Janet K. Freburger

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.

Infection Risk with Bolus versus Maintenance Iron Supplementation in Hemodialysis Patients

Intravenous iron may promote bacterial growth and impair host defense, but the risk of infection associated with iron supplementation is not well defined. We conducted a retrospective cohort study of hemodialysis patients to compare the safety of bolus dosing, which provides a large amount of iron over a short period of time on an as-needed basis, with maintenance dosing, which provides smaller amounts of iron on a regular schedule to maintain iron repletion. Using clinical data from 117,050 patients of a large US dialysis provider merged with data from Medicares ESRD program, we estimated the effects of iron dosing patterns during repeated 1-month exposure periods on risks of mortality and infection-related hospitalizations during the subsequent 3 months. Of 776,203 exposure/follow-up pairs, 13% involved bolus dosing, 49% involved maintenance dosing, and 38% did not include exposure to iron. Multivariable additive risk models found that patients receiving bolus versus maintenance iron were at increased risk of infection-related hospitalization (risk difference [RD], 25 additional events/1000 patient-years; 95% confidence interval [CI], 16 to 33) during follow-up. Risks were largest among patients with a catheter (RD, 73 events/1000 patient-years; 95% CI, 48 to 99) and a recent infection (RD, 57 events/1000 patient-years; 95% CI, 19 to 99). We also observed an association between bolus dosing and infection-related mortality. Compared with no iron, maintenance dosing did not associate with increased risks for adverse outcomes. These results suggest that maintenance iron supplementation may result in fewer infections than bolus dosing, particularly among patients with a catheter.

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.

A randomized controlled trial of the people with arthritis can exercise program: Symptoms, function, physical activity, and psychosocial outcomes

OBJECTIVE To evaluate the basic 8-week People with Arthritis Can Exercise (PACE) program for improvements in primary (symptoms, functioning, level of physical activity) and secondary (psychosocial) outcomes. METHODS A total of 346 individuals with self-reported arthritis from 18 sites participated in a randomized controlled trial of PACE. Outcomes were measured at baseline and 8 weeks. The intervention group completed self-reported assessments at 3 and 6 months. Two-level multiple linear regression models were estimated to calculate adjusted outcome means in the intervention and control groups. A mixed-effects repeated-measures model was used to calculate adjusted means in the intervention group at 3 and 6 months. Both intent-to-treat (ITT) and as-treated (AT) analyses were conducted. RESULTS At 8 weeks, the intervention group had improvements in the following outcomes: 2 symptom outcomes (pain, fatigue) and 1 psychosocial outcome (self-efficacy for managing arthritis) in the ITT analyses; 1 symptom outcome (pain), 1 function outcome (chair stands), and 1 psychosocial outcome (self-efficacy for arthritis management) in the AT analyses. In addition, completers who attended>or=9 classes had improvements in 3 symptom outcomes (pain, fatigue, stiffness), 2 function outcomes (10-pound lifts, chair stands), and 1 psychosocial outcome (self-efficacy for arthritis management) at 8 weeks. Relative to baseline, PACE participants maintained significant improvements in symptoms at 6 months, but declined in function and self-efficacy for exercise. CONCLUSION If adults with arthritis attend a majority of PACE classes, they may expect improvements in symptoms, self-efficacy for arthritis management, and upper and lower extremity function. Achieving sustained improvement in outcomes may require continued participation in PACE.

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.

Prevalence, Practice Patterns and Evidence for Chronic Neck Pain

To estimate the prevalence of chronic neck pain in North Carolina, to describe health care use (providers, treatments, and diagnostic testing) for chronic neck pain, and to correlate health care use with the current best evidence.

Changing Patterns of Anemia Management in US Hemodialysis Patients

BACKGROUND Erythropoiesis-stimulating agents and adjuvant intravenous iron have been the primary treatment for anemia in chronic kidney disease. Recent clinical and policy-related events have challenged this traditional paradigm, particularly in regard to erythropoiesis-stimulating agents. Less is known about the impact of these events on intravenous iron use. METHODS United States Renal Data System data (2002-2008) on Medicare hemodialysis patients were examined. For each patient, monthly intravenous iron dose, erythropoiesis-stimulating agent dose, and hemoglobin values were determined. Data were summarized by calendar quarter and plotted for the entire sample and by demographic, clinical, and facility-level subgroups. Marginal means for these variables also were computed to account for changes in patient characteristics over time. RESULTS Quarterly iron use increased from 64% in 2002 to 76% in 2008. Mean quarterly iron dose increased from 500 mg in 2002 to 650 mg in 2008. Mean monthly erythropoiesis-stimulating agent dose (per quarter) increased from 2002 to 2006 and then declined. Mean hemoglobin values followed a pattern similar to erythropoiesis-stimulating agent dose. The same patterns in iron, erythropoiesis-stimulating agent dose, and hemoglobin were generally observed across demographic, clinical, facility, and geographic subgroups, with some important differences between subgroups, specifically race and dialysis vintage. CONCLUSIONS Anemia management patterns have changed markedly between 2002 and 2008, with a steady increase in intravenous iron use even after declines in erythropoiesis-stimulating agent dose and hemoglobin. The clinical impacts of these changes need further evaluation.

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.

Temporal Trends in Fracture Rates and Postdischarge Outcomes among Hemodialysis Patients

Patients with ESRD have a substantially increased risk of bone fractures, but the burden of fractures has not been sufficiently characterized in this population. Here, we analyzed fracture rates and postdischarge outcomes using Medicare data from hemodialysis patients in the United States between 2000 and 2009. We assessed adjusted quarterly fracture rates (inpatient and outpatient) and consequences of postfracture hospitalization for seven categories of fracture location. Pelvis/hip, vertebral, and lower leg fractures were the most prevalent fracture types. Pelvis/hip fractures declined slightly from 29.6 to 20.6 per 1000 patient-years between early 2000 and late 2009, but the incidence rates for all other fracture types remained relatively constant. Median lengths of stay for the primary fracture hospitalization ranged from 5 days (interquartile range [IQR], 3-9 days) for forearm/wrist fractures to 8 days (IQR, 5-12 days) for femur fractures. The proportion of patients discharged from the primary hospitalization to a skilled-nursing facility ranged from 28% (ribs/sternum) to 47% (pelvis/hip). A negative binomial regression model suggested that patients had an adjusted mean of 3.8-5.2 additional hospitalizations during the year after discharge from the index hospitalization, varying by fracture type, comprising a mean of 33-52 inpatient days. Case-mix-adjusted mortality rates after discharge ranged from 0.43 to 0.91 per patient-year and were highest for vertebral, pelvis/hip, and femur fractures. In conclusion, fractures in the dialysis population are common and are associated with a substantially increased risk for death and hospitalization.

Chronic Low Back Pain Among Older Adults: A Population-Based Perspective

Objectives: To determine the prevalence of chronic low back pain (LBP) in older North Carolinians, describe their health and health care utilization, and compare these findings with younger subgroups. Method: A cross-sectional, telephone survey of 5,357 households was conducted to identify 732 adults with chronic, impairing LBP. Results: Chronic LBP prevalence in older adults was significantly higher than the 21-to-44-year age group (12.3% vs. 6.5%, p < .001). Older adults were more disabled, had longer symptom duration, and were less depressed. Chronic LBP care seeking in older adults was significantly lower than the 45-to-64-year age group (80.6% vs. 88.6%, p = .02). Older adults were less likely to receive bed rest, spinal manipulation, heat/cold treatments, electrical stimulation, and massage therapy. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, strong narcotics, and antidepressants was significantly lower in the older age group. Discussion: There are age-related differences in health and health care use among individuals with chronic LBP.