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Sears JM, Edmonds AT, MacEachen E, Fulton-Kehoe D. Appraisal of Washington State workers' compensation-based return-to-work programs and suggested system improvements: A survey of workers with permanent impairments. Am J Ind Med 2021; 64:924-940. [PMID: 34462931 PMCID: PMC8500921 DOI: 10.1002/ajim.23289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 08/19/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Following a work-related permanent impairment, injured workers commonly face barriers to safe and successful return to work (RTW). Examining workers' experiences with the workers' compensation (WC) system could highlight opportunities to improve RTW outcomes. Objectives included summarizing workers': (1) appraisal of several WC-based RTW programs, and (2) suggestions for vocational rehabilitation and WC system improvements to promote safe and sustained RTW. METHODS In telephone interviews, 582 Washington State workers with work-related permanent impairments were asked whether participation in specified WC-based RTW programs helped them RTW and/or stay at work. Suggestions for program and system improvements were solicited using open-ended questions; qualitative content analysis methods were used to inductively code responses. RESULTS Most respondents reported positive impacts from RTW program participation; for example, 62.5% of vocational rehabilitation participants reported it helped them RTW, and 51.7% reported it helped them stay at work. Among 582 respondents, 28.0% reported that no change was needed to the WC system, while 57.6% provided suggestions or critiques. Reduce delays/simplify process/improve efficiency was the most frequent WC system theme-mentioned by 34.9%. Among 120 vocational rehabilitation participants, 35.8% reported that no change was needed to vocational rehabilitation, while 46.7% (N = 56) provided suggestions or critiques. More worker choice/input into the vocational retraining plan was the most frequent vocational rehabilitation theme-mentioned by 33.9%. CONCLUSIONS This study's findings suggest that there is substantial room for improvement in workers' experience with the WC system. In addition, injured workers' feedback may reflect opportunities to reduce administrative burden and to improve worker health and RTW outcomes.
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Affiliation(s)
- Jeanne M. Sears
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Amy T. Edmonds
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Ellen MacEachen
- School of Public Health Sciences, University of Waterloo, Ontario, Canada
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
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Sears JM, Fulton-Kehoe D, Schulman BA, Hogg-Johnson S, Franklin GM. Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines. Public Health Rep 2019; 134:567-576. [PMID: 31365317 PMCID: PMC6852059 DOI: 10.1177/0033354919864362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES High-risk opioid-prescribing practices contribute to a national epidemic of opioid-related morbidity and mortality. The objective of this study was to determine whether the adoption of state-level opioid-prescribing guidelines that specify a high-dose threshold is associated with trends in rates of opioid overdose hospitalizations, for prescription opioids, for heroin, and for all opioids. METHODS We identified 3 guideline states (Colorado, Utah, Washington) and 5 comparator states (Arizona, California, Michigan, New Jersey, South Carolina). We used state-level opioid overdose hospitalization data from 2001-2014 for these 8 states. Data were based on the State Inpatient Databases and provided by the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, via HCUPnet. We used negative binomial panel regression to model trends in annual rates of opioid overdose hospitalizations. We used a multiple-baseline difference-in-differences study design to compare postguideline trends with concurrent trends for comparator states. RESULTS For each guideline state, postguideline trends in rates of prescription opioid and all opioid overdose hospitalizations decreased compared with trends in the comparator states. The mean annual relative percentage decrease ranged from 3.2%-7.5% for trends in rates of prescription opioid overdose hospitalizations and from 5.4%-8.5% for trends in rates of all opioid overdose hospitalizations. CONCLUSIONS These findings provide preliminary evidence that opioid-dosing guidelines may be an effective strategy for combating this public health crisis. Further research is needed to identify the individual effects of opioid-related interventions that occurred during the study period.
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Affiliation(s)
- Jeanne M. Sears
- Department of Health Services, University of Washington, Seattle, WA,
USA
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
| | - Beryl A. Schulman
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
| | - Sheilah Hogg-Johnson
- Institute for Work and Health, Toronto, Ontario, Canada
- Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario,
Canada
| | - Gary M. Franklin
- Department of Health Services, University of Washington, Seattle, WA,
USA
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
- Washington State Department of Labor and Industries, Tumwater, WA, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
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Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption. Spine (Phila Pa 1976) 2016; 41:647-655. [PMID: 26679877 PMCID: PMC4884145 DOI: 10.1097/brs.0000000000001390] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An analysis of the State Inpatient Database of North Carolina, 2005 to 2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from nonfederal hospitals. OBJECTIVE The aim of the study was to examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications and to forecast the potential impact if the policy were adopted nationally. SUMMARY OF BACKGROUND DATA Few studies have examined the effects of recent changes in commercial coverage policies that restrict the use of lumbar fusion. METHODS We included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. We aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1, 2011. RESULTS There was a substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100,000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100,000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis, or revision procedures, but there was a coincident increase in decompression without fusion. CONCLUSION This commercial insurance policy change had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in spine surgery. Nevertheless, broader adoption of the policy could significantly reduce the national rates of fusion operations and associated costs. LEVEL OF EVIDENCE 3.
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Stockbridge H, d’Urso N. Application and Outcomes of Treatment Guidelines in a Utilization Review Program. Phys Med Rehabil Clin N Am 2015; 26:445-52. [DOI: 10.1016/j.pmr.2015.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
STUDY DESIGN A mixed-effects model was used to evaluate the effects specific surgical procedure by International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code, patient age, sex, ethnic group, payers for the inpatient hospital stay, and number of additional diagnoses beyond the principal diagnosis that led to the procedure (as a proxy for severity of illness) on the charges for lumbar fusion surgery. OBJECTIVE The present research examined the charges and the predictors of the charges for lumbar fusion surgery in Florida hospitals in 2010. SUMMARY OF BACKGROUND DATA The number of spinal fusion surgical procedures in the United States has grown exponentially in recent years despite the procedure's high costs and questionable efficacy for many of the principal diagnoses associated with it. METHODS All records with any of the 5 International Classification of Diseases, Ninth Revision, Clinical Modification, principal procedure codes for lumbar fusion were extracted (cases) from the Florida Agency for Health Care Administration (AHCA) hospital discharge data for the year 2010. A control group was obtained by taking all patients who had the same principal diagnoses as the cases, but who did not have fusion surgery. This produced 16,236 cases and 21,856 controls. RESULTS The total hospital charges for lumbar fusion surgery in Florida in 2010 were $2,095,413,584. Despite having the same principal diagnoses and a similar number of additional diagnoses, patients who underwent a fusion surgery had 3 times the charges as those incurred by the controls. The number of additional diagnoses, sex, age, payer, and principal procedure, were all found to be statistically significant predictors of charges. Ethnicity was not significant. Of all the predictors, the number of additional diagnoses was the most significant in the model (F=2577, P<0.0001). CONCLUSION The high incidence and charges for fusion surgical procedures shown in this study emphasize the need for a better understanding of when these surgical procedures are justified and for which patients. LEVEL OF EVIDENCE N/A.
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Martin B, Franklin G, Deyo R, Wickizer T, Lurie J, Mirza S. How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems. Spine J 2014; 14:1237-46. [PMID: 24210578 PMCID: PMC4013264 DOI: 10.1016/j.spinee.2013.08.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 06/27/2013] [Accepted: 08/20/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion. PURPOSE The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies. STUDY DESIGN AND SETTING The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009. PATIENT SAMPLE All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample. OUTCOME MEASURE(S) Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs. METHODS Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics. RESULTS Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114). CONCLUSIONS Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.
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Affiliation(s)
- B.I. Martin
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - G.M. Franklin
- Washington State Department of Labor & Industries, Olympia, Washington, USA
| | - R.A. Deyo
- Oregon Health & Science University, Portland, Oregon, USA
| | - T Wickizer
- Ohio State University, Columbus, Ohio, USA
| | - J.D. Lurie
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - S.K. Mirza
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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Abstract
STUDY DESIGN We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs. OBJECTIVE To answer the following questions: (1) what diagnosis codes should be used to identify patients with neck pain and back pain in administrative data; (2) because the majority of complaints are characterized as nonspecific or mechanical, what diagnosis codes should be used to identify patients with nonspecific or mechanical problems in administrative data; and (3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back. SUMMARY OF BACKGROUND DATA Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of health care utilization. Administrative data have been widely used in formative research, which has largely relied on the original work of Volinn, Cherkin, Deyo, and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to nonstandard or conflicting methods to define study cohorts. METHODS A literature review produced 7 methods for identifying neck and back pain in administrative data. These code lists were used to search Veterans Health Administration data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as nonspecific/mechanical and as surgical or not. RESULTS There is considerable overlap in most algorithms. However, gaps persist. CONCLUSION Gaps are evident in existing methods and a new framework to identify patients with neck pain and back pain in administrative data is proposed.
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Pourat N, Kominski G, Roby D, Cameron M. Physician Perceptions of Access to Quality Care in California's Workers' Compensation System. J Occup Environ Med 2007; 49:618-25. [PMID: 17563604 DOI: 10.1097/jom.0b013e318074bb57] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We measured the association of physician perceptions of access to quality care with intentions to change workers' compensation (WC) participation levels, barriers to delivery of quality care, levels of payment, and type of provider after the implementation of California WC reforms in 2004. METHODS Bivariate and logistic regression models were employed using a representative survey of WC providers. RESULTS The analyses revealed that intentions to quit or decrease the volume of WC patients, reporting utilization review as a barrier to quality care, and being a chiropractor or acupuncturist were significantly associated with perceptions of decline in access or quality since 2004 and the belief that injured workers do not have access to quality care. CONCLUSIONS The results indicate specific aspects of WC reform that lead to negative perceptions among providers and require further scrutiny and improvement.
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Affiliation(s)
- Nadereh Pourat
- UCLA Center for Health Policy Research, Los Angeles, CA 90024, USA.
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Abstract
Examining trends and geographic variations in clinical care offers insights into changes in clinical decision making. We summarized data on spine surgical rates, trends, and variations in the United States to highlight areas of professional uncertainty and questions for future research. The United States has the highest rate of spine surgery in the world, but spine surgery shows wider geographic variations than most other procedures. For example, Medicare data for 2001 showed sixfold variations in spine surgery rates among United States cities, and 10-fold variations in spine fusion rates. United States spine surgery rates rose 55% in the 1980s. In the 1990s, studies of surgical rates became more difficult because 20% of discectomies shifted to an out-patient setting. Extrapolations from states with ambulatory surgery data suggest overall lumbar surgery rates continued to rise throughout the 1990s. The most rapid increase was for spinal fusion, which tripled during the 1990s and accounted for an increasing proportion of all spine procedures. Some increases coincided with the introduction of new surgical implants. Despite new technologies, rates of repeat surgery after fusion were no lower than the rates after decompression alone. As new technology for spine surgery is introduced at an accelerating pace, we anticipate substantial changes in surgery patterns. Analysis of population-based data may be useful for surveillance of changes and their impacts.
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Affiliation(s)
- Richard A Deyo
- Department of Medicine, Center for Cost and Outcomes Research, University of Washington, Seattle, WA 98104, USA.
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Abstract
Evidence-based medicine is most meaningful to policy makers when research questions are clearly informed by strategic health policy questions. In Washington State workers' compensation, key structural characteristics allow for the conduct of effective policy-relevant research. These include clear authority and a stable funding stream, a formal relationship between a policy agency and a University, development of appropriate research capacity, development of research questions related to strategic goals, and a robust data source. The research conducted relies on computerized medical bills and work disability records, medical records, structured telephone surveys to collect data on pain, functional status, quality of life, and computerized data on employment status. The types of policy-relevant research include identification of factors leading to preventable disability, outcomes research of specific procedures, technology assessment, and "real-time" research that addresses rapidly emerging questions. Health policy changes implemented from research have been substantial in Washington State workers' compensation, including: 1) noncoverage or partial coverage decisions for emerging technologies not proven to be of value to injured workers, 2) formal treatment guidelines and utilization review criteria for invasive, expensive, or marginally effective procedures, 3) disability prevention efforts, and 4) relatively rapid changes in policy as emerging patterns suggest harmful outcomes from existing treatments (e.g., schedule II opioids). Key structural characteristics must be in place to conduct policy-relevant research effectively. The workers' compensation system in Washington State is a single-payer system with other unique properties that have allowed the emergence of these structural characteristics and the conduct of research linked to the strategic goals of policy makers.
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Affiliation(s)
- Gary M Franklin
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, 98103, USA.
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Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE. Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies. Int J Technol Assess Health Care 2004; 19:613-23. [PMID: 15095767 DOI: 10.1017/s0266462303000576] [Citation(s) in RCA: 487] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES In an interrupted time series (ITS) design, data are collected at multiple instances over time before and after an intervention to detect whether the intervention has an effect significantly greater than the underlying secular trend. We critically reviewed the methodological quality of ITS designs using studies included in two systematic reviews (a review of mass media interventions and a review of guideline dissemination and implementation strategies). METHODS Quality criteria were developed, and data were abstracted from each study. If the primary study analyzed the ITS design inappropriately, we reanalyzed the results by using time series regression. RESULTS Twenty mass media studies and thirty-eight guideline studies were included. A total of 66% of ITS studies did not rule out the threat that another event could have occurred at the point of intervention. Thirty-three studies were reanalyzed, of which eight had significant preintervention trends. All of the studies were considered "effective" in the original report, but approximately half of the reanalyzed studies showed no statistically significant differences. CONCLUSIONS We demonstrated that ITS designs are often analyzed inappropriately, underpowered, and poorly reported in implementation research. We have illustrated a framework for appraising ITS designs, and more widespread adoption of this framework would strengthen reviews that use ITS designs.
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Affiliation(s)
- Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Foresterhill, UK.
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Wickizer TM, Kopjar B, Franklin G, Joesch J. Do drug-free workplace programs prevent occupational injuries? Evidence from Washington State. Health Serv Res 2004; 39:91-110. [PMID: 14965079 PMCID: PMC1360996 DOI: 10.1111/j.1475-6773.2004.00217.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the effect of a publicly sponsored drug-free workplace program on reducing the risk of occupational injuries. DATA SOURCES Workers' compensation claims data from the Washington State Department of Labor and Industries covering the period 1994 through 2000 and work-hours data reported by employers served as the data sources for the analysis. STUDY DESIGN We used a pre-post design with a nonequivalent comparison group to assess the impact of the intervention on injury risk, measured in terms of differences in injury incidence rates. Two hundred and sixty-one companies that enrolled in the drug-free workplace program during the latter half of 1996 were compared with approximately 20,500 nonintervention companies. We tested autoregressive, integrated moving-average (ARIMA) models to assess the robustness of our findings. PRINCIPAL FINDINGS The drug-free workplace intervention was associated (p < .05) with a statistically significant decrease in injury rates for three industry groups: construction, manufacturing, and services. It was associated (p < .05) with a reduction in the incidence rate of more serious injuries involving four or more days of lost work time for two industry groups: construction and services. The ARIMA analysis supported CONCLUSIONS The drug-free workplace program we studied was associated with a selective, industry-specific preventive effect. The strongest evidence of an intervention effect was for the construction industry. Estimated net cost savings for this industry were positive though small in magnitude.
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Affiliation(s)
- Thomas M Wickizer
- Department of Health Services, University of Washington, Seattle 98195-7660, USA
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Abstract
BACKGROUND Clinical practice guidelines have proliferated in the past several decades, starting with only a handful in the 1980s to over 1000 approved through The National Guideline Clearinghouse in 2002. METHODS The purposes of this article to review research related to guideline adoption and impact and to make recommendations for assessing the outcomes of guidelines, using the CDC guideline process as an example. RESULTS Despite the national movement toward standardization of evidence-based practice, few studies have been conducted to assess the costs of guideline development and implementation, and some practice guidelines have been implemented without concomitant assessment on patient outcomes and costs and benefits of changes in care. CONCLUSIONS An immediate mandate is to ensure that when guidelines are promulgated, they include an evaluation plan, developed by the implementer of the guideline, which takes advantage of existing qualitative and quantitative data and programs (e.g., patient-centered care, quality assurance, risk management) not limited to expensive and sophisticated clinical trials.
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Affiliation(s)
- Elaine Larson
- Columbia University School of Nursing, 630 West 168th Street, New York, NY 10032, USA.
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Smith JC. Fighting to help lower costs: Making a financial case for chiropractic. J Chiropr Med 2002; 1:189-98. [DOI: 10.1016/s0899-3467(07)60035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2002] [Indexed: 12/19/2022] Open
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Fritzell P, Hägg O, Wessberg P, Nordwall A. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 2001; 26:2521-32; discussion 2532-4. [PMID: 11725230 DOI: 10.1097/00007632-200112010-00002] [Citation(s) in RCA: 709] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A randomized controlled multicenter study with a 2-year follow-up by an independent observer. OBJECTIVES To determine whether fusion of the lower lumbar spine could reduce pain and diminish disability more effectively when compared with nonsurgical treatment in patients with severe chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA The reported results after fusion surgery on patients with CLBP vary considerably, and the evidence of treatment efficacy is weak in the absence of randomized controlled studies. PATIENTS AND METHODS A total of 294 patients referred to 19 spinal centers from 1992 through 1998 were randomized blindly into four treatment groups. Patients aged 25-65 years with CLBP for at least 2 years and with radiologic evidence of disc degeneration at L4-L5, L5-S1, or both were eligible to participate in the study. The surgical group (n=222) included three different fusion techniques, not analyzed separately in this study. Patients in the nonsurgical group (n=72) were treated with different kinds of physical therapy. The surgical group comprised 49.5% men, and the mean age was 43 years. The corresponding figures for the nonsurgical group were 48.6% and 44 years. The patients had suffered from low back pain for a mean of 7.8 and 8.5 years and been on sick leave due to back pain for a mean of 3.2 and 2.9 years, respectively. The Visual Analogue Scale (VAS) was used to measure pain. The Oswestry Low Back Pain Questionnaire, the Million Score and the General Function Score (GFS) were used to measure disability. The Zung Depression Scale was used to measure depressive symptoms. The overall result was assessed by the patient and by an independent observer. Records from the Swedish Social Insurance were used to evaluate work disability. Patients who changed groups were included in the analyses of significance according to the intention-to-treat principle. RESULTS At the 2-year follow-up 289 of 294 (98%) patients, including 25 who had changed groups, were examined. Back pain was reduced in the surgical group by 33% (64 to 43), compared with 7% (63 to 58) in the nonsurgical group (P=0.0002). Pain improved most during the first 6 months and then gradually deteriorated. Disability according to Oswestry was reduced by 25% (47 to 36) compared with 6% (48 to 46) among nonsurgical patients (P=0.015), according to Million by 28% (64 to 46) compared with 8% (66 to 60) (P=0.004), and accordingtoGFS by 31% (49 to 34) compared with 4% (48 to 46) (P=0.005). The depressive symptoms, according to Zung, were reduced by 20% (39 to 31) in the surgical group compared with 7% (39 to 36) in the nonsurgical group (P=0.123). In the surgical group 63% (122/195) rated themselves as "much better" or "better" compared with 29% (18/62) in the nonsurgical group (P<0.0001). The "net back to work rate" was significantly in favor of surgical treatment, or 36% vs. 13% (P=0.002). The early complication rate in the surgical group was 17%. CONCLUSION Lumbar fusion in a well-informed and selected group of patients with severe CLBP can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatment.
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Affiliation(s)
- P Fritzell
- Department of Orthopedic Surgery, Falun Hospital, 79182 Falun, Sweden.
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16
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Seres JL. The fallacy of using 50% pain relief as the standard for satisfactory pain treatment outcome. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s1082-3174(99)70005-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abraham DJ, Herkowitz HN, Katz JN. Indications for thoracic and lumbar spine fusion and trends in use. Orthop Clin North Am 1998; 29:803. [PMID: 9756973 DOI: 10.1016/s0030-5898(05)70049-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Over the last 10 years, the annual number of spinal procedures performed in the United States has more than doubled. In 1996, there were roughly 29,000 thoracic or dorsal fusion procedures, which made up almost 13% of all spine fusions performed. Scoliosis was the most common condition necessitating posterior thoracic fusion. The first half of this article focuses on the indications for thoracic and lumbar fusions; whereas, the second half of this article discusses the trends in use of thoracic and lumbar spine fusions.
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Affiliation(s)
- D J Abraham
- Fellow, Spine Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
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