First Provider Seen for an Acute Episode of Low Back Pain Influences Subsequent Health Care Utilization

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.

Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

Results from a patient-centered medical home pilot at UPMC Health Plan hold lessons for broader adoption of the model

The patient-centered medical home is a promising model for improving access to high-quality care for more Americans at lower cost. However, feasible pathways for achieving a transformation from current primary care practices to this new model have yet to be fully identified. We report on the experience of UPMC Health Plan-part of a large, integrated delivery and financing system headquartered in Pittsburgh, Pennsylvania-in its efforts to support primary care practices as they converted to patient-centered medical homes. From 2008 through 2010, sites participating in the UPMC pilot achieved lower medical and pharmacy costs; more efficient service delivery, such as lower hospital admissions and readmissions and less use of hospital emergency departments; and a 160 percent return on the plan's investment when compared with nonparticipating sites. We suggest approaches that could spur the adoption and spread of the model, including that payers be offered incentives to enter into patient-centered medical home contracts with interested providers; that payers increase efforts to provide primary care practices with access to usable data on their patient populations; and that telehealth be instituted to connect care managers to patients and practices when in-person visits are not possible or necessary.

Understanding medication compliance and persistence from an economics perspective

OBJECTIVES

An increased understanding of the reasons for noncompliance and lack of persistence with prescribed medication is an important step to improve treatment effectiveness, and thus patient health. Explanations have been attempted from epidemiological, sociological, and psychological perspectives. Economic models (utility maximization, time preferences, health capital, bilateral bargaining, stated preference, and prospect theory) may contribute to the understanding of medication-taking behavior.

METHODS

Economic models are applied to medication noncompliance. Traditional consumer choice models under a budget constraint do apply to medication-taking behavior in that increased prices cause decreased utilization. Nevertheless, empiric evidence suggests that budget constraints are not the only factor affecting consumer choice around medicines. Examination of time preference models suggests that the intuitive association between time preference and medication compliance has not been investigated extensively, and has not been proven empirically. The health capital model has theoretical relevance, but has not been applied to compliance. Bilateral bargaining may present an alternative model to concordance of the patient-prescriber relationship, taking account of game-playing by either party. Nevertheless, there is limited empiric evidence to test its usefulness. Stated preference methods have been applied most extensively to medicines use.

RESULTS

Evidence suggests that patients' preferences are consistently affected by side effects, and that preferences change over time, with age and experience. Prospect theory attempts to explain how new information changes risk perceptions and associated behavior but has not been applied empirically to medication use.

CONCLUSIONS

Economic models of behavior may contribute to the understanding of medication use, but more empiric work is needed to assess their applicability.

Appetitive odor learning does not change olfactory coding in a subpopulation of honeybee antennal lobe neurons

Odors elicit spatio-temporal patterns of activity in the olfactory bulb of vertebrates and the antennal lobe of insects. There have been several reports of changes in these patterns following olfactory learning. These studies pose a conundrum: how can an animal learn to efficiently respond to a particular odor with an adequate response, if its primary representation already changes during this process? In this study, we offer a possible solution for this problem. We measured odor-evoked calcium responses in a subpopulation of uniglomerular AL output neurons in honeybees. We show that their responses to odors are remarkably resistant to plasticity following a variety of appetitive olfactory learning paradigms. There was no significant difference in the changes of odor-evoked activity between single and multiple trial forward or backward conditioning, differential conditioning, or unrewarded successive odor stimulation. In a behavioral learning experiment we show that these neurons are necessary for conditioned odor responses. We conclude that these uniglomerular projection neurons are necessary for reliable odor coding and are not modified by learning in this paradigm. The role that other projection neurons play in olfactory learning remains to be investigated.

Low molecular weight constituents of male mouse urine mediate the pregnancy block effect and convey information about the identity of the mating male

Mouse urine contains a complex mixture of chemosignals including a variety of small volatile molecules that are bound to major urinary proteins. In addition to signalling maleness, male urine also conveys information about individuality, which allows recently mated female mice to distinguish the urinary chemosignals of the mating male from those of an unfamiliar male. The highly polymorphic nature of the major urinary proteins makes them a likely candidate for conveying individuality information in the context of the pregnancy block effect. This was investigated by comparing the pregnancy-blocking effectiveness of a high molecular weight urinary fraction, containing major urinary proteins, with that of a low molecular weight fraction containing volatile ligands. Not only was the high molecular weight fraction ineffective in blocking pregnancy, but it also appeared to be less important in signalling individuality than the low molecular fraction. The high molecular weight fraction was ineffective in inducing expression of the immediate early gene product egr-1 in the accessory olfactory bulb. In contrast, the low molecular weight fraction induced egr-1 expression in the mitral/tufted neurons in the anterior subregion of the accessory olfactory bulb, suggesting that they activate the V1R class of vomeronasal receptor neuron.

Towards an understanding of the pregnancy-blocking urinary chemosignals of mice

Male mouse urine contains a pregnancy-blocking chemosignal that causes pre-implantation pregnancy failure in recently mated female mice. However, females are able to recognize the chemosignal of the male with which they mated, preventing it from aborting his own offspring. The individuality of the pregnancy-blocking chemosignal is influenced by genes of the major histocompatibility complex (MHC), although the chemical nature of the signal remains unclear. Possible candidates include fragments of MHC proteins, the highly polymorphic major urinary proteins (MUPs) and the profile of low-molecular-mass volatiles, which possess male pheromonal activity in other contexts. A recent study has found a high-molecular-mass fraction of male urine containing MUPs to be ineffective in eliciting pregnancy block. Moreover, both the pregnancy-blocking activity and the individuality of the signal were associated with the low-molecular-mass fraction of male urine.

Recruiting older adults for clinical trials

More than 400 community-dwelling older adults were recruited into a clinical trial which compared the effectiveness of diagnosis and treatment through geriatric assessment with that provided through usual community physician care. Six recruitment methods were utilized: referrals, solicitations, presentations, media, mailings, and fliers. Each method is described and its results reported in terms of numbers recruited, yield, and cost per participant. The most efficient method was referrals; the method producing the largest number was presentations; the least effective method was fliers. Problems and solutions are discussed, and guidelines for recruiting older adults are suggested. These guidelines include: monitoring with accompanying adaptation, targeting the groups most likely to benefit, providing incentives, and reducing uncertainty among potential participants.