Longitudinal evaluation of health care utilization and costs during the first three years after a new diagnosis of fibromyalgia

Fibromyalgia pain management effectiveness from the patient perspective: a qualitative evidence synthesis

PURPOSE

This qualitative evidence synthesis aimed to identify and integrate findings where adults with fibromyalgia discussed how they managed their pain, and their perceptions of prescribed treatments from healthcare professionals.

MATERIALS AND METHODS

A comprehensive search strategy was implemented in PubMed, Scopus, ISI Web of Science, and Cinahl Plus databases. The GRADE-CERQual framework was used to evaluate the findings confidence. The findings were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 35 studies (N = 728) were included. The confidence in the findings ranged from high to low confidence. Patients with fibromyalgia often do not benefit from seeking medical attention due to provider stigma, and have varying views on medication effectiveness commonly reporting feeling like "walking chemists." They find mixed effects from exercise, and consider psychological support essential, although the benefits of cognitive-behavioral therapy were controversial. Combining cognitive-behavioral therapy with physical exercise appears more effective, while natural and complementary therapies have short-term benefits and high costs.

CONCLUSIONS

Pain management is a source for frustration and an unmet need for patients with fibromyalgia. The current findings provide crucial insight for providers and researchers; and support the need for fibromyalgia phenotyping and precision medicine approaches to pain management.Implications for RehabilitationChronic widespread pain is the defining feature of fibromyalgia, yet pain reduction is often an unmet need for these individuals.The lack of effective treatments resulting in long-term relief proves frustrating for patients and healthcare providers.Rehabilitation professional should consider the unique insight into this complex, heterogeneous condition that this qualitative synthesis provides to better understand their patient's perspective on pain management.Given the differing perspectives on pain treatment approaches individuals with fibromyalgia report, providers should discuss with each patient their current strategies and take a patient-centered, individualized approach to form an effective treatment plan.

Prevalence of survey-based criteria for fibromyalgia and impact on hospital burden: a 7 year follow-up study from an outpatient clinic

OBJECTIVES

To evaluate the prevalence of survey-based criteria for fibromyalgia (FM) among newly referred patients in a rheumatic outpatient clinic, and to compare the use of secondary healthcare services between survey-based FM and non-FM cases.

METHOD

Newly referred patients to an outpatient clinic were screened for the fulfilment of the 2011 FM survey criteria during a 6 month period in 2013 in this observational cohort study. Demographic data were obtained at baseline. Patients' medical files were evaluated and comparisons between groups were made regarding the use of hospital healthcare facilities during the 7 year observation period.

RESULTS

Out of 300 invited patients, 248 (83%) completed the questionnaire; 90 patients (36%) fulfilled survey-based criteria for FM at enrolment. FM cases were primarily women (80% vs 54% of non-FM cases), and received more medications (median 4 vs 3 drugs) and public economic support (62% vs 20%). At the 7 year follow-up, crude analyses showed that FM cases had a higher number of hospital courses (median 10 vs 8) and had undergone more invasive procedures (78% vs 60%). Neurologists (42% vs 28%), gastroenterologists (30% vs 13%), endocrinologists (40% vs 21%), pain specialists (13% vs 3%), psychiatrists (20% vs 7%), and abdominal surgeons (43% vs 30%) were consulted more often by FM than by non-FM cases.

CONCLUSION

Fulfilment of FM survey criteria among newly referred patients to a rheumatic outpatient clinic is frequent. Our study findings show that FM continues to present a challenge for healthcare professionals as well as for patients.

RESEARCH HIGHLIGHTS

● Fulfilment of FM survey criteria among newly referred patients to a rheumatic outpatient clinic is frequent.● The burden on the secondary healthcare system for these patients is significant.● This study suggests the need for increased awareness about the diagnosis of FM among certain medical and surgical specialties.

Utilisation of healthcare services and drug consumption in fibromyalgia: A cross-sectional analysis of the Clalit Health Service database

AIM

To investigate the health care utilisation and drug consumption of patients with fibromyalgia (FM).

MATERIALS AND METHODS

This is a cross-sectional study using the Clalit Health Care database. Clalit is the largest HMO in Israel, serving more than 4.4 million enrollees. We identified FM patients and age and sex-matched controls. Indicators of healthcare utilisation and drug consumption were extracted and analysed for both groups.

RESULTS

The study included 14 296 FM patients and 71 324 controls. The mean age was 56 years, with a women predominance of 92%. The mean number of visits across of all healthcare services (hospitalisations, emergency department visit, general practitioner clinic visits, rheumatology clinic visits, and pain clinic visits) and the mean difference (MD) were significantly higher for FM patients compared with controls (MD 0.66, P < .001; MD 0.23, P < .001; MD 7.49, P < .001; MD 0.31, P < .001; MD 0.13, P < .001), respectively. Drug use was significantly and consistently higher among FM patients compared with controls; NSAIDs (non-steroidal anti-inflammatory drugs) OR 2.56, P < .001; Opioids OR 4.23, P < .001; TCA (tricyclic antidepressants) OR 8.21, P < .001; Gabapentinoids OR 6.31, P < .001; SSRI (selective serotonin reuptake inhibitors) OR 2.07, P < .001; SNRI (serotonin-norepinephrine reuptake inhibitor) OR 7.43, P < .001.

CONCLUSION

Healthcare utilisation and drug use are substantially higher among patients with FM compared with controls.

Association between health care utilization and musculoskeletal pain. A 21-year follow-up of a population cohort

Background and aims Few studies have reported the long-term impact of chronic pain on health care utilization. The primary aim of this study was to investigate if chronic musculoskeletal pain was associated with health care utilization in the general population in a 21-year follow-up of a longitudinal cohort. The secondary aim was to identify and describe factors that characterize different long-term trajectories of health care utilization. Methods A prospective cohort design with a baseline sample of 2,425 subjects (aged 20-74). Data were collected by self-reported questionnaires, and three time points (1995, 2007, and 2016) were included in the present 21-year follow up study. Data on health care utilization were dichotomized at each time point to either high or low health care utilization. High utilization was defined as >5 consultations with at least one health care provider, or ≥1 consultation with at least 3 different health care providers during the last 12 months. Low health care utilization was defined as ≤5 consultations with one health care provider and <3 consultations with different health care providers. The associations between baseline variables and health care utilization in 2016 were analyzed by multiple logistic regression. Five different trajectories for health care utilization were identified by visual analysis, whereof four of clinical relevance were included in the analyses. Results Baseline predictors for high health care utilization at the 21-year follow-up in 2016 were chronic widespread pain (OR: 3.2, CI: 1.9-5.1), chronic regional pain (OR:1.8, CI: 1.2-2.6), female gender (OR: 2.0, CI: 1.4-3.0), and high age (OR: 1.6, CI:0.9-2.9). A stable high health care utilization trajectory group was characterized by high levels of health care utilization, and a high prevalence of chronic pain at baseline and female gender (n = 23). A stable low health care utilization trajectory group (n = 744) was characterized by low health care utilization, and low prevalence of chronic pain at baseline. The two remaining trajectories were: increasing trajectory group (n = 108), characterized by increasing health care utilization, chronic pain at baseline and female gender, and decreasing trajectory group (n = 107) characterized by decreasing health care utilization despite a stable high prevalence of chronic pain over time. Conclusions The results suggest that chronic pain is related to long-term health care utilization in the general population. Stable high health care utilization was identified among a group characterized by female gender and a report of chronic widespread pain. Implications This cohort study revealed that chronic widespread pain predicted high health care utilization over a 21-year follow-up period. The results indicate the importance of early identification of musculoskeletal pain to improve the management of pain in the long run.

Gender Differences in the Prevalence of Fibromyalgia and in Concomitant Medical and Psychiatric Disorders: A National Veterans Health Administration Study

BACKGROUND

Fibromyalgia is a poorly understood, chronically disabling pain syndrome. While research has focused on its clinical presentation and treatment, less is known about fibromyalgia's clinical epidemiology in real-world healthcare systems. Gender differences have been difficult to study because relatively few males are diagnosed with fibromyalgia.

METHODS

Veterans Health Administration (VHA) patients diagnosed with fibromyalgia nationwide in FY 2012 were compared to Veterans with other pain diagnoses on sociodemographic characteristics, medical and psychiatric diagnoses, health service use, and opioid and psychotropic prescription fills. Additional analyses compared characteristics of men and women diagnosed with fibromyalgia. Risk ratios and Cohen's d were used for bivariate comparisons, followed by logistic regression analyses to identify independent factors associated with a diagnosis of fibromyalgia in the VHA.

RESULTS

Altogether, 77,087 of 2,216,621 Veterans with pain diagnoses (3.48%) were diagnosed with fibromyalgia. They were more likely to be female, younger than patients with other pain conditions, more likely to have multiple psychiatric comorbidities and other types of pain, and used more medical outpatient services. Women diagnosed with fibromyalgia were younger and more likely to have headaches, connective tissue diseases (CTD), and psychiatric comorbidities, while men had more comorbid medical conditions.

CONCLUSIONS

In this large, predominantly older male sample of Veterans with pain diagnoses, those with fibromyalgia were far more likely to be women. Gender comparisons showed women with fibromyalgia were more likely to be diagnosed with psychiatric disorders and CTD, while males were more likely to be diagnosed with medical conditions. Fibromyalgia shows a striking, gender-dependent picture of multimorbidity, which should be considered in treatment.

Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia

In this study, 67 participants (95% female) with fibromyalgia (FM) were randomly assigned to an online acceptance and commitment therapy (online ACT) and treatment as usual (TAU; ACT + TAU) protocol or a TAU control condition. Online ACT + TAU participants were asked to complete 7 modules over an 8-week period. Assessments were completed at pre-treatment, post-treatment, and 3-month follow-up periods and included measures of FM impact (primary outcome), depression, pain, sleep, 6-minute walk, sit to stand, pain acceptance (primary process variable), mindfulness, cognitive fusion, valued living, kinesiophobia, and pain catastrophizing. The results indicated that online ACT + TAU participants significantly improved in FM impact, relative to TAU (P <.001), with large between condition effect sizes at post-treatment (1.26) and follow-up (1.59). Increases in pain acceptance significantly mediated these improvements (P = .005). Significant improvements in favor of online ACT + TAU were also found on measures of depression (P = .02), pain (P = .01), and kinesiophobia (P = .001). Although preliminary, this study highlights the potential for online ACT to be an efficacious, accessible, and cost-effective treatment for people with FM and other chronic pain conditions.

PERSPECTIVE

Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM.

The use of prescription medication in 239 patients with multiple functional somatic syndromes

OBJECTIVE

To describe the use of prescription drugs and their association with patient characteristics in patients with multiple functional somatic syndromes (FSS) focusing on drugs generally recommended and not recommended in FSS treatment.

METHOD

Using data from a national prescription registry, we describe the drug use during a two-year period for 239 trial participants. Using regression models, we analyse the associations of patient characteristics with the patterns of use of antidepressants, anticonvulsants, opioids and sedatives.

RESULTS

The use of prescription drugs was highly heterogeneous. Antidepressants were used at least temporarily by 34% (88/239), anticonvulsants by 7% (16/239), opioids by 26% (61/239) and sedatives by 20% (47/239) of the patients. Severe impairment due to multiple FSS was associated with use of opioids or sedatives (OR 6.49 (95% CI 2.68-15.68; p < 0.001)) but also with use of antidepressants or anticonvulsants (OR 3.42 (95% CI 1.35-8.65; p = 0.009)). Poor self-reported physical health, additional physical comorbidities and low socioeconomic status were associated with use of opioids or sedatives only.

CONCLUSION

Antidepressants and anticonvulsants were modestly used. Opioids and sedatives were especially used by the severely affected patients. Balancing treatment expectations and enhancing patients' understanding of FSS may direct treatments towards more generally recommended drugs.

Severe forms of fibromyalgia with acute exacerbation of pain: costs, comorbidities, and length of stay in inpatient care

Background and purpose

As a disease of the musculoskeletal system, fibromyalgia is becoming increasingly important, because of the direct and indirect costs to health systems. The purpose of this study of health economics was to obtain information about staff costs differentiated by service provider, and staff and material costs of the nonmedical infrastructure in inpatient care.

Patients and methods

This study looked at 263 patients who received interdisciplinary inpatient treatment for severe forms of fibromyalgia with acute exacerbation of pain between 2011 and 2014. Standardized cost accounting and an analysis of additional diagnoses were performed.

Results

The average cost per patient was €3,725.84, with staff and material costs of the nonmedical infrastructure and staff costs of doctors and nurses accounting for the highest proportions of the costs. Each fibromyalgia patient had an average of 6.1 additional diagnoses.

Conclusion

Severe forms of fibromyalgia are accompanied by many concomitant diseases and associated with both high clinical staff costs and high medical and nonmedical infrastructure costs. Indication-based cost calculations provide important information for health policy and hospital managers if they include all elements that incur costs in both a differentiated and standardized way.

Polypharmacy, Opioid Use, and Fibromyalgia: A Secondary Analysis of Clinical Trial Data

The major therapeutic approach for treating fibromyalgia (FM), a chronic widespread pain syndrome, is pharmacotherapy-centered symptom management. Complexity of treatment often leads to multiple medication prescriptions. While there is no current alternative to the probable need for polypharmacy in this patient population, there remains concern related to potential side effects and adverse drug events. In this secondary analysis of data on medications taken collected from two parent studies, all medications were broken down into the following categories: opioid, nonopioid, antidepressant, anticonvulsant, muscle relaxant, and benzodiazepine. The impact on pain severity and pain interference of these medication categories as well as perceived stress, fatigue, and depression scores was assessed. Baseline pain severity ( p = .0106) and pain interference ( p = .0002) were significantly correlated with opioid use as compared to nonopioid use. A multivariate regression with backward elimination resulted in a model for pain severity with one significant predictor variable, fatigue ( p < .0001); pain interference had three significant predictor variables: opioid use ( p = .04), fatigue ( p < .0001), and depression ( p = .04). While future studies should further address the utility of opioids and examine the role of polypharmacy as part of symptom management strategies for individuals with FM, study findings suggest that, for those who suffer chronic widespread pain as the predominant symptom experience, a challenge equally as perplexing for nurses and nursing research alike as managing the pain lies in addressing the fatigue and depression in this patient population.

Fibromyalgia is associated to receiving chronic medications beyond appropriateness: a cross-sectional study

The objectives of this study are to describe appropriateness and drug treatment of comorbidities in fibromyalgia (FM). Cross-sectional study of a group of patients. Number of drugs, indication, duration and appropriateness of prescriptions were evaluated. Patients were classified as: group 1, (FM/FM) previous FM diagnosis and fulfilling criteria; group 2, (noFM/noFM) other diagnosis and not fulfilling criteria; and group 3, (noFM/FM) other diagnosis but fulfilling criteria. Drugs were classified into drugs for nervous system, analgesics/NSAID and drugs for other comorbidities. Appropriateness was evaluated following clinical therapeutic guidelines. A total of 159 patients were included in the study and classified into group 1, with 59 patients; group 2, with 67 patients; and group 3, with 33 patients. Group 1 received a greater number of different drugs and for a longer period of time, there were less severe comorbidities and more unjustified treatments. No difference was found between the other two groups. Major opioids were only consumed in group 1. Also, in group 1, 45.8 % of patients were attended in psychiatry versus 15.6 % in group 3 and 3 % in group 2. The number of somatic symptoms correlated significantly with the number of drugs. Nervous system treatments were of shorter duration than other drug treatments. There was no difference in severe comorbidities. Comorbidities in FM are similar to those of other patients, but they receive more drugs and for a longer period of time. Drugs for nervous system comorbidities are introduced later, when other somatic symptoms are already treated. In patients with FM the treatments for mild comorbidities are not well justified.

Managing chronic widespread pain in primary care: a qualitative study of patient perspectives and implications for treatment delivery

Background

Clinical guidelines recommend a combination of physical, pharmacological and psychological treatments for chronic widespread pain, but published accounts of treatment acceptability are lacking.

Methods

Semi-structured interviews (n = 44) nested within a randomised controlled trial comparing the clinical and cost effectiveness of prescribed exercise, cognitive behavioural therapy (CBT), and combined exercise and CBT to treatment as usual for adults with chronic widespread pain.

Results

Three main themes emerged from the data: i) the illness context (how people experience chronic pain and associated health services); ii) the identity context (how people react to their symptoms and accommodate these within themselves) and iii) the intervention context (the extent and manner by which the trial interventions models aligned with these responses).

Referral to a prescribed exercise programme resonated most closely with participants’ tendency to attribute pain to a structural or mechanical defect. Psychological therapy brought with it connotations of social judgement, deviance and stigma. Experience of psychological therapy often exceeded expectation. Participants who engaged in cognitive reflection and behavioural adaptation reported an upward identity shift independent of increased physical exercise behaviour.

Conclusions

A logical rationale for a health intervention is in itself insufficient to ensure uptake and participation. Potential differences in treatment meaning emphasise the importance of acknowledging different phases of illness acceptance and of providing the most appropriate treatment option for the stage of reconciliation. Health service providers must not only understand people’s own perceptions of chronic widespread pain but also the broader spheres of influence in which this pain is experienced.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Perspectives on Living With Fibromyalgia

Perceptions of people living with chronic illness change over time, contributing to health-related stress that necessitates coping skills. Paterson's shifting perspectives model provides an explanation of chronically ill people's variations in attention to their symptoms. In this qualitative study, 20 people with fibromyalgia living in a rural setting were interviewed in 2013 with the aim of gaining insight into their experiences and the meaning-making associated with their chronic condition. Analysis of the interview data categorized five recurrent, or common, themes: experiences of loss, feelings of fear and uncertainty, influence of stress, stigmatization of the disease, and coping through courage. Difficulties attendant to losses, distress, and stigma associated with this chronic condition led the participants to report poor health-related quality of life. The study findings can be useful across clinical settings to nurses and other health care providers in understanding those diagnosed with fibromyalgia and their care needs.

The Maintaining Musculoskeletal Health (MAmMOTH) Study: Protocol for a randomised trial of cognitive behavioural therapy versus usual care for the prevention of chronic widespread pain

BACKGROUND

Cognitive behavioural therapy (CBT) has been shown to improve outcomes for patients with fibromyalgia, and its cardinal feature chronic widespread pain (CWP). Prediction models have now been developed which identify groups who are at high-risk of developing CWP. It would be beneficial to be able to prevent the development of CWP in these people because of the high cost of symptoms and because once established they are difficult to manage. We will test the hypothesis that among patients who are identified as at high-risk, a short course of telephone-delivered CBT (tCBT) reduces the onset of CWP. We will further determine the cost-effectiveness of such a preventative intervention.

METHODS

The study will be a two-arm randomised trial testing a course of tCBT against usual care for prevention of CWP. Eligible participants will be identified from a screening questionnaire sent to patients registered at general practices within three Scottish health boards. Those returning questionnaires indicating they have visited their doctor for regional pain in the last 6 months, and who have two of, sleep problems, maladaptive behaviour response to illness, or high number of somatic symptoms, will be invited to participate. After giving consent, participants will be randomly allocated to either tCBT or usual care. We aim to recruit 473 participants to each treatment arm. Participants in the tCBT group will have an initial assessment with a CBT therapist by telephone, then 6 weekly sessions, and booster sessions 3 and 6 months after treatment start. Those in the usual care group will receive no additional intervention. Follow-up questionnaires measuring the same items as the screening survey questionnaire will be sent 3, 12 and 24 months after start of treatment. The main outcome will be CWP at the 12 month questionnaire.

DISCUSSION

This will be the first trial of an intervention aimed at preventing fibromyalgia or CWP. The results of the study will help to inform future treatments for the prevention of chronic pain, and aetiological models of its development.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02668003URL: Please check that the following URLs are working. If not, please provide alternatives: NCT02668003Alternative is: https://www.clinicaltrials.gov/ct2/show/NCT02668003> . Date registered: 28-Jan-2016.

Fibromyalgia-related costs and loss of productivity: a substantial societal burden

BACKGROUND

This study aimed at describing pain-related health care resource use, direct costs, and productivity loss among patients suffering from fibromyalgia syndrome (FMS).

METHODS

A cost-of-illness study with a sample of 57 adults having a diagnosis of FMS was conducted in the province of Quebec (Canada). Data regarding FMS-related direct costs and productivity loss from paid and unpaid work over a three-month period were collected using a standardized structured telephone interview protocol. Direct costs were valued in 2009 Canadian dollars using a societal perspective.

RESULTS

Results showed that average direct costs over a three-month period added up to $951 per patient (SD: $710), which could be translated in a mean annual cost of $3804. The purchase of prescribed medications led to the highest costs (mean: $329, SD: $321), followed by consultations to health care professionals other than physicians (mean: $129, SD: $222) and physicians consultations (mean: $98, SD: $116). Results further showed a high economic burden for patients themselves, aside from costs covered by public or private insurers. Among the subsample of participants who had a paid job (45.6%), an average of 5.6 days (SD: 13.2) were lost due to pain during the past three months. Among those who were not employed (54.4%), an average of 25.1 days in household productivity (SD: 24.8) were lost.

CONCLUSIONS

FMS is associated with a substantial socioeconomic burden. Further research is clearly needed to improve the management of this type of disorder and make better decisions regarding resource allocation.

Treatment Patterns Associated with ACR-Recommended Medications in the Management of Fibromyalgia in the United States

BACKGROUND

Fibromyalgia (FM) affects up to 6% of U.S. adults, resulting in a significant burden on the health care system and poor quality of life for patients. Duloxetine, pregabalin, and milnacipran are approved for management of FM; however, consensus is lacking regarding optimal therapy. Patients with FM taking approved medications often do not experience meaningful symptom relief, and many experience intolerable adverse events.

OBJECTIVE

To assess treatment patterns associated with available and commonly used medications for the management of FM using U.S. health insurance claims.

METHODS

This retrospective analysis used the MarketScan claims database to identify adults with a first diagnosis of FM (ICD-9-CM code 729.1) between 2009 and 2011 with continuous health plan enrollment for 12 months pre- and post-index. Medications of interest were pregabalin, gabapentin, duloxetine, milnacipran, cyclobenzaprine, and tramadol. These are 6 of the 8 medications recommended by the American College of Rheumatology (ACR) for treating FM; the other 2 (amitriptyline and venlafaxine) were only included in some initial assessments. The Charlson Comorbidity Index (CCI) was used to assess overall comorbidity burden. Endpoints included proportion of patients treated within 1 year after first diagnosis; initial treatment pattern; adherence over the first-year follow-up period for the medications of interest; and discontinuation, switching, and combination therapy patterns among pain medications of interest at different time points. Proportion of days covered (PDC; defined as number of days in the period when the patient had drug supply divided by the number of days in the period) was used to define adherence, which was categorized as low (PDC < 50%), medium (PDC 50% to < 80%), or high (PDC ≥ 80%). The time to discontinuation (defined as the first drug supply gap ≥ 90 days) was estimated using Kaplan-Meier analysis.

RESULTS

Overall, 240,144 patients met the inclusion criteria. Patients were predominantly women (68%), had preferred provider organization insurance coverage (68%), and had a CCI score < 1 at baseline (69%). Only 31% (n = 74,738) initiated a treatment with a prescription medication listed in the ACR guidelines, and many patients received less than the recommended dose. Most (n = 70,919) patients initially received monotherapy with one of the 8 prescription medications. Of those who started with ≥ 2 medications (n = 3,819), cyclobenzaprine plus tramadol was the most frequent combination. Adherence was suboptimal for all 6 medications of interest. Duloxetine had the highest mean PDC (59%); for all other agents, mean PDC was < 50%. With the exception of duloxetine, discontinuation rates at 6 months were > 50% for all agents. Alterations in therapy were common. Among patients who discontinued their initial treatment of duloxetine, pregabalin, or milnacipran, approximately one-third had switched treatments within 90 days after their first prescription. For those who maintained their initial treatment agent, approximately 50% of patients added a second pain medication within 1 year of treatment initiation.

CONCLUSIONS

The evidence suggests that patients with FM often do not receive 1 of the prescription medications recommended by ACR guidelines, and those who do are commonly prescribed lower-than-recommended doses, potentially resulting in poor effectiveness and tolerability. Discontinuation, switching, and addition of new pain medications are common, which may indicate low levels of satisfaction with initial treatment. New therapies with improved effectiveness and better tolerability are urgently needed for patients with FM.

Fibromyalgia diagnosis: a review of the past, present and future

Diagnosis of fibromyalgia (FM) remains controversial even though diverse diagnostic criteria have been developed. This review looks at the history, evolution of diagnostic criteria, endless controversy, recent trends and future perspectives regarding FM diagnosis. Some have criticized that diagnosis of FM could lead to medicalization, whereas others have raised concerns of under-diagnosing FM. With the evolution of diagnosis criteria from American College of Rheumatology 1990 to modified American College of Rheumatology 2010, diagnosis of FM has become simpler. The recent trend of applying patient-reported questionnaires has also increased a simpler FM diagnosis. Reliable biomarkers will not be available for the foreseeable future, so diverse assessment tools will have to be used more pro-actively. After initial diagnosis, multiple and comprehensive assessment measures are needed during the course of treatment in order to better understand type and severity of FM symptoms. These, in turn, could help classify FM based on symptom domain, symptom severity, and comorbidity which would enable more personalized treatment.

Fibromyalgia: management strategies for primary care providers

AIMS

Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management.

METHODS

We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements.

RESULTS

The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes.

DISCUSSION

The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training.

CONCLUSION

Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting.

Resource utilisation and direct costs in patients with recently diagnosed fibromyalgia who are offered one of three different interventions in a randomised pragmatic trial

The purpose of this study is to understand the course of costs over a 2-year period in a cohort of recently diagnosed fibromyalgia (FM) patients receiving different treatment strategies. Following the diagnosis, patients were randomly assigned to a multidisciplinary programme (MD), aerobic exercise (AE) or usual care (UC) without being aware of alternative interventions. Time between diagnosis and start of treatment varied between patients. Resource utilisation, health care costs and costs for patients and families were collected through cost diaries. Mixed linear model analyses (MLM) examined the course of costs over time. Linear regression was used to explore predictors of health care costs in the post-intervention period. Two hundred three participants, 90 % women, mean (SD) age 41.7 (9.8) years, were included in the cohort. Intervention costs per patient varied from €864 to 1392 for MD and were €121 for AE. Health care costs (excluding intervention costs) decreased after diagnosis, but before the intervention in each group, and increased again afterwards to the level close to the diagnostic phase. In contrast, patient and family costs slightly increased over time in all groups without initial decrease immediately after diagnosis. Annualised health care costs post-intervention varied between €1872 and 2310 per patient and were predicted by worse functioning and high health care costs at diagnosis. In patients with FM, health care costs decreased following the diagnosis by a rheumatologist. Offering patients a specific intervention after diagnosis incurred substantial costs while having only marginal effects on costs.

Classifying fibromyalgia patients according to severity: the combined index of severity in fibromyalgia

The aim of this study was to establish the cutoff points in the Combined Index of Fibromyalgia Severity (ICAF) questionnaire which allow classification of patients by severity and to evaluate its application in the clinical practice. The cutoff points were calculated using the area under the ROC curve in two cohorts of patients. Three visits, basal, fourth month and 15th month, were considered. The external criterion for grading severity was the number of drugs consumed by the patient. Sequential changes were calculated and compared. Correlations with drug consumption and comparisons of severity between patients with different types of coping were also calculated. Correlation between the number of drugs and the ICAF total score was significant. Three cutoff points were established: absence of Fibromyalgia (FM), <34; mild, 34-41; moderate, 41-50 and severe, >50, with the following distribution of severity: absence in 0.4 %, mild in 18.7 %, moderate in 32.5 % and severe in 48.4 % of the patients. There were significant differences between groups. The treatment under daily clinical conditions showed a significant improvement of the patients which was maintained at the end of follow-up. There was a 17 % reduction in the severe category. The patients with more passive coping factor showed highest punctuations in the remaining scores and were more prevalent in the severe category. The patients with a predominance of the emotional factor showed a better response at the end of follow-up. The established cutoff points allow the classification of FM patients by severity, to know the prognostic and to predict the response to the treatment.

Calf muscle pump stimulation as a means to reduce symptoms of fibromyalgia syndrome

Fibromyalgia (FM) is a debilitating chronic condition that often affects women in midlife with widespread pain that interrupts attempts to exercise. The purpose of this pilot study was to test the efficacy of calf muscle pump (CMP) stimulation as an adjuvant therapy for FM by (1) assessing the correlation of the level of symptoms, as measured by the revised Fibromyalgia Impact Questionnaire (FIQR), and blood pressure (BP), (2) measuring change in mean FIQR scores for subjects who use a CMP-stimulation device for 12 weeks, and (3) measuring the correlation of total device usage and the level of symptoms as measured by the FIQR. The 29 male and female participants (mean age = 47.3 years) were screened using the Widespread Pain Index (WPI), Symptom Severity (SS) score, and the FIQR. Participants were contacted weekly, and progress was assessed using the WPI, SS score, and the FIQR as well as general questions regarding responses to CMP stimulation. The attrition rate was high, which is not uncommon in studies of patients with FM. We found that diastolic BP was significantly inversely correlated with baseline FIQR scores during quiet sitting. Further, 12 weeks of CMP stimulation was associated with significant improvement in average FIQR scores at a rate of approximately -1.5 points per week (R (2) = .9; p ≤ .0001). Total device usage was strongly and inversely correlated with baseline FIQR scores (R (2) = .43; p = .02). These findings suggest that CMP stimulation may provide an additional treatment option for individuals with FM who are challenged to perform traditional forms of exercise.

[Use of health services in Brazil: association with overweight and body fat indicators]

The aim of the study was to analyze the association between use of health services and obesity in Brazilian adults. We carried out a population-based cross-sectional study in 100 districts of five Brazilian regions. The outcomes were: home care, use of medical services in the primary health care, use of medical services outside of the primary health care, use of emergency services and hospitalization. Excess weight was assessed by measurement of BMI and waist circumference (WC). Among the 8,603 subjects studied, the medical care in the primary health care was 14% and 18% higher among obese and high risk of WC, respectively, after controlled for socio-demographic variables and physical inactivity, but lost significance when adjusted for hypertension and diabetes. For the emergency services, both exposures resulted in increase of nearly 20% in the use of this service, after adjustments. The excess weight increased the use of medical services in the primary health care and emergency services.

Validity and reliability of the Spanish version of the 10-item CD-RISC in patients with fibromyalgia

Background

No resilience scale has been validated in Spanish patients with fibromyalgia. The aim of this study was to evaluate the validity and reliability of the 10-item CD-RISC in a sample of Spanish patients with fibromyalgia.

Methods

Design: Observational prospective multicenter study. Sample: Patients with diagnoses of fibromyalgia recruited from primary care settings (N = 208). Instruments: In addition to sociodemographic data, the following questionnaires were administered: Pain Visual Analogue Scale (PVAS), the 10-item Connor-Davidson Resilience scale (10-item CD-RISC), the Fibromyalgia Impact Questionnaire (FIQ), the Hospital Anxiety and Depression Scale (HADS), the Pain Catastrophizing Scale (PCS), the Chronic Pain Acceptance Questionnaire (CPAQ), and the Mindful Attention Awareness Scale (MAAS).

Results

Regarding construct validity, the factor solution in the Principal Component Analysis (PCA) was considered adequate, so the KMO test had a value of 0.91, and the Barlett’s test of sphericity was significant (χ2 = 852.8; gl = 45; p < 0.001). Only one factor showed an eigenvalue greater than 1, and it explained 50.4% of the variance. PCA and Confirmatory Factor Analysis (CFA) results did not show significant differences between groups. The 10-item CD-RISC scale demonstrated good internal consistency (Cronbach’s alpha = 0.88) and test-retest reliability (r = 0.89 for a six-week interval). The 10-item CD-RISC score was significantly correlated with all of the other psychometric instruments in the expected direction, except for the PVAS (−0.115; p = 0.113).

Conclusions

Our study confirms that the Spanish version of the 10-item CD-RISC shows, in patients with fibromyalgia, acceptable psychometric properties, with a high level of reliability and validity.

Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project

OBJECTIVE

To estimate and compare the prevalence of fibromyalgia by 2 different methods in Olmsted County, Minnesota.

METHODS

The first method was a retrospective review of medical records of potential cases of fibromyalgia in Olmsted County using the Rochester Epidemiology Project (from January 1, 2005, to December 31, 2009) to estimate the prevalence of diagnosed fibromyalgia in clinical practice. The second method was a random survey of adults in Olmsted County using the fibromyalgia research survey criteria to estimate the percentage of responders who met the fibromyalgia research survey criteria.

RESULTS

Of the 3,410 potential patients identified by the first method, 1,115 had a fibromyalgia diagnosis documented in the medical record by a health care provider. The age- and sex-adjusted prevalence of diagnosed fibromyalgia by this method was 1.1%. By the second method, of the 2,994 people who received the survey by mail, 830 (27.6%) responded and 44 (5.3%) met the fibromyalgia research survey criteria. The age- and sex-adjusted prevalence of fibromyalgia in the general population of Olmsted County by this method was estimated at 6.4%.

CONCLUSION

To the best of our knowledge, this is the first report of the rate at which fibromyalgia is being diagnosed in a community. This is also the first report of prevalence as assessed by the fibromyalgia research survey criteria. Our results suggest that patients, particularly men, who meet the fibromyalgia research survey criteria are unlikely to have been given a diagnosis of fibromyalgia.

High rates of physician services utilization at least five years before multiple sclerosis diagnosis

BACKGROUND

Multiple sclerosis (MS) management has changed over time, but changes in health care utilization by MS patients remain understudied. We estimated physician services utilization in the five-year periods before and after MS diagnosis, and over the period 1984-2008.

METHODS

Using administrative data we identified 4092 persons with MS and a matched general population (GPOP) cohort of 21,446 persons. Using general linear models we compared physician visits between the MS and GPOPs for the period 1984-2008, the year of MS diagnosis, and for the five-year periods pre- and post-diagnosis.

RESULTS

From 1984 to 2008, 98% of the MS population averaged ≥1 physician visits/year versus 87% of the GPOP. In 2008, the MS population had 12.9 physician visits/person-year while the GPOP had 8.4 (rate ratio (RR) 1.53; 95% confidence interval (CI): 1.52-1.55). Five years pre-MS diagnosis, the MS population had more physician visits than the GPOP (RR 1.15; 95% CI; 1.10-1.21). The number of visits peaked the year of MS diagnosis (19.0), decreasing thereafter, but remaining elevated versus the pre-diagnosis period.

CONCLUSION

The MS population uses more physician services than the GPOP, starting at least five years pre-MS diagnosis. A better understanding of the reasons for these higher utilization rates may ultimately improve outcomes in MS.

Burden of illness and treatment patterns for patients with fibromyalgia

OBJECTIVE

  This study was designed to describe burden of illness and treatment patterns, and to examine the patient, physician, and care factors associated with the treatment choices of individuals receiving new prescriptions for fibromyalgia (FM).

DESIGN

  This is a baseline assessment of the Real-World Examination of Fibromyalgia: Longitudinal Evaluation of Costs and Treatments (REFLECTIONS), a prospective observational study. Baseline data (including a physician survey, a patient visit form, and computer-assisted telephone interviews) were collected from July 2008 through May 2010 in 58 care settings in the United States, including Puerto Rico.

RESULTS

  Patients (N = 1,700) were mostly female (94.6%) and white (82.9%). Mean age was 50.4 years and mean duration of illness was 5.6 years. Mean Fibromyalgia Impact Questionnaire total score was 54.4 (range 0-80), and Brief Pain Inventory average pain severity level was 5.5 (range 0-10). Patients reported high annual health care use and numerous work limitations related to FM. Patients were taking 182 unique types of medications prescribed for FM, including duloxetine (26.8%), nonsteroidal anti-inflammatory drugs (26.6%), pregabalin (24.5%), opioids (24.2%), tramadol (15.3%), benzodiazepines (15.2%), cyclobenzaprine (12.9%), milnacipran (8.9%), and others. Most patients took more than one medication concurrently (77.8%). Type of current medications used was most strongly associated with medication history and physician specialty.

CONCLUSIONS

  Burden of illness was high for patients with FM, and treatment patterns were highly variable. Importantly, the treatments with the most evidence to support their use were not always the most frequently chosen.