Andrea S. Wallace

The Rising Prevalence of Chronic Low Back Pain

BACKGROUND National or state-level estimates on trends in the prevalence of chronic low back pain (LBP) are lacking. The objective of this study was to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care-seeking characteristics of individuals with the condition have changed over the last 14 years. METHODS A cross-sectional, telephone survey of a representative sample of North Carolina households was conducted in 1992 and repeated in 2006. A total of 4437 households were contacted in 1992 and 5357 households in 2006 to identify noninstitutionalized adults 21 years or older with chronic (>3 months), impairing LBP or neck pain that limits daily activities. These individuals were interviewed in more detail about their health and health care seeking. RESULTS The prevalence of chronic, impairing LBP rose significantly over the 14-year interval, from 3.9% (95% confidence interval [CI], 3.4%-4.4%) in 1992 to 10.2% (95% CI, 9.3%-11.0%) in 2006. Increases were seen for all adult age strata, in men and women, and in white and black races. Symptom severity and general health were similar for both years. The proportion of individuals who sought care from a health care provider in the past year increased from 73.1% (95% CI, 65.2%-79.8%) to 84.0% (95% CI, 80.8%-86.8%), while the mean number of visits to all health care providers were similar (19.5 [1992] vs 19.4 [2006]). CONCLUSIONS The prevalence of chronic, impairing LBP has risen significantly in North Carolina, with continuing high levels of disability and health care use. A substantial portion of the rise in LBP care costs over the past 2 decades may be related to this rising prevalence.

Goal setting in diabetes self-management: taking the baby steps to success.

OBJECTIVE To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals. METHODS We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study. RESULTS We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide. CONCLUSIONS A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals. PRACTICE IMPLICATIONS Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.

Race, Care Seeking, and Utilization for Chronic Back and Neck Pain: Population Perspectives

UNLABELLED We analyzed a statewide survey of individuals with chronic back and neck pain to determine whether prevalence and care use varied by patient race or ethnicity. We conducted a telephone survey of a random sample of 5,357 North Carolina households in 2006. Adults with chronic (>3 months duration or >24 episodes of pain per year), impairing back or neck pain were identified and were asked to complete a survey about their health and care utilization. 837 respondents (620 white, 183 black, 34 Latino) reported chronic back or neck pain. Whites and blacks had similar rates of chronic back pain. Back pain prevalence was lower in Latinos (10.4% [9.3-11.6] vs 6.3% [3.8-8.8]), likely due to their younger age; and the prevalence of chronic, disabling neck pain was lower in blacks (2.5% [1.9-3.1] vs 1.1% [.04-1.9]). Blacks had higher pain scores in the previous 3 months (5.2 vs 5.9 P < .05), and higher Roland disability scores (0-23 point scale): 14.2 vs 16.8, P < .05. Care seeking was similar among races (83% white, 85% black, 72% Latino). Use of opioids was also similar between races, at 49% for whites, 52% for blacks, and trended lower at 35% for Latinos. We found few racial/ethnic differences in care seeking, treatment use, and use of narcotics for the treatment of chronic back and neck pain. PERSPECTIVE This article presents new, population-based data on the issue of racial and ethnic disparities in neck- and back-pain prevalence and care. Few disparities were found; care quality issues may affect all ethnic groups similarly. Previous findings of disparities in chronic-pain management may be decreasing, or may perhaps be site specific.

Successful school-based intervention for inner-city children with persistent asthma

Objective: Because children attend school daily, school‐based interventions for children with persistent asthma could provide effective disease management for inner‐city asthmatic children. The Kunsberg School in Denver, Colorado, enrolls children with chronic diseases, including asthma, into a daily program of school‐based disease management. This study sought to determine the impact of the Kunsberg program on asthma utilization. Methods: Children attending Kunsberg (n = 18) who received primary care at Denver Health were compared with a group of matched control children who also received primary care at Denver Health, but did not attend Kunsberg (n = 36). Asthma‐related utilization for an average of 2.9 years before and after Kunsberg enrollment was assessed. Results: The 18 Kunsberg and 36 control subjects were mostly minority children in low‐income families, without significant demographic differences between groups. Compared with controls, the Kunsberg cohort experienced fewer hospitalizations (0.5 vs. 0.9 hospitalizations/subject/year, p = 0.05), fewer emergency department (ED) visits (1.4 vs. 2.8 ED visits/subject/year, p = 0.04), and fewer follow‐up visits for asthma (3.7 vs. 5.0 visits/subject/year, p = 0.01) in the time period (mean 2.9 years; range 1–6 years) following the intervention. Hospital‐ and clinic‐based asthma utilization costs decreased 80% following enrollment in the school (

Exercise prescription for chronic back or neck pain: who prescribes it? who gets it? What is prescribed?

8122/year to

An Overview of Research and Evaluation Designs for Dissemination and Implementation

1588/year per child), compared to a 19% decrease in the control group. Among the Kunsberg children with hospitalizations prior to school enrollment (n = 8), hospital days decreased from 3.5 days to 0.1 days annually (p < 0.01), ED visits decreased from 2.1 to 0.6 visits annually (p = 0.02), and follow‐up visits decreased from 6.8 to 2.1 visits annually (p = 0.02). As part of their school program, 89% of Kunsberg enrollees received inhaled corticosteroids daily on a monitored basis while at school. Conclusions: The Kunsberg school program improved asthma control and reduced disease severity for at‐risk inner‐city asthmatic children, leading to cost reduction for asthma management. Directly observed controller therapy at school can be an important component of a school‐based program for children with chronic conditions.

The Influence of Literacy on Patient-Reported Experiences of Diabetes Self-Management Support.

OBJECTIVE To describe exercise prescription in routine clinical practice for individuals with chronic back or neck pain because, although current practice guidelines promote exercise for chronic back and neck pain, little is known about exercise prescription in routine care. METHODS We conducted a computer-assisted telephone survey of a representative sample of individuals (n = 684) with chronic back or neck pain who saw a physician, chiropractor, and/or physical therapist (PT) in the past 12 months. Individuals were asked about whether they were prescribed exercise, the amount of supervision received, and the type, duration, and frequency of the prescribed exercise. Descriptive and multivariable regression analyses were conducted. RESULTS Of the 684 subjects, 48% were prescribed exercise. Of those prescribed exercise, 46% received the prescription from a PT, 29% from a physician, 21% from a chiropractor, and 4% from other. In multivariable analyses, seeing a PT or a chiropractor were the strongest predictors of exercise prescription. The likelihood of exercise prescription was increased in women, those with higher education, and those receiving workers compensation. PTs were more likely to provide supervision and prescribe strengthening exercises compared with physicians and chiropractors, and were more likely to prescribe stretching exercises compared with physicians. CONCLUSION Our findings suggest that exercise is being underutilized as a treatment for chronic back and neck pain and, to some extent, that the amount of supervision and types of exercises prescribed do not follow current practice guidelines. Exercise prescription provided by PTs appears to be most in line with current guidelines.

Readiness for Hospital Discharge, Health Literacy, and Social Living Status.

The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. This article is one product of a design workgroup that was formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. This article emphasizes randomized and nonrandomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.

Influence of Patient Characteristics on Assessment of Diabetes Self-Management Support.

Background:Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings. Objectives:The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters. Methods:A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management. Results:The Patient Assessment of Chronic Illness Care ratings decreased with age (r = −.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p= .010), and were greater for those with more education (F= 3.927, p = .009) and greater literacy skills (t = 3.839, p< .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r= .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings. Discussion:Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.

Diabetes self-management: Using the colored eco-genetic relationship map to assess social support

Patient characteristics and lack of preparedness are associated with poor outcomes after hospital discharge. Our purpose was to explore the association between patient characteristics and patient- and nurse-completed Readiness for Hospital Discharge Scale (RHDS). We conducted a prospective study of 70 Veterans being discharged from medical and surgical units. Differences in RHDS knowledge subscale scores were found among literacy levels, with lower perceived knowledge reported for those with marginal or inadequate literacy (p = .03). Differences in RHDS expected support subscale scores were also found, with those who were unmarried and/or living alone (p < .001) anticipating less support upon discharge. No other differences were found. Similar differences were found for the RHDS completed by nurses. These findings suggest that the RHDS appears responsive to differences in health literacy and social environment, adding to evidence of its utility as a tool to identify, and plan interventions for, those at risk for readmission.