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1.
J Eval Clin Pract ; 30(3): 355-366, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38062882

ABSTRACT

RATIONALE, AIMS AND OBJECTIVES: Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation). METHOD: The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016. RESULTS: The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates. CONCLUSION: Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.


Subject(s)
Analgesics, Opioid , Manipulation, Spinal , Humans , Analgesics, Opioid/therapeutic use , Retrospective Studies , Practice Patterns, Physicians' , Exercise Therapy , Primary Health Care , Pain
2.
J Eval Clin Pract ; 28(6): 1157-1167, 2022 12.
Article in English | MEDLINE | ID: mdl-35666601

ABSTRACT

RATIONALE, AIMS AND OBJECTIVES: Emergency department (ED) clinicians account for approximately 13% of all opioid prescriptions to opioid-naïve patients and variability in the rates of prescribing have been noted among individual clinicians and different EDs. This study elucidates the amount of variability within a unified health system (the U.S. Military Health System [MHS]) with the expectation that understanding the sources of variability will enable health system leaders to improve the quality of decision making. METHODS: The design was a retrospective cohort study examining variation in opioid prescribing within EDs of the US MHS. Participants were Army soldiers who returned from a deployment and received care between October 2009 and September 2016. The exposure was ED encounters at a military treatment facility. Key measures were the proportion of ED encounters with an opioid prescription fill; total opioid dose of the fill (morphine milligram equivalent, MME); and total opioid days-supply of the fill. RESULTS: The mean proportion of ED encounters with an opioid fill across providers was 19.7% (SD 8.8%), median proportion was 18.6%, and the distribution was close to symmetric with the 75th percentile provider prescribing opioids in 24.6% of their ED encounters and the 25th percentile provider prescribing in 13.4% of their encounters. The provider-level mean opioid dose per encounter was 113.1 MME (SD 56.0) with the 75th percentile (130.1) 50% higher than the 25th percentile (87.4). The mean opioid supply per encounter was 6.8 days (SD 3.9) with more than a twofold ratio between the 75th percentile (8.3) and the 25th (4.1). Using a series of multilevel regression models to examine opioid fills associated with ED encounters and their dose levels, the variation among providers within facilities was much larger in magnitude than the variation among facilities. CONCLUSION: Among ED encounters of Army soldiers at military treatment facilities, there was substantial variation among providers in prescribing opioid prescriptions that were not explained by patient case-mix. These results suggest that programmes and protocols to address less than optimal prescribing in the ED should be initiated to improve the quality of care.


Subject(s)
Analgesics, Opioid , Military Health Services , Humans , Analgesics, Opioid/therapeutic use , Cohort Studies , Retrospective Studies , Practice Patterns, Physicians' , Emergency Service, Hospital
3.
Acad Emerg Med ; 28(11): 1251-1261, 2021 11.
Article in English | MEDLINE | ID: mdl-34245641

ABSTRACT

OBJECTIVE: The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). METHODS: This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active-duty opioid-naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow-up measurement was from 31 to 365 days after the index encounter. The primary outcome was long-term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow-up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military-duty restriction. RESULTS: We found a 2.5-fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180-day opioid supply during follow-up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. CONCLUSION: In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes.


Subject(s)
Analgesics, Opioid , Military Personnel , Analgesics, Opioid/adverse effects , Cohort Studies , Emergency Service, Hospital , Humans , Practice Patterns, Physicians' , Retrospective Studies
4.
Psychiatr Serv ; 72(3): 264-272, 2021 03 01.
Article in English | MEDLINE | ID: mdl-33467870

ABSTRACT

OBJECTIVE: This study examined the prevalence of chronic pain alone, posttraumatic stress disorder (PTSD) alone, and both chronic pain and PTSD among U.S. Army soldiers during the postdeployment year. METHODS: The sample was 576,425 active duty soldiers returning from deployment in Afghanistan or Iraq between October 1, 2008, and September 30, 2014. Bivariate statistics were used to compare health care utilization among subgroups. Multivariate logistic regression with additional covariates was used to identify predictors of receiving an opioid days' supply of >30 days in the postdeployment year among soldiers with chronic pain, focusing on the effect of PTSD alone and on an interaction of PTSD with nonpharmacologic treatments (including therapeutic exercise, chiropractic treatment, acupuncture, and biofeedback). RESULTS: In total, 12.2% of the soldiers received a chronic pain diagnosis, 5.1% a PTSD diagnosis, and 1.8% had both. Among soldiers with both conditions, 80.3% received nonpharmacologic treatment, and 31.4% received an opioid days' supply of >30 days. Among soldiers with chronic pain, comorbid PTSD and lack of nonpharmacologic treatment was associated with increased odds of receiving an opioid days' supply of >30 days (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.3-1.6). PTSD combined with specific nonpharmacologic treatment modalities had a variable relationship with opioid receipt, and only PTSD with acupuncture or biofeedback was associated with reduced odds (OR=0.8, 95% CI=0.7-0.9). CONCLUSIONS: Soldiers having both chronic pain and PTSD have significant health care needs. Although these soldiers accessed mental health care and received nonpharmacologic treatment, additional interventions are needed to mitigate protracted opioid utilization.


Subject(s)
Chronic Pain , Military Personnel , Stress Disorders, Post-Traumatic , Analgesics, Opioid/therapeutic use , Chronic Pain/drug therapy , Chronic Pain/therapy , Humans , Iraq War, 2003-2011 , Prevalence , Stress Disorders, Post-Traumatic/drug therapy , Stress Disorders, Post-Traumatic/therapy
5.
J Am Dent Assoc ; 152(2): 94-104.e18, 2021 02.
Article in English | MEDLINE | ID: mdl-33358238

ABSTRACT

BACKGROUND: Variation in opioid prescribing rates among geographic regions is well known and, to the authors' knowledge, there have been no studies of variation from 1 dental clinic to another, and such variation might suggest an excess of opioid prescriptions. METHODS: The authors used a retrospective cohort design study of all dental encounter records for 819,453 soldiers in the dental clinics (n = 250) of the US Military Health System during the period from 2008 through 2017. RESULTS: There were 743,459 dental surgical encounters. Opioid prescriptions were filled for 36.7% of these encounters. Multinomial multilevel regression found statistically significant between-facility variance in opioid prescribing, which was partially explained via facility-level characteristics (region, type, and percentage of surgeries for young patients), and practice variables (mean percentage extractions, percentage periodontic surgery, and percentage specialists). CONCLUSIONS: The authors found a substantial variation in opioid prescribing among dental clinics in the US Military Health System. Dentists at 11 of the 30 largest military treatment facilities prescribed at a rate 4 percentage points higher than expected, and dentists at 9 of these military treatment facilities had a rate of 4 percentage points lower than expected. Additional study of the factors allowing the low-prescribing facilities to achieve these rates might lead to an overall decrease in opioid prescribing. PRACTICAL IMPLICATIONS: The authors' findings of dental opioid prescribing in the military can lead to appreciation of the guidelines from the American Dental Association and the American Association of Oral and Maxillofacial Surgeons, which suggest alternatives to opioid prescribing for surgical procedures, particularly for tooth extractions.


Subject(s)
Military Personnel , Practice Patterns, Dentists' , Analgesics, Opioid/therapeutic use , Dental Clinics , Humans , Practice Patterns, Physicians' , Retrospective Studies , United States/epidemiology
6.
J Gen Intern Med ; 35(3): 775-783, 2020 03.
Article in English | MEDLINE | ID: mdl-31659663

ABSTRACT

BACKGROUND: Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE: To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS: A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES: NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES: Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS: The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS: NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.


Subject(s)
Chronic Pain , Military Personnel , Stress Disorders, Post-Traumatic , Veterans Health , Veterans , Adult , Chronic Pain/epidemiology , Chronic Pain/therapy , Female , Humans , Longitudinal Studies , Male , United States/epidemiology , Young Adult
7.
J Altern Complement Med ; 24(7): 666-676, 2018 Jul.
Article in English | MEDLINE | ID: mdl-29589956

ABSTRACT

BACKGROUND: Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids. OBJECTIVE: To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol. RESULTS: Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes. CONCLUSION: This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.


Subject(s)
Low Back Pain , Military Personnel/statistics & numerical data , Adult , Analgesics, Opioid/therapeutic use , Female , Humans , Integrative Medicine , Low Back Pain/drug therapy , Low Back Pain/epidemiology , Low Back Pain/physiopathology , Male , Middle Aged , Retrospective Studies , Treatment Outcome , Young Adult
8.
J Gen Intern Med ; 28(11): 1396-404, 2013 Nov.
Article in English | MEDLINE | ID: mdl-23494213

ABSTRACT

BACKGROUND: Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients. OBJECTIVE: To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting. DESIGN: Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients' primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later. SUBJECTS: Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization. MEASUREMENTS: Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database. RESULTS: At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p < 0.01), hypochondriacal symptoms (p < 0.01), overall psychiatric distress (p < 0.01), and role impairment (p < 0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p = 0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (pp = 0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged. CONCLUSIONS: Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.


Subject(s)
Cognitive Behavioral Therapy/methods , Delivery of Health Care/statistics & numerical data , Self Report , Somatoform Disorders/psychology , Somatoform Disorders/therapy , Adult , Female , Follow-Up Studies , Humans , Hypochondriasis/diagnosis , Hypochondriasis/psychology , Hypochondriasis/therapy , Male , Middle Aged , Somatoform Disorders/diagnosis , Treatment Outcome
9.
Am J Health Promot ; 26(2): 77-89, 2011.
Article in English | MEDLINE | ID: mdl-22040388

ABSTRACT

PURPOSE. Examine the efficacy of a computer-tailored intervention (CTI) based on the transtheoretical model (TTM) for reducing depression, an increasingly important component of health promotion programs. DESIGN. Pretest-posttest randomized trial. Setting . Participants were recruited and treated at home after being identified in two primary care clinics in Eastern Massachusetts and Chicago, Illinois. SUBJECTS. A total of 350 adults experiencing at least mild symptoms of depression but not involved in or planning to seek treatment for depression. INTERVENTION. A print manual and three CTI reports tailored to stage of change for using effective methods to prevent or reduce depression, other TTM variables, level of depression, and behavior. . Pre-post changes and reliable and clinically significant change on the Beck Depression scale II and pre-post changes on the 20-item Medical Outcomes Study Short Form survey-based measure of physical functioning at 9 months' follow-up. ANALYSIS. t-tests and χ(2) tests. Complete-case analysis and two intention-to-treat analyses-assumption of no change and multiple imputation (MI)-are reported. Exploratory analyses examined whether the effects of the intervention on depression were moderated by five subject characteristics: baseline level of depression, baseline level of physical functioning, baseline stage of change for preventing or managing depression, age, and education. RESULTS. Complete-case and intention-to-treat analyses showed that the intervention group experienced significantly greater improvements in depression (d  =  .220-.355); results for physical functioning were weaker (d  =  .150-.309) and did not reach statistical significance in the MI analysis. The effects of the intervention on reliable and clinically significant change in depression were largest among participants who were experiencing moderate depression (d  =  .363-.519) or severe depression (d  =  .603-.718) or who were in the precontemplation or contemplation stage (d  =  .573-.856) at baseline.


Subject(s)
Decision Support Systems, Clinical/instrumentation , Depression/prevention & control , Diagnosis, Computer-Assisted , Health Promotion/methods , Models, Psychological , Social Marketing , Adolescent , Adult , Aged , Aged, 80 and over , Chi-Square Distribution , Depression/epidemiology , Female , Health Surveys , Humans , Illinois , Male , Massachusetts , Middle Aged , Psychometrics , Surveys and Questionnaires , Time Factors , United States/epidemiology , Young Adult
10.
J Gen Intern Med ; 22(4): 508-13, 2007 Apr.
Article in English | MEDLINE | ID: mdl-17372801

ABSTRACT

OBJECTIVES: To compare screening practices and beliefs in patients with and without a clinically important family history. DESIGN: We mailed a brief questionnaire asking about family history and a second, longer survey asking about knowledge of and beliefs about colorectal cancer to all respondents with a family history and a random sample of respondents without a family history of colorectal cancer. We reviewed electronic medical records for screening examinations and recording of family history. PARTICIPANTS: One thousand eight hundred seventy of 6,807 randomly selected patients ages 35-55 years who had been continuously enrolled in a large multispecialty group practice for at least 5 years. MEASUREMENTS: Recognition of increased risk, screening practices, and beliefs-all according to strength of family history and patient's age. RESULTS: Nineteen percent of respondents reported a family history of colorectal cancer. In 11%, this history was strong enough to warrant screening before age 50 years. However, only 39% (95% CI 36, 42) of respondents under the age of 50 years said they had been asked about family history and only 45% of those with a strong family history of colorectal cancer had been screened appropriately. Forty-six percent of patients with a strong family history did not know that they should be screened at a younger age than average risk people. Medical records mentioned family history of colorectal cancer in 59% of patients reporting a family history. CONCLUSIONS: More efforts are needed to translate information about family history of colorectal cancer into the care of patients.


Subject(s)
Colorectal Neoplasms/epidemiology , Colorectal Neoplasms/genetics , Health Surveys , Mass Screening , Adult , Colorectal Neoplasms/diagnosis , Female , Follow-Up Studies , Humans , Male , Mass Screening/methods , Middle Aged
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