Timothy S. Carey

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 Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

BACKGROUND Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. METHODS Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. RESULTS The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors. CONCLUSIONS Among patients with acute low back pain, the outcomes are similar whether they receive care from primary care practitioners, chiropractors, or orthopedic surgeons. Primary care practitioners provide the least expensive care for acute low back pain.

Clinical course of anti-neutrophil cytoplasmic autoantibody-associated glomerulonephritis and systemic vasculitis

OBJECTIVES To determine the spectrum of clinical manifestations in patients with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated glomerulonephritis; to determine renal and patient survival in these patients; to compare survival among patients treated with corticosteroids alone, corticosteroids plus intravenous cyclophosphamide or corticosteroids plus oral cyclophosphamide; and to assess the correlation of disease manifestations and treatment response with ANCA subtypes and serial autoantibody titers. DESIGN Inception cohort study; mean follow-up of 24 months. SETTING Collaborative network of 120 university and private practice nephrologists (The Glomerular Disease Collaborative Network). PARTICIPANTS Seventy patients with ANCA and pauci-immune necrotizing and crescentic glomerulonephritis, of whom 59 were treated with either corticosteroids alone (14 patients), corticosteroids plus oral cyclophosphamide (30 patients), or corticosteroids plus intravenous cyclophosphamide (15 patients). MAIN RESULTS Of the 70 patients, 18 had renal-limited disease (idiopathic crescentic glomerulonephritis); 15, nonpulmonary extrarenal disease consistent with polyarteritis nodosa; and 37, pulmonary disease consistent with Wegener granulomatosis or alveolar capillaritis. There were overlapping manifestations of disease between patients with autoantibodies producing a cytoplasmic pattern and patients with autoantibodies producing a perinuclear pattern; however, the perinuclear pattern occurred more frequently in patients with renal-limited disease. Renal and patient survival was 75% at 24 months, and no difference in survival was seen between patients with renal-limited disease and those with systemic disease. No differences in survival were seen between patients treated with oral cyclophosphamide and those treated with intravenous cyclophosphamide; however, the comparative data from patients treated with corticosteroids alone were inconclusive. In general, autoantibody titers correlated with response to treatment and disease activity, but there were exceptions. CONCLUSIONS Patients with ANCA have various forms of necrotizing vascular inflammation, ranging from renal-limited disease to widespread systemic vasculitis, including polyarteritis nodosa and Wegener granulomatosis. Oral corticosteroids with either oral or intravenous cyclophosphamide appear to be equally effective therapy for ANCA-associated glomerulonephritis.

Standard scales for measurement of functional outcome for cervical pain or dysfunction: A systematic review

Study Design. A systematic review was conducted. Objective. To identify, evaluate, and compare standard scales for assessing neck pain or dysfunction. Summary of Background Data. The degree of a patient’s neck pain or dysfunction can be evaluated using standardized scales at the time of a clinical encounter or during the performance of clinical research protocols. The choice of a scale with the most appropriate characteristics, however, is always a challenge to clinicians and researchers. Methods. Articles concerning scales for functional evaluation of neck pain or dysfunction were identified by computer searching of MEDLINE (January 1966 to June 1999) and CINAHL (1985 to 2000), citation tracking using the Citation Index, hand searching of relevant journals, and correspondence with experts. Results. Five standard scales were found. Three scales were remarkably similar in terms of structure and psychometric properties: the Neck Disability Index, the Copenhagen Neck Functional Disability Scale, and the Northwick Park Scale. However, only the first instrument has been revalidated in different study populations. The Neck Pain and Disability Scale provides a visual template for collection of information, but its usefulness is limited if the questionnaire must be read to the patient. The Patient-Specific Functional Scale is very sensitive to functional changes in individual patients, but comparisons between patients are virtually impossible. Conclusions. The five scales identified in this study have similar characteristics. The Neck Disability Index, however, has been revalidated more times for evaluation of patient groups. For individual patient follow-up evaluation, the Patient-Specific Functional Scale has high sensitivity to change, and thus represents a good choice for clinical use. The final choice should be tailored according to the target population and the purpose of the evaluation.

The Effects of Having a Regular Doctor on Access to Primary Care

The authors assessed the relationship between having a regular doctor and access to care, as measured by a set of preventive and primary care utilization indicators recommended by the Institute of Medicine. The 1987 National Medical Expenditure Survey was used in the analyses (n = 30,012). The results of the regression analyses suggest that individuals with any type of regular source of care had better access than those without a regular source of care. Persons with a regular doctor had better access to primary care than those with a regular site but no regular doctor. However, the apparent advantage of having a regular doctor over a regular site disappeared when only those individuals reporting a physicians office, clinic, or health maintenance organization as their regular source of care were compared. These results suggest that policies that promote the doctor-patient relationship will increase access, although the gains may be negligible for individuals who use mainstream primary care sites (physicians office, clinic, or health maintenance organization) versus sites such as walk-in clinics or emergency rooms.

Acute severe low back pain : a population-based study of prevalence and care-seeking

Study Design Telephone interviews were conducted with a random sample of adults in 4437 North Carolina households. The response rate was 79%. Objective The prevalence of low back pain and the correlates of care-seeking in a defined population were examined. Summary of Background Data Previous research on low back pain has used varying definitions of the illness of low back pain, and has admixed patients with acute and chronic low back pain. Acute low back pain was examined in this study as a distinct phenomenon separate from chronic low back pain. Methods Respondents completed a detailed interview regarding the occurrence of and care sought for back pain in 1991. Acute back pain was defined as functionally limiting pain lasting less than 3 months. Results From this sample, 485 individuals had at least one occurrence of acute severe low back pain in 1991, representing 7.6% of the adult population. Symptoms were reported less commonly in individuals older than age 60 years (5% vs. 8.5%) and in nonwhites compared with whites (5% vs. 8%). Thirty-nine percent of those with back pain sought medical care; 24% sought care initially from an allopathic physician, 13% from a chiropractor, and 2% from other providers. More prolonged pain, more severe pain, and sciatica were associated with care-seeking. Gender, income, age, rural residence, and health insurance status did not correlate with the decision to seek medical care. Younger age, male gender, and nonjob-related pain did correlate with the decision to seek care from a chiropractor. Conclusions Acute back pain is common. Care is often sought regardless of income and insurance status. Seeing a health care provider for acute back pain may not be discretionary from the perspective of the patient.

Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder

Context The relative benefits and harms of newer, second-generation antidepressants are sometimes confusing. Contribution In this review of 46 head-to-head randomized trials, the authors generally found no major differences in the numbers of adults with major depression who responded to second-generation antidepressants, such as selective serotonin reuptake inhibitors, bupropion, duloxetine, mirtazapine, and venlafaxine. The overall incidence of adverse events appeared similar across drugs, although types of adverse events varied. Cautions Trials were funded by industry and had variable quality and follow-up duration. Implications Second-generation antidepressants generally have similar benefits but different possible harms for adults with major depression. The Editors Major depressive disorder is a serious disabling illness that affects more than 16% of adults in the United States at some point in their lifetime (1). In 2000, the economic burden of depressive disorders in the United States was estimated to be

Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002.

83.1 billion (2). Current practice guidelines for the treatment of major depressive disorder recommend pharmacotherapy, psychotherapy, psychotherapy plus pharmacotherapy, or electroconvulsive therapy. In most cases, pharmacotherapy is first-line treatment for major depressive disorder. Moreover, it is a practical tool for primary care physicians, who prescribe the majority of antidepressants in the United States (3). Pharmacologic treatment for major depressive disorder includes first-generation antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and second-generation antidepressants. Second-generation medications include selective serotonin reuptake inhibitors (SSRIs); selective norepinephrine reuptake inhibitors; and other drugs that selectively affect the activity of neurotransmitters, such as serotonin, norepinephrine, and dopamine. In general, the efficacy of first- and second-generation antidepressant medications is similar (4-6). However, first-generation antidepressants often cause multiple side effects that many patients find intolerable (7-9), and the risk for harm when taken in overdose or in combination with certain medications is high. Because of their relatively favorable side effect profile, the second-generation antidepressants play a prominent role in the management of patients with major depressive disorder. Reviews have compared the efficacy and tolerability of newer second-generation antidepressants with those of placebo or older treatments (6, 10, 11) but did not evaluate comparative evidence for second-generation antidepressants. We therefore sought to systematically evaluate comparative data on the efficacy, effectiveness, and tolerability of commonly prescribed second-generation antidepressants. Specifically, we conducted a systematic review and meta-analysis of comparative evidence for 6 SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline) and 4 other second-generation antidepressants (bupropion, duloxetine, mirtazapine, and venlafaxine). From here on, we refer to these agents collectively as antidepressants. We examine the role of these agents in the initial treatment of ambulatory adult patients with major depressive disorder. Methods Key Questions Key questions designed to address the comparative efficacy, effectiveness, safety, and tolerability of antidepressants guided our research. A consortium of 12 state Medicaid programs, the Canadian Coordinating Office for Health Technology Assessment, the California HealthCare Foundation, and key experts formulated the questions and provided funding for this research. Literature Search To identify articles relevant to each key question, we searched MEDLINE, EMBASE, and PsychLit; the Cochrane Library; and the International Pharmaceutical Abstracts. To capture articles relevant to the scope of our topic, our searches covered 1980 through 28 February 2005. We manually searched reference lists of relevant review articles and letters to the editor. Pharmaceutical manufacturers were invited to submit dossiers, including citations, as outlined by the Drug Effectiveness Review Project (12). We requested unpublished studies from the U.S. Food and Drug Administration, but this agency did not release unpublished data. Study Selection Two persons independently reviewed titles and abstracts. If both reviewers agreed that a trial did not meet preestablished eligibility criteria (Appendix Table), we excluded it. To assess efficacy and effectiveness, we included head-to-head trials comparing one antidepressant with another. We defined effectiveness trials as those that were conducted in primary care settings, had an adequate duration of follow-up (3 months), had minimal inclusion and exclusion criteria (so that participants represented the general population), assessed health outcomes rather than intermediate outcomes, and had an adequate sample size to determine a minimally important difference (from a patients perspective) on a health-related quality of life instrument (13). To assess safety and tolerability, we included head-to-head trials, placebo-controlled trials, and observational studies with large samples (>100 patients) lasting at least 1 year. We required a larger sample size for observational studies because we wanted primarily to detect adverse events that were not frequent enough to be apparent in smaller trials. Data Abstraction and Quality Assessment Trained reviewers abstracted data from each study, and a senior reviewer read each abstracted article and evaluated completeness of data extraction. We recorded intention-to-treat results if they were available. We assessed the internal validity (quality) of trials by using predefined criteria from the U.S. Preventive Services Task Force (ratings of good, fair, or poor) (14) and the National Health Service Centre for Reviews and Dissemination (15). Elements of internal validity assessment included randomization, allocation concealment, similarity of compared groups at baseline, use of intention-to-treat analysis, and overall and differential loss to follow-up. We defined loss to follow-up as the number of persons who underwent randomization but did not complete the study (16), independent of the reason and whether intention-to-treat analysis was used. We rated studies as poor if they had more than 40% overall loss to follow-up or more than 15 percentage points of differential loss to follow-up between study groups. Data Synthesis We first qualitatively summarized the studies. When more than 3 head-to-head trials compared the same treatments, we did quantitative analyses. In these, the primary outcome measure was treatment response, defined as 50% or greater improvement on the Hamilton Rating Scale for Depression (HAM-D) or the MontgomeryAsberg Depression Rating Scale from baseline to study end. The relative benefit reflects the ratio of benefits or risks in one treatment group compared with another. When treatment effects differed between studies, we explored potential reasons for these differences. For each meta-analysis, we tested for heterogeneity of treatment effects by using I2 statistics. If no heterogeneity was detected, we applied both a random-effects and a fixed-effects model. We report the results of the more conservative random-effects models (17) because the validity of tests of heterogeneity can be limited with a small number of component studies. To estimate possible publication bias caused by the tendency of published studies to be positive, we used funnel plots, the Begg adjusted rank correlation test (18), and the Egger regression approach (19). However, because these tests have low statistical power when the number of trials is small (20), undetected bias may still be present. All statistical analyses were conducted by using StatsDirect Statistical Software, version 2.3.8 (StatsDirect, Ltd., Sale, United Kingdom). We calculated the mean incidence and 95% CIs for specific adverse events reported in included trials. Because assessment and reporting of adverse events varied greatly among trials, this evidence should be interpreted with caution. Role of the Funding Sources The funding sources contributed to the development of the key questions but had no role in the conduct or reporting of the study or in the decision to submit the manuscript for publication. Results We found 820 unduplicated citations. Manual review of the reference lists of pertinent review articles produced another 74 articles. Although 6 pharmaceutical companies submitted dossiers, no included studies stemmed from the dossiers. Therefore, 894 citations were included in our database (Appendix Figure). Forty-six randomized, controlled trials compared the effectiveness or efficacy of one SSRI or other antidepressant with that of another in the treatment of major depressive disorder (Tables 1 and 2). (Complete evidence tables are available at www.ohsu.edu/drugeffectiveness/reports/final.cfm or from the authors.) Most studies were efficacy trials and received a rating of fair for internal validity; some trials rated fair may have fulfilled all quality criteria but did not report methods to an extent that answered all of our questions. We considered 2 trials from Europe (21, 22) and 1 trial from the United States (23) conducted in primary care settings to be effectiveness trials. Sixty percent of included trials were less than 12 weeks in duration. The samples consisted mostly of persons younger than 60 years of age; samples consisted of persons 60 years of age or older in 6 trials (13%) and children or adolescents younger than 18 years of age in 3 trials (7%). Although sponsorship did not influence our quality rating, it may have influenced reporting. About 85% of trials in our review were sponsored by a pharmaceutical company, and an additional 11% had at least 1 author affiliated with a pharmaceutical company. The remaining 4% of included studies

Beyond the good prognosis: Examination of an inception cohort of patients with chronic low back pain

Objective:Patients who require tracheostomy for prolonged mechanical ventilation have poor outcomes and high costs of care. However, recent longitudinal trends relevant to these patients and their care have not been described. We aimed to describe trends in the annual incidence and timing of tracheostomy for prolonged mechanical ventilation, as well as prolonged mechanical ventilation patient resource utilization and overall in-hospital mortality. Design and Setting:Retrospective review of the North Carolina Hospital Discharge Database, a comprehensive record of all state nonfederal, nonpsychiatric hospital discharges between 1993 and 2002. Patients:Patients were 9,794 medical and surgical patients ≥18 yrs of age with International Classification of Diseases, Ninth Revision, Clinical Modification code 96.72 (mechanical ventilation for >96 hrs) and Diagnosis Related Group code 483 (tracheostomy except for face, neck, and mouth diagnoses). Interventions:None. Measurements:Incidence rates adjusted for annual population growth, mechanical ventilation days until tracheostomy placement, length of stay, and hospital charges and payments adjusted by the medical component of the Consumer Price Index. Main results:Between 1993 and 2002, the incidence of tracheostomy for prolonged mechanical ventilation increased across all age groups from 8.3 of 100,000 to 24.2 of 100,000 (p < .001), although most significantly among patients <55 yrs of age. During this period, a decrease was seen in mortality (from 39% to 25%), median mechanical ventilation days to tracheostomy placement (from 12 to 10 days), and median length of stay (from 47 to 33 days). By 2002, patients were almost three times less likely to be discharged to home independently although twice as likely to be sent to a skilled nursing facility. Although prolonged mechanical ventilation patients with tracheostomies represented only 7% of all who required mechanical ventilation, their total charges during the study period were

Care-seeking Among Individuals With Chronic Low Back Pain

1.74 billion—22% of all mechanical ventilation patient charges. Conclusion:The incidence of tracheostomy for prolonged mechanical ventilation increased by nearly 200% during the past decade in North Carolina, exceeding changes in the overall incidence of respiratory failure three-fold. Although in-hospital mortality, length of stay, and charges per patient fell over time, the overall resource utilization of prolonged mechanical ventilation patients increased dramatically.