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The 0 to 10 numeric rating scale (NRS) of pain intensity is a standard outcome in randomized controlled trials (RCTs) of pain treatments. For individuals taking analgesics, there may be a disparity between “observed” pain intensity (the NRS, irrespective of concurrent analgesic use), and “underlying” pain intensity (what the NRS would be had concurrent analgesics not been taken). Using a contemporary causal inference framework, we compare analytic methods that can potentially account for concurrent analgesic use, first in statistical simulations, and second in analyses of real (non-simulated) data from an RCT of lumbar epidural steroid injections (LESI). The default analytic method was ignoring analgesic use, which is the most common approach in pain RCTs. Compared to ignoring analgesic use and other analytic methods, simulations showed that a quantitative pain and analgesia composite outcome based on adding 1.5 points to observed pain intensity for those who were taking an analgesic (the QPAC1.5) optimized power and minimized bias. Analyses of real RCT data supported the results of the simulations, showing greater power with analysis of the QPAC1.5 as compared to ignoring analgesic use and most other methods examined. We propose alternative methods that should be considered in the analysis of pain RCTs.

Though it is well documented that antidepressants are associated with an increased risk of falls in older adults at the drug class level, the comparative risk between individual antidepressants for fall injury in older adults with depression is unknown. Currently, clinicians are making decisions at the drug class level without consideration of the potential that there could be safer choices within classes. We compared the risk of fall injury among initiators of bupropion, duloxetine, fluoxetine, paroxetine, and venlafaxine to those of (es)citalopram and, separately, sertraline. We performed a retrospective cohort study using the MarketScan® Medicare Supplemental claims from 2007 to 2019. Individuals had incident depression (washout in previous continually enrolled year) with a first antidepressant claim up to three months after depression diagnosis. Individuals were followed for the first three months of antidepressant use until the first occurrence of fall injury, change/discontinuation of antidepressant, discontinued insurance coverage, or end of study. Propensity score inverse probability of treatment-weighted Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals for each antidepressant comparison and fall injury. We identified 114,505 individuals (mean age 76.6 years, 68% female, 97% without prior fall). A higher risk of fall injury was associated with initiating bupropion (HR 1.20 to 1.61), duloxetine (HR 1.27 to 1.36), paroxetine (HR 1.14 to 1.22), and venlafaxine (HR 1.22 to 1.34) when compared to (es)citalopram or sertraline. New use of duloxetine, bupropion, paroxetine, and venlafaxine was associated with a higher risk of fall injury compared to (es)citalopram and sertraline.

Background Home spirometry with regular symptom assessment is one strategy to track lung health to intervene early in episodes of pulmonary exacerbations (PE). In a multi-center randomized controlled trial home spirometry and symptom tracking demonstrated no significant differences regarding the primary clinical endpoint, FEV1, compared to usual care, but did identify differences in healthcare utilization. We used data from the Early Intervention in Cystic Fibrosis Exacerbation (eICE) study to evaluate whether home monitoring of PE is a cost-minimizing intervention in the context of this randomized trial. Methods We reviewed healthcare resource utilization of all 267 eICE participants, including outpatient visits, antibiotics and hospitalizations. Prices were identified in the IBM/Watson MarketScanⓇ Commercial Claims and Encounters Databases and averaged over the 2014-2017 period. Using total healthcare utilization costs, we generated summary statistics by intervention and protocol arm (total cost, mean cost, standard deviation). We performed Welch Two Sample t-tests to determine if total costs and cost by type of utilization differed significantly between groups. Results Outpatient visit costs were significantly higher by 13% in the Early Intervention (EI) than in the usual care (UC) arm ($3,345 vs. $2,966). We found no significant differences in outpatient antibiotic, hospitalization, or total health care costs between the arms. Conclusions Within the context of the eICE trial, outpatient visits were significantly higher in those with experimental home spirometry care, but that did not translate into statistically significant differences of overall health care costs between the two arms.

Background Identification of novel risk factors for dementia in older adults could facilitate development of methods to identify patients most at risk and improve their cognitive outcomes. We aimed to determine whether lower appendicular lean mass (ALM), assessed by dual-energy x-ray absorptiometry (DXA), and lower grip strength are associated with a greater likelihood of incident dementia among older adults in the Health Aging and Body Composition Study (Health ABC). Methods Health ABC data from 1997 to 2008 were analyzed (n = 2 704). Baseline ALM to body mass index (BMI) ratio (ALMBMI) was assessed by DXA. Baseline grip strength was assessed by hand-held dynamometry. Incident dementia diagnosis was defined as either (i) dementia-related hospitalization plus a Modified Mini-Mental State Examination (3MS) score of ≤ 90; or (ii) record of prescription for anti-dementia medication; or (iii) decline of at least 1.5 SDs on the 3MS score compared to baseline. Cox proportional hazard models estimated associations of ALMBMI and grip strength with incident dementia over follow-up with and without adjusting for covariates, stratified by sex. Results Among older men, each standard deviation decrement in ALMBMI (adjusted hazard ratio [aHR]: 1.33; 95% confidence interval [CI]: 1.07, 1.65) or grip strength (aHR 1.22; 95% CI: 1.06, 1.41) was associated with increased likelihood of incident dementia. Conclusions Lower ALMBMI and grip strength may be important risk factors for the development of dementia among older men. How these factors may belong to a causal pathway of dementia must be elucidated in future work.

Background Many coronavirus disease 2019 (COVID‐19) survivors experience persistent symptoms, such as fatigue, dyspnea, and musculoskeletal pain. However, less is known about the impact of COVID‐19 on longer term functional outcomes. Objective To evaluate patient‐reported activity of daily living (ADL) function and fatigue symptoms 30 days after hospitalization for COVID‐19. Design Cross‐sectional study. Setting Tertiary care university hospital. Participants Adults 18 years or older hospitalized for COVID‐19 and survived to 30 days after discharge. Methods A standardized telephone questionnaire was administered 30 days after hospital discharge. Main Outcome Measures Ability to perform basic and instrumental ADLs and fatigue symptoms severity (Patient‐Reported Outcome Measurement Information System [PROMIS] Fatigue Short Form 7a) were assessed by self‐report. Results Participants (n = 55) were 22‐95 years old. Compared to pre‐COVID hospitalization, 52% developed new difficulty and 6% new dependence with performing basic ADLs (bADLs), 48% developed new difficulty and 11% new dependence with instrumental ADLs (iADLs), and 69% experienced a clinically significant worsening in their fatigue symptom severity. The average fatigue symptom severity T‐score before hospitalization was 44.2 ± 7.4 and after hospitalization was 54.5 ± 9.8. In exploratory multivariate analyses, each additional COVID symptom at presentation was associated with a predicted increase of 1.43 units (95% confidence interval [CI], 0.45–2.42) in the 30‐day fatigue symptom severity T‐score, each additional day of hospitalization was associated with an 1.2 times increased odds of worsening fatigue (95% CI, 0.98–1.5; p = .08), and each unit increase in baseline body mass index was associated with 0.8 times decreased odds of new bADL or iADL dependence at 30 days (95% CI, 0.65–0.99). Conclusions New functional impairments are common at 30 days after discharge among survivors of hospitalization for COVID‐19. Early rehabilitation, advance care planning, and referrals to appropriate therapies should be considered in postacute COVID‐19 care to maximize patients' functional outcomes. However, ongoing research is still needed regarding management of these patients.

Background Modifying physician behavior to more closely align with guideline-based care can be challenging. Few effective strategies resulting in appropriate spine-related health care have been reported. The Lumbar Imaging With Reporting of Epidemiology (LIRE) intervention did not result in reductions in spine care but did in opioid prescriptions written. Objectives To estimate organizational resource needs and costs associated with implementing a pragmatic, decision support-type intervention that inserted age- and modality-matched prevalence information for common lumbar spine imaging findings, using site-based resource use data from the LIRE trial. Research design Time and cost estimation associated with implementing the LIRE intervention in a health organization. Subjects Providers and patients assessed in the LIRE trial. Measures Expected personnel costs required to implement the LIRE intervention. Results Annual salaries were converted to daily average per person costs, ranging from $400 to $2,200 per day (base case) for personnel (range: $300-$2,600). Estimated total average cost for implementing LIRE was $5,009 (range: $2,651-$12,020), including conducting pilot testing with providers. Costs associated with a small amount of time for a radiologist (6-12 hours) and imaging-ordering providers (1-8 hours each) account for approximately 75% of the estimated total cost. Conclusions The process of implementing an intervention for lumbar spine imaging reports containing age- and modality-appropriate epidemiological benchmarks for common imaging findings required radiologists, imaging-ordering providers, information technology specialists, and limited testing and monitoring. The LIRE intervention seems to be a relatively low-cost, evidence-based, complementary tool that can be easily integrated into the reporting of spine imaging.

Background: To describe characteristics of patients, providers, and clinics associated with opioid or non-opioid pain medication prescribing patterns for patients who received lower spine imaging in primary care clinics. Methods: In these secondary analyses of the Lumbar Imaging with Reporting of Epidemiology (LIRE) study, a randomized controlled trial conducted in 4 health systems in the United States, we evaluated characteristics associated with receipt of pain medication prescriptions. The outcomes were receipt of prescriptions for opioid or, separately, non-opioid pain medications within 90 days after imaging. Among patients who received opioid or non-opioid prescriptions, we evaluated receipt of multiple prescriptions in the year following imaging. Mixed models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: Compared with whites, patients identified as Asian (OR, 0.53; 95% CI, 0.51–0.56), Native Hawaiian/Pacific Islander (OR, 0.73; 95% CI, 0.64–0.83), multiracial (OR, 0.84; 95% CI, 0.71–0.98) or Black (OR, 0.92; 95% CI, 0.89–0.96) had significantly reduced odds for receiving prescriptions for opioids within 90 days. Patients identified as Native American/Alaska Native had greater odds for receiving prescriptions for non-opioid pain medications within 90 days (OR, 1.12; 95% CI, 1.01–1.24). Receipt of pain prescriptions 120 days before imaging was strongly predictive of subsequent receipt of pain prescriptions across all categories. Conclusions: After adjusting for factors that could affect prescribing, the strongest differences observed in pain-medication prescribing were across racial categories and for patients with previous pain prescriptions. Further research is needed to understand these differences and to optimize prescribing.

BACKGROUND CONTEXT: Osteoporotic vertebral fractures (OVFs) can lead to severe pain and reduced function and quality-of-life, but the strength of evidence for treatments remains low, particularly in younger populations. PURPOSE: To determine whether patients with OVFs who received kyphoplasty had different patterns of healthcare utilization compared to propensity-matched patients who did not receive vertebral augmentation. DESIGN: Observational cohort study. PATIENT SAMPLE: We identified patients with OVFs from 2007-2018 in the IBM® MarketScan® Commercial Claims and Encounters Databases who received kyphoplasty and compared them to propensity-matched controls who did not receive vertebral augmentation (either kyphoplasty or vertebroplasty). OUTCOME MEASURES: Major medical complications within 30 days, fills of opioids from 1-week through 1-month post-augmentation, and spine-related gross covered payments from 3-days post-kyphoplasty through 1-year post-OVF. METHODS: We used logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (95% CIs) to compare binary outcomes and median analysis to compare continuous outcomes. RESULTS: Of the 15,197 OVF patients identified, 1969 (13%) received kyphoplasty and 1928 (98%) of these were propensity matched to non-augmented controls. We did not observe differences in the odds of major medical complications within 30 days (adjusted OR (95% CI): 1.0 (0.6, 1.8)) but patients who received kyphoplasty were more likely to have filled opioid medications within 30 days (adjusted OR (95% CI): 1.3 (1.1, 1.5)) and had greater spine-related gross covered payments (kyphoplasty median (95% CI): $1340 ($240, $4850); non-augmented: $7870 ($7480, $8270); adjusted difference in medians (95% CI): $260 ($190, $2050)). CONCLUSIONS: In this cohort of patients

Objective To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. Design Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. Setting Primary care clinics within four integrated health care systems in the United States. Subjects 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. Methods Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the “LIRE intervention”). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). Results The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93–1.09; P = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91–1.07; P = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. Conclusions Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging.

There is limited research on the long-term effectiveness of epidural steroid injections (ESI) in older adults despite the high prevalence of back and leg pain in this age group. We tested the hypotheses that older adults undergoing ESI, compared to patients not receiving ESI: (1) have worse pain, disability and quality of life ('outcomes') pre-ESI, (2) have improved outcomes after ESI and (3) have improved outcomes due to a specific ESI effect.We prospectively studied patients ≥65 years old presenting to primary care with new episodes of back pain in three US healthcare systems (BOLD registry). Outcomes were leg and back pain intensity, disability and quality of life, assessed at baseline and 3-, 6-, 12- and 24-month follow-ups. We categorized participants as: (1) ESI within 6 months from the index visit (n = 295); (2) no ESI within 6 months (n = 4809); (3) no ESI within 6 months, propensity-score matched to group 1 (n = 483). We analysed the data using linear regression and Generalized Estimating Equations.Pain intensity, disability and quality of life at baseline were significantly worse at baseline in ESI patients (group 1) than in group 2. The improvement from baseline to 24 months in all outcomes was statistically significant for group 1. However, no statistically significant differences were observed between outcome trajectories for the propensity-score matched groups 1 and 3.Older adults treated with ESI have long-term improvement. However, the improvement is unlikely the result of a specific ESI effect.In this large, two-year, prospective study in older adults with a new episode of low back pain, back pain, leg pain, disability and quality of life improved after epidural steroid injections; however, propensity-score matching revealed that the improvement was unlikely the result of a specific effect of the injections, indicating that epidural steroids are unlikely to provide long-term benefits in older adults with new episodes of back and leg pain.

There are an increasing number of individuals with long-term symptoms of coronavirus-19 disease (COVID-19); however, the prognosis for recovery of physical function and fatigue after COVID-19 is uncertain.To report the changes in functional recovery between 1 and 6 months after hospitalization of adults hospitalized for COVID-19 and explore the baseline factors associated with physical function recovery.A prospective cohort study.Tertiary care hospital.U.S. adult COVID-19 survivors.N/A.Telephone interviews assessed three outcome domains: basic and instrumental activities of daily living (ADLs) performance, fatigue, and general physical function (Health Assessment Questionnaire [HAQ]).The age of participants (n = 92) ranged from 22 to 95 years (54.3 ± 17.2). Across outcome domains, a majority (63%-67%) of participants developed new ADL impairment, fatigue, or worsening HAQ severity by 1 month. Of those, 50%-79% partially or fully recovered by 6 months, but 21%-50% did not recover at least partially. Fifteen to 30% developed new impairment between 1 and 6 months. For those without any improvement in ADL impairments at 6 months, lower socioeconomic status was significantly more common (p = .01) and age ≥ 65 (p = .06), trending toward being more common.In this cohort, a substantial proportion of the participants who developed new ADL impairment, worsening fatigue, or HAQ severity after hospitalization for COVID-19 did not recover at least partially by 6 months after discharge. Evaluating functional status 1 month after discharge may be important in understanding functional prognosis and recovery after hospitalization for COVID-19.

BACKGROUND: The purpose of these analyses was to determine whether overall costs were reduced in cystic fibrosis (CF) patients experiencing pulmonary exacerbation (PEx) who received shorter versus longer durations of treatment. METHODS: Among people with CF experiencing PEx, we calculated 30-day inpatient, outpatient, emergency room, and medication costs and summed these to derive total costs in 2020 USD. Using the Kaplan-Meier sample average (KMSA) method, we calculated adjusted costs and differences in costs within two pairs of randomized groups: early robust responders (ERR) randomized to receive treatment for 10 days (ERR-10 days) or 14 days (ERR-14 days), and non-early robust responders (NERR) randomized to receive treatment for 14 days (NERR-14 days) or 21 days (NERR-21 days). RESULTS: Patients in the shorter treatment duration groups had shorter lengths of stay per hospitalization (mean ± standard deviation (SD) for ERR-10 days: 7.9 ± 3.0 days per hospitalization compared to 10.1 ± 4.2 days in ERR-14 days; for NERR-14 days: 8.7 ± 4.9 days per hospitalization compared to 9.6 ± 6.5 days in NERR-21 days). We found statistically significantly lower adjusted mean costs (95% confidence interval) among those who were randomized to receive shorter treatment durations (ERR-10 days: $60,800 ($59,150 – $62,430) vs $74,420 ($72,610 – $76,450) in ERR-14 days; NERR-14 days: $66,690 ($65,960–$67,400) versus $74,830 ($73,980–$75,650) in NERR-21 days). CONCLUSIONS: Tied with earlier evidence that shorter treatment duration was not associated with worse clinical outcomes, our analyses indicate that treating with shorter antimicrobial durations can reduce costs without diminishing clinical outcomes.

OBJECTIVE: While the effectiveness of medial branch nerve radiofrequency ablation (RFA) for lumbosacral facet pain has been described, little is known regarding patterns of repeat RFA utilization and prescription opioid use afterwards. DESIGN: Retrospective cohort analysis. SUBJECTS: Patients undergoing lumbosacral RFA in MarketScan from 2007 – 2016. METHODS: The time until and number of staged RFAs (

Laura S Gold,1,2 Tara A Nazareth,3 Tzy-Chyi Yu,3 Keith R Fry,3 Nancy Ho Mahler,3 Andrew Rava,3 Royce W Waltrip II,3 Ryan N Hansen2,4 1Department of Radiology, University of Washington, Seattle, WA, USA; 2CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA; 3Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA; 4Department of Health Services, University of Washington, Seattle, WA, USACorrespondence: Laura S GoldDepartment of Radiology, University of Washington, Box 359558, Seattle, WA 98195-9558, USATel +1 206-543-2749Fax +1 206-543-8609Email goldl@uw.eduIntroduction: Infantile spasms (IS) is a rare and devastating form of early childhood epilepsy. Two drugs are approved in the United States for treatment of IS, H.P. Acthar® Gel (repository corticotropin injection, RCI) and Sabril® (vigabatrin). Given real-world variation in treatment of patients with IS, this study characterized treatment patterns with IS medications and determined all-cause health care resource utilization (HCRU) during the 90 days before initiating therapy with RCI in patients with IS.Materials and methods: Truven Health MarketScan® Research Databases were used to identify commercially insured US patients 1 drug class before RCI initiation. Other AEDs were dispensed most often, either alone (31.3%) or with other drug classes (9.3%). Mean HCRU included 11.8 all-cause outpatient visits and 4.5 medications dispensed. Patients who received RCI or corticosteroids as their initial IS treatment had the lowest and second-lowest HCRU.Conclusion: In the 90 days before initiating RCI, patients with IS received multiple diagnoses and treatments, characterized by frequent HCRU. Use of RCI first (no prior IS medications) and AEDs first were associated with the lowest and highest HCRU, respectively, across all categories (all-cause outpatient visits, emergency department visits, hospital admissions, prescription medications).Keywords: Infantile spasms, early diagnosis, early treatment, health care resource utilization, medication patterns

Conventional "1-variable-at-a-time" analyses to identify treatment effect modifiers are often underpowered and prone to false-positive results. This study used a "risk-modeling" approach guided by the Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement framework: (1) developing and validating a multivariable model to estimate predicted future back-related functional limitations as measured by the Roland-Morris Disability Questionnaire (RMDQ) and (2) stratifying patients from a randomized controlled trial (RCT) of lumbar epidural steroid injections (LESIs) for the treatment of lumbar spinal stenosis into subgroups with different individualized treatment effects on RMDQ scores at the 3-week follow-up. Model development and validation were conducted in a cohort (n = 3259) randomly split into training and testing sets in a 4:1 ratio. The model was developed in the testing set using linear regression with least absolute shrinkage and selection regularization and 5-fold cross-validation. The model was then applied in the testing set and subsequently in patients receiving the control treatment in the RCT of LESI. R2 values in the training set, testing set, and RCT were 0.38, 0.32, and 0.34, respectively. There was statistically significant modification ( P = 0.03) of the LESI treatment effect according to predicted risk quartile, with clinically relevant LESI treatment effect point estimates in the 2 quartiles with greatest predicted risk (-3.7 and -3.3 RMDQ points) and no effect in the lowest 2 quartiles. A multivariable risk-modeling approach identified subgroups of patients with lumbar spinal stenosis with a clinically relevant treatment effect of LESI on back-related functional limitations.

Background Half of all physical disability, including activity of daily living (ADL) disability, among older adults occurs in the setting of hospitalization. This study examines whether appendicular lean mass (ALM) and grip strength, which are commonly included in various definitions of sarcopenia, are associated with the development of hospital-associated ADL disability in older adults in the Health ABC Study. Methods Individuals hospitalized during the first 5 years of follow-up (n = 1 724) were analyzed. ALM to body mass index (BMI) ratio (ALMBMI), by dual-energy x-ray absorptiometry (DXA), and grip strength, by hand-held dynamometery, were assessed annually. Development of new ADL disability was assessed at the time of the next annual assessment after hospitalization. Separate regression analyses modeled the association of prehospitalization ALMBMI or grip strength with death before the next scheduled annual assessment. Next, among those who survived to the next annual assessment, separate regression analyses modeled the association of ALMBMI or grip strength with development of ADL disability. Results Each standard deviation decrement in prehospitalization grip strength was associated with an adjusted 1.80 odds of new ADL disability at follow-up (95% CI: 1.18, 2.74). Low, compared with not low, grip strength (per FNIH definition) was associated with an adjusted 2.36 odds of ADL disability at follow-up (95% CI: 1.12, 4.97). ALM measures were not associated with the development of hospital-associated ADL disability. ALM and grip strength measures were not associated with death. Conclusions Prehospitalization lower grip strength may be an important risk factor for ADL disability among older adult survivors of hospitalization.

Older adults with cognitive impairment, including those with Alzheimer's disease and related dementias, are particularly at risk for hospitalization and hospital-associated disability. Understanding of key risk factors for hospital-associated disability is limited. Sarcopenia, age-related declines in muscle mass and strength, is common in older adults with cognitive impairment and may be an important risk factor for hospital-associated disability.Using data from the Health ABC Study, we examined associations of pre-hospitalization appendicular lean mass (ALM) and grip strength with the development of a new activity of daily living (ADL) disability at the next annual assessment after hospitalization.Grip strength, but not ALM, was negatively associated with increased risk of hospital-associated ADL disability, and this association was greater among those with cognitive impairment compared to those without.Lower grip strength may be an important risk factor for hospital-associated ADL disability in older adults, particularly those with cognitive impairment.

BACKGROUND: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) patients reduce quality of life. Lung function, measured by the percent predicted forced expiratory volume in one second (ppFEV1), is widely used to evaluate PEx treatments. We analyzed the correspondence of ppFEV1 with 8 patient-reported symptom-based questions from the Cystic Fibrosis Respiratory Symptom Diary–Chronic Respiratory Infection Symptom Score (CFRSD-CRISS). METHODS: Data were derived from the observational Standardized Treatment of Pulmonary Exacerbations (STOP) study. CF patients who had CFRSD-CRISS and ppFEV1 measurements on ≥2 timepoints were included: 1) day of initial PEx, 2) 7 days later, and/or 3) end of PEx. We calculated age-stratified Spearman correlation coefficients and 95% confidence intervals (95% CIs) between the change in ppFEV1 and change in CFRSD-CRISS items from index to day 7 and from index to the end of PEx treatment. RESULTS: Lung function and symptom scores improved by the end of treatment; however, correlations between ppFEV1 and the specific CFRSD-CRISS measures were mostly weak to moderate. An exception was that among patients

BACKGROUND: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) patients decrease lung function, increase symptoms and reduce health-related quality of life (HRQoL). We evaluated associations between 8 symptom-based questions from the Cystic Fibrosis Respiratory Symptom Diary - Chronic Respiratory Infection Symptom Score (CFRSD-CRISS) and the 5-level EuroQOL-5 Dimensions (EQ-5D-5L) summary score and hypothesized the CFRSD-CRISS would be a meaningful way to asses quality-of-life in future cost effectiveness studies among CF patients with PEx. METHODS: CF patients who had CFRSD-CRISS and EQ-5D-5L measurements on the day of the initial PEx, 7 days later, and at the end of intravenous antibiotic treatment were included. We examined age-stratified (

Introduction: As of December 19th 2020, Coronavirus Disease 2019 (COVID-19) has resulted in approximately 17.6 million cases and 315,000 deaths in the United States. The hospitalization rate for COVID-19 in the US continues to rise and is currently around 295.8 hospitalizations per 100,000 population. Despite the increasing number of individuals who are contracting and recovering from this disease, little is known about their functional recovery. Understanding functional outcomes in these patients is critical to address their rehabilitation needs. The purpose of this study is to characterize the 30-day patient-reported functional outcomes of older and younger adults following acute hospitalization for COVID-19. Methods: A single-center prospective cohort study was performed from April to October 2020 of adult survivors of hospitalization for COVID-19 (n=28). A standardized telephone questionnaire was administered 30-days after hospital discharge to participants addressing their ability to perform basic activities of daily living (ADLs), instrumental ADLs, mobility, fatigue symptoms (Patient-Reported Outcomes Measurement Information Systems-PROMIS) and general disability (Health Assessment Questionnaire Disability Index - HAQ-DI). Results: Participants' were 23-95 years old. Twenty-one (75%) were less than 65 years old. Fifteen (54%) were female and 19 (68%) were white. Mean hospital length of stay was 11.3 days and 10 (36%) participants required ICU admission. Among adults aged 65 years developed new impairments and 29% new dependence. The most common new impairments in both age groups were transferring for basic ADLs and preparing meals and grocery shopping for instrumental ADLs. Seventy-one percent of older and 76% of younger adults experienced a decline in at least one mobility task (getting up from a chair, walking up 10 stairs, or walking mile). Seventy-six percent of younger adults and 43% of older adults experienced a clinically significant worsening (> 5 points) in their PROMIS fatigue scores. Sixty-two percent of younger adults and 43% of older adults experienced a clinically significant worsening (> 0.22 points) in their HAQ-DI scores. Conclusions: Among adults hospitalized with COVID-19, the majority experienced a decline in ≥1 functional task 30 days after discharge compared to pre-hospitalization. Younger adults had similar to worse impairment in physical functional outcomes than older adults. These results indicate all adults, regardless of age, are at risk for prolonged, clinically significant functional impairment following hospitalization for COVID-19.

Author(s): Andrews, James S; Gold, Laura S; Nevitt, Michael; Heagerty, Patrick J; Cawthon, Peggy M | Abstract: ObjectiveThe association of sarcopenia with development of knee osteoarthritis (OA) or knee pain in older adults is uncertain. We examined the relationship of grip strength and appendicular lean mass (ALM) with the likelihood of developing knee OA and knee pain in older adults in the Health ABC (Health, Aging, and Body Composition) Study.MethodsALM and grip strength were assessed at baseline by dual-energy x-ray absorptiometry and handheld dynamometry, respectively. Incident clinically diagnosed, symptomatic knee OA, defined as new participant report of physician-diagnosed knee OA and concurrent frequent knee pain, and incident frequent knee pain over 5 years of follow-up were examined. Separate regression analyses, stratified by sex, modeled associations of baseline ALM and grip strength with the likelihood of incident clinically diagnosed, symptomatic knee OA and incident knee pain over follow-up, adjusting for covariates.ResultsAmong the 2779 subjects without OA at baseline, 95 men (6.9%) and 158 women (11.3%) developed clinically diagnosed, symptomatic knee OA, and, among the 2182 subjects without knee pain at baseline, 315 men (28.3%) and 385 women (36.1%) developed knee pain over follow-up. Among men only, each SD decrement of ALM was associated with decreasing likelihood of incident knee OA (odds ratio [OR] per SD decrement: 0.68; 95% confidence interval [CI]: 0.47-0.97), and each SD decrement of grip strength was associated with increasing likelihood of incident knee pain (OR per SD decrement: 1.20; 95% CI: 1.01-1.42).ConclusionIn older men, ALM and grip strength may be associated with the development of knee OA and knee pain, respectively.

Key Points Question What is the impact of including benchmark prevalence data of common findings in reports of spinal imaging ordered by primary care clinicians? Findings In this randomized clinical trial that included 250 401 adults, no overall decrease in subsequent spine-related health care utilization after the intervention was observed. However, there was a significant decrease in opioid prescriptions at 1 year in the intervention group compared with the control group. Meaning The findings of this study suggest that including epidemiological benchmarks on spinal imaging reports has little impact on subsequent spine-related utilization overall but may reduce subsequent opioid prescriptions., This randomized clinical trial evaluates the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions., Importance Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions. Objective To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions. Design, Setting, and Participants This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019. Interventions Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group). Main Outcomes and Measures Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality. Results We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, −0.7%; 95% CI, −2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, −29.3%; 95% CI, −42.1% to −13.5%; magnetic resonance imaging: difference, −3.4%; 95% CI, −8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04). Conclusions and Relevance In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented. Trial Registration ClinicalTrials.gov Identifier: NCT02015455

BACKGROUND: Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing. OBJECTIVE: To evaluate the effect of epidemiologic information in spine imaging reports on non-opioid pain medication prescribing for primary care patients with back pain. DESIGN: Post hoc analysis of the Lumbar Imaging with Reporting of Epidemiology cluster-randomized trial. PARTICIPANTS: A total of 170,680 patients aged ≥ 18 years from four healthcare systems who received thoracolumbar, lumbar, or lumbosacral spine imaging from 2013 to 2016 and had not received a prescription for non-opioid pain medication in the preceding 120 days. INTERVENTION: Text of age- and modality-specific epidemiologic benchmarks indicating the prevalence of common findings in people without back pain inserted into thoracolumbar, lumbar, or lumbosacral spine imaging reports at intervention clinics. MAIN MEASURES: Primary outcomes: any non-opioid prescription within 90 days after index imaging, overall, and by sub-class (skeletal muscle relaxants, NSAIDs, gabapentinoids, tricyclic antidepressants, benzodiazepines, duloxetine). Secondary outcomes: count of non-opioid prescriptions within 90 days, overall, and by sub-class. KEY RESULTS: The intervention was not associated with the likelihood of patients receiving at least one prescription for new non-opioid pain-related medications, overall (adjusted OR, 1.02; 95% CI, 0.97–1.08) or by sub-class. The intervention was not associated with the number of prescriptions for any non-opioid medication (adjusted incidence rate ratio [IRR], 1.02; 95% CI, 0.99–1.04). However, the intervention was associated with more new prescriptions for NSAIDs (IRR, 1.12) and tricyclic antidepressants (IRR, 1.11). CONCLUSIONS: Inserting epidemiologic text in spine imaging reports had no effect on whether new non-opioid pain-related medications were prescribed but was associated with the number of new prescriptions for certain non-opioid sub-classes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02015455 SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06627-6.

Clinical, demographic, and service use patterns of youths ages 6-18 years who had a medically treated self-injury were examined to understand factors associated with recurrence of such an injury in the subsequent year.This retrospective cohort analysis used data from 31,147 youths who were medically treated for self-injury. Data were from IBM/Watson MarketScan commercial claims and encounters databases (2007-2016). The index self-injury was defined as the first event with anApproximately 2% of the 31,147 youths had another medically treated self-injury in the year following the index self-injury. The hospitalized group had higher service use in the years prior to and following their self-injury, but the mean number of outpatient psychiatric visits before the index self-injury did not differ significantly between groups. Hazard ratios for clinical, demographic, and service use variables indicated that those who were hospitalized in psychiatric facilities for the index event were twice as likely (95% CI=1.7-2.7) as those who were not to have another medically treated self-injury in the year after the index event.In this retrospective, observational study, psychiatric hospitalization after self-injury was strongly associated with recurrence of self-injury in the subsequent year.

Background Context Although back pain is common among older adults, there is relatively little research on the course of back pain in this age group. Purpose Our primary goals were to report 2-year outcomes of older adults initiating primary care for back pain and to examine the relative importance of patient factors versus medical interventions in predicting 2-year disability and pain. Study Design/Setting This study used a predictive model using data from a prospective, observational cohort from a primary care setting. Patient Sample The study included patients aged ≥65 years at the time of new primary care visits for back pain. Outcome Measures Self-reported 2-year disability (Roland-Morris Disability Questionnaire [RDQ]) and back pain (0–10 numerical rating scale [NRS]). Methods We developed our models using a machine learning least absolute shrinkage and selection operator approach. We evaluated the predictive value of baseline characteristics and the incremental value of interventions that occurred between 0 and 90 days, and the change in patient disability and pain from 0 to 90 days. Limitations included confounding by indication and unmeasured confounding. Results Of 4,665 patients (89%) with follow-up, both RDQ (from mean 9.6 [95% confidence interval {CI} 9.4–9.7] to mean 8.3 [95% CI 8.0–8.5]) and back pain NRS (from mean 5.0 [95% CI 4.9–5.1] to mean 3.5 [95% CI 3.4–3.6]) scores improved slightly. Only 16% (15%-18%) reported no back pain-related disability or back pain at 2 years after initial visits. Regression model parameters explained 40% of the variation (R2) in 2-year RDQ scores, and the addition of 0- to 3-month change in RDQ score and pain improved prediction (R2=51%). The most consistent predictors of 2-year RDQ scores and back pain NRS scores were 0- to 90-day change in each respective outcome and patient confidence in improvement. Patients experienced 50% and 43% improvement in back pain and disability, respectively, 2 years after their initial visit. However, fewer than 20% of patients had complete resolution of their back pain and disability at that time. Conclusions Baseline patient factors were more important than early interventions in explaining disability and pain after 2 years.

The purpose of this study was to compare the clinical effectiveness of embolization with that of sorafenib in the management of hepatocellular carcinoma as practiced in real-world settings.This population-based observational study was conducted with the Surveillance, Epidemiology, and End Results-Medicare linked database. Patients 65 years old and older with a diagnosis of primary liver cancer between 2007 and 2011 who underwent embolization or sorafenib treatment were identified. Patients were excluded if they had insufficient claims records, a diagnosis of intrahepatic cholangiocarcinoma, or other primary cancer or had undergone liver transplant or combination therapy. The primary outcome of interest was overall survival. Inverse probability of treatment weighting models were used to control for selection bias.The inclusion and exclusion criteria were met by 1017 patients. Models showed good balance between treatment groups. Compared with those who underwent embolization, patients treated with sorafenib had significantly higher hazard of earlier death from time of treatment (hazard ratio, 1.87; 95% CI, 1.46-2.37; p0.0001) and from time of cancer diagnosis (hazard ratio, 1.87; 95% CI, 1.46-2.39; p0.0001). The survival advantage after embolization was seen in both intermediate- and advanced-stage disease.This comparative effectiveness study of Medicare patients with hepatocellular carcinoma showed significantly longer overall survival after treatment with embolization than with sorafenib. Because these findings conflict with expert opinion-based guidelines for treatment of advanced-stage disease, prospective randomized comparative trials in this subpopulation would be justified.

Introduction Multiple sclerosis (MS) is an autoimmune disorder with large annual costs. This study evaluated utilization and costs for the management of MS relapses with H.P. Acthar® Gel (repository corticotropin injection; Acthar; Mallinckrodt) compared to receipt of plasmapheresis (PMP) or intravenous immunoglobulin (IVIG) among patients with MS who experienced multiple relapses. Methods We identified patients with MS diagnoses who had relapses treated with intravenous methylprednisolone (IVMP), the first-line treatment for MS relapse. Patients who were treated for the subsequent relapses were eligible for the study. We analyzed 12- and 24-month healthcare utilization and costs among patients who received Acthar prescriptions compared to patients who were treated with PMP/IVIG using generalized linear and logistic regression models to calculate unadjusted and adjusted means and 95% confidence intervals. Results For the 12-month analysis, a total of 213 patients received Acthar prescriptions and 226 were treated with PMP or IVIG. Patients who received Acthar prescriptions were similar to those who received other treatments in terms of most demographic variables. Acthar recipients had fewer hospitalizations (0.2 vs. 0.4; P = 0.01) and received fewer outpatient services (29 vs. 43; P

Introduction The purpose of this study was to describe healthcare resource utilization and costs resulting from early (within 30 days of diagnosis) versus late (>30 days after diagnosis) treatment with prescriptions for H.P. Acthar® Gel (repository corticotropin injection; Acthar; Mallinckrodt) to manage infantile spasms (IS). Methods We included all patients in the Truven Health MarketScan® Commercial Claims and Encounters Database and the Truven Health MarketScan Multi-State Medicaid Database who were diagnosed with IS from 2007 to 2012. We performed unadjusted and adjusted regressions examining the relationship between healthcare resource utilization variables and their associated costs to compare outcomes in the early and late Acthar users. Results A total of 252 patients with IS who received Acthar fit our study criteria; 191 (76%) were early Acthar users. In adjusted analyses, we found that early Acthar use was associated with, on average, 3.8 fewer outpatient services (99% CI 0.7–6.7 fewer services). We did not find significant associations between early prescriptions for Acthar and number of hospitalizations, emergency room visits, prescription medications filled, or total costs of health services. Conclusion Patients prescribed Acthar within 30 days of their IS diagnoses tended to have fewer outpatient services performed compared to patients prescribed Acthar later in the disease process. Although additional research is needed to confirm these exploratory findings, physicians may consider early treatment with Acthar to manage IS. Funding This study was funded by a grant to the University of Washington from Mallinckrodt Pharmaceuticals. Electronic supplementary material The online version of this article (doi:10.1007/s12325-016-0361-2) contains supplementary material, which is available to authorized users.

Purpose To compare relative cost-effectiveness of serial large-volume paracentesis (LVP) and transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of refractory ascites. Materials and Methods A decisional Markov model was developed to estimate payer cost and quality-adjusted life-ears (QALYs) associated with LVP and TIPS treatment strategies for cirrhotic patients with refractory ascites. Survival estimates were derived from an individual patient-level meta-analysis of prospective randomized clinical trials. Health utilities for potential health states were derived from a prospective study of patients with cirrhosis. Cost data were derived from national representative claims databases (MarketScan and Medicare) and included reimbursement amounts for relevant procedures, hospitalizations, and outpatient pharmaceutical costs. One-way and probabilistic sensitivity analyses were performed. Results LVP resulted in 1.72 QALYs gained at a cost of $41,391, whereas TIPS resulted in 2.76 QALYs gained at a cost of $100,538. Incremental cost-effectiveness ratio of TIPS versus LVP was $57,003/QALY. At a willingness-to-pay ratio of $100,000/QALY, TIPS has a 62% probability of being acceptable compared with LVP. Conclusions This study suggests that TIPS should be considered cost-effective in a country that places a relatively high value on health improvements but less so in countries with lower levels of health care resources.

Objectives The objective of this study was to compare outcomes and health care utilization of older patients who did versus did not fill opioid prescriptions within 90 days of initiating care for low back pain. Materials and methods For patients ≥65 years with new back pain visits, we used propensity scores to match those who filled no opioid prescriptions to those who filled ≥2 opioid prescriptions within 90 days (and the first opioid prescription within 30 d) of the index visit. Over 24 months, we examined patient-reported outcomes, health care utilization, and subsequent opioid prescription fills. Results Among 1954 patients eligible for matching, 238 (12%) filled ≥2 opioid prescriptions within 90 days; 200 of these were matched to controls. Patients with versus without early opioid prescriptions had similar patient-reported outcomes but were more likely to have filled ≥1 opioid prescription 18 to 24 months after the index visit (odds ratio [95% confidence interval]=2.4 [1.5-3.9]) and to have had ≥1 visit to the emergency department in the subsequent 24 months (OR, 1.6; 95% confidence interval, 1.0-2.5). Discussion Among older patients with new back pain visits, filling ≥2 opioid prescriptions within 90 days of the visit was associated with similar back pain-related outcomes but increased likelihood of filling opioid prescriptions 18 to 24 months later compared with matched patients who did not fill early opioid prescriptions.

Diagnostic imaging is often the first step in evaluating patients with back pain and likely functions as a "gateway" to a subsequent cascade of interventions. However, lumbar spine imaging frequently reveals incidental findings among normal, pain-free individuals suggesting that treatment of these "abnormalities" may not be warranted. Our prior work suggested that inserting the prevalence of imaging findings in patients without back pain into spine imaging reports may reduce subsequent interventions. We are now conducting a pragmatic cluster randomized clinical trial to test the hypothesis that inserting this prevalence data into lumbar spine imaging reports for studies ordered by primary care providers will reduce subsequent spine-related interventions.We are using a stepped wedge design that sequentially randomizes 100 primary care clinics at four health systems to receive either standard lumbar spine imaging reports, or reports containing prevalence data for common imaging findings in patients without back pain. We capture all outcomes passively through the electronic medical record. Our primary outcome is spine-related intervention intensity based on Relative Value Units (RVUs) during the following year. Secondary outcomes include subsequent prescriptions for opioid analgesics and cross-sectional lumbar spine re-imaging.If our study shows that adding prevalence data to spine imaging reports decreases subsequent back-related RVUs, this intervention could be easily generalized and applied to other kinds of testing, as well as other conditions where incidental findings may be common. Our study also serves as a model for cluster randomized trials that are minimal risk and highly pragmatic.

Aim: Investigate how the results of predictive models of preoperative MRI for breast cancer change based on available data. Materials & methods: A total of 1919 insured women aged ≥18 with stage 0–III breast cancer diagnosed 2002–2009. Four models were compared using nested multivariable logistic, backwards stepwise regression; model fit was assessed via area under the curve (AUC), R 2 . Results: MRI recipients (n = 245) were more recently diagnosed, younger, less comorbid, with higher stage disease. Significant variables included: Model 1/Claims (AUC = 0.76, R 2 = 0.10): year, age, location, income; Model 2/Cancer Registry (AUC = 0.78, R 2 = 0.12): stage, breast density, imaging indication; Model 3/Medical Record (AUC = 0.80, R 2 = 0.13): radiologic recommendations; Model 4/Risk Factor Survey (AUC = 0.81, R 2 = 0.14): procedure count. Conclusion: Clinical variables accounted for little of the observed variability compared with claims data.

Objective: Few patients with asthma have disease that is wellcontrolled, particularly in Latin American countries. The purpose of this study was to investigate whether partly controlled and uncontrolled asthma are associated with increased costs for asthma-related medications and health care utilization compared with wellcontrolled asthma in five Latin American countries. Methods: Using the Global Initiative for Asthma guidelines, we classified respondents from the Latin American Asthma Insights and Management survey into those with well-controlled, partly controlled, and uncontrolled asthma and compared the utilization of health care services and costs among these groups. Results: Most respondents to our survey (93%) had asthma that was classified as partly controlled or uncontrolled. Across all countries, patients whose asthma was partly controlled or uncontrolled had greater use of asthmarelated medications and medical services than did patients whose asthma was well-controlled. After adjusting for age, sex, and country of residence, total costs for asthma-related medications and health care were greater in patients whose asthma was classified as partly controlled and uncontrolled. Conclusions: Our findings indicate that patients with asthma that are not well-controlled used more health care resources and had greater medical costs in Latin America.

Summary Background Data on the impact of asthma in many countries in the Asia-Pacific region is limited. This study investigated whether partly- and uncontrolled asthma were associated with increased medication use/healthcare utilization and productivity loss among a population of asthma patients from nine Asia-Pacific countries. Methods We used cross-sectional data from 3630 asthma patients ≥12 years from the 2011 Asia-Pacific Asthma Insights and Management (AP-AIM) survey. Using Global Initiative for Asthma (GINA) guidelines, patients were categorized as having well-controlled, partly- controlled, or uncontrolled asthma. Chi-square tests were used to assess the relation of degree of asthma control with utilization of asthma medications, health services, productivity, and mood. Results Overall, 7.6% of the patients surveyed had asthma that was well-controlled, with the highest proportions in Singapore (14%) and the lowest in India (0%) and China (2%). Patients whose asthma was not well-controlled reported greater use of asthma medications, more emergency healthcare visits or hospitalizations for their asthma, and more interference of their mood due to asthma. They also reported significant decreases in productivity due to asthma. Conclusions Patients who did not have well-controlled asthma had greater utilization rates of asthma medications and healthcare services and were more likely to report missing multiple days of work/school compared to patients whose asthma was well-controlled. These associations suggest that emphasis on improving asthma control could have dramatic effects on patient well-being and utilization of healthcare resources.

Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups.We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites.Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites.Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.

Rationale, aims and objectives To assess if co-morbidity is associated with higher use of back-related care and adherence to back pain guidelines. Methods We conducted a retrospective cohort study using administrative claims data from 2007-2011. We included individuals ≥18 years with an index visit for back pain. Co-morbidities were measured 12 months prior to index. Co-morbidity burden was measured using Quan's Co-morbidity Index. Co-morbidities categories were measured using chronic condition indicators from the Agency for Healthcare Research and Quality. Total lumbar spine-related resource use for three years was ascertained using procedure codes. A clustering algorithm identified higher long-term utilizer. We identified initial use from day 0-42 for several categories of spine-related care. We used logistic regression to test the association between co-morbidities and resource use. Results Greater co-morbidity burden was associated with higher long-term spine-related resource use. Those with ≥2 on Quan's Co-morbidity Index had 29% higher odds of being a high back-specific resource user compared to those with no co-morbidities [Odds Ratio (OR): 1.29, 95% Confidence Interval (CI): 1.23-1.35]. Greater co-morbidity burden was associated with more frequent initial use of imaging, emergency visits, injections, and opioid fills; and less frequent initial use of medical and physical therapy visits. Co-morbid musculoskeletal conditions had the strongest association with being a high utilizer of long-term back-specific resources (OR: 1.53, 95% CI: 1.50-1.57). Conclusions Co-morbidity burden and the presence of specific chronic conditions, such as musculoskeletal conditions, were associated with high long-term use of back-related care and care inconsistent with guidelines.

Objective.It is unknown whether advanced imaging (AI) is associated with higher quality breast cancer (BC) care.Materials and Methods.Claims and Surveillance Epidemiology and End Results data were linked for women diagnosed with incident stage I-III BC between 2002 and 2008 in western Washington State. We examined receipt of preoperative breast magnetic resonance imaging (MRI) or AI (defined as computed tomography [CT]/positron emission tomography [PET]/PET/CT) versus mammogram and/or ultrasound (M-US) alone and receipt of guideline concordant care (GCC) using multivariable logistic regression.Results.Of 5247 women, 67% received M-US, 23% MRI, 8% CT, and 3% PET/PET-CT. In 2002, 5% received MRI and 5% AI compared to 45% and 12%, respectively, in 2008. 79% received GCC, but GCC declined over time and was associated with younger age, urban residence, less comorbidity, shorter time from diagnosis to surgery, and earlier year of diagnosis. Breast MRI was associated with GCC for lumpectomy plus radiation therapy (RT) (OR 1.55, 95% CI 1.08–2.26, andp=0.02) and AI was associated with GCC for adjuvant chemotherapy for estrogen-receptor positive (ER+) BC (OR 1.74, 95% CI 1.17–2.59, andp=0.01).Conclusion.GCC was associated with prior receipt of breast MRI and AI for lumpectomy plus RT and adjuvant chemotherapy for ER+ BC, respectively.

Objective To examine if a comorbid diagnosis of knee or hip osteoarthritis (OA) in older adults with new back pain visits is associated with long-term patient-reported outcomes and back-related health care use. Design Prospective cohort study. Setting Three integrated health systems forming the Back pain Outcomes using Longitudinal Data cohort. Participants Participants (N=5155) were older adults (≥65y) with a new visit for back pain and a complete electronic health record data. Interventions Not applicable; we obtained OA diagnoses using diagnostic codes in the electronic health record 12 months prior to the new back pain visit. Main Outcome Measures The Roland-Morris Disability Questionnaire (RDQ) and the EuroQol-5D (EQ-5D) were key patient-reported outcomes. Health care use, measured by relative-value units (RVUs), was summed for the 12 months after the initial visit. We used linear mixed-effects models to model patient-reported outcomes. We also used generalized linear models to test the association between comorbid knee or hip OA and total back-related RVUs. Results Of the 5155 participants, 368 (7.1%) had a comorbid knee OA diagnosis, and 94 (1.8%) had a hip OA diagnosis. Of the participants, 4711 (91.4%) had neither knee nor hip OA. In adjusted models, the 12-month RDQ score was 1.23 points higher (95% confidence interval [CI], 0.72–1.74) for patients with knee OA and 1.26 points higher (95% CI, 0.24–2.27) for those with hip OA than those without knee or hip OA, respectively. A lower EQ-5D score was found among participants with knee OA (.02 lower; 95% CI, −.04 to −.01) and hip OA diagnoses (.03 lower; 95% CI, −.05 to −.01) compared with those without knee or hip OA, respectively. Comorbid knee or hip OA was not significantly associated with total 12-month back-related resource use. Conclusions Comorbid knee or hip OA in older adults with a new back pain visit was associated with modestly worse long-term disability and health-related quality of life.

In this article, we trace the chronology of developments in breast imaging technologies that are used for diagnosis and staging of breast cancer, including mammography, ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography. We explore factors that affected clinical acceptance and utilization of these technologies from discovery to clinical use, including milestones in peer-reviewed publication, US Food and Drug Administration approval, reimbursement by payers, and adoption into clinical guidelines. The factors driving utilization of new imaging technologies are mainly driven by regulatory approval and reimbursement by payers rather than evidence that they provide benefits to patients. Comparative effectiveness research can serve as a useful tool to investigate whether these imaging modalities provide information that improves patient outcomes in real-world settings.

Severe pain after joint replacement surgeries is common and is usually managed by opioid analgesics. We described joint replacement surgery patients who received prescriptions for long-acting opioids (LAOs) and compared their health care utilization and costs with postsurgical patients who did not receive LAO prescriptions.Patients undergoing hip, knee, or shoulder replacement surgery between January 1, 2008 and December 31, 2011were included in the study and were classified by their exposure to LAOs. We estimated multivariate models to compare the groups' health care utilization and costs in the first 7 days and in the 1, 3, 6, and 12 months after surgery.Of 118,816 patients who met our inclusion criteria, 15,094 (13%) received LAO prescriptions in 30 days following surgery. LAO recipients were slightly younger and more likely than nonrecipients to have taken antibiotics, antidepressants, benzodiazepines, antihypertensives, sedatives, muscle relaxants, and short-acting opioids in the 60 days before surgery. LAO recipients were more likely to have had a hospitalization and an emergency department visit in the subsequent 1 week and in the next 1, 3, 6, and 12 months. Patients receiving LAO prescriptions incurred greater costs in the 1 week and in the 1, 3, 6, and 12 months following their surgeries compared with patients who did not receive LAO prescriptions.We found associations between patients who received prescriptions for LAOs and increased costs and utilization. Future studies should elucidate causal relationships between LAOs and increased resource use. Providers should consider alternative pain management strategies.