Assessing the validity of health administrative data compared to population health survey data for the measurement of low back pain

Care trajectories for musculoskeletal disorders following a new episode of low back pain

ABSTRACT

This study explored diverse care trajectories (CTs) for low back pain (LBP) and other musculoskeletal disorders (MSDs), over a 5-year period following a first episode of LBP. Based on Quebec's administrative health data from 2007 to 2011, this longitudinal cohort study involved 12,608 adults seeking health care for LBP. Using a new multidimensional state sequence analysis, we identified 6 distinct types of CTs. The most prevalent types 1, 2, and 3 (comprising 79.2%, 18.0%, and 21.7% of the cohort, respectively) exhibit rapid recovery and similar patterns of healthcare use over 5 years but differing in initial diagnoses: nonspecific LBP in type 1, trauma-related LBP in type 2 (mostly younger men and highest initial emergency consultation), and specific LBP in type 3. Types 4 to 6, representing smaller groups, show high healthcare utilization with comparable mixed LBP diagnoses at entry but distinctive subsequent care use patterns. Patients in types 4 and 6 (mainly older age groups and women) sought care for other MSDs from general practitioners or specialists, while middle-aged patients in type 5 experienced persistent nonspecific LBP with frequent general practitioner consultations over 5 years. The CTs typology revealed several key areas for improvement in nonpharmacological interventions, including the need to address possible inappropriate medical imaging and invasive interventions for older women with MSDs and the lack of ambulatory care access for younger patients with trauma-related LBP. Finally, results clearly highlighted poor access to rehabilitation physicians and rehabilitation services for all patients suffering from LBP and MSDs.

Use of General Practitioner Services Among Workers with Work-Related Low Back Pain: A Systematic Review

PURPOSE

Work-related low back pain (WRLBP) is a highly prevalent health problem worldwide leading to work disability and increased healthcare utilisation. General practitioners (GPs) play an important role in the management of WRLBP. Despite this, understanding of GP service use for WRLBP is limited. This systematic review aimed to determine the prevalence, patterns and determinants of GP service use for WRLBP.

METHODS

MEDLINE, Embase via Ovid, Scopus and Web of Science were searched for relevant peer-reviewed articles published in English without any restriction on time of publications. Low back pain (LBP) was considered work-related if the study included workers' compensation claim data analysis, participants with accepted workers' compensation claims or reported a connection with work and LBP. The eligibility criteria for GP service use are met if there is any reported consultation with family practitioner, medical doctor or General Practitioner. Two reviewers screened articles and extracted data independently. Narrative synthesis was conducted.

RESULTS

Seven eligible studies reported prevalence of GP service use among workers with WRLBP ranging from 11% to 99.3%. Only studies from Australia, Canada and the United States met the eligibility criteria. The prevalence of GP service use was higher in Australia (70%) and Canada (99.3%) compared to the United States (25.3% to 39%). The mean (standard deviation) number of GP visits ranged from 2.6 (1.6) to 9.6 (12.4) over a two-year time interval post-WRLBP onset. Determinants of higher GP service use included prior history of low back pain, more severe injury, prior GP visits and younger age.

CONCLUSION

Only seven studies met the eligibility indicating a relative lack of evidence, despite the acknowledged important role that GPs play in the care of workers with low back pain. More research is needed to understand the prevalence, patterns and determinants to support effective service delivery and policy development.

Characterizing high-cost healthcare users among adults with back pain in Ontario, Canada: a population-based cohort study

ABSTRACT

Some patients with back pain contribute disproportionately to high healthcare costs; however, characteristics of high-cost users with back pain are not well defined. We described high-cost healthcare users based on total costs among a population-based cohort of adults with back pain within the Ontario government's single-payer health system across sociodemographic, health, and behavioural characteristics. We conducted a population-based cohort study of Ontario adult (aged 18 years or older) respondents of the Canadian Community Health Survey (CCHS) with back pain (2003-2012), linked to administrative data (n = 36,605; weighted n = 2,076,937, representative of Ontario). Respondents were ranked based on gradients of total healthcare costs (top 1%, top 2%-5%, top 6%-50%, and bottom 50%) for 1 year following the CCHS survey, with high-cost users as top 5%. We used multinomial logistic regression to investigate characteristics associated with the 4 cost groups. Top 5% of cost users accounted for 49% ($4 billion CAD) of total healthcare spending, with inpatient hospital care as the largest contributing service type (approximately 40% of costs). Top 5% high-cost users were more likely aged 65 years or older (OR top1% = 16.6; OR top2-5% = 44.2), with lower income (OR top1% = 3.6; OR top 2-5% = 1.8), chronic disease(s) (OR top1% = 3.8; OR top2-5% = 1.6), Aggregated Diagnosis Groups measuring comorbidities (OR top1% = 25.4; OR top2-5% = 13.9), and fair/poor self-rated general health (OR top1% = 6.7; OR top2-5% = 4.6) compared with bottom 50% users. High-cost users tended to be current/former smokers, obese, and report fair/poor mental health. High-cost users (based on total costs) among adults with back pain account for nearly half of all healthcare spending over a 1-year period and are associated with older age, lower income, comorbidities, and fair/poor general health. Findings identify characteristics associated with a high-risk group for back pain to inform healthcare and public health strategies that target upstream determinants.

Treated versus self-reported prevalence of chronic pain and costs of patients' health services utilization: a population-based study of health administrative databases

Objectives

To compare treated to self-reported prevalence of chronic pain (CP) and to estimate health services utilization (HSU) costs of patients treated for CP in Alberta, Canada.

Methods

Patients treated for CP were identified by the physician billing codes of health services for CP from the practitioner claims database in fiscal year 2021/22. The treated prevalence of CP (number of these patients divided by the population) was compared to the self-reported prevalence of CP previously estimated (doi:10.1371/journal.pone.0272638). Costs of patients' HSU included costs for general practitioner (GP), specialist, inpatient, emergency department, outpatient clinic services, and prescription drugs.

Results

The treated prevalence of CP was 6.0% (4.4% among males and 7.8% among females) which was 30% to 41% of the self-reported prevalence. The highest treated prevalence (7.2%) was found in the age group of 18-64 years, followed by age groups of >64 years (7.0%) and <18 years (2.1%). The average cost per patient per year was $5096 ($5878 for males and $4652 for females), of which hospitalizations accounted for 65.0%, outpatient clinic visits 16.4%, ED visits 9.5%, prescription drugs 4.7%, GP visits 3.9%, and specialist visits 0.4%. The total cost of patients with CP for the health system was $1.37 billion (∼7% of total health expenditure), of which males accounted for 41.7% and females for 58.3%.

Discussion

Our findings suggest that the economic burden of CP is considerable and that many people with self-reported CP do not use the public healthcare services. This can be multifactorial, including lack of availability and accessibility of publicly funded services, people's lack of awareness of available services, lower utilization due to COVID-19 pandemic, and reliance on self-management, private services, and alternative treatments. Further studies are warranted to inform future policies and health system initiatives aiming to reduce the burden of CP and improve lives of people living with it.

Association between physiotherapy utilization and medical healthcare utilization and costs in adults with back pain from Ontario, Canada: a population-based cohort study

ABSTRACT

This study examined the association between physiotherapy utilization and subsequent medical healthcare utilization and costs in a population-based sample of adults with back pain in Ontario. We conducted a population-based cohort study of Ontario respondents with back pain (≥18 years) of the Canadian Community Health Survey 2003 to 2010 cycles, linked to health administrative data up to 2018. Physiotherapy utilization was defined as self-reported consultation with a physiotherapist in the past 12 months. A propensity score-matched cohort was conducted to match adults with and without physiotherapy utilization, accounting for potential confounders. We assessed associations using negative-binomial and linear (log-transformed) regression to evaluate outcomes of healthcare utilization (back pain-specific and all-cause) and costs, respectively, at 1- and 5-year follow-up. There were 4343 pairs of matched respondents. Compared with those who did not receive physiotherapy, adults who received physiotherapy were more likely to have back pain-specific physician visits (RR women (5years) = 1.48, 95% CI 1.24-1.75; RR men (5years) = 1.42, 95% CI 1.10-1.84). Women who received physiotherapy had 1.11 times the rate of all-cause physician visits (RR 1year = 1.11, 95% CI 1.02-1.20), and men who received physiotherapy had 0.84 times the rate of all-cause hospitalizations (RR 5years = 0.84, 95% CI 0.71-0.99) than those who did not. There was no association between physiotherapy utilization and healthcare costs. Adults with back pain who received physiotherapy are more likely to have back pain-specific physician visits up to 5-year follow-up than those who did not. Physiotherapy utilization is linked to some sex-based differences in all-cause healthcare utilization but not differences in costs. Findings inform interprofessional collaboration and allied healthcare delivery for back pain in Ontario.

Effects of chiropractic use on medical healthcare utilization and costs in adults with back pain in Ontario, Canada from 2003 to 2018: a population-based cohort study

BACKGROUND

Adults with back pain commonly consult chiropractors, but the impact of chiropractic use on medical utilization and costs within the Canadian health system is unclear. We assessed the association between chiropractic utilization and subsequent medical healthcare utilization and costs in a population-based cohort of Ontario adults with back pain.

METHODS

We conducted a population-based cohort study that included Ontario adult respondents of the Canadian Community Health Survey (CCHS) with back pain from 2003 to 2010 (n = 29,475), followed up to 2018. The CCHS data were individually-linked to individual-level health administrative data up to 2018. Chiropractic utilization was self-reported consultation with a chiropractor in the past 12 months. We propensity score-matched adults with and without chiropractic utilization, accounting for confounders. We evaluated back pain-specific and all-cause medical utilization and costs at 1- and 5-year follow-up using negative binomial and linear (log-transformed) regression, respectively. We assessed whether sex and prior specialist consultation in the past 12 months were effect modifiers of the association.

RESULTS

There were 6972 matched pairs of CCHS respondents with and without chiropractic utilization. Women with chiropractic utilization had 0.8 times lower rate of cause-specific medical visits at follow-up than those without chiropractic utilization (RR_5years = 0.82, 95% CI 0.68-1.00); this association was not found in men (RR_5years = 0.96, 95% CI 0.73-1.24). There were no associations between chiropractic utilization and all-cause physician visits, all-cause emergency department visits, all-cause hospitalizations, or costs. Effect modification of the association between chiropractic utilization and cause-specific utilization by prior specialist consultation was found at 1-year but not 5-year follow-up; cause-specific utilization at 1 year was lower in adults without prior specialist consultation only (RR_1year = 0.74, 95% CI 0.57-0.97).

CONCLUSIONS

Among adults with back pain, chiropractic use is associated with lower rates of back pain-specific utilization in women but not men over a 5-year follow-up period. Findings have implications for guiding allied healthcare delivery in the Ontario health system.

Sensitivity and specificity of algorithms for the identification of nonspecific low back pain in medico-administrative databases

ABSTRACT

Identifying nonspecific low back pain (LBP) in medico-administrative databases is a major challenge because of the number and heterogeneity of existing diagnostic codes and the absence of standard definitions to use as reference. The objective of this study was to evaluate the sensitivity and specificity of algorithms for the identification of nonspecific LBP from medico-administrative data using self-report information as the reference standard. Self-report data came from the PROspective Québec Study on Work and Health , a 24-year prospective cohort study of white-collar workers. All diagnostic codes that could be associated with nonspecific LBP were identified from the International Classification of Diseases, Ninth and Tenth Revisions ( ICD-9 and ICD-10 ) in physician and hospital claims. Seven algorithms for identifying nonspecific LBP were built and compared with self-report information. Sensitivity analyses were also conducted using more stringent definitions of LBP. There were 5980 study participants with (n = 2847) and without (n = 3133) LBP included in the analyses. An algorithm that included at least 1 diagnostic code for nonspecific LBP was best to identify cases of LBP in medico-administrative data with sensitivity varying between 8.9% (95% confidence interval [CI] 7.9-10.0) for a 1-year window and 21.5% (95% CI 20.0-23.0) for a 3-year window. Specificity varied from 97.1% (95% CI 96.5-97.7) for a 1-year window to 90.4% (95% CI 89.4-91.5) for a 3-year window. The low sensitivity we found reveals that the identification of nonspecific cases of LBP in administrative data is limited, possibly due to the lack of traditional medical consultation.

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

BACKGROUND

Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications.

METHODS

Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long-term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain.

RESULTS

Our study sample includes 973,074 persons living with ADRD who had a long-term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain.

CONCLUSIONS

Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk-benefit for dementia care warrants further scrutiny.

Comorbidity and familial aggregation of back/neck pain in the NIMH Family Study of Affective Spectrum Disorders

OBJECTIVE

Back pain is associated with substantial Global Burden of Disease and is highly comorbid with mood and anxiety symptoms and syndromes. However, mechanisms underlying this association have not been well-elucidated. Here we apply data from the NIMH Family Study of Affective Spectrum Disorders to investigate the comorbidity, familial aggregation, and cross-aggregation of back/neck pain with mood disorder subtypes.

METHODS

The sample includes 519 probands and 560 interviewed first-degree relatives. Lifetime DSM-IV Bipolar I, Bipolar II, and Major Depressive Disorder [MDD] were derived from semi-structured diagnostic interviews. Lifetime history of back or neck pain and its age of onset were self-reported retrospectively. Familial aggregation and cross-aggregation were estimated via mixed effects models in probands and interviewed first-degree relatives, while heritability and co-heritability (endophenotypic ranking value [ERV]) were estimated using full pedigrees.

RESULTS

Over 45% of participants endorsed a history of back/neck pain. Back/neck pain was familial (adjusted odds ratio [aOR] 1.5, p = 0.04; h2 = 0.24, p = 0.009). Back/neck pain in probands was associated with MDD in relatives (aOR 1.5, p = 0.04; ERV = 0.17, p = 0.024), but not with bipolar disorder. Onset of back/neck pain occurred earlier in those with bipolar disorder compared to controls.

CONCLUSION

Findings suggest common familial risk factors underlying back/neck pain with MDD, whereas there was within-individual comorbidity of bipolar with back/neck pain. Future studies that identify common factors that lead to either back/neck pain or MDD can inform prevention and interventions.

Joint effects of back pain and mental health conditions on health care utilization and costs in Ontario, Canada: A population-based cohort study

ABSTRACT

We assessed the joint effects of back pain and mental health conditions on healthcare utilization and costs in a population-based sample of Ontario adults. We included Ontario adult respondents of Canadian Community Health Survey between 2003-2012, followed to 2018 by linking survey data to administrative databases. Joint exposures were self-reported back pain and mental health conditions (fair/poor mental health, mood, anxiety disorder). We built negative binomial, modified Poisson, and linear (log-transformed) models to assess joint effects (effects of two exposures in combination) of comorbid back pain and mental health condition on healthcare utilization, opioid prescription, and costs, adjusting for sociodemographic, health-related and behavioural factors. We evaluated positive additive and multiplicative interaction (synergism) between back pain and mental health conditions with relative-excess risk due-to-interaction (RERI) and ratio of rate-ratios (RR). The cohort (n=147,486) had a mean age of 46 years (SD=17), and 51% were female. We found positive additive and multiplicative interaction between back pain and fair/poor mental health (RERI=0.40;RR=1.12) and mood disorder (RERI=0.41;RR=1.04), but not anxiety for back pain-specific utilization. For opioid prescription, we found positive additive and multiplicative interaction between back pain and fair/poor mental health (RERI=2.71;RR=3.20) and anxiety (RERI=1.60;RR=1.80), and positive additive interaction with mood disorder (RERI=0.74). There was no evidence of synergism for all-cause utilization or costs. Combined effects of back pain and mental health conditions on back pain-specific utilization or opioid prescription were greater than expected, with evidence of synergism. Health services targeting back pain and mental health conditions together may provide greater improvements in outcomes.

Effect of back problems on healthcare utilization and costs in Ontario, Canada: a population-based matched cohort study

ABSTRACT

We assessed the effect of back problems on healthcare utilization and costs in a population-based sample of adults from a single-payer health system in Ontario. We conducted a population-based cohort study of Ontario respondents aged ≥18 years of the Canadian Community Health Survey (CCHS) from 2003 to 2012. The CCHS data were individually linked to health administrative data to measure healthcare utilization and costs up to 2018. We propensity score-matched (hard matched on sex) adults with self-reported back problems to those without back problems, accounting for sociodemographic, health-related, and behavioural factors. We evaluated cause-specific and all-cause healthcare utilization and costs adjusted to 2018 Canadian dollars using negative binomial and linear (log transformed) regression models. After propensity score matching, we identified 36,806 pairs (women: 21,054 pairs; men: 15,752 pairs) of CCHS respondents with and without back problems (mean age 51 years, standard deviation = 18). Compared with propensity score matched adults without back problems, adults with back problems had 2 times the rate of cause-specific visits (rate ratio [RR]women 2.06, 95% confidence interval [CI] 1.88-2.25; RRmen 2.32, 95% CI 2.04-2.64), slightly more all-cause physician visits (RRwomen 1.12, 95% CI 1.09-1.16; RRmen 1.10, 95% CI 1.05-1.14), and 1.2 times the costs (women: 1.21, 95% CI 1.16-1.27; men: 1.16, 95% CI 1.09-1.23). Incremental annual per-person costs were higher in adults with back problems than those without back problems (women: $395, 95% CI $281-$509; men: $196, 95% CI $94-$300). This corresponded to $532 million for women and $227 million for men (adjusted to 2018 Canadian dollars) annually in Ontario given the high prevalence of back problems. Given the high health system burden, new strategies to effectively prevent and treat back problems and thus potentially reduce the long-term costs are warranted.