Optimizing number and timing of appointment reminders: a randomized trial.

OBJECTIVES: To compare missed appointment rates for patients receiving a single reminder either 3 days prior to a primary care visit, 1 day prior to the visit, or both 3 days and 1 day prior to the visit. STUDY DESIGN: Three-armed randomized controlled trial. METHODS: Text messages or interactive voice response calls were sent to patients with appointments at 25 primary care clinics in an integrated delivery system. A multivariable prediction model was developed to identify patients at high risk of missing appointments, based on prior appointment-keeping history and other variables from electronic health records. RESULTS: Among 54,066 randomized patients, those who received reminders both 3 days and 1 day prior to the visit were less likely to miss their appointment than those who received only a 3-day or 1-day reminder (4.4% vs 5.8% vs 5.3%, respectively; P <.001). In patients at high risk, 20.5% of those who received 2 reminders missed their visit, compared with 25.0% and 24.2% of those with only 3-day or 1-day reminders, respectively (P <.001). Visit satisfaction was unaffected by providing an additional reminder. CONCLUSIONS: Two automated reminders were more effective than 1 in reducing missed appointments and did not reduce visit satisfaction. A predictive model based on clinical characteristics and prior appointment history can accurately identify patients who are at highest risk of missing appointments. These individuals may benefit more from multiple reminders, but additional strategies are necessary to further reduce their rates of missed appointments.

Reducing Missed Primary Care Appointments in a Learning Health System: Two Randomized Trials and Validation of a Predictive Model.

BACKGROUND: Collaborations between clinical/operational leaders and researchers are advocated to develop "learning health systems," but few practical examples are reported. OBJECTIVES: To describe collaborative efforts to reduce missed appointments through an interactive voice response and text message (IVR-T) intervention, and to develop and validate a prediction model to identify individuals at high risk of missing appointments. RESEARCH SUBJECTS AND DESIGN: Random assignment of 8804 adults with primary care appointments to a single IVR-T reminder or no reminder at an index clinic (IC) and 7497 at a replication clinic (RC) in an integrated health system in Denver, CO. MEASURES: Proportion of missed appointments; demographic, clinical, and appointment-specific predictors of missed appointments. RESULTS: Patients receiving IVR-T had a lower rate of missed appointments than those receiving no reminder at the IC (6.5% vs. 7.5%, relative risk=0.85, 95% confidence interval, 0.72-1.00) and RC (8.2% vs. 10.5%, relative risk=0.76, 95% confidence interval, 0.65-0.89). A 10-variable prediction model for missed appointments demonstrated excellent discrimination (C-statistic 0.90 at IC, 0.89 at RC) and calibration (P=0.99 for Osius and McCullagh tests). Patients in the 3 lowest-risk quartiles missed 0.4% and 0.4% of appointments at the IC and RC, respectively, whereas patients in the highest-risk quartile missed 24.1% and 28.9% of appointments, respectively. CONCLUSIONS: A single IVR-T call reduced missed appointments, whereas a locally validated prediction model accurately identified patients at high risk of missing appointments. These rigorous studies promoted dissemination of the intervention and prompted additional research questions from operational leaders.

Synergistic effect of statins and postmenopausal hormone therapy in the prevention of skeletal fractures in elderly women.

STUDY OBJECTIVE: To examine the role of concurrent 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) use and postmenopausal hormone therapy on osteoporosis-related fractures. DESIGN: Case-control study. Data Source. Large integrated health plan in New Mexico. Patients. Case patients were 1001 women with incident fractures of the hip, wrist, forearm, or spine that occurred between January 1, 2000, and December 31, 2005, and controls were 2607 women without fractures during the same time frame; both groups were selected from the same population of women aged 50 years or older who utilized health plan services during the study time frame. MEASUREMENTS AND MAIN RESULTS: Postmenopausal hormone therapy use was classified as "current" (12 mo before index date) or "never or past." The risk of fractures was ascertained among continuous (> or = 80% medication possession ratio during 12 mo before the index date) and current (3 mo before index date) statin users relative to patients without hyperlipidemia who did not use lipid-lowering drugs. The interaction between statins and hormone therapy was examined in multivariable logistic regression. The association between statin use and fractures was examined separately among current and never or past hormone therapy users after controlling for other risk factors. Nineteen percent of the study participants were current hormone therapy users; 9.5% were current and 4.8% were continuous statin users. No association between continuous statin use and fractures was observed among never or past hormone therapy users (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.53-1.22). In contrast, a strong protective effect (OR 0.19, 95% CI 0.04-0.87) was observed among women who concurrently used statins and hormone therapy for 1 year, independent of age; corticosteroid, bisphosphonate, thiazide diuretic, calcitonin, methotrexate, or antiepileptic drug use; chronic kidney disease; and Charlson comorbidity index. CONCLUSION: Concurrent statin use and hormone therapy may have a synergistic protective effect on skeletal fractures beyond the additive effect of each individual therapy.

Predicting SF-6D utility scores from the Oswestry disability index and numeric rating scales for back and leg pain.

STUDY DESIGN: Cross-sectional cohort. OBJECTIVE: The purpose of this study is to provide a model to allow estimation of utility from the Short Form (SF)-6D using data from the Oswestry Disability Index (ODI), Back Pain Numeric Rating Scale (BPNRS), and the Leg Pain Numeric Rating Scale (LPNRS). SUMMARY OF BACKGROUND DATA: Cost-utility analysis provides important information about the relative value of interventions and requires a measure of utility not often available from clinical trial data. The ODI and numeric rating scales for back (BPNRS) and leg pain (LPNRS), are widely used disease-specific measures for health-related quality of life in patients with lumbar degenerative disorders. The purpose of this study is to provide a model to allow estimation of utility from the SF-6D using data from the ODI, BPNRS, and the LPNRS. METHODS: SF-36, ODI, BPNRS, and LPNRS were prospectively collected before surgery, at 12 and 24 months after surgery in 2640 patients undergoing lumbar fusion for degenerative disorders. Spearman correlation coefficients for paired observations from multiple time points between ODI, BPNRS, and LPNRS, and SF-6D utility scores were determined. Regression modeling was done to compute the SF-6D score from the ODI, BPNRS, and LPNRS. Using a separate, independent dataset of 2174 patients in which actual SF-6D and ODI scores were available, the SF-6D was estimated for each subject and compared to their actual SF-6D. RESULTS: In the development sample, the mean age was 52.5 +/- 15 years and 34% were male. In the validation sample, the mean age was 52.9 +/- 14.2 years and 44% were male. Correlations between the SF-6D and the ODI, BPNRS, and LPNRS were statistically significant (P < 0.0001) with correlation coefficients of 0.82, 0.78, and 0.72, respectively. The regression equation using ODI, BPNRS,and LPNRS to predict SF-6D had an R of 0.69 and a root mean square error of 0.076. The model using ODI alone had an R of 0.67 and a root mean square error of 0.078. The correlation coefficient between the observed and estimated SF-6D score was 0.80. In the validation analysis, there was no statistically significant difference (P = 0.11) between actual mean SF-6D (0.55 +/- 0.12) and the estimated mean SF-6D score (0.55 +/- 0.10) using the ODI regression model. CONCLUSION: This regression-based algorithm may be used to predict SF-6D scores in studies of lumbar degenerative disease that have collected ODI but not utility scores.

Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up.

STUDY DESIGN: Retrospective review of a prospective, multicenter study. OBJECTIVE: The purpose of this study was to assess the prevalence and severity of leg pain in adults with scoliosis and to assess whether surgery significantly improved leg pain compared with nonoperative management. SUMMARY OF BACKGROUND DATA: Patients with adult scoliosis characteristically present with pain. The presence of leg pain is an independent predictor of a patient's choice for operative over nonoperative care. METHODS: Data were extracted from a prospective, multicenter database for adult spinal deformity. At enrollment and follow-up, patients complete the Oswestry Disability Index (ODI) and assessment of leg pain using the numerical rating scale (NRS) score, with 0 and 10 representing no pain and unbearable pain, respectively. Plan for operative or nonoperative treatment was made at enrollment. The vast majority of adult scoliosis patients seen in our surgical clinics have received nonoperative therapies and are being seen for a surgical evaluation. Patients are counseled regarding operative and nonoperative management options and are in general encouraged to maximize nonoperative treatments. RESULTS: Two hundred eight (64%) of 326 adults with scoliosis had leg pain at presentation (mean NRS score = 4.7). Ninety-six patients with leg pain (46%) were managed operatively and 112 were treated nonoperatively. The operative group had higher baseline mean NRS score for leg pain (5.4 vs. 4.1, P < 0.001) and higher mean ODI (41 vs. 30, P < 0.001). At 2-year follow-up, nonoperative patients had no significant change in ODI or NRS score for leg pain (P = 0.2). In contrast, at 2-year follow-up surgically treated patients had significant improvement in mean NRS score for leg pain (5.4 vs. 2.2, P < 0.001) and ODI (41 vs. 24, P < 0.001). Compared with nonsurgically treated patients, at 2-year follow-up operative patients had lower mean NRS score for leg pain (2.2 vs. 3.8, P < 0.001) and mean ODI (24 vs. 31, P = 0.005). CONCLUSION: Despite having started with significantly greater leg pain and disability, surgically treated patients at 2-year follow-up had significantly less leg pain and disability than nonoperatively treated patients. Surgical treatment has the potential to provide significant improvement of leg pain in adults with scoliosis.

Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study.

STUDY DESIGN: Prospective observational cohort study with matched and unmatched comparisons. Level II evidence. OBJECTIVE: The purpose of this study is to compare results of adult symptomatic lumbar scoliosis (ASLS) patients treated nonoperatively and operatively. This is an evidence-based prospective multicenter study to answer the question of whether nonoperative and operative treatment improves the quality of life (QOL) in these patients at 2-year follow-up. SUMMARY OF BACKGROUND DATA: Only 1 paper in the peer-reviewed published data directly addresses this question. That paper suggested that operative treatment was more beneficial than nonoperative care, but the limitations relate to historical context (all patients treated with Harrington implants) and the absence of validated patient-reported QOL (QOL) data. METHODS: This study assesses 160 consecutively enrolled patients (ages 40-80 years) with baseline and 2-year follow-up data from 5 centers. Lumbar scoliosis without prior surgical treatment was defined as a minimum Cobb angle of 30 degrees (mean: 54 degrees for patients in this study). All patients had either an Oswestry Disability Index (ODI) score of 20 or more (mean: 33) or Scoliosis Research Society (SRS) domain scores of 4 or less in pain, function, and self-image (mean: 3.2) at baseline. Pretreatment and 2-year follow-up data collected prospectively included basic radiographic parameters, complications and SRS QOL, ODI, and Numerical Rating Scale back and leg pain scores. RESULTS: At 2 years, follow-up on the operative patients was 95% and for the nonoperative patients it was 45%. The demographics for the nonoperative patients who were followed up for 2 years versus those who were lost to follow-up were identical. The operative cohort significantly improved in all QOL measures. The nonoperative cohort did not improve and nonsignificant decline in QOL scores was common. At minimum 2-year follow-up, operative patients outperformed nonoperative patients by all measures. CONCLUSION: It would appear from this study that common nonoperative treatments do not change the QOL in patients with ASLS at 2-year follow-up. However, operative treatment does significantly improve the QOL for this group of patients. Our conclusions are limited by the fact that we were only able to follow-up 45% of the nonoperative group to 2-year follow-up, in spite of extensive efforts on our part to accomplish such.

Improvement of back pain with operative and nonoperative treatment in adults with scoliosis.

OBJECTIVE: The purpose of this study was to assess whether back pain is improved with surgical treatment compared with nonoperative management in adults with scoliosis. METHODS: This is a retrospective review of a prospective, multicentered database of adults with spinal deformity. At the time of enrollment and follow-up, patients completed standardized questionnaires, including the Oswestry Disability Index (ODI) and Scoliosis Research Society 22 questionnaire (SRS-22), and assessment of back pain using a numeric rating scale (NRS) score, with 0 and 10 corresponding to no and maximal pain, respectively. The initial plan for surgical or nonoperative treatment was made at the time of enrollment. RESULTS: Of 317 patients with back pain, 147 (46%) were managed surgically. Compared with patients managed nonoperatively, operative patients had higher baseline mean NRS scores for back pain (6.3 versus 4.8; P < 0.001), higher mean ODI scores (35 versus 26; P < 0.001), and lower mean SRS-22 scores (3.1 versus 3.4; P < 0.001). At the time of the 2-year follow-up evaluation, nonoperatively managed patients did not have significant change in the NRS score for back pain (P = 0.9), ODI (P = 0.7), or SRS-22 (P = 0.9). In contrast, at the 2-year follow-up evaluation, surgically treated patients had significant improvement in the mean NRS score for back pain (6.3 to 2.6; P < 0.001), ODI score (35 to 20; P < 0.001), and SRS-22 score (3.1 to 3.8; P < 0.001). Compared with nonoperatively treated patients, at the time of the 2-year follow-up evaluation, operatively treated patients had a lower NRS score for back pain (P < 0.001) and ODI (P = 0.001), and higher SRS-22 (P < 0.001). CONCLUSIONS: Despite having started with significantly greater back pain and disability and worse health status, surgically treated patients had significantly less back pain and disability and improved health status compared with nonoperatively treated patients at the time of the 2-year follow-up evaluation. Compared with nonoperative treatment, surgery can offer significant improvement of back pain for adults with scoliosis.

Predicting outcome and complications in the surgical treatment of adult scoliosis.

STUDY DESIGN: prospective, multicenter. OBJECTIVE: To determine if models for predicting outcome and complications in the setting of adult deformity surgery can be constructed. SUMMARY OF BACKGROUND DATA: A classification of adult spinal deformity has been established. The latter categorizes patients radiographically and ties to disability as well as most likely treatment approach. Classification by radiographs alone is insufficient to guide treatment and models for predicting outcome are necessary to establish algorithms. METHODS: This is a longitudinal study of adult patients with spinal deformity. All subjects were drawn from a prospective multicenter database. Baseline, 1-year and 2-year radiographic and health related quality of life measures were obtained (SRS, ODI, SF-12). Any peri- or postoperative complications were tabulated. Binary and logistic regressions were applied to create models of outcome and complications. RESULTS: Predictive models of reaching a minimal clinically important difference had an area under the ROC curve above 0.82 and correct classification from 75% to 81%. Development of a complication was correctly classified in 71% of cases. Patients most likely to reach threshold improvement through surgery: older, lower apex deformity, greater disability, higher deformity score by classification. Patients most likely to develop complications: high sagittal balance grade and fusion to sacrum. CONCLUSION: By applying the classification of adult deformity and considering baseline health status, models for predicting outcome can be established. Further work will refine these models and permit clinical validation. This effort will help establish reliable clinical models such that treatment algorithms can be established for the challenging patients suffering from adult spinal deformity.

Surgical rates and operative outcome analysis in thoracolumbar and lumbar major adult scoliosis: application of the new adult deformity classification.

STUDY DESIGN: Multicenter prospective consecutive clinical series. OBJECTIVE: Investigate the interaction between the Adult Deformity Classification and treatment patterns, surgical strategies, surgery effectiveness, and complication rates. SUMMARY OF BACKGROUND DATA: An Adult Deformity Classification has been established that applies radiographic parameters of disability. Preliminary intraobserver and interobserver analysis reveals excellent reliability of the classification. Outcomes studies have not been reported to date. METHODS: A total of 784 adult patients with thoracolumbar or lumbar deformity underwent radiographic evaluation (full-length frontal/sagittal) as well as health assessment: Oswestry Disability Index, Scoliosis Research Society-22, and SF-12. Patients were subdivided by treatment and surgical strategies; 1 year (111 patients) and 2 year (45 patients) follow-up data were analyzed. Interaction between classification, treatment, surgical strategy, health assessment changes, and complications were analyzed. RESULTS: Classification modifiers (lordosis, subluxation, sagittal balance) were found to have significant variation (higher rates) in surgical care as the grade of the modifier increased. Classification differentiated patients by surgical approach and/or technique. Interaction between classification and baseline health assessment impacts both postoperative health scores and complication rates. CONCLUSION: This investigation appears to offer the first comprehensive analysis of classification, treatment, and outcomes in a large adult deformity patient group. Significant treatment patterns and outcomes are coming to light as is the impact of surgical strategy.

Is the SRS-22 instrument responsive to change in adult scoliosis patients having primary spinal deformity surgery?

STUDY DESIGN: Multicenter study. OBJECTIVE: The purpose of this study is to prospectively analyze responsiveness of the SRS-22 to change at 1 and 2 years following primary surgery. SUMMARY OF BACKGROUND DATA: A number of efforts have been directed at validation of the SRS-22 instrument in the setting of adolescent and adult spinal deformity. However, few have extensively analyzed the ability of the instrument to detect change (brought on by surgical treatment) in adult scoliosis patients. METHODS: A multicenter prospective series of consecutive adult scoliosis patients (all primary/no revisions) were administered SRS-22, Oswestry Disability Index (ODI)and Short Form-12 (SF-12) questionnaires preoperation and 1 and 2 years postoperation. Fifty-six patients had preoperative, 1-year postoperative, and 2-year postoperative data. RESULTS: The greatest changes from preoperation to 2-year postoperation were the SRS self-image domain followed by SRS total, SRS pain, and ODI scores. SRS pain and function scores significantly (P < 0.05) improved from 1-year to 2-year postoperation. There were not substantial differences in the outcome measures according to age or curve type. All outcome measures except SF-12 mental health showed statistically significant (P < 0.05) improvement from baseline to 2-year follow-up. CONCLUSION: Based on these 3 outcome tools, the greatest responsiveness to change was demonstrated by the SRS self-image domain followed by SRS total, then SRS pain, then ODI. This suggests that the SRS tool is more responsive than ODI, which is more responsive than SF-12 to change brought on by primary surgical treatment of adult scoliosis patients. Surgical treatment in adult scoliosis significantly improved pain, self-image, and function based on the health-related quality of life measures used in this study.

Hospital, pharmacy, and outpatient costs for osteoarthritis and chronic back pain.

OBJECTIVE: We examined the direct medical costs for patients with osteoarthritis (OA) and chronic back pain (CBP) in comparison to similar patients not treated for these conditions. METHODS: All persons age 18 years and over enrolled in the Lovelace Health Plan (LHP) who had at least 2 outpatient or one inpatient visits during the study period (June 30, 2000 to July 1, 2001) for OA or CBP were identified using discharge billing records. Each patient with OA or CBP was matched to 3 persons of the same age group, sex, and ethnicity, and then utilization and pharmacy records for each study subject were abstracted for comparison. RESULTS: The prevalence of OA and CBP increased with age (11.0% and 7.2% of persons in the 75-79 age group, respectively), although more than two-thirds of OA and CBP patients in the LHP were below age 65. Patients with OA or CBP were more than 3 times more likely than controls to be admitted to hospital, and their average length of stay, costs per hospital day, and readmission rate were all significantly higher (p < 0.01). However, only 58.8% of the excess admissions in the OA group and 48.8% of the excess admissions in the CBP group were attributed to musculoskeletal disease. Outpatient costs were more than doubled among both OA and CBP cases (mean annual outpatient costs of US dollars 4684 and US dollars 4350, respectively), with increased costs seen in all service areas. Prescription drug costs for OA patients (mean average wholesale price, AWP, US dollars 1184) were increased by 102%, with the greatest increases seen in the use of nonsteroidal antiinflammatory drugs (NSAID), gastric acid secretion reducers, and antidepressants. Prescription drug costs for CBP patients were increased by 107% (mean AWP US dollars 1331), with the greatest increases seen in the use of antidepressants, NSAID, narcotics, and gastric acid secretion reducers. CONCLUSION: Health services and prescription medication costs for patients with OA and CBP were more than double those of matched controls. Much of the increased utilization occurred in areas not commonly associated with musculoskeletal conditions.