. Cox proportional hazards models were calculated using inverse probability weighting on propensity scores to evaluate the time to event and the relationship to the first choice of provider. RESULTS The primary outcome was the timing and use of health care resources. Total health care use was lowest in those who first sought care with chiropractic care or physical therapy. Highest health care use was seen in those patients who chose the emergency department. CONCLUSION Overall, there appears to be an association between the first choice of provider and future health care use. Chiropractic care and physical therapy provide nonpharmacologic and nonsurgical, guideline-based interventions. The use of physical therapists and chiropractors as entry points into the health system appears related to a decrease in immediate and long-term use of health resources. This study expands the existing body of literature and provides a compelling case for the influence of the first provider on an acute episode of LBP. IMPACT The first provider seen for an acute episode of LBP influences immediate treatment decisions, the trajectory of a specific patient episode, and future health care choices in the management of LBP.
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Affiliation(s)
- Christopher G Bise
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Health Plan, Department of Health Economics, Pittsburgh, Pennsylvania, USA
| | - Michael Schneider
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janet Freburger
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - G Kelley Fitzgerald
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Galen Switzer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Garry Smyda
- UPMC Health Plan, Department of Health Economics, Pittsburgh, Pennsylvania, USA
| | - Pamela Peele
- UPMC Health Plan, Department of Health Economics, Pittsburgh, Pennsylvania, USA
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony Delitto
- School of Health and Rehabilitation Science, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- School of Health and Rehabilitation Science, Office of the Dean, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Wadhwa H, Varshneya K, Stienen MN, Veeravagu A. Do Epidural Steroid Injections Affect Outcomes and Costs in Cervical Degenerative Disease? A Retrospective MarketScan Database Analysis. Global Spine J 2023; 13:1812-1820. [PMID: 34686085 PMCID: PMC10556907 DOI: 10.1177/21925682211050320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To investigate the effect of preoperative epidural steroid injection (ESI) on quality outcomes and costs in patients undergoing surgery for cervical degenerative disease. METHODS We queried the MarketScan database, a national administrative claims dataset, to identify patients who underwent cervical degenerative surgery from 2007 to 2016. Patients under 18 and patients with history of tumor or trauma were excluded. Patients were stratified by ESI use at 3, 6, 12, 18, and 24 or more months preoperative. Propensity score matched controls for these groups were obtained. Baseline demographics, postoperative complications, reoperations, readmissions, and costs were compared via univariate and multivariate analysis. RESULTS 97 117 patients underwent cervical degenerative surgery, of which 29 963 (30.7%) had ESI use at any time preoperatively. Overall, 90-day complication rate was not significantly different between groups. The ESI cohorts had shorter length of stay, but higher 90-day readmission and reoperation rates. ESI use was associated with higher total payments through the 2-year follow-up period. Among patients who received preoperative ESI, male sex, history of cancer, obesity, PVD, rheumatoid arthritis, nonsmokers, cervical myelopathy, BMP use, anterior approach, 90-day complication, 90-day reoperation, and 90-day readmission were independently associated with increased 90-day total cost. CONCLUSION ESI can offer pain relief in some patients refractory to other conservative management techniques, but those who eventually undergo surgery have greater healthcare resource utilization. Certain characteristics can predispose patients who receive preoperative ESI to incur higher healthcare costs.
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Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
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Zouch J, Comachio J, Bussières A, Ashton-James CE, dos Reis AHS, Chen Y, Ferreira M, Ferreira P. Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review. Phys Ther 2022; 102:pzac150. [PMID: 36317766 PMCID: PMC10071499 DOI: 10.1093/ptj/pzac150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/05/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP). METHODS Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure. RESULTS A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent. CONCLUSIONS Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings. IMPACT This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems. LAY SUMMARY This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- James Zouch
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Josielli Comachio
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - André Bussières
- Department de Chiropractique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Claire E Ashton-James
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Yanyu Chen
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela Ferreira
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Paulo Ferreira
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Jin MC, Jensen M, Zhou Z, Rodrigues A, Ren A, Barros Guinle MI, Veeravagu A, Zygourakis CC, Desai AM, Ratliff JK. Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain. JAMA Netw Open 2022; 5:e2222062. [PMID: 35816312 PMCID: PMC9280399 DOI: 10.1001/jamanetworkopen.2022.22062] [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] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain. OBJECTIVE To understand health care utilization in patients with new-onset idiopathic neck pain. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022. MAIN OUTCOMES AND MEASURES The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used. RESULTS In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were $24 267.55 per surgical patient and $515.69 per nonsurgical patient. Across all health care services, $95 379 949 was accounted for by nonsurgical patients undergoing early imaging who did not receive any additional conservative therapy or epidural steroid injections, for a mean (SD) of $477.53 ($1375.60) per patient and median (IQR) of $120.60 ($20.70-$452.37) per patient. On average, patients not undergoing surgery, physical therapy, chiropractic manipulative therapy, or epidural steroid injection, who underwent either early advanced imaging (magnetic resonance imaging or computed tomography) or both early advanced and radiographic imaging, accumulated significantly elevated health care costs ($850.69 and $1181.67, respectively). Early conservative therapy was independently associated with 24.8% (95% CI, 23.5%-26.2%) lower health care costs. CONCLUSIONS AND RELEVANCE In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael Jensen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Zeyi Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Adrian Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Alexander Ren
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | | | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Clements CM, Hanson KT, Zavaleta KW, Stitz AM, Clark SE, Schwarz RR, Homan JR, Larson MV, Habermann EB, Gazelka HM. Collaborative improvement on acute opioid prescribing among diverse health systems. PLoS One 2022; 17:e0270179. [PMID: 35737715 PMCID: PMC9223335 DOI: 10.1371/journal.pone.0270179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite broad awareness of the opioid epidemic and the understanding that patients require much fewer opioids than traditionally prescribed, improvement efforts to decrease prescribing have only produced modest advances in recent years. Methods and findings By using a collaborative model for shared expertise and accountability, nine diverse health care systems completed quality improvement projects together over the course of one year to reduce opioid prescriptions for acute pain. The collaborative approach was flexible to each individual system’s goals, and seven of the nine participant institutions definitively achieved their desired results. Conclusions This report demonstrates the utility of a collaborative model of improvement to bring about real change in opioid prescribing practices and may inform quality improvement efforts at other institutions.
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Affiliation(s)
- Casey M. Clements
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America
- * E-mail:
| | - Kristine T. Hanson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Kathryn W. Zavaleta
- Management, Engineering, and Consulting, Mayo Clinic, Rochester, MN, United States of America
| | - Amber M. Stitz
- Department of Nursing, Mayo Clinic, Rochester, MN, United States of America
| | - Sean E. Clark
- Quality Academy, Mayo Clinic, Rochester, MN, United States of America
| | - Randy R. Schwarz
- Department of Provider Relations, Mayo Clinic, Rochester, MN, United States of America
| | - Jessica R. Homan
- Department of Provider Relations, Mayo Clinic, Rochester, MN, United States of America
| | - Mark V. Larson
- Department of Provider Relations, Mayo Clinic, Rochester, MN, United States of America
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Elizabeth B. Habermann
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Halena M. Gazelka
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America
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Anderson BR, McClellan SW. Three Patterns of Spinal Manipulative Therapy for Back Pain and Their Association With Imaging Studies, Injection Procedures, and Surgery: A Cohort Study of Insurance Claims. J Manipulative Physiol Ther 2022; 44:683-689. [PMID: 35753873 DOI: 10.1016/j.jmpt.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the relationship between procedures and care patterns in back pain episodes by analyzing health insurance claims. METHODS We performed a retrospective cohort study of insurance claims data from a single Fortune 500 company. The 3 care patterns we analyzed were initial spinal manipulative therapy, delayed spinal manipulative therapy, and no spinal manipulative therapy. The 3 procedures analyzed were imaging studies, injection procedures, and back surgery. We considered "escalated care" to be any claims with diagnostic imaging, injection procedures, or back surgery. Modified-Poisson regression modeling was used to determine relative risk of escalated care. RESULTS There were 83 025 claims that were categorized into 10 372 unique patient first episodes. Spinal manipulative therapy was present in 2943 episodes (28%). Initial spinal manipulation was present in 2519 episodes (24%), delayed spinal manipulation was present in 424 episodes (4%), and 7429 (72%) had no evidence of spinal manipulative therapy. The estimated relative risk, adjusted for age, sex, and risk score, for care escalation (eg, imaging, injections, or surgery) was 0.70 (95% confidence interval 0.65-0.75, P < .001) for initial spinal manipulation and 1.22 (95% confidence interval 1.10-1.35, P < .001) for delayed spinal manipulation with no spinal manipulation used as the reference group. CONCLUSION For claims associated with initial episodes of back pain, initial spinal manipulative therapy was associated with an approximately 30% decrease in the risk of imaging studies, injection procedures, or back surgery compared with no spinal manipulative therapy. The risk of imaging studies, injection procedures, or back surgery in episodes in the delayed spinal manipulative therapy group was higher than those without spinal manipulative therapy.
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Affiliation(s)
- Brian R Anderson
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA.
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Inferior Clinical Outcomes for Patients with Medicaid Insurance following Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients. World Neurosurg 2022; 164:e1024-e1033. [DOI: 10.1016/j.wneu.2022.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022]
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Nikpour J, Franklin M, Calhoun N, Broome M. Influence of provider type on chronic pain prescribing patterns A systematic review. J Am Assoc Nurse Pract 2022; 34:474-488. [PMID: 34935726 PMCID: PMC9562618 DOI: 10.1097/jxx.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues. OBJECTIVE Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist. DATA SOURCES Searches within PubMed, Embase, CINAHL, and Web of Science. CONCLUSIONS Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines. IMPLICATIONS FOR PRACTICE Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.
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Affiliation(s)
- Jacqueline Nikpour
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Durham, North Carolina
| | | | - Nicole Calhoun
- Duke University School of Nursing, Durham, North Carolina
| | - Marion Broome
- Ruby F. Wilson Professor of Nursing, Duke University School of Nursing, Durham, North Carolina
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Varshneya K, Wadhwa H, Ho AL, Medress ZA, Stienen MN, Desai A, Ratliff JK, Veeravagu A. Surgical Outcomes of Human Immunodeficiency Virus-positive Patients Undergoing Lumbar Degenerative Surgery. Clin Spine Surg 2022; 35:E339-E344. [PMID: 34183544 DOI: 10.1097/bsd.0000000000001221] [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: 01/05/2021] [Accepted: 06/01/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort studying using a national administrative database. OBJECTIVE The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD). METHODS This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. RESULTS A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts ($30,056 vs. $29,720, P=0.6853). The total costs were also similar throughout the 2-year follow-up period. CONCLUSION Patients who are HIV positive at the time of LDD surgery are at a higher risk for postoperative central nervous system and renal complications and unplanned readmissions.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Harsh Wadhwa
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Allen L Ho
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Zachary A Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Atman Desai
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - John K Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Murphy DR, Justice B, Bise CG, Timko M, Stevans JM, Schneider MJ. The primary spine practitioner as a new role in healthcare systems in North America. Chiropr Man Therap 2022; 30:6. [PMID: 35139859 PMCID: PMC8826679 DOI: 10.1186/s12998-022-00414-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies. Main body The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly. Conclusion Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.
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Affiliation(s)
- Donald R Murphy
- Department of Family Medicine, Alpert Medical School of Brown University, 133 Dellwood Road, Cranston, RI, 02920, USA
| | - Brian Justice
- Excellus BlueCross BlueShield, 165 Court Street, Rochester, NY, 14647, USA
| | - Christopher G Bise
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA
| | - Michael Timko
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point Suite 228, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA
| | - Joel M Stevans
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219-3130, USA
| | - Michael J Schneider
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219-3130, USA.
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Jin MC, Azad TD, Fatemi P, Ho AL, Vail D, Zhang Y, Feng AY, Kim LH, Bentley JP, Stienen MN, Li G, Desai AM, Veeravagu A, Ratliff JK. Defining and describing treatment heterogeneity in new-onset idiopathic lower back and extremity pain through reconstruction of longitudinal care sequences. Spine J 2021; 21:1993-2002. [PMID: 34033933 DOI: 10.1016/j.spinee.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/12/2021] [Accepted: 05/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices. PURPOSE To describe treatment heterogeneity in surgically-managed LBP and LEP. STUDY DESIGN/SETTING Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016). PATIENT SAMPLE A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up. EXPOSURE Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion). OUTCOME MEASURES Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage. METHODS Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance. RESULTS A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs. 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs. 63.8%, p<.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs. 7.4%, p<.001). CONCLUSIONS Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Parastou Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Daniel Vail
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jason P Bentley
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Martin N Stienen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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12
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Di Gangi S, Bagnoud C, Pichierri G, Rosemann T, Plate A. Treatment Patterns in Patients with Diagnostic Imaging for Low Back Pain: A Retrospective Observational Study. J Pain Res 2021; 14:3109-3120. [PMID: 34675640 PMCID: PMC8504656 DOI: 10.2147/jpr.s328033] [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: 07/06/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Low back pain (LBP) is one of the most frequent reasons for medical consultations. Literature suggests a large evidence-performance gap, especially regarding pain management. Therefore, the monitoring of treatment patterns is important to ensure high quality of treatment. This study aimed to describe treatment patterns specific to patients with diagnostic imaging of the spine for LBP. Patients and Methods The study was retrospective observational and based on health claims data from 2015 to 2019 provided by a Swiss health insurance company covering around 12% of the population. Patients, ≥18 years of age, with diagnostic imaging of the spine were included and observed 12 months before and after imaging. Patients with back surgery or comorbidities associated with the use of pain medications were excluded. Results In total, 60,822 patients (mean age: 53.5 y, 56.1% female) were included and 85% received at least one pain medication. Of these, non-steroidal anti-inflammatory drugs, paracetamol, or opioids were prescribed in 88.6%, 70.7%, and 40.3% of patients, respectively. Strong opioids were used in 17% of patients given opioids. Patients with combinations of diagnostic imaging methods had the highest odds of receiving pain medication prescriptions (1.81, 95% CI: 1.66, 1.96, P < 0.001). Prescribed defined daily doses corresponded to short-term therapies. Conclusion Although the majority of patients received non-opioid short-term therapies, we found a substantial use of opioids, and in particular, a relative high usage of strong opioids. Our results highlighted the importance of both patient and healthcare provider awareness regarding the prudent treatment of LBP.
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Affiliation(s)
- Stefania Di Gangi
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
| | | | - Giuseppe Pichierri
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
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13
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Varshneya K, Bhattacharjya A, Jokhai RT, Fatemi P, Medress ZA, Stienen MN, Ho AL, Ratliff JK, Veeravagu A. The impact of osteoporosis on adult deformity surgery outcomes in Medicare patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:88-94. [PMID: 34655336 DOI: 10.1007/s00586-021-06985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify the impact of osteoporosis (OS) on postoperative outcomes in Medicare patients undergoing ASD surgery. BACKGROUND Patients with OP and advanced age experience higher than average rates of ASD. However, poor bone density could undermine the durability of a deformity correction. METHODS We queried the MarketScan Medicare Supplemental database to identify patients Medicare patients who underwent ASD surgery from 2007 to 2016. RESULTS A total of 2564 patients met the inclusion criteria of this study, of whom n = 971 (61.0%) were diagnosed with osteoporosis. Patients with OP had a similar 90-day postoperative complication rates (OP: 54.6% vs. non-OP: 49.2%, p = 0.0076, not significant after multivariate regression correction). This was primarily driven by posthemorrhagic anemia (37.6% in OP, vs. 33.1% in non-OP). Rates of revision surgery were similar at 90 days (non-OP 15.0%, OP 16.8%), but by 2 years, OP patients had a significantly higher reoperation rate (30.4% vs. 22.9%, p < 0.0001). In multivariate regression analysis, OP increased odds for revision surgery at 1 year (OR 1.4) and 2 years (OR 1.5) following surgery (all p < 0.05). OP was also an independent predictor of readmission at all time points (90 days, OR 1.3, p < 0.005). CONCLUSION Medicare patients with OP had elevated rates of complications, reoperations, and outpatient costs after undergoing primary ASD surgery.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA. .,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.
| | - Anika Bhattacharjya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Rayyan T Jokhai
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Parastou Fatemi
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary A Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Allen L Ho
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - John K Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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14
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Obesity in Patients Undergoing Lumbar Degenerative Surgery-A Retrospective Cohort Study of Postoperative Outcomes. Spine (Phila Pa 1976) 2021; 46:1191-1196. [PMID: 34384097 DOI: 10.1097/brs.0000000000004001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort studying using a national, administrative database. OBJECTIVE The aim of this study was to determine the postoperative complications and quality outcomes of patients with and without obesity undergoing surgical management for lumbar degenerative disease (LDD). SUMMARY OF BACKGROUND DATA Obesity is a global epidemic that negatively impacts health outcomes. Characterizing the effect of obesity on LDD surgery is important given the growing elderly obese population. METHODS This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether the patient had a concurrent diagnosis of obesity at time of surgery. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between patients with and without obesity. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any previous history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. RESULTS A total of 67,215 patients underwent primary lumbar degenerative surgery, of which 22,405 (33%) were obese. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 8.3% in the nonobese cohort and 10.4% in the obese cohort (P < 0.0001). Patients with obesity also had longer lengths of stay (2.7 days vs. 2.4 days, P < 0.05), and higher rates of reoperation and readmission at all time-points through the study follow-up period to their nonobese counterparts (P < 0.05). Including payments after discharge, lumbar degenerative surgery in patients with obesity was associated with higher payments throughout the 2-year follow-up period ($68,061 vs. $59,068 P < 0.05). CONCLUSION Patients with a diagnosis of obesity at time of LDD surgery are at a higher risk for postoperative complications, reoperation, and readmission.Level of Evidence: 4.
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15
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Lynch CP, Cha EDK, Mohan S, Geoghegan CE, Jadczak CN, Singh K. The Influence of Preoperative Narcotic Consumption on Patient-Reported Outcomes of Lumbar Decompression. Asian Spine J 2021; 16:195-203. [PMID: 34130382 PMCID: PMC9066254 DOI: 10.31616/asj.2020.0582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/17/2021] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective cohort. Purpose This study aimed to assess the relationship between preoperative narcotic consumption and patient-reported outcomes (PRO) in patients undergoing minimally invasive (MIS) lumbar decompression (LD). Overview of Literature Previous studies report negative effects of narcotic consumption on perioperative outcomes and recovery; however, its impact on quality of life and surgical outcomes is not fully understood. Methods A surgical database was retrospectively reviewed for patients undergoing primary, single-level MIS LD from 2013 to 2020. Patients lacking preoperative narcotic consumption data were excluded. Demographics, spinal pathologies, and operative characteristics were collected. Patients were grouped based on preoperative narcotic consumption. Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) for back and leg, Oswestry Disability Index (ODI), 12-item Short Form Physical Component Summary, and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) were collected preoperatively and postoperatively. Preestablished values were used to calculate achievement of minimum clinically important difference (MCID). Differences in mean PROs and MCID achievement between groups were evaluated. Results The cohort was 453 patients; 184 used preoperative narcotics and 269 did not. Significant differences were found in American Society of Anesthesiologists classification, ethnicity, insurance type, and estimated blood loss between groups. Significant differences were also found in preoperative PHQ-9, VAS leg, ODI, and PROMIS-PF between groups (all p<0.05). Mean postoperative PROs did not differ by group (p>0.05). A higher rate of MCID achievement was associated with the narcotic group for PHQ-9 and PROMIS-PF at 6 weeks (both p≤0.050), VAS leg at 1 year (p=0.009), and overall for ODI and PHQ-9 (both p≤0.050). Conclusions Preoperative narcotic consumption was associated with worse preoperative depression, leg pain, disability, and physical function. In patients consuming preoperative narcotics, a higher proportion achieved an overall MCID for disability and depressive symptoms. Patients taking preoperative narcotic medications may report significantly worse preoperative PROs but demonstrate greater improvements in postoperative disability and mental health.
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Affiliation(s)
- Conor P Lynch
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Shruthi Mohan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Caroline N Jadczak
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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16
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Single-Stage Versus Multistage Surgical Management of Single- and Two-Level Lumbar Degenerative Disease. World Neurosurg 2021; 152:e449-e454. [PMID: 34087456 DOI: 10.1016/j.wneu.2021.05.115] [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] [Received: 03/14/2021] [Revised: 05/16/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine postoperative complications and quality outcomes of single-stage and multistage surgical management for lumbar degenerative disease (LDD). METHODS This retrospective cohort study using a national administrative database identified patients who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether their surgeon chose to perform single-stage or multistage LDD surgery, and these cohorts were mutually exclusive. Propensity score matching was used to mitigate intergroup differences between single-stage and multistage patients. Patients who underwent ≥3 levels of surgical correction, who were <18 years old, or who had any prior history of trauma or tumor were excluded from the study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. RESULTS Primary surgery for LDD was performed in 47,190 patients; 9438 (20%) of these patients underwent multistage surgery. After propensity score matching, baseline covariates of the 2 cohorts were similar. The complication rate was 6.1% in the single-stage cohort and 11.0% in the multistage cohort. Rates of posthemorrhagic anemia, infection, wound complication, deep vein thrombosis, and hematoma all were higher in the multistage cohort. Length of stay, revisions, and readmissions were also significantly higher in the multistage cohort. Through 2 years of follow-up, multistage surgery was associated with higher payments throughout the 2-year follow-up period ($57,036 vs. $39,318, P < 0.05). CONCLUSIONS Single-stage surgery for LDD demonstrated improved outcomes and lower health care utilization. Spine surgeons should carefully consider single-stage surgery when treating patients with LDD requiring <3 levels of correction.
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de Oliveira Costa J, Bruno C, Baranwal N, Gisev N, Dobbins TA, Degenhardt L, Pearson SA. Variations in Long-term Opioid Therapy Definitions: A Systematic Review of Observational Studies Using Routinely Collected Data (2000-2019). Br J Clin Pharmacol 2021; 87:3706-3720. [PMID: 33629352 DOI: 10.1111/bcp.14798] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2020] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Routinely collected data have been increasingly used to assess long-term opioid therapy (LTOT) patterns, with very little guidance on how to measure LTOT from these data sources. We conducted a systematic review of studies published between January 2000 and July 2019 to catalogue LTOT definitions, the rationale for definitions and LTOT rates in observational research using routinely collected data in nonsurgical settings. We screened 4056 abstracts, 210 full-text manuscripts and included 128 studies, mostly from the United States (81%) and published between 2015 and 2019 (69%). We identified 78 definitions of LTOT, commonly operationalised as 90 days of use within a year (23%). Studies often used multiple criteria to derive definitions (60%), mostly based on measures of duration, such as supply days/days of use (66%), episode length (21%) or prescription fills within specified time periods (12%). Definitions were based on previous publications (63%), clinical judgment (16%) or empirical data (3%); 10% of studies applied more than one definition. LTOT definition was not provided with enough details for replication in 14 studies and 38 studies did not specify the opioids evaluated. Rates of LTOT within study populations ranged from 0.2% to 57% according to study design and definition used. We observed a substantial rise in the last 5 years in studies evaluating LTOT with large variability in the definitions used and poor reporting of the rationale and implementation of definitions. This variation impacts on research reproducibility, comparability of findings and the development of strategies aiming to curb therapy that is not guideline-recommended.
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Affiliation(s)
| | - Claudia Bruno
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Navya Baranwal
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Timothy A Dobbins
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,Menzies Centre for Health Policy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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18
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Complications, Costs, and Quality Outcomes of Patients Undergoing Cervical Deformity Surgery With Intraoperative BMP Use. Spine (Phila Pa 1976) 2020; 45:1553-1558. [PMID: 32756275 DOI: 10.1097/brs.0000000000003629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An epidemiological study using national administrative data from the MarketScan database. OBJECTIVE The aim of this study was to identify the impact of bone morphogenetic protein (BMP) on postoperative outcomes in patients undergoing adult cervical deformity (ACD) surgery. SUMMARY OF BACKGROUND DATA BMP has been shown to stimulate bone growth and improve fusion rates in spine surgery. However, the impact of BMP on reoperation rates and postoperative complication rate is controversial. METHODS We queried the MarketScan database to identify patients who underwent ACD surgery from 2007 to 2015. Patients were stratified by BMP use in the index operation. Patients <18 years and those with any history of tumor or trauma were excluded. Baseline demographics and comorbidities, postoperative complication rates, and reoperation rates were analyzed. RESULTS A total of 13,549 patients underwent primary ACD surgery, of which 1155 (8.5%) had intraoperative BMP use. The overall 90-day complication rate was 27.6% in the non-BMP cohort and 31.1% in the BMP cohort (P < 0.05). Patients in the BMP cohort had longer average length of stay (4.0 days vs. 3.7 days, P < 0.05) but lower revision surgery rates at 90 days (14.5% vs. 28.3%, P < 0.05), 6 months (14.9% vs. 28.6%, P < 0.05), 1 year (15.7% vs. 29.2%, P < 0.05), and 2 years (16.5% vs. 29.9%, P < 0.05) postoperatively. BMP use was associated with higher payments throughout the 2-year follow-up period ($107,975 vs. $97,620, P < 0.05). When controlling for baseline group differences, BMP use independently increased the odds of postoperative complication (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.1-1.4) and reduced the odds of reoperation throughout 2 years of follow-up (OR 0.49, 95% CI 0.4-0.6). CONCLUSION Intraoperative BMP use has benefits for fusion integrity in ACD surgery but is associated with increased postoperative complication rate. Spine surgeons should weigh these benefits and drawbacks to identify optimal candidates for BMP use in ACD surgery. LEVEL OF EVIDENCE 3.
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19
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Abstract
: Level of Evidence: 3.
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20
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Åkesson KE, Buchbinder R, Nordin M, Hurley MV, Overgaard S, Chang LY, Yang RS, Chan DC, Dahlberg L, Nero H, Woolf A. Advances in delivery of health care for MSK conditions. Best Pract Res Clin Rheumatol 2020; 34:101597. [DOI: 10.1016/j.berh.2020.101597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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21
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Azad TD, Zhang Y, Stienen MN, Vail D, Bentley JP, Ho AL, Fatemi P, Herrick D, Kim LH, Feng A, Varshneya K, Jin M, Veeravagu A, Bhattacharya J, Desai M, Lembke A, Ratliff JK. Patterns of Opioid and Benzodiazepine Use in Opioid-Naïve Patients with Newly Diagnosed Low Back and Lower Extremity Pain. J Gen Intern Med 2020; 35:291-297. [PMID: 31720966 PMCID: PMC6957597 DOI: 10.1007/s11606-019-05549-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/07/2019] [Accepted: 10/24/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The morbidity and mortality associated with opioid and benzodiazepine co-prescription is a pressing national concern. Little is known about patterns of opioid and benzodiazepine use in patients with acute low back pain or lower extremity pain. OBJECTIVE To characterize patterns of opioid and benzodiazepine prescribing among opioid-naïve, newly diagnosed low back pain (LBP) or lower extremity pain (LEP) patients and to investigate the relationship between benzodiazepine prescribing and long-term opioid use. DESIGN/SETTING We performed a retrospective analysis of a commercial database containing claims for more than 75 million enrollees in the USA. PARTICIPANTS Participants were adult patients newly diagnosed with LBP or LEP between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6 months prior to diagnosis, and had 12 months of continuous enrollment after diagnosis. MAIN OUTCOMES AND MEASURES Among patients receiving at least one opioid prescription within 12 months of diagnosis, we defined discrete patterns of benzodiazepine prescribing-continued use, new use, stopped use, and never use. We tested the association of these prescription patterns with long-term opioid use, defined as six or more fills within 12 months. RESULTS We identified 2,497,653 opioid-naïve patients with newly diagnosed LBP or LEP. Between 2008 and 2015, 31.9% and 11.5% of these patients received opioid and benzodiazepine prescriptions, respectively, within 12 months of diagnosis. Rates of opioid prescription decreased from 34.8% in 2008 to 27.0% in 2015 (P < 0.001); however, prescribing of benzodiazepines only decreased from 11.6% in 2008 to 10.8% in 2015. Patients with continued or new benzodiazepine use consistently used more opioids than patients who never used or stopped using benzodiazepines during the study period (one-way ANOVA, P < 0.001). For patients with continued and new benzodiazepine use, the odds ratio of long-term opioid use compared with those never prescribed a benzodiazepine was 2.99 (95% CI, 2.89-3.08) and 2.68 (95% CI, 2.62-2.75), respectively. LIMITATIONS This study used administrative claims analyses, which rely on accuracy and completeness of diagnostic, procedural, and prescription codes. CONCLUSION Overall opioid prescribing for low back pain or lower extremity pain decreased substantially during the study period, indicating a shift in management within the medical community. Rates of benzodiazepine prescribing, however, remained at approximately 11%. Concurrent prescriptions of benzodiazepines and opioids after LBP or LEP diagnosis were associated with increased risk of long-term opioid use.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Martin N Stienen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.,Department of Neurosurgery & Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniel Vail
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason P Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Paras Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel Herrick
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Austin Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jayanta Bhattacharya
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
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Affiliation(s)
| | | | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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23
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TO THE EDITOR. Spine (Phila Pa 1976) 2019; 44:E1109. [PMID: 31479039 DOI: 10.1097/brs.0000000000003142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Kim LH, Vail D, Azad TD, Bentley JP, Zhang Y, Ho AL, Fatemi P, Feng A, Varshneya K, Desai M, Veeravagu A, Ratliff JK. Expenditures and Health Care Utilization Among Adults With Newly Diagnosed Low Back and Lower Extremity Pain. JAMA Netw Open 2019; 2:e193676. [PMID: 31074820 PMCID: PMC6512284 DOI: 10.1001/jamanetworkopen.2019.3676] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Low back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery. OBJECTIVES To assess use of health care resources for LBP and LEP management and analyze associated costs. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019. EXPOSURES Newly diagnosed LBP or LEP. MAIN OUTCOMES AND MEASURES The primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated. RESULTS A total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. CONCLUSIONS AND RELEVANCE The findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.
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Affiliation(s)
- Lily H. Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Daniel Vail
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Tej D. Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Jason P. Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Allen L. Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Paras Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Austin Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - John K. Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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