Marcia A. Ciol

Physician Views About Treating Low Back Pain: The Results of a National Survey

Study Design. Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain. Objective. To document physician beliefs about the efficacy of specific treatmets and the extent to which these beliefs correspond to current knowledge. Summary of Background Data. Little is known about physician beliefs regarding the efficacy of specific back pain treatments. Methods. A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders. Results. Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acture or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute or chronic back painor that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorties of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use. Conclusions. The lack of consensus among physicians could be attributable to the absence of clear evidencebsed clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy, or a tendency to discount the efficacy of competing treatments.

Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure.

We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patients age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.

Lumbar spinal fusion: A cohort study of complications, reoperations, and resource use in the medicare population

Regional variations in lumbar spinal fusion rates suggest a poor consensus on surgical indications. Therefore, complications, costs, and reoperation rates were compared for elderly patients undergoing surgery with or without spinal fusion. Subjects were Medicare recipients who underwent surgery in 1985, with 4 years of subsequent follow-up. There were 27,111 eligible patients, of whom 5.6% had fusions. Mean age was 72 years. Patients undergoing fusion had a complication rate 1.9 times greater than those who had surgery without fusion. The blood transfusion rate was 5.8 times greater, nursing home placement rate 2.2 times greater, and hospital charges 1.5 times higher (all P < 0.0005). Six-week mortality was 2.0 times greater for patients undergoing fusions (P = 0.025). Reoperation rates at 4 years were no lower for patients who had fusion surgery and results were similar in most diagnostic subgroups. Indications for fusion among older patients require better definition, preferably based on outcomes from prospective controlled studies.

An Assessment of Surgery for Spinal Stenosis: Time Trends, Geographic Variations, Complications, and Reoperations

OBJECTIVE: To study temporal trends and geographic variations in the use of surgery for spinal stenosis, estimate short‐term morbidity and mortality of the procedure, and examine the likelihood of repeat back surgery after surgical repair.

Falls in the Medicare Population: Incidence, Associated Factors, and Impact on Health Care

Background and Purpose: Falls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries. Participants: The participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS). Methods: Categories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data. Results: Population estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, “fallers” consistently had larger utilization costs than “nonfallers” for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information. Discussion and Conclusions: Falls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people.

Exercise Adherence Following Physical Therapy Intervention in Older Adults With Impaired Balance

BACKGROUND AND PURPOSE This study looked at adherence, and factors affecting adherence, to a prescribed home exercise program (HEP) in older adults with impaired balance following discharge from physical therapy. SUBJECTS The subjects were 556 older adults (> or =65 years of age) who were discharged from physical therapy during the period 2000 to 2003. METHODS A survey was developed to determine participation in a HEP. Univariate logistic regressions identified specific barriers and motivators that were associated with exercise participation following discharge from physical therapy. RESULTS Ninety percent of respondents reported receiving a HEP; 37% no longer performed it. Change in health status was the primary reason for poor adherence to a HEP. Eight barriers (no interest, poor health, weather, depression, weakness, fear of falling, shortness of breath, and low outcomes expectation) were associated with a lack of postdischarge participation in exercise. DISCUSSION AND CONCLUSIONS Exercise adherence following discharge from a physical therapy program is poor among older adults. Barriers, not motivators, appear to predict adherence.

Environmental components of mobility disability in community-living older persons.

OBJECTIVES:  To examine the relationship between characteristics of the physical environment and mobility disability in community‐living older persons.

Involving patients in clinical decisions: Impact of an interactive video program on use of back surgery

Background.Back surgery rates are rapidly rising in the United States. This surgery is usually elective, so patient preferences are important in the treatment decision. Objectives.The objective of this study was to determine the impact on outcomes and surgical choices of an interactive, diagnosis-specific videodisk program for informing patients about treatment choices. Research Design.This was a randomized, controlled trial at 2 sites comparing the interactive video plus a booklet with the booklet alone. Subjects.Elective surgery candidates (n = 393) included 171 patients with herniated disks, 110 with spinal stenosis, and 112 with other diagnoses. Measures.Mailed questionnaires were used to assess outcomes and satisfaction; surgery rates were determined by questionnaires and automated records. Results.Symptom and functional outcomes at 3 months and 1 year were similar between study groups. The overall surgery rate was 22% lower in the videodisk group (26% versus 33%, P = 0.08). Among patients with herniated disks, those in the video group underwent significantly less surgery (32% versus 47%, P = 0.05 by Kaplan-Meier test). Among patients with spinal stenosis, surgery rates in the video group were higher (39% for the video group, 29% for the booklet group;P = 0.4). There was little effect on patient satisfaction, but patients in the video group felt better informed. Conclusions.The program appears to facilitate decision making and may help to ensure informed consent. For patients with herniated disks, it reduced the surgery rate without diminishing patient outcomes. Its impact on costs of care depends on the proportion of patients with various diagnoses and on local surgery rates.

Age-Associated Declines in Complex Walking Task Performance: The Walking InCHIANTI Toolkit

OBJECTIVES: To describe a set of complex walking tasks (CWTs) that can be used to evaluate mobility and to characterize age‐ and sex‐specific performance on these tests.

Mobility Limitations in the Medicare Population: Prevalence and Sociodemographic and Clinical Correlates

Objectives: To examine the prevalence of and clinical markers associated with mobility limitations in Medicare Current Beneficiary Community Survey (MCBS) respondents.