George M. Holmes

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.

The Changing Epidemiology of Mechanical Ventilation: A Population-Based Study

The number of critical care beds in the United States has been increasing considerably, but it is unclear how these additional beds have been used. Mechanical ventilation for acute respiratory failure almost always demands ICU care and is likely to be a reliable indicator of critical care resource requirements on a population level. The objective of this study was to measure changes in the yearly incidence of mechanical ventilation in a statewide population. The North Carolina Hospital Discharge Database contains data on all discharges from nonfederal, nonpsychiatric hospitals in North Carolina. Authors extracted data on adult patients with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for mechanical ventilation from 1996 to 2002. The incidence of mechanical ventilation for adults grew from 284/100 000 population in 1996 to 314/100 000 in 2002, an increase of 11% (P < .05). While patients aged >64 had the highest age-specific incidence of mechanical ventilation each year, the greatest increase in incidence occurred in younger age groups (19% increase for age 18-64 vs 4% increase for age >64). The mean Charlson score increased from 1.76 ± 1.73 to 1.89 ± 1.86 (P < .001). Renal disease became more prevalent among patients requiring mechanical ventilation (17% of patients in 1996 vs 24% in 2002). Hospital charges adjusted for the medical consumer price index increased by 12%. The proportion of patients discharged to home declined from 45.4% to 34.4%, and discharges to nursing homes grew from 7.3% to 10.7%. The incidence of mechanical ventilation is increasing, and the increase is associated with a higher burden of comorbidities and fewer discharges to home.

A long way to go: Practice patterns and evidence in chronic low back pain care

Study Design. A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006. Objective. The primary objectives of these analyses were to describe health care use (providers, medications, treatments, diagnostic tests) for chronic low back pain (LBP) and relate current patterns of use to current best evidence for care of the condition. Summary of Background Data. Chronic LBP is common and expensive. Prior research on care utilization often was derived from medical claims databases, reflecting reimbursed health care use, often by one payer. Methods. Five thousand three hundred fifty-seven households were contacted in 2006 to identify 732 noninstitutionalized adults 21 years and older with chronic LBP. Five hundred ninety individuals sought care. Patient reported health care utilization, comparison with efficacy was demonstrated by current systematic reviews. Results. Individuals with chronic back pain were middle-aged (mean age 53 years), and the majority were women (62%). Provider and treatment use was common and varied. Sixty percent used narcotics in the previous month. The mean number of provider visits was 21, and over one-third had an advanced imaging procedure in the past year. Physical treatments were common, and often not supported by evidence. Only 3% had engaged in a formal spine rehabilitation program. Half of patients not taking antidepressants were positive on a 2-item depression screen. Although this study was population-based, it was conducted in only one state. Conclusion. Provider and treatment use for chronic LBP are both very common and varied. Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.

Multisite Randomized Trial of a Single-Session Versus Multisession Literacy-Sensitive Self-Care Intervention for Patients With Heart Failure

Background— Self-care training can reduce hospitalization for heart failure (HF), and more intensive intervention may benefit more vulnerable patients, including those with low literacy. Methods and Results— A 1-year, multisite, randomized, controlled comparative effectiveness trial with 605 patients with HF was conducted. Those randomized to a single session received a 40-minute in-person, literacy-sensitive training; the multisession group received the same initial training and then ongoing telephone-based support. The primary outcome was combined incidence of all-cause hospitalization or death; secondary outcomes included HF-related hospitalization and HF-related quality of life, with prespecified stratification by literacy. Overall, the incidence of all-cause hospitalization and death did not differ between intervention groups (incidence rate ratio, 1.01; 95% confidence interval, 0.83–1.22). The effect of multisession training compared with single-session training differed by literacy group: Among those with low literacy, the multisession training yielded a lower incidence of all-cause hospitalization and death (incidence rate ratio, 0.75; 95% confidence interval, 0.45–1.25), and among those with higher literacy, the multisession intervention yielded a higher incidence (incidence rate ratio, 1.22; 95% confidence interval, 0.99–1.50; interaction P=0.048). For HF-related hospitalization, among those with low literacy, multisession training yielded a lower incidence (incidence rate ratio, 0.53; 95% confidence interval, 0.25–1.12), and among those with higher literacy, it yielded a higher incidence (incidence rate ratio, 1.32; 95% confidence interval, 0.92–1.88; interaction P=0.005). HF-related quality of life improved more for patients receiving multisession than for those receiving single-session interventions at 1 and 6 months, but the difference at 12 months was smaller. Effects on HF-related quality of life did not differ by literacy. Conclusions— Overall, an intensive multisession intervention did not change clinical outcomes compared with a single-session intervention. People with low literacy appear to benefit more from multisession interventions than people with higher literacy. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00378950.

Disparities in Post-Acute Rehabilitation Care for Joint Replacement

To determine the extent to which demographic and geographic disparities exist in the use of post–acute rehabilitation care (PARC) for joint replacement.

An Investigation into the Determinants of Flight Cancellations

This paper uses Bureau of Transportation data on 35 million US domestic flights between 1995 and 2001 to investigate the determinants of flight cancellations. The paper is novel in two regards, it focuses exclusively on flight cancellations, and it explores the service quality–flight revenue relationship. We find that carriers have some control over the occurrence of flight cancellations given that cancellations are significantly less likely on Thursdays, Fridays and Sundays and for the last flight of the day. There is some evidence linking cancellations with revenue.

Disparities in Postacute Rehabilitation Care for Stroke: An Analysis of the State Inpatient Databases

Objective To use population-based, hospital discharge data to determine the extent to which demographic and geographic disparities exist in the use of PARC following stroke. Design Cross-sectional analysis of two years (2005-2006) of population-based, hospital discharge data. Setting All short-term acute care hospitals in four demographically and geographically diverse states (AZ, FL, NJ, WI). Participants Individuals 45 years and older (mean age of 72.6 years) admitted to the hospital with a primary diagnosis of stroke, who survived their inpatient stay and who were not transferred to a hospice or other short-term, acute care facility (N=187,188). The sample was 52.4 percent female, 79.5 percent White, 11.4 percent Black, and 9.1 percent Hispanic. Interventions Not applicable. Main Outcome Measures 1) Discharge to an institution versus home. 2) For those discharged home, discharge home with or without home health (HH). 3) For those discharged to an institution, discharge to an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply. Results Blacks, females, older individuals, and those with lower incomes were more likely to be discharged to an institution; Hispanic individuals and the uninsured were less likely. Racial minorities, females, older individuals, and those with lower incomes were more likely to receive HH; uninsured individuals and rural residents were less likely. Blacks, females, older individuals, the uninsured, and those with lower incomes were more likely to use SNF vs IRF care. PARC use varied significantly by state and by hospital. Conclusions Several demographic and geographic disparities in PARC use were identified.OBJECTIVE To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke. DESIGN Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases. SETTING All short-term acute-care hospitals in 4 demographically and geographically diverse states. PARTICIPANTS Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES (1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply. RESULTS Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location. CONCLUSIONS Several sociodemographic and geographic disparities in PARC use were identified.

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

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.

The Rising Rate of Rural Hospital Closures.

PURPOSE Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities. METHODS The 2009 financial performance and market characteristics of rural hospitals that closed from 2010 through 2014 were compared to rural hospitals that remained open during the same period, stratified by critical access hospitals (CAHs) and other rural hospitals (ORHs). Differences were tested using Pearsons chi-square (categorical variables) and Wilcoxon rank test of medians. The relationships between negative operating margin and (1) market factors and (2) utilization/staffing factors were explored using logistic regression. FINDINGS In 2009, CAHs that subsequently closed from 2010 through 2014 had, in general, lower levels of profitability, liquidity, equity, patient volume, and staffing. In addition, ORHs that closed had smaller market shares and operated in markets with smaller populations compared to ORHs that remained open. Odds of unprofitability were associated with both market and utilization factors. Although half of the closed hospitals ceased providing health services altogether, the remainder have since converted to an alternative health care delivery model. CONCLUSIONS Financial and market characteristics appear to be associated with closure of rural hospitals from 2010 through 2014, suggesting that it is possible to identify hospitals at risk of closure. As closure rates show no sign of abating, it is important to study the drivers of distress in rural hospitals, as well as the potential for alternative health care delivery models.

Is adherence to weight monitoring or weight-based diuretic self-adjustment associated with fewer heart failure-related emergency department visits or hospitalizations?

BACKGROUND Heart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related emergency department (ED) visits or hospitalizations. METHODS AND RESULTS We performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training, including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined case time periods as HF-related ED visits or hospitalizations in the 7 preceding days; control time periods were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in case and control time periods, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over 1 year of follow-up. Weight monitoring adherence (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.23-0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19-0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. CONCLUSIONS Adherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity.