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Walter F Stewart,1 Xiaowei Yan,1 Joseph A Boscarino,1 Daniel D Maeng,1 Jack Mardekian,2 Robert J Sanchez,3 Michael R Von Korff41Geisinger Center for Health Research, 2Pfizer, Inc., 3Regeneron Pharmaceuticals, Inc., 4Group Health Research Institute, Seattle, WA, USABackground: The purpose of this study was to determine if primary care patients with low back pain (LBP) cluster into definable care utilization subgroups that can be explained by patient and provider characteristics.Materials and methods: Adult primary care patients with an incident LBP encounter were identified from Geisinger Clinic electronic health records over 5 years. Two-thirds of the cohort had only one to two encounters. Principal component analysis was applied to the data from the remaining one-third on use of ambulatory, inpatient, emergency department, and surgery care and use of magnetic resonance imaging, injections, and opioids in 12 months following the incident encounter. Groups were compared on demographics, health behaviors, chronic and symptomatic disease burden, and a measure of physician efficiency.Results: Six factors with eigenvalues >1.5 explained 71% of the utilization variance. Patient subgroups were defined as: 1–2 LBP encounters; 2+ surgeries; one surgery; specialty care without primary care; 3+ opioid prescriptions; laboratory dominant care; and others. The surgery and 3+ opioid subgroups, while accounting for only 10.4% of the cohort, had used disproportionately more magnetic resonance imaging, emergency department, inpatient, and injectable resources. The specialty care subgroup was characterized by heavy use of inpatient care and the lowest use of injectables. Anxiety disorder and depression were not more prevalent among the surgery patients than in the others. Surgery patients had features in common with specialty care patients, but were older, had higher prevalence of Fibromyalgia, and were associated primary care physicians with worse efficiency scores.Conclusion: LBP care utilization is highly variable and concentrated in small subgroups using disproportionate amounts of potentially avoidable care that reflect both patient and provider characteristics.Keywords: low back pain, primary care, opioids, back surgery, provider efficiency

High impact chronic pain (HICP) is a recently proposed concept for treatment stratifying patients with chronic pain and monitoring their progress. The goal is to reduce the impact of chronic pain on the individual, their family, and society. The US National Pain Strategy defined HICP as the chronic pain associated with substantial restrictions on participation in work, social, and self-care activities for at least 6 months. To understand the meaning and characteristics of HICP from the younger (<65 years old) and older adults (≥65 years old) with chronic pain, our study examined patients' perceived pain impact between the two age groups. We also characterize the degree of pain impact, assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI), between adults and older adults with HICP. We recruited patients at a tertiary pain clinic. The survey included open-ended questions about pain impact, the Graded Chronic Pain Scale-Revised to identify patients' meeting criteria for HICP, and the Patient-Reported Outcomes Measurement Information System (PROMIS ® ) 8-item PI short form (v.8a). A total of 55 younger adults (65.5% women, 72.7% HICP, mean age = 55.0 with SD of 16.2) and 28 older adults (53.6% women, 64.3% HICP, mean age = 72.6 with SD of 5.4) with chronic pain participated in this study. In response to an open-ended question in which participants were asked to list out the areas of major impact pain, those with HICP in the younger group most commonly listed work, social activity, and basic physical activity (e.g., walking and standing); for those in the older group, basic physical activity, instrumental activity of daily living (e.g., housework, grocery shopping), and participating in social or fun activity for older adults with HICP were the most common. A 2 × 2 ANOVA was conducted using age (younger adults vs. older adults) and HICP classification (HICP vs. No HICP). A statistically significant difference was found in the PROMIS-PI T-scores by HICP status (HICP: M = 58.4, SD = 6.3; No HICP: M = 67.8, SD = 6.3), but not by age groups with HICP. In conclusion, perceived pain impacts were qualitatively, but not quantitatively different between younger and older adults with HICP. We discuss limitations and offer recommendations for future research., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 You, Ziadni, Hettie, Darnall, Cook, Von Korff and Mackey.)

Background: Low back pain (LBP) is a debilitating condition that is complex to manage. One reason is that clinicians lack means to identify early on patients who are likely to become high care utilizers., Objective: To explore the feasibility of developing a 'dynamic' predictive model using electronic health record data to identify costly LBP patients within the first year after their initial LBP encounter with a primary care provider. Dynamic, in this context, indicates a process in which the decision on how to manage patients is dependent on whether they are at their first, second or third LBP visit with the provider., Methods: A series of logistic regression models was developed to predict who will be a high-cost patient (defined as top 30% of the cost distribution) at each of the first three LBP visits., Results: The c-statistics of the three logistic regression models corresponding to each of the first three visits were 0.683, 0.795 and 0.741, respectively. The overall sensitivity of the model was 42%, the specificity was 86% and the positive predictive value was 48%. Men were more likely to become expensive than women, while patients who had workers' compensation as their primary payer type had higher use of prescription opioid drugs or were smokers before the first LBP visit were also more likely to become expensive., Conclusion: The results suggest that it is feasible to develop a dynamic, primary care provider visit-based predictive model for LBP care based on longitudinal data obtained via electronic health records.

Background: The use of chronic opioid therapy (COT) has risen dramatically in recent years, especially among women. However, little is known about factors influencing overall pain and function (global pain status) among COT users. Characterizing the typical experiences of COT patients by age-sex group could help clinicians and patients better weigh the risks and benefits of COT. Thus, we sought to characterize global pain status among COT users in community practice by age and sex., Methods: Telephone survey of 2,163 health plan members aged 21-80 years using COT. We assessed average/usual pain (0-10 scale); pain-related interference (0-10); activity limitation days, last 3 months; and pain impact, last 2 weeks (0-11). Status on each indicator was classified as low (better pain/function), moderate, or high (worse pain/function). Global pain status was categorized as favorable if 2-4 indicators were low and 0-1 was high and unfavorable if 2-4 indicators were high and 0-1 was low., Results: Among female COT patients, 15% (vs. 26% of males) had favorable global pain status and 59% (vs. 42% of males) had unfavorable status. Under age 65 years, women fared more poorly than men on every indicator. Among 65- to 80-year-olds, women and men had similar global pain status., Conclusions: Although pain and function among COT users vary considerably, only one in five reported low pain levels and high levels of function. Young and middle-aged women seem to be at particularly high risk for unfavorable global pain status. More research is needed about how to best manage pain in this group.

Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: Although psychosocial and clinical factors have been found to be associated with hypoglycemic episodes in patients with diabetes, few studies have examined the association of depression with severe hypoglycemic episodes. This study examined the prospective association of depression with risk of hypoglycemic episodes requiring either an emergency department visit or hospitalization., Methods: In a longitudinal cohort study, a sample of 4,117 patients with diabetes enrolled between 2000 and 2002 were observed from 2005 to 2007. Meeting major depression criteria on the Patient Health Questionnaire-9 was the exposure of interest, and the outcome of interest was an International Classification of Disease, Ninth Revision code for a hypoglycemic episode requiring an emergency department visit or hospitalization. Proportional hazard models were used to analyze the association of baseline depression and risk of one or more severe hypoglycemic episodes. Poisson regression was used to determine whether depression status was associated with the number of hypoglycemic episodes., Results: After adjusting for sociodemographic, clinical measures of diabetes severity, non-diabetes-related medical comorbidity, prior hypoglycemic episodes, and health risk behaviors, depressed compared with nondepressed patients who had diabetes had a significantly higher risk of a severe hypoglycemic episode (hazard ratio = 1.42, 95% CI, 1.03-1.96) and a greater number of hypoglycemic episodes (odds ratio = 1.34, 95% CI, 1.03-1.74)., Conclusion: Depression was significantly associated with time to first severe hypoglycemic episode and number of hypoglycemic episodes. Research assessing whether recognition and effective treatment of depression among persons with diabetes prevents severe hypoglycemic episodes is needed.

Purpose: Opioid misuse in the context of chronic opioid therapy (COT) is a growing concern. Depression may be a risk factor for opioid misuse, but it has been difficult to tease out the contribution of co-occurring substance abuse. This study aims to examine whether there is an association between depression and opioid misuse in patients receiving COT who have no history of substance abuse., Methods: A telephone survey was conducted at Group Health Cooperative and Kaiser Permanente of Northern California. We interviewed 1,334 patients on COT for noncancer pain who had no history of substance abuse. Patients were asked about 3 forms of opioid misuse: (1) self-medicating for symptoms other than pain, (2) self-increasing doses, and (3) giving to or getting opioids from others. Depression was evaluated by the 8-item Patient Health Questionnaire (PHQ-8)., Results: Compared with patients who were not depressed (PHQ-8 score 0 to 4), patients with moderate depression (PHQ-8 score 10 to 14) and severe depression (PHQ-8 score 15 or higher) were 1.8 and 2.4 times more likely, respectively, to misuse their opioid medications for non-pain symptoms. Patients with mild (PHQ-8 score 5 to 9), moderate, and severe depression were 1.9, 2.9, and 3.1 times more likely, respectively, to misuse their opioid medications by self-increasing their dose. There was no statistically significant association between depression and giving opioids to or getting them from others., Conclusion: In patients with no substance abuse history, depressive symptoms are associated with increased rates of some forms of self-reported opioid misuse. Clinicians should be alert to the risk of patients with depressive symptoms using opioids to relieve these symptoms and thereby using more opioids than prescribed.

Increased opioid prescribing for chronic pain that is not due to cancer has been accompanied by large increases in abuse and overdose of prescription opioids. This paper describes how Group Health, a Seattle-based nonprofit health care system, implemented a major initiative to make opioid prescribing safer. In the initiative's first nine months, clinicians developed documented care plans for almost 6,000 patients receiving long-term opioid therapy for chronic pain. Evaluation of the initiative's effects on care processes and trends in adverse events is under way.

Unlabelled: This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence., Perspective: Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP., (Copyright 2010 American Pain Society. All rights reserved.)

Context: Little is known about the extent or severity of untreated mental disorders, especially in less-developed countries., Objective: To estimate prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders in 14 countries (6 less developed, 8 developed) in the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative., Design, Setting, and Participants: Face-to-face household surveys of 60 463 community adults conducted from 2001-2003 in 14 countries in the Americas, Europe, the Middle East, Africa, and Asia., Main Outcome Measures: The DSM-IV disorders, severity, and treatment were assessed with the WMH version of the WHO Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay-administered psychiatric diagnostic interview., Results: The prevalence of having any WMH-CIDI/DSM-IV disorder in the prior year varied widely, from 4.3% in Shanghai to 26.4% in the United States, with an interquartile range (IQR) of 9.1%-16.9%. Between 33.1% (Colombia) and 80.9% (Nigeria) of 12-month cases were mild (IQR, 40.2%-53.3%). Serious disorders were associated with substantial role disability. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5% to 50.3% of serious cases in developed countries and 76.3% to 85.4% in less-developed countries received no treatment in the 12 months before the interview. Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country., Conclusions: Reallocation of treatment resources could substantially decrease the problem of unmet need for treatment of mental disorders among serious cases. Structural barriers exist to this reallocation. Careful consideration needs to be given to the value of treating some mild cases, especially those at risk for progressing to more serious disorders.

Objective: Previous research, based on retrospective reporting, suggests that parental reinforcement and modeling may be important mechanisms in the development of gastrointestinal illness behavior in children and adults. The aim of this study was to determine the relationship between the illness behavior of parents, in the form of health care use for irritable bowel symptoms, and the illness behavior of their children, without relying on retrospective recall., Methods: A comparison of two matched groups was made. Groups included 631 children of parents who were diagnosed with irritable bowel syndrome during 1 calendar yr and 646 children of parents matched by parental age, gender, and number of children in the family who did not receive an IBS diagnosis during the same 1 yr. Health care use and costs over a 3-yr calendar period for all children and their parents collected from the health care database of a large health maintenance organization were evaluated., Results: Case children had significantly more ambulatory care visits for all causes (mean 12.26 vs. 9.81, p = 0.0001) and more ambulatory visits for gastrointestinal symptoms (0.35 vs. 0.18, p = 0.0001). Outpatient health care costs over the 3-yr period were also significantly higher for case than control children ($1979 vs. $1546, p = 0.0001). Controlling for the total number of ambulatory visits of the parents, excluding gastrointestinal visits, did not alter the findings. Gender of the IBS parent was not related to children's gastrointestinal visits., Conclusion: This study extends previous research by showing that specific types of illness behavior may be learned through modeling.

Temporomandibular disorders (TMD) are common pain conditions that have their highest prevalence among women of reproductive age. The higher prevalence of TMD pain among women, pattern of onset after puberty and lowered prevalence rates in the post-menopausal years suggest that female reproductive hormones may play an etiologic role in TMD. Two epidemiologic studies were designed to assess whether use of exogenous hormones is associated with increased risk of TMD pain. Both used data from automated pharmacy records of women enrolled in a large health maintenance organization to identify prescriptions filled for post-menopausal hormone replacement therapies (Study 1) or for oral contraceptives (OCs) (Study 2). Study 1 employed an age-matched case-control design to compare post-menopausal hormone use among 1291 women over age 40 referred for TMD treatment and 5164 controls not referred. After controlling for health services use, the odds of being a TMD case were approximately 30% higher among those receiving estrogen compared to those not exposed (P = 0.002); a clear dose-response relationship was evident. The relationship of progestin use to TMD was not statistically significant. Study 2 used a similar design to examine the relationship of OC use to referral for TMD care, drawing on data from 1473 cases and 5892 controls aged 15-35. Use of OCs was also associated with referral for TMD care, with an increased risk of TMD of approximately 20% for OC users, after controlling for health services use (P < 0.05). These results suggest that female reproductive hormones may play an etiologic role in orofacial pain. This relationship warrants further investigation through epidemiologic, clinical and basic research.

Unlabelled: Adequate data on the incidence, prevalence, natural history, and clinical course of temperomandibular disorders (TMD) and other chronic pain conditions are largely lacking, though the need to derive such basic data is recognized by clinicians, researchers, and public health agencies. This paper discusses challenges to the epidemiologic study of TMD diagnosis. These challenges include:•, Case Definition: There is currently poor agreement regarding which combinations of clinical and psychosocial findings differentially define cases of TMD• Differentiation of normal variation v pathophysiologic signs: To what extent do commonly gathered clinical measurements constitute pathophysiologic signs of TMD v reflect normal biologic variation• Reliability of clinical measurement: Factors influencing reliability of clinical signs and reliability of examiners have not been adequately assessed• Progressive v self-limiting disease activity: Do TMD subtypes represent a continuum of pathologic disease activity, or nonmutually exclusive categories describing largely symptomatic pain conditions that are selflimiting or stable.It is recommended that epidemiologic studies not be constrained by a priori definitions of TMD subtypes, but continue to gather data on clinical signs and symptoms that have theoretical and clinical relevance to mandibular dysfunction and psychosocial status. An approach is proposed for development of reliable and valid criteria of TMD subtypes suitable for epidemiologic research.

The authors report findings pertaining to panic disorder from the first three sites of the National Institute of Mental Health Epidemiologic Catchment Area Program. Probability samples of about 3,000 persons aged 18 years or older were interviewed in the New Haven, Connecticut area, eastern Baltimore City, Maryland, and the greater St. Louis, Missouri area in 1980-1982. Information on panic attacks and panic disorder was obtained using the Diagnostic Interview Schedule. The prevalence rate of panic attacks in the prior six months was found to be about 3% at each of the sites, while the prevalence of panic disorder varied from 0.6 to 1.0%. Age at onset was found to peak at 15-19 years. Simple panic attacks, severe and recurrent panic attacks, and panic disorder were found to be characterized by similar symptom profiles and age at onset distributions, and to have similar distributions by demographic factors.

This research describes the extent of variability in diagnosis and treatment of temporomandibular disorders (TMD) and relates this variability to treatment outcomes. A health maintenance organization sequentially referred 145 patients with orofacial pain and dysfunction to two TMD clinics. The two clinics differed substantially in their use of tomography (applied to 28% vs. 64% of all patients), and varied moderately in diagnoses assigned to the patient groups. There was large variation in selection of treatments including appliances for bruxism (64% vs. 5%), mandibular repositioning (10% vs. 25%), and joint stabilization (3% vs. 30%); anti-inflammatory medications (44% vs. 19%) and analgesics (16% vs. 2%); and subsequent referral for dental or orthodontic treatment (1% vs. 42%). The differences in diagnostic and therapeutic practice that were found were not associated with important differences in patient-reported pain and dysfunction at 1-year follow-up. These data indicate the need for systematic approaches to identifying, evaluating, and modifying variation in health care practices for common presenting problems lacking reliable methods of evaluation and generally accepted clinical standards for choice of treatments.

We studied DSM-III diagnoses made by the lay Diagnostic Interview Schedule (DIS) method in relation to a standardized DSM-III diagnosis by psychiatrists in the two-stage Baltimore Epidemiologic Catchment Area mental morbidity survey. Generally, prevalence estimates based on the DIS one-month diagnoses were significantly different from those based on the psychiatric diagnoses. Subjects identified as cases by each method were often different subjects. Measured in terms of kappa, the chance-corrected degree of agreement between the DIS and psychiatrists' one-month diagnoses was moderate for DSM-III alcohol-use disorder (abuse and dependence combined), and lower for other mental disorder categories. The unreliability of either the DIS or psychiatric diagnoses is one potential explanation for the observed disagreements. Others include the following: insufficient or inadequate information (on which to base a diagnosis); recency of disorder; incomplete criterion coverage; overinclusive DIS questions; and degree of reliance on subject symptom reports. Further study of the nature and sources of these discrepancies is underway. This work should produce a more complete understanding of obstacles to mental disorder case ascertainment by lay interview and clinical examination methods in the context of a field survey.

With a psychiatrist's standardized clinical diagnosis as the criterion, the 'Mini-Mental State' Examination (MMSE) was 87% sensitive and 82% specific in detecting dementia and delirium among hospital patients on a general medical ward. The false positive ratio was 39% and the false negative ratio was 5%. All false positives had less than 9 years of education; many were 60 years of age or older. Performance on specific MMSE items was related to education or age. These findings confirm the MMSE's value as a screen instrument for dementia and delirium when later, more intensive diagnostic enquiry is possible; they reinforce earlier suggestions that the MMSE alone cannot yield a diagnosis for these conditions.

The National Institute of Mental Health Diagnostic Interview Schedule (DIS) was modified to record detailed information on current mental status in addition to the lifetime symptom history. Use of the modified DIS in a field survey indicates that information on current symptoms is required to distinguish persons who meet all DSM-III criteria for Major Depressive Episode at or around the time of interview from former cases who fail to meet all criteria at interview. Thus, the unmodified DIS may overestimate the 1-month period prevalence rates for Major Depressive Episode, by counting symptomatic former cases as having the disorder at or around the time of the interview. An analysis of symptom count data also suggests that the unmodified DIS count of lifetime depressive symptoms is not a good measure of current symptom status.

With a psychiatrist's standardized clinical diagnosis as the criterion, the "Hand-Held Tachistoscope" was 100% sensitive, but only 45% specific in detecting delirium among hospital patients on a general medical ward. For each true positive in this sample of 97 patients, there were almost 5 false positives. The 10 patients with clinically diagnosed delirium could not see the stimulus. This was also true for 24 of the 87 nondelirious patients. Performance on the tachistoscope was related to age and education. This was not true for another method of delirium case detection, the global accessibility rating. This rating was 90% sensitive and 95% specific when compared with the psychiatric diagnosis, and was stable across two days of ratings. The global accessibility rating warrants further evaluation as a simple screening test for delirium.