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Chowdhury AR, Graham PL, Schofield D, Costa DS, Nicholas M. Productivity outcomes from chronic pain management interventions in the working age population; a systematic review. Pain 2024; 165:1233-1246. [PMID: 38323645 PMCID: PMC11090028 DOI: 10.1097/j.pain.0000000000003149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 02/08/2024]
Abstract
ABSTRACT Productivity loss because of chronic pain in the working age population is a widespread concern internationally. Interventions for chronic pain in working age adults might be expected to achieve enhanced productivity in terms of reduced costs of workers' compensation insurance, reduced disability support, and improved rates of return to work for injured workers. This would require the use of measures of productivity in the evaluation of chronic pain management interventions. The aim of this review was to identify and interpret the productivity outcomes of randomised controlled trials reported by studies that conducted economic evaluations (eg, cost-effectiveness and cost-utility) of chronic pain management interventions in the working age population published from database inception to March 2023. Econlit, Embase, and Pubmed electronic databases were searched, yielding 12 studies that met the selection criteria. All 12 studies used absenteeism to measure productivity, translating return to work measures into indirect costs. Only one study included return to work as a primary outcome. Ten studies found no statistically significant improvements in productivity-related costs. Despite evidence for reduced pain-related disability after pain management interventions, this review suggests that the use of measures for assessing productivity gains is lacking. Including such measures would greatly assist administrators and payers when considering the broader societal benefits of such interventions.
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Affiliation(s)
- Anonnya Rizwana Chowdhury
- Faculty of Medicine and Health, Pain Management Research Institute, University of Sydney, Sydney, Australia
| | - Petra L. Graham
- School of Mathematical and Physical Sciences, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Deborah Schofield
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie Business School, Macquarie University, Sydney, Australia
| | - Daniel S.J. Costa
- Faculty of Medicine and Health, Pain Management Research Institute, University of Sydney, Sydney, Australia
| | - Michael Nicholas
- Faculty of Medicine and Health, Pain Management Research Institute, University of Sydney, Sydney, Australia
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2
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Nabi MH, Hawlader MDH, Naz F, Siddiquea SR, Hasan M, Hossian M, Dalal K. Low back pain among professional bus drivers: a cross-sectional study from Bangladesh. BMC Public Health 2023; 23:1172. [PMID: 37331993 DOI: 10.1186/s12889-023-16018-7] [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: 09/28/2022] [Accepted: 05/30/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Low back pain (LBP) is a common condition contributing to impaired quality of life among professional vehicle drivers. Our study aimed to assess LBP prevalence and associated factors among professional bus drivers in Bangladesh. METHODS A cross-sectional study was conducted among 368 professional bus drivers using a semi-structured questionnaire. A Nordic Musculoskeletal Questionnaire (NMQ) subscale was used to measure LBP. Multivariable logistic regression analysis was used to identify the factors associated with LBP. RESULTS In the last month, 127 (34.51%) participants reported experiencing pain or discomfort in the lower backside. Multivariable logistic regression analysis showed that age of more than 40 years (adjusted odds ratio (aOR): 2.07, 95% confidence interval (CI): 1.14 to 3.75), the income of more than 15,000 BDT per month (aOR: 1.91, 95% CI: 1.11 to 3.26), work duration more than ten years (aOR: 2.53, 95% CI: 1.12 to 5.70), working more than 15 days per month (aOR: 1.93, 95% CI: 1.02 to 3.65), working more than 10 h per day (aOR: 2.46, 95% CI: 1.05 to 5.75), poor condition of the driving seat (aOR: 1.80, 95% CI: 1.08 to 3.02), current smoking habit (aOR: 9.71, 95% CI: 1.25 to 75.15), illicit substances use (aOR: 1.97, 95% CI: 1.11 to 3.48), and four hours or less sleeping time per day (aOR: 1.83, 95% CI: 1.09 to 3.06) were positively associated with LBP. CONCLUSION The high burden of LBP among the participants calls for a focus on this vulnerable group's occupational health and safety, with particular emphasis on implementing standard measures.
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Affiliation(s)
| | | | - Farah Naz
- Department of Physiology, Green Life Medical College, Dhaka, 1205, Bangladesh
| | | | - Mehedi Hasan
- Public Health Promotion and Development Society (PPDS), Dhaka, 1205, Bangladesh
| | - Mosharop Hossian
- Public Health Promotion and Development Society (PPDS), Dhaka, 1205, Bangladesh
| | - Koustuv Dalal
- School of Health Sciences, Division of Public Health Science, Mid Sweden University, Sundsvall, Sweden.
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Nozawa K, Matsuyama S, Higa S, Yamamoto Y, Asami Y. Physician consultation rates and characteristics among workers with chronic pain or headache who participated in a behavioural change program: a retrospective database analysis using real-world healthcare data. BMJ Open 2022; 12:e056846. [PMID: 36356992 PMCID: PMC9660713 DOI: 10.1136/bmjopen-2021-056846] [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] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To assess the potential benefit of a behavioural change programme in working individuals with chronic pain or headache, in the form of increased physician consultation. DESIGN Retrospective observational database study. SETTING Members of employment-based healthcare insurance in Japan. PARTICIPANTS Individual-level data of working individuals aged <75 years from November 2019 through March 2020 were extracted from a database managed by MinaCare Co., Ltd. Included individuals had records of programme participation and chronic pain or headache (self-reported), and did not consult physicians for ≥3 months before programme participation. OUTCOME MEASURES Physician consultation rates after participating in the programme were examined from December 2019 through March 2020, separately for chronic pain and headache. Baseline characteristics included age, pain numeric rating scale (NRS) score (for chronic pain), suspected migraine (for headache), labour productivity including absenteeism and presenteeism, and 4-month indirect costs in Japanese yen (JPY). RESULTS The baseline mean age (±SD) of 506 individuals with chronic pain was 46.8±10.1 years; that of 352 individuals with headache was 43.6±9.9 years. Of those with chronic pain, 71.4% had an NRS score≥4, and 49.7% of those with headache had suspected migraine. Overall, 11.3% and 5.4% of those with chronic pain or headache consulted physicians, respectively. The mean baseline absenteeism and presenteeism were 1.5% and 19.1% in those with chronic pain, and 1.5% and 23.0% in those with headache. The baseline indirect costs were 586 941.6 JPY and 1 060 281.6 JPY among those with chronic pain or headache, respectively. CONCLUSION Given that the individuals did not regularly consult physicians before the programme despite reporting substantial symptoms, our results suggest the potential benefit of educational programmes encouraging physician consultation. Further studies are required to evaluate how to effectively implement such educational programmes via healthcare insurers to reduce the burden of pain symptoms and overall medical costs.
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Affiliation(s)
| | | | - Shingo Higa
- Viatris Pharmaceuticals Japan Inc, Minato-ku, Tokyo, Japan
| | | | - Yuko Asami
- Viatris Pharmaceuticals Japan Inc, Minato-ku, Tokyo, Japan
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Hnatešen D, Pavić R, Radoš I, Dimitrijević I, Budrovac D, Čebohin M, Gusar I. Quality of Life and Mental Distress in Patients with Chronic Low Back Pain: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10657. [PMID: 36078372 PMCID: PMC9518072 DOI: 10.3390/ijerph191710657] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/15/2022] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
The aim of this study was to examine the levels of health-related quality of life (HRQoL), pain intensity, and mental distress in participants with chronic low back pain (CLBP), and to examine the differences in the HRQoL of participants with respect to mental distress and the correlations of the examined variables. Data were collected from 148 patients using the SF-36 Health Status Questionnaire (SF-36), the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) questionnaire, and the visual-analog pain scale (VAS). The results indicate poorer self-assessment of physical health (Me = 28.1) compared to mental health (Me = 39.4). Participants with higher levels of mental distress reported significant emotional limitations (p = 0.003), lower energy (p < 0.001), poorer psychological health (p < 0.001) and social functioning (p < 0.001), more pain (p = 0.007), and, ultimately, poorer general health (p < 0.001). The level of mental distress was related to the level of HRQoL, while a correlation with the level of pain of the participants was not found. The study results indicate a connection between the presence of mental distress and almost all aspects of HRQoL in participants with CLBP.
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Affiliation(s)
- Dijana Hnatešen
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Nursing Institute “Professor Radivoje Radić”, Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Clinical Department of Pain Management, University Hospital Osijek, 31000 Osijek, Croatia
| | - Roman Pavić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Clinical Hospital of Traumatology, University Hospital Centre “Sestre Milosrdnice”, 10000 Zagreb, Croatia
| | - Ivan Radoš
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Clinical Department of Pain Management, University Hospital Osijek, 31000 Osijek, Croatia
| | - Iva Dimitrijević
- Clinical Department of Pain Management, University Hospital Osijek, 31000 Osijek, Croatia
| | - Dino Budrovac
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Clinical Department of Pain Management, University Hospital Osijek, 31000 Osijek, Croatia
| | - Maja Čebohin
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Nursing Institute “Professor Radivoje Radić”, Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Medical School Osijek, 31000 Osijek, Croatia
| | - Ivana Gusar
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Health Studies, University of Zadar, 23000 Zadar, Croatia
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Itoh N, Mishima H, Yoshida Y, Yoshida M, Oka H, Matsudaira K. Evaluation of the Effect of Patient Education and Strengthening Exercise Therapy Using a Mobile Messaging App on Work Productivity in Japanese Patients With Chronic Low Back Pain: Open-Label, Randomized, Parallel-Group Trial. JMIR Mhealth Uhealth 2022; 10:e35867. [PMID: 35576560 PMCID: PMC9152720 DOI: 10.2196/35867] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Artificial intelligence–assisted interactive health promotion systems are useful tools for the management of musculoskeletal conditions. Objective This study aimed to explore the effects of web-based video patient education and strengthening exercise therapy, using a mobile messaging app, on work productivity and pain in patients with chronic low back pain (CLBP) receiving pharmacological treatment. Methods Patients with CLBP were randomly allocated to either the exercise group, who received education and exercise therapy using a mobile messaging app, or the conventional group. For patient education, a web-based video program was used to provide evidence-based thinking regarding the importance of a cognitive behavioral approach for CLBP. The exercise therapy was developed in accordance with the recommendations for alignment, core muscles, and endogenous activation, including improvement of posture and mobility for proper alignment, stimulation and/or strengthening of deep muscles for spinal stability, and operation of intrinsic pain for the activation of endogenous substances by aerobic exercise. Both groups continued to receive the usual medical care with pharmacological treatment. The end points were changes in work productivity, pain intensity, quality of life, fear of movement, and depression. The observation period for this study was 12 weeks. An analysis adjusted for baseline values, age at the time of consent acquisition, sex, and willingness to strengthen the exercise therapy was performed. Results The exercise and conventional groups included 48 and 51 patients, with a mean age of 47.9 years (SD 10.2 years; n=27, 56.3% male patients) and 46.9 years (SD 12.3 years; n=28, 54.9% male patients) in the full analysis set, respectively. No significant impact of these interventions on work productivity was observed in the exercise group compared with the conventional group (primary end point: Quantity and Quality method; 0.062 vs 0.114; difference between groups −0.053, 95% CI −0.184 to 0.079; P=.43). However, the exercise group showed consistently better trends for the other end points than did the conventional group. Compared with the conventional group, the exercise group showed a significant improvement in the symptoms of low back pain (3.2 vs 3.8; difference between groups −0.5, 95% CI −1.1 to 0.0; P=.04), quality of life (EuroQoL 5 Dimensions 5 Level: 0.068 vs 0.006; difference between groups 0.061, 95% CI 0.008 to 0.114; P=.03), and fear of movement at week 12 (−2.3 vs 0.5; difference between groups −2.8, 95% CI −5.5 to −0.1; P=.04). Conclusions This study suggests that patient education and strengthening exercise therapy using a mobile messaging app may be useful for treating CLBP. This study does not reveal the effect of therapeutic interventions on CLBP on work productivity. Thus, further research is required to assess work productivity with therapeutic interventions. Trial Registration University Hospital Medical Information Network Clinical Trials Registry UMIN000041037; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046866
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Affiliation(s)
- Naohiro Itoh
- Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan
| | | | - Yuki Yoshida
- Data Science Department, Shionogi & Co, Ltd, Osaka, Japan
| | - Manami Yoshida
- Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ko Matsudaira
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Magalhães S, Barbosa J, Borges E. The relationship between presenteeism, quality of life and social support in higher education professionals: A cross-sectional path analysis. PLoS One 2022; 17:e0267514. [PMID: 35446913 PMCID: PMC9022867 DOI: 10.1371/journal.pone.0267514] [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: 01/05/2022] [Accepted: 04/10/2022] [Indexed: 11/19/2022] Open
Abstract
Presenteeism is the practice of being present at workplace, but not being able to carry out all the tasks due to health problems. Social support globally associated with health and wellbeing might positively influence presenteeism and consequently, the quality of life of these professionals. With this in mind, the aim of this study was to investigate the relationships between presenteeism, quality of life and social support in the work of non-teaching and non-research professionals within the context of higher education. A cross-sectional study was conducted, in which sociodemographic data were collected and the Portuguese versions of the Stanford Presenteeism Scale (SPS-6) (which includes the dimensions work-completed and distraction avoided) and Quality of Life Index (EUROSHIS-QOL-8) and the subscales of Supervisor’s Social Support and Peers’ Social Support of the Copenhagen Psychosocial Questionnaire (COPSOQ) were used. The questionnaire was applied online, and 322 professionals from a public university higher education institution in Northern Portugal participated in the study. Presenteeism was reported by 97 (30.1%) professionals. The peers’ social support was positively associated with quality of life. The supervisor’s social support was positively associated with distraction avoided and work completed and positively indirectly associated with quality of life, and the association was mediated by distraction avoided. We conclude that implementing strategies that can promote social support in the work context, namely strengthening networks between colleagues and competent and well-trained supervisors may prevent or reduce presenteeism in higher education professionals, as well as, provide a better quality of life.
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Affiliation(s)
- Sónia Magalhães
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
- * E-mail:
| | | | - Elisabete Borges
- Nursing School of Porto, ESEP, Porto, Portugal
- Center for Health Technology and Services Research–CINTESIS@RISE, Porto, Portugal
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7
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Unsgaard-Tøndel M, Nordstoga AL. Are Work Demand, Support and Control Associated with Work Ability and Disability during Back Pain Treatment? A Prospective Explorative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063154. [PMID: 35328841 PMCID: PMC8950009 DOI: 10.3390/ijerph19063154] [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: 01/28/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 12/02/2022]
Abstract
Background: Low back pain is a multifactorial disease with consequences for work ability and social participation. Improved integration of the work domain in health care management is needed. The aim of this study was to explore the relation between working conditions with outcome of low back pain treatment. Methods: Observational study of 41 patients attending physiotherapy for low back pain. Work demands, support and control were registered at baseline and work ability and disability also at baseline, with follow up after three and nine months. We used mixed-effects models to estimate the longitudinal associations between working conditions and outcome. Results: Higher work demands were related to reduced work ability (−1.1 points, 95% CI: −2.1 to −0.1) and slightly increased disability (5.6 points, 95% CI: 0.5 to 10.7). Lack of social support from colleagues was associated with reduced work ability (−2.7 points, 95% CI: −0.2 to 1.5) and disability (14.0 points, 95% CI: 4.9 to 23.1). Conclusions: This explorative study found associations between work demands and support, and work ability and disability outcome. Screening for psychosocial working conditions may influence the work ability and disability treatment outcome. The results need replication in larger samples and may indicate that patients seeking primary care management for low back pain should be screened for work demands, support and control.
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Affiliation(s)
- Monica Unsgaard-Tøndel
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, N-7491 Trondheim, Norway
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, N-7491 Trondheim, Norway;
- Trondheim Municipality, Department of Physiotherapy, N-7004 Trondheim, Norway
- Correspondence: ; Tel.: +47-7341-2509
| | - Anne Lovise Nordstoga
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, N-7491 Trondheim, Norway;
- Department of Physical Medicine and Rehabilitation, St Olavs Hospital, Trondheim University Hospital, N-7006 Trondheim, Norway
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Janela D, Costa F, Molinos M, Moulder RG, Lains J, Francisco GE, Bento V, Cohen SP, Correia FD. Asynchronous and Tailored Digital Rehabilitation of Chronic Shoulder Pain: A Prospective Longitudinal Cohort Study. J Pain Res 2022; 15:53-66. [PMID: 35035234 PMCID: PMC8755939 DOI: 10.2147/jpr.s343308] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/22/2021] [Indexed: 12/21/2022] Open
Abstract
Background Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs. Purpose Present the results of a fully remote digital care program (DCP) for chronic SP. Patients and Methods Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement. Results From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean −13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6). Conclusion This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.
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Affiliation(s)
- Dora Janela
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Fabíola Costa
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Maria Molinos
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Robert G Moulder
- Institute for Cognitive Science, University of Colorado Boulder, Boulder, CO, USA
| | - Jorge Lains
- Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, and TIRR Memorial Hermann, Houston, TX, USA
| | - Virgílio Bento
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Steven P Cohen
- Departments of Anesthesiology & Critical Care Medicine, Physical Medicine and Rehabilitation, Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Departments of Anesthesiology and Physical Medicine and Rehabilitation and Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Fernando Dias Correia
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA.,Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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Agnus Tom A, Rajkumar E, John R, Joshua George A. Determinants of quality of life in individuals with chronic low back pain: a systematic review. Health Psychol Behav Med 2022; 10:124-144. [PMID: 35003902 PMCID: PMC8741254 DOI: 10.1080/21642850.2021.2022487] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 12/20/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Chronic low back pain (CLBP) is a prominent medical condition that can affect an individual at some point in their life time which could lead to poor quality of life (QOL). Low back pain has affected approximately 577 million individuals globally by 2017. The aim of the current systematic review is to synthesise the existing evidence on the factors influencing the QOL in individuals with CLBP and to identify strategies to improve their QOL. METHOD PubMed, ScienceDirect, PsychNet and Google Scholar were used to extract studies reporting quantitative relationships between QOL and its possible determinants in individuals having CLBP and the intervention strategies to improve QOL. RESULTS 10,851 studies were initially identified and twenty-six studies which met the inclusion criteria were selected for the review. 21 studies reported relationship between QOL and potential determinants and five studies assessed the influence of interventions on QOL. Determinants were classified as kinesiophobia, fear avoidance belief, or pain belief; occupation-related factors; pain and disability; activity; personal factors including age, gender, employment status; and other psychological factors including anxiety, quality of sleep, and health locus of control. Intervention strategies including MBSR, Pilates method and Back School Programme improved QOL in individuals with CLBP. CONCLUSION Psychosocial factors as well as the physical status of the individual contributed to the QOL in individuals having CLBP.
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Affiliation(s)
- Aleena Agnus Tom
- Department of Psychology, Central University of Karnataka, Kalaburagi, India
| | - Eslavath Rajkumar
- Department of Psychology, Central University of Karnataka, Kalaburagi, India
| | - Romate John
- Department of Psychology, Central University of Karnataka, Kalaburagi, India
| | - Allen Joshua George
- Department of Psychology, Central University of Karnataka, Kalaburagi, India
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Toyoshima K, Inoue T, Shimura A, Uchida Y, Masuya J, Fujimura Y, Higashi S, Kusumi I. The mediating effects of perceived cognitive disturbances on reported sleep disturbance, presenteeism, and functional disability in Japanese adult workers. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021. [DOI: 10.1016/j.jadr.2021.100180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Impact of neovascular age-related macular degeneration: burden of patients receiving therapies in Japan. Sci Rep 2021; 11:13152. [PMID: 34162934 PMCID: PMC8222235 DOI: 10.1038/s41598-021-92567-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/01/2021] [Indexed: 11/19/2022] Open
Abstract
The chronic eye disorder, neovascular age-related macular degeneration (nAMD), is a common cause of permanent vision impairment and blindness among the elderly in developed countries, including Japan. This study aimed to investigate the disease burden of nAMD patients under treatment, using data from the Japan National Health and Wellness surveys 2009–2014. Out of 147,272 respondents, 100 nAMD patients reported currently receiving treatment. Controls without nAMD were selected by 1:4 propensity score matching. Healthcare Resource Utilisation (HRU), Health-Related Quality of Life (HRQoL), and work productivity loss were compared between the groups. Regarding HRU, nAMD patients had significantly increased number of visits to any healthcare provider (HCP) (13.8 vs. 8.2), ophthalmologist (5.6 vs. 0.8), and other HCP (9.5 vs. 7.1) compared to controls after adjusting for confounding factors. Additionally, nAMD patients had reduced HRQoL and work productivity, i.e., reduced physical component summary (PCS) score (46.3 vs. 47.9), increased absenteeism (18.14% vs. 0.24%), presenteeism (23.89% vs. 12.44%), and total work productivity impairment (33.57% vs. 16.24%). The increased number of ophthalmologist visits were associated with decreased PCS score, increased presenteeism and total work productivity impairment. The current study highlighted substantial burden for nAMD patients, requiring further attention for future healthcare planning and treatment development.
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12
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Toyoshima K, Inoue T, Shimura A, Uchida Y, Masuya J, Fujimura Y, Higashi S, Kusumi I. Mediating Roles of Cognitive Complaints on Relationships between Insomnia, State Anxiety, and Presenteeism in Japanese Adult Workers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094516. [PMID: 33923141 PMCID: PMC8123047 DOI: 10.3390/ijerph18094516] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 12/31/2022]
Abstract
Complaints of cognitive functions (CCFs), defined as subjective cognitive dysfunction, affect social function; additionally, for workers, this condition is an important factor in presenteeism and mediates the effect of depressive symptoms on presenteeism. This study aimed to investigate whether CCFs mediate the relationships among insomnia, state anxiety (SA), and presenteeism. Participants were 471 Japanese adult workers evaluated using the Athens Insomnia Scale, State-Trait Anxiety Inventory (Form Y), Cognitive Complaints in Bipolar Disorder Rating Assessment, and Work Limitations Questionnaire 8 to assess insomnia, SA, CCFs, and presenteeism, respectively. Path analysis was used to evaluate the correlations between variables. CCFs significantly mediated the associations among insomnia, SA, and presenteeism. To address the presenteeism associated with insomnia and SA, it may be useful to assess the mediating roles of CCFs.
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Affiliation(s)
- Kuniyoshi Toyoshima
- Department of Psychiatry, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Sapporo 060-8638, Japan;
- Correspondence: ; Tel.: +81-011-716-1161; Fax: +81-011-706-5081
| | - Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan; (T.I.); (A.S.); (Y.U.); (J.M.); (Y.F.); (S.H.)
| | - Akiyoshi Shimura
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan; (T.I.); (A.S.); (Y.U.); (J.M.); (Y.F.); (S.H.)
| | - Yoshihiro Uchida
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan; (T.I.); (A.S.); (Y.U.); (J.M.); (Y.F.); (S.H.)
- Department of Psychiatry, Ibaraki Medical Center, Tokyo Medical University, Ami-machi, Inashiki-gun, Ibaraki 300-0395, Japan
| | - Jiro Masuya
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan; (T.I.); (A.S.); (Y.U.); (J.M.); (Y.F.); (S.H.)
| | - Yota Fujimura
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan; (T.I.); (A.S.); (Y.U.); (J.M.); (Y.F.); (S.H.)
- Department of Psychiatry, Hachioji Medical Center, Tokyo Medical University, Tokyo 193-0998, Japan
| | - Shinji Higashi
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan; (T.I.); (A.S.); (Y.U.); (J.M.); (Y.F.); (S.H.)
- Department of Psychiatry, Ibaraki Medical Center, Tokyo Medical University, Ami-machi, Inashiki-gun, Ibaraki 300-0395, Japan
| | - Ichiro Kusumi
- Department of Psychiatry, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Sapporo 060-8638, Japan;
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Mochizuki T, Yano K, Ikari K, Hiroshima R, Fukagawa S, Nasu Y, Okazaki K. Association between low back pain and quality of life in patients with rheumatoid arthritis according to patient-reported outcomes using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ): A cross-sectional study. Mod Rheumatol 2020; 31:992-996. [PMID: 33084458 DOI: 10.1080/14397595.2020.1840047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To evaluate factors associated with low back pain (LBP) and effect on quality of life (QOL) using patient-reported outcome in patients with rheumatoid arthritis (RA). METHODS Overall, 414 patients with RA who answered the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were included in this study. LBP-positive was defined a visual analog scale (VAS) of LBP (LBP VAS) of ≥ 30 mm. RESULTS The rate of LBP-positive group was 24.9%. Body mass index (BMI) (odds ratio [OR]: 1.116), tender joint count (TJC) (OR: 1.598), global VAS (OR: 1.016), and Health Assessment Questionnaire Disability Index (HAQ-DI) (OR: 2.392) were found as significant LBP-associated factors. When adjusted for sex and van der Heijde-modified total Sharp score, BMI (OR: 1.120), TJC (OR: 1.619), global VAS (OR: 1.016), pain VAS (OR: 1.015), and HAQ-DI (OR: 2.312) were found to be the significant factors associated with LBP. Moreover, LBP VAS had relatively high correlations in all domains of the JOABPEQ scores (correlation coefficient: LBP, -0.601; lumbar function, -0.624; walking ability, -0.548; social life function, -0.479; and mental health, -0.463). CONCLUSIONS This study investigated the effect of LBP in patients with RA. The results of this study indicate that LBP is associated with the physical function and QOL in patients with RA. We believe that our results will be useful for physical function and QOL assessments in patients with RA with LBP.
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Affiliation(s)
- Takeshi Mochizuki
- Department of Orthopedic Surgery, Kamagaya General Hospital, Chiba, Japan
| | - Koichiro Yano
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Katsunori Ikari
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Ryo Hiroshima
- Department of Orthopedic Surgery, Kamagaya General Hospital, Chiba, Japan
| | - Shingo Fukagawa
- Department of Orthopedic Surgery, Kamagaya General Hospital, Chiba, Japan
| | - Yuki Nasu
- Department of Orthopedic Surgery, Kamagaya General Hospital, Chiba, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
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Kamchatnov PR, Abusueva BA, Khanmurzaeva SB, Khanmurzaeva NB. [Choosing of therapy for a patient with dorsalgia]. TERAPEVT ARKH 2020; 92:102-107. [PMID: 33346438 DOI: 10.26442/00403660.2020.09.000836] [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: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/22/2022]
Abstract
Dorsalgia is one of the most common skeletal muscle syndromes. Dorsalgia often develops in patients of older age groups with polymorbidity that requires the appointment of a large number of medications. In these conditions, the choice of effective and safe therapy is a difficult problem. Discusses management of a patient suffering dorsalgia with comorbidities, the risks of complications of therapy, possible safety treatment, in particular, through the use of combination therapy.
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Sasahara I, Yamamoto A, Takeshita M, Suga Y, Suzuki K, Nishikata N, Takada M, Hashimoto M, Mine T, Kobuna Y, Nagao K. l-Serine and EPA Relieve Chronic Low-Back and Knee Pain in Adults: A Randomized, Double-Blind, Placebo-Controlled Trial. J Nutr 2020; 150:2278-2286. [PMID: 32520991 PMCID: PMC7467851 DOI: 10.1093/jn/nxaa156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/23/2020] [Accepted: 05/07/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Multisite pain, including low-back and knee pain, is a major health issue that greatly decreases quality of life. OBJECTIVES This study analyzed the effects of l-serine, which provides necessary components for nerve function, and EPA, which exerts anti-inflammatory properties, on pain scores of adults with pain in at least the low back and knee for ≥3 mo. METHODS This was a randomized, double-blind, placebo-controlled, parallel-group study. The Japan Low Back Pain Evaluation Questionnaire (JLEQ) and Japanese Knee Osteoarthritis Measure (JKOM) were applied as primary outcomes. The Brief Pain Inventory (BPI) and safety evaluation were secondary outcomes. We enrolled 120 participants aged ≥20 y (36 men and 84 women: mean ± SD age = 40.8 ± 10.9 y). The participants were randomly allocated to either the active group (daily ingestion of 594 mg l-serine and 149 mg EPA) or placebo group. The study period consisted of 8-wk dosing and 4-wk posttreatment observation. ANCOVA between groups for each time point was conducted using the baseline scores as covariates. RESULTS The JLEQ scores (active compared with placebo: 14.2 ± 11.2 compared with 19.0 ± 10.2) at week 8 were lower in the active group (P < 0.001). The JKOM scores at week 4 (11.7 ± 9.0 compared with 13.9 ± 7.9), week 8 (10.4 ± 7.9 compared with 13.1 ± 7.1), and week 12 (10.3 ± 7.4 compared with 13.8 ± 7.5) were lower in the active group (P ≤ 0.04). Additionally, the active group had 11-27% better scores compared with the placebo group for BPI1 (worst pain), BPI3 (average pain), and BPI5D (pain during moving) at week 4 (P ≤ 0.028) and week 8 (P ≤ 0.019), respectively, and BPI5D was 23% better in the active group at week 12 (P = 0.007). No adverse events were observed. CONCLUSIONS l-Serine and EPA were effective for pain relief in adults with low-back and knee pain after multiplicity adjustment.This trial was registered at the University Hospital Medical Information Network Clinical Trials Registry as UMIN000035056.
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Affiliation(s)
- Ikuko Sasahara
- Institute of Food Sciences and Technologies, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Akiko Yamamoto
- Institute of Food Sciences and Technologies, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Masamichi Takeshita
- Research Institute for Bioscience Products & Fine Chemicals, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Yasuyo Suga
- Institute of Food Sciences and Technologies, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Katsuya Suzuki
- Institute of Food Sciences and Technologies, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Natsumi Nishikata
- Research Institute for Bioscience Products & Fine Chemicals, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Michihiro Takada
- Research Institute for Bioscience Products & Fine Chemicals, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | | | - Tomoyuki Mine
- Institute of Food Sciences and Technologies, Ajinomoto Co, Inc, Kawasaki, Kanagawa, Japan
| | - Yasuo Kobuna
- Kobuna Orthopedic Clinic, Maebashi, Gunma, Japan
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Relationship Between Pain Alleviation and Disease-specific Health-related Quality of Life Measures in Patients With Chronic Low Back Pain Receiving Duloxetine: Exploratory Post Hoc Analysis of a Japanese Phase 3 Randomized Study. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:JAAOSGlobal-D-18-00086. [PMID: 31875196 PMCID: PMC6903819 DOI: 10.5435/jaaosglobal-d-18-00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This post hoc analysis of a Japanese phase 3 randomized study (ClinicalTrials.gov identifier: NCT01855919) investigated relationships between pain severity (assessed by the Brief Pain Inventory [BPI]) and disease-specific health-related quality of life (assessed by the 24-item Roland-Morris Disability Questionnaire [RDQ-24]) in duloxetine-treated patients with chronic low back pain (CLBP).
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Kawamata M, Iseki M, Kawakami M, Yabuki S, Sasaki T, Ishida M, Nishiyori A, Hida H, Kikuchi SI. Efficacy And Safety Of Controlled-Release Oxycodone For The Management Of Moderate-To-Severe Chronic Non-Cancer Pain In Japanese Patients: Results From An Open-Label Study. J Pain Res 2019; 12:3423-3436. [PMID: 31920367 PMCID: PMC6934115 DOI: 10.2147/jpr.s210502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/19/2019] [Indexed: 01/20/2023] Open
Abstract
Purpose To assess the efficacy and safety of S-8117, an oral, controlled-release formulation of oxycodone hydrochloride, in Japanese patients with chronic non-cancer pain (CNCP). Patients and methods In this multicenter, non-randomized, open-label, 2-part (part 1, dose-titration followed by maintenance period; part 2, long-term administration period) study at 38 centers in Japan (2013-2015), adult patients with CNCP for ≥12 weeks were administered S-8117. The primary endpoint was proportion of patients with successful maintenance of pain control in part 1 and long-term safety in part 2. Secondary endpoints included time to inadequate analgesia, rate of transition to the maintenance period, and discontinuation due to inadequate analgesia/adverse events (AEs), Brief Pain Inventory (BPI) pain severity, BPI pain interference, 36-item Short Form Health Survey (SF-36) score, and Western Ontario and McMaster Universities (WOMAC) index, Subjective Opioid Withdrawal Scale (SOWS), Clinical Opioid Withdrawal Scale (COWS), Dependency-2-A (D-2-A), and Dependency-2-B (D-2-B) questionnaires. Results Of 130 patients (mean age, 63.6 years; women, 62.3%) in the dose-titration period, 95 entered the maintenance period; 60 of 83 who entered the long-term administration period completed it. The proportion of patients (95% confidence interval) with successful maintenance of pain control, transition to maintenance period, and discontinuation due to inadequate analgesia/AEs was 78.9% (69.4-86.6), 73.1% (64.6-80.5), and 21.1% (13.4-30.6), respectively. Time to inadequate analgesia could not be estimated. Changes from baseline in BPI, SF-36, and WOMAC index scores suggested improvements in pain relief and quality of life. Based on the SOWS, COWS, D-2-A and D-2-B questionnaires, no patient developed clinically relevant withdrawal syndrome or was ascertained to have developed drug dependence. Overall, the incidence of treatment-emergent AEs (TEAEs) was 93.8%; most common TEAEs were constipation (49.2%), nausea (42.3%), nasopharyngitis (34.6%), and somnolence (32.3%). Conclusion These results demonstrate the efficacy and safety of S-8117 in Japanese patients with CNCP.
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Affiliation(s)
- Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masako Iseki
- Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Shoji Yabuki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takuma Sasaki
- Clinical Development Department, Shionogi & Co., Ltd., Osaka, Japan
| | - Mitsuhiro Ishida
- Clinical Development Department, Shionogi & Co., Ltd., Osaka, Japan
| | | | - Hideaki Hida
- Biostatistics Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Shin-Ichi Kikuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Huang WC, Kuo CH, Wu JC, Chen YC. Higher Risk of Intervertebral Disc Herniation among Neurosurgeons Than Neurologists: 15 Year-Follow-Up of a Physician Cohort. J Clin Med 2018; 7:jcm7080198. [PMID: 30072677 PMCID: PMC6111668 DOI: 10.3390/jcm7080198] [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: 07/05/2018] [Revised: 07/25/2018] [Accepted: 08/01/2018] [Indexed: 11/16/2022] Open
Abstract
High physical activity or workload has been associated with intervertebral disc degeneration. However, there is little data on physicians' risks of disc disease. The study aimed to investigate the incidences of spinal problems among neurologists and neurosurgeons. A cohort of neurologists and neurosurgeons was derived from Taiwan's national research database. During the study period, the incidences of intervertebral disc herniation or spondylosis among these specialists were calculated. Another one-to-one by propensity score matched cohort, composed of neurologists and neurosurgeons, was also analyzed. A Cox regression hazard ratio (HR) model and Kaplan-Meier analysis were conducted to compare the risks and incidences. The entire cohort comprised 481 and 317 newly board-certified neurologists and neurosurgeons, respectively. During the 15 years of follow-up, neurosurgeons were approximately six-fold more likely to develop disc problems than neurologists (crude HR = 5.98 and adjusted HR = 6.08, both p < 0.05). In the one-to-one propensity-score matched cohort (317 neurologists versus 317 neurosurgeons), there were even higher risks among neurosurgeons than neurologists (crude HR = 8.15, and adjusted HR = 10.14, both p < 0.05). Neurosurgeons have a higher chance of intervertebral disc disorders than neurologists. This is potentially an occupational risk that warrants further investigation.
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Affiliation(s)
- Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
| | - Chao-Hung Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Biomedical Engineering, School of Biomedical Science and Engineering, National Yang-Ming University, Taipei 11221, Taiwan.
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
| | - Yu-Chun Chen
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Family Medicine, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei 11221, Taiwan.
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