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Quantifying the Economic Impact of Depression for Spine Patients in the United States
Abstract
Study design:
This was a retrospective cross-sectional analysis.
Objective:
The objective of this study was to estimate the incremental health care costs of depression in patients with spine pathology and offer insight into the drivers behind the increased cost burden.
Summary of background data:
Low back pain is estimated to cost over $100 billion per year in the United States. Depression has been shown to negatively impact clinical outcomes in patients with low back pain and those undergoing spine surgery.
Materials and methods:
Data was collected from the Medical Expenditure Panel Survey from 2007 to 2015. Spine patients were identified and stratified based on concurrent depression International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Health care utilization and expenditures were analyzed between patients with and without depression using a multivariate 2-part logistic regression with adjustments for sociodemographic characteristics and Charlson Comorbidity Index.
Results:
A total of 37,094 patients over 18 years old with a spine condition were included (mean expenditure: $7829±241.67). Of these patients, 7986 had depression (mean expenditure: $11,455.41±651.25) and 29,108 did not have depression (mean expenditure: $6837.89±244.51). The cost of care for spine patients with depression was 1.42 times higher (95% confidence interval, 1.34-1.52; P<0.001) than patients without depression. The incremental expenditure of spine patients with depression was $3388.22 (95% confidence interval, 2906.60-3918.96; P<0.001). Comorbid depression was associated with greater inpatient, outpatient, emergency room, home health, and prescription medication utilization and expenditures compared with the nondepressed cohort.
Conclusions:
Spine patients with depression had significantly increased incremental economic cost of nearly $3500 more annually than those without depression. When extrapolated nationally, this translates to an additional $27.5 billion annually in incremental expenditures that can be attributed directly to depression among spine patients, which equates to roughly 10% of the total estimated spending on depression nationally. Strategies focused on optimizing the treatment of depression have the potential for dramatically reducing health care costs in spine surgery patients.
... Our study demonstrated that patients with depressive disorders experience significantly longer in-hospital length of stay, increased ninety-day medical and surgical complications, and higher reimbursement. The literature regarding depressive disorder is consistent with the findings of this study [22][23][24][25][26][27][28][29]. For instance, patients with depressive disorders have higher in-hospital length of stay [22][23][24]. ...
... These findings are also supported by similar studies conducted on patients with depression encountering various forms of spine pathology. In a retrospective cross-sectional analysis conducted on 37,094 patients, Ren et al. investigated the increased health care reimbursement for patients with depression undergoing treatment for spine pathology [28]. It was found that for spine patients with depression, the cost of treatment was 1.42 times more than cost of treatment for patients without depression (95% CI, 1.34-1.52; ...
Purpose
In recent years, depression rates have been on the rise, resulting in soaring mental health issues globally. There is paucity of literature about the impact of depression on lumbar fusion for adult spine deformity. The purpose of this study is to investigate whether patients with depressive disorders undergoing lumbar deformity fusion have higher rates of (1) in-hospital length of stay; (2) ninety-day medical and surgical complications; and (3) medical reimbursement.
Methods
A retrospective study was performed using a nationwide administrative claims database from January 2007 to December 2015 for patients undergoing lumbar fusion for spine deformity. Study participants with depressive disorders were selected and matched to controls by adjusting for sex, age, and comorbidities. In total, the query yielded 3706 patients, with 1286 who were experiencing symptoms of depressive disorders, and 2420 who served as the control cohort.
Results
The study revealed that patients with depressive disorders had significantly higher in-hospital length of stay (6.0 days vs. 5.0 days, p < 0.0001) compared to controls. Study group patients also had higher incidence and odds of ninety-day medical and surgical complications (10.2% vs. 5.0%; OR, 2.50; 95% CI, 2.16–2.89; p < .0001). Moreover, patients with depressive disorders had significantly higher episode of care reimbursement ($54,539.2 vs. $51,645.2, p < 0.0001).
Conclusion
This study illustrated that even after controlling for factors such as sex, age, and comorbidities, patients with depressive disorders had higher rates of in-hospital length of stay, medical and surgical complications, and total reimbursement.
... Low back pain (LBP) is one of the most common health concerns in the world. It affects a significant part of the population and, in the United States, has the highest health-related economic cost of up to 560-630 billion dollars per year (1)(2)(3). It is estimated that between 70 and 85% of the population will experience LBP at some point in their lives and that it can already limit activities in those under the age of 45, posing a significant socioeconomic impact by accounting for over 100 million lost workdays annually in the USA alone (4,5). ...
Degeneration of the intervertebral disc (IVD) is a normal part of aging. Due to the spine's declining function and the development of pain, it may affect one's physical health, mental health, and socioeconomic status. Most of the intervertebral disc degeneration (IVDD) therapies today focus on the symptoms of low back pain rather than the underlying etiology or mechanical function of the disc. The deteriorated disc is typically not restored by conservative or surgical therapies that largely focus on correcting symptoms and structural abnormalities. To enhance the clinical outcome and the quality of life of a patient, several therapeutic modalities have been created. In this review, we discuss genetic and environmental causes of IVDD and describe promising modern endogenous and exogenous therapeutic approaches including their applicability and relevance to the degeneration process.
... In recognition of the increased risk that spine patients with poor mental health may face, a multitude of studies have examined the relationship between preintervention mental health and postintervention outcomes for both surgical and nonoperatively managed patients. These studies have consistently found patients with inferior mental health scores or diagnosed with depression prior to intervention to suffer inferior outcomes in relation to physical function, pain, and disability and even result in greater economic burden [8,12,19,23,25,27,32,39]. However, few studies have examined the relationship between mental health status of patients at various postoperative time periods and their reported outcomes at those times. ...
Background
Limited spine literature has studied the strength of association of mental health with other outcomes at time of survey collection. We aim to evaluate the degree to which mental health correlates with outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) at several postoperative periods.
Methods
Patients having undergone elective MIS-TLIF were searched within a retrospective single-surgeon database. Five hundred eighty-five patients were included. Patient-reported outcomes (PROs) including Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), 12-item Short Form Physical Component Score (SF-12 PCS) and Mental Component Score (SF-12 MCS), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) back and leg pain, and Oswestry Disability Index (ODI) scores were collected preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year periods. Pearson’s correlation tests were used to evaluate the association between both SF-12 MCS and PHQ-9 scores to other PROs at each period.
Results
SF-12 MCS correlated with PROMIS PF (|r|= 0.308–0.531), SF-12 PCS (|r|= 0.207–0.328), VAS back (|r|= 0.279–0.474), VAS leg (|r|= 0.178–0.395), and ODI (|r|= 0.450–0.538) at all time points (P ≤ 0.021, all) except for preoperative SF-12 PCS and 1-year VAS leg. PHQ-9 correlated with PROMIS PF (|r|= 0.366–0.701), SF-12 PCS (|r|= 0.305–0.568), VAS back (|r|= 0.362–0.714), VAS leg (|r|= 0.319–0.694), and ODI (|r|= 0.613–0.784) at all periods (P < 0.001, all).
Conclusion
Poor mental health scores were correlated with lower physical function, elevated pain scores, and higher disability. PHQ-9 scores demonstrated stronger correlation in all relationships compared to SF-12 MCS. Optimization of patient mental health may lead to improved patient perception regarding function, pain, and disability following MIS-TLIF.
... To the best of the authors' knowledge, this is the first study to corelate AP to back pain and lumbar back pain disorders. Consistent with the prior literature, depression was also found to have a substantially increased odds of back pain in our study [15]. ...
Introduction
Prior studies have shown an association of atherosclerosis with lumbar disc degeneration and spondylosis. Patients with coronary artery atherosclerosis may present clinically with angina pectoris (AP). However, it is unknown if there is an association of AP with lumbar disc degeneration, The purpose of this study is to determine whether patients with AP have a higher prevalence of back pain.
Methods
Analysis was focused on respondents to back pain items of the 2018 Medicare Expenditure Panel Survey (MEPS). Odds ratios were calculated, and logistic regression analyses adjusting for demographic, education, occupation, cardiovascular and mental health conditions.
Results
Of 1,063 respondents, 455 (43%) reported back pain. Amongst the respondents, 43% of male respondents and 45% of female respondents had back pain. Mean age of respondents was 62.6± 16.1. Back pain was more prevalent in those with depression (p<0.05). On univariate analysis, depression (OR=1.80 [95% CI 1.53–2.12] p<0.001) and AP (OR=1.45 [95% CI 1.11–1.90] p=0.007) were significantly higher in those with a back pain. Multivariate analysis revealed that AP was independently associated with increased odds of back pain after controlling for confounders (OR =1.34 [95%CI 1.02–1.79], p=0.038).
Conclusions
In this study, AP was independently associated with 34% increased odds of having back pain. Further study into the musculoskeletal manifestations of atherosclerosis may offer additional insights into the treatment of prevalent conditions such as back pain.
Objectives:
Studies have reported the detrimental effects of depression following spine surgery, however none have evaluated whether preoperative depression screening, in patients with a history of depression, is protective from adverse outcomes and lowers healthcare costs. We studied whether depression screenings/psychotherapy visits within 3 months prior to 1-2 level lumbar fusion (1-2LF) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations; 3) readmissions; and 4) healthcare costs.
Methods:
The PearlDiver database from 2010 to 2020 was queried for depressive disorder (DD) patients undergoing primary 1-2LF. Two cohorts were 1:5 ratio matched and included those with (n=2,622) or without (n=13,058) a pre-operative depression screen/psychotherapy visit within 3 months of LF. A 90-day surveillance period was utilized to compare outcomes. Logistic regression models computed odds ratios (OR) of complications and readmissions. P values less than 0.003 were significant.
Results:
DD patients without depression screening had significantly greater incidence and odds of experiencing medical complications (40.57% vs. 16.00%; OR: 2.71,p<0.0001). Rates of ED utilization were increased in patients without screening vs. screening (15.78% vs 4.23%; OR: 4.25,p<0.0001), despite no difference in readmissions (9.31% vs 9.53%; OR: 0.97,p=0.721). Finally, 90-day reimbursements ($51,160 vs $54,731) were significantly lower in the screened cohort (all p<0.0001).
Conclusions:
Patients who underwent a pre-operative depression screening within 3 months of lumbar fusion had decreased medical complications, ED utilizations, and lower healthcare costs. Spine surgeons may use this data to counsel their patients with depression prior to surgical intervention.
Study design:
Retrospective cohort analysis.
Objective:
To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression.
Summary of background data:
Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression.
Methods:
Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05.
Results:
A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P=0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days.
Conclusions:
Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.
Prcis:
Adjusting for sociodemographics and comorbidities, patients with glaucoma incur an annual incremental economic burden of $1863.17, translating to $9.2 billion nationally. When analyzed by the health care service sector, prescription medication expenditures were higher for glaucoma patients.
Purpose:
The purpose of this study was to estimate the incremental health care burden, defined as attributable costs solely due to a diagnosis, of patients with diagnosed glaucoma, controlling for comorbidities, and sociodemographics.
Design:
A retrospective cross-sectional analysis of Medical Expenditure Panel Survey (MEPS) participants (age above 18 y) between 2016 and 2018.
Methods:
A cross-validated 2-part generalized linear regression model estimated the incremental glaucoma expenditures in aggregate and by sociodemographic subgroups and health care service sector [inpatient, outpatient (including surgical procedures), emergency room, home health, and medications] after 1:3 propensity matching.
Results:
After 1:3 propensity matching for sociodemographics and the Charlson Comorbidity Index, this study analyzed 1521 glaucoma patients (mean expenditures: $13,585.68±1367.03) and 4563 patients without glaucoma (mean expenditures: $12,048.92±782.49). A higher proportion of glaucoma patients are female, elderly, publicly insured (Medicare/Medicaid), college educated, identify ethnically as non-Hispanic, reside in the Northeast, and have more comorbidities (P<0.001). There were no differences in health care burden based on sex, income, insurance status, education, and year of care received for patients with glaucoma. Controlling for comorbidities and socioeconomic factors, propensity-matched glaucoma patients incur an annual incremental health care burden of $1863.17 (95% confidence interval, 393.44-3117.23, P=0.013), translating into an additional $9.2 billion in population-level US health care expenditures. By health care service sector, the expenditure ratio for health care expenditures was higher for prescription medications (expenditure ratio=1.20, 95% confidence interval, 1.02-1.42, P=0.031).
Conclusions:
Glaucoma patients have a substantial incremental economic health care burden after accounting for demographics and comorbidities, largely secondary to prescription medications. There is a need to continue identifying and studying treatment options for patients with glaucoma to maintain vision while minimizing health care expenditures.
Antidepressant drugs can be advantageous in treating psychiatric and non-psychiatric illnesses, including spinal disorders. However, spine surgeons remain unfamiliar with the advantages and disadvantages of the use of antidepressant drugs as a part of the medical management of diseases of the spine. Our review article describes a systematic method using the PubMed/Medline database with a specific set of keywords to identify such benefits and drawbacks based on 17 original relevant articles published between January 2000 and February 2018; this provides the community of spine surgeons with available cumulative evidence contained within two tables illustrating both observational (10 studies; three cross-sectional, three case-control, and four cohort studies) and interventional (seven randomized clinical trials) studies. While tricyclic antidepressants (e.g., amitriptyline) and duloxetine can be effective in the treatment of neuropathic pain caused by root compression, venlafaxine may be more appropriate for patients with spinal cord injury presenting with depression and/or nociceptive pain. Despite the potential associated consequences of a prolonged hospital stay, higher cost, and controversial reports regarding the lowering of bone mineral density in the elderly, antidepressants may improve patient satisfaction and quality of life following surgery, and reduce postoperative pain and risk of delirium. The preoperative treatment of preexisting psychiatric diseases, such as anxiety and depression, can improve outcomes for patients with spinal cord injury-related disabilities; however, a preoperative platelet function assay is advocated prior to major spine surgical procedures to protect against significant intraoperative blood loss, as serotonergic antidepressants (e.g., selective serotonin reuptake inhibitors) and bupropion can increase the likelihood of bleeding intraoperatively due to drug-induced platelet dysfunction. This comprehensive review of this evolving topic can assist spine surgeons in better understanding the benefits and risks of antidepressant drugs to optimize outcomes and avoid potential hazards in a spine surgical setting.
Health care expenditures and use are challenging to model because these dependent variables typically have distributions that are skewed with a large mass at zero. In this article, we describe estimation and interpretation of the effects of a natural experiment using two classes of nonlinear statistical models: one for health care expenditures and the other for counts of health care use. We extend prior analyses to test the effect of the ACA's young adult expansion on three different outcomes: total health care expenditures, office-based visits, and emergency department visits. Modeling the outcomes with a two-part or hurdle model, instead of a single-equation model, reveals that the ACA policy increased the number of office-based visits but decreased emergency department visits and overall spending. Expected final online publication date for the Annual Review of Public Health Volume 39 is April 1, 2018. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Background
The interaction of depression and anesthesia and surgery may result in significant increases in morbidity and mortality of patients. Major depressive disorder is a frequent complication of surgery, which may lead to further morbidity and mortality.
Literature search
Several electronic data bases, including PubMed, were searched pairing “depression” with surgery, postoperative complications, postoperative cognitive impairment, cognition disorder, intensive care unit, mild cognitive impairment and Alzheimer’s disease.
Review of the literature
The suppression of the immune system in depressive disorders may expose the patients to increased rates of postoperative infections and increased mortality from cancer. Depression is commonly associated with cognitive impairment, which may be exacerbated postoperatively. There is evidence that acute postoperative pain causes depression and depression lowers the threshold for pain. Depression is also a strong predictor and correlate of chronic post-surgical pain. Many studies have identified depression as an independent risk factor for development of postoperative delirium, which may be a cause for a long and incomplete recovery after surgery. Depression is also frequent in intensive care unit patients and is associated with a lower health-related quality of life and increased mortality. Depression and anxiety have been widely reported soon after coronary artery bypass surgery and remain evident one year after surgery. They may increase the likelihood for new coronary artery events, further hospitalizations and increased mortality. Morbidly obese patients who undergo bariatric surgery have an increased risk of depression. Postoperative depression may also be associated with less weight loss at one year and longer. The extent of preoperative depression in patients scheduled for lumbar discectomy is a predictor of functional outcome and patient’s dissatisfaction, especially after revision surgery. General postoperative mortality is increased.
Conclusions
Depression is a frequent cause of morbidity in surgery patients suffering from a wide range of conditions. Depression may be identified through the use of Patient Health Questionnaire-9 or similar instruments. Counseling interventions may be useful in ameliorating depression, but should be subject to clinical trials.
Context
After marked increases from 1987 to 1997, trends in depression treatment in the United States increased modestly from 1998 to 2007. However, multiple policy changes that expanded insurance coverage for mental health conditions may have shifted these trends again since 2007.
Objective
To examine national trends in outpatient treatment of depression from 1998 to 2015, with particular focus on 2007 to 2015.
Design, Setting, and Participants
This analysis of the use of health services and spending for treatment of depression in the United States assessed data from the 1998 (n = 22 953), 2007 (n = 29 370), and 2015 (n = 33 893) Medical Expenditure Panel Surveys (MEPSs). Participants included respondent households to the nationally representative survey. Data were analyzed from June 15 through December 18, 2018.
Main Outcomes and Measures
Rates of outpatient and pharmaceutical treatment of depression; counts of outpatient visits, psychotherapy visits, and prescriptions; and expenditures.
Results
The analysis included 86 216 individuals from the 1998, 2007, and 2015 MEPSs. Respondents’ mean (SD) age was 37.2 (22.7) years; 45 086 (52.3%) were female, 24 312 (28.2%) were Hispanic, 15 463 (17.9%) were black, and 62 926 (72.9%) were white. Rates of outpatient treatment of depression increased from 2.36 (95% CI, 2.12-2.61) per 100 population in 1998 to 3.47 (95% CI, 3.16-3.79) per 100 population in 2015. The proportion of respondents who were treated for depression using psychotherapy decreased from 53.7% (95% CI, 48.3%-59.1%) in 1998 to 43.2% (95% CI, 39.0%-47.4%) in 2007 and then increased to 50.4% (95% CI, 46.0%-54.9%) in 2015, whereas the proportion receiving pharmacotherapy remained steady at 81.9% (95% CI, 77.9%-85.9%) in 1998, 82.4% (95% CI, 79.3%-85.4%) in 2007, and 80.8% (95% CI, 77.9%-83.7%) in 2015. After adjusting for inflation using 2015 US dollars, prescription expenditures for these individuals decreased from $848 (95% CI, $713-$984) per year in 1998 to $603 (95% CI, $484-$722) per year in 2015, whereas the mean number of prescriptions decreased from 7.64 (95% CI, 6.61-8.67) in 1998 to 7.03 (95% CI, 6.51-7.56) in 2015. National expenditures for outpatient treatment of depression increased from $12 430 000 in 1997 to $15 554 000 in 2007 and then to $17 404 000 in 2015, consistent with a slowing growth in national outpatient expenditures for depression. The percentage of this spending that came from self-pay (uninsured) individuals decreased from 32% in 1998 to 29% in 2007 and then to 20% in 2015. This decrease was largely associated with increasing Medicaid coverage, because the percentage of this spending covered was 19% in 1998, 15% in 2007, and 36% in 2015.
Conclusions and Relevance
Recent policy changes that increased insurance coverage for depression may be associated with reduced uninsured burden and with modest increases in the prevalence of and overall spending for outpatient treatment of depression. The lower-than-expected rate of treatment suggests that substantial barriers remain to individuals receiving treatment for their depression.
Background:
Patients with depression frequently seek care in the emergency department (ED), especially in the context of suicidal ideation (SI) and self-harm (SH). However, the prevalence and trends in the United States (US) of ED visits for depression have not yet been characterized using a nationally representative sample. This study evaluates ED trends for depression in the US from 2006 to 2014.
Methods:
Data was obtained from the Nationwide Emergency Department Sample (NEDS) in 2006 and 2014 using a primary ICD-9 diagnosis of depression or a primary diagnosis of suicidal ideation (SI) and a secondary diagnosis of depression.
Results:
Between 2006 and 2014, there was a 25.9% increase in visits to the ED for depression, which was higher than the 14.8% increase in total ED visits during this time period. The mean inflation adjusted charges associated with depression-related ED visits increased by 107.7%, which was higher than the increase in mean charges for all ED visits in the same time period (40.47%). Visit rates were bimodally distributed with respect to age, with peaks in adolescence and middle age. Notably there was a 61.3% increase in ED visits for depression in individuals younger than 20 between 2006 and 2014. Over half of patients were admitted for inpatient care with a mean length of stay of 5.6 days in both years. Inpatient charges increased 71.8% between 2006 and 2014.
Conclusions:
ED visits for depression in the United States rose 25.9% between 2006 and 2014, which was higher than the 14.8% increase in total ED visits during this time period. Over half of ED depression visits were admitted to inpatient stay (mean 5.6 days both years).
Background
Depression is one of the most common illnesses in the U.S., with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the Emergency Department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a non‐psychiatric emergency department (ED) population and its association with subsequent ED visits and hospitalizations.
Methods
This prospective cohort study enrolled a convenience sample of English‐speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015 and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD‐MDD) and dimensional depression severity measurement test (CAT‐DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes.
Results
Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (IRR=1.61, 95% CI: 1.27‐2.03) and a 49% increase in the rate of hospitalizations (IRR=1.49, 95% CI: 1.06‐2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (incident rate ratio, IRR=1.10, 95% CI: 1.04‐1.16) and hospitalizations (IRR=1.10, 95% CI: 1.02‐1.18). Across the range of the severity scale there was over a 2.5‐fold increase in the rate of ED visits and hospitalization rates.
Conclusions
Rates of depression were high among a convenience sample of English‐speaking adult ED patients presenting with non‐psychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.
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Background:
Emergency department (ED) overuse is a costly and often neglected source of postdischarge resource utilization after spine surgery. Failing to investigate drivers of ED visits represents a missed opportunity to improve the value of care in spine patients.
Objective:
To identify the prevalence, drivers, and timing of ED visits following elective spine surgery.
Methods:
Patients undergoing elective spine surgery for degenerative disease at a major medical center were enrolled in a prospective longitudinal registry. Patient and surgery characteristics, and patient-reported outcomes were recorded at baseline and 3 mo after surgery, along with self-reported 90-d ED visits. A multivariable regression model was used to identify independent factors associated with 90-d ED visits. For a sample of patients presenting to our institution's ED, charts were reviewed to identify the reason and time to ED postdischarge.
Results:
Of 2762 patients, we found a 90-d ED visit rate of 9.4%. One-third of patients presented to our institution's ED and of these, 70% presented due to pain or medical concerns at 9 and 7 d postdischarge, respectively, with 60% presenting outside normal clinic hours. Independent risk factors for 90-d ED visits included younger age, preoperative opioid use, chronic obstructive pulmonary disorder, and more vertebral levels involved.
Conclusion:
Nearly 10% of elective spine patients had 90-d ED visits not requiring readmission. Pain and medical concerns accounted for 70% of visits at our center, occurring within 10 d of discharge. This study provides the clinical details and a timeline necessary to guide individualized interventions to prevent unnecessary, costly ED visits after spine surgery.
OBJECTIVE
Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs.
METHODS
A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug–use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs.
RESULTS
The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17–1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95–0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03–1.25), revision fusions (OR 1.15, 95% CI 1.05–1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04–1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84–1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively.
CONCLUSIONS
Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.
Study design:
Review of TRICARE claims (2006-2014) data to assess Emergency Department (ED) utilization following spine surgery.
Objective:
To determine utilization rates and predictors of ED utilization following spine surgical interventions.
Summary of background data:
Visits to the ED following surgical intervention represent an additional stress to the healthcare system. While factors associated with readmission following spine surgery have been studied, drivers of post-surgical ED visits, including appropriate and inappropriate use, remain under-investigated.
Methods:
TRICARE claims were queried to identify patients who had undergone one of three common spine procedures (lumbar arthrodesis, discectomy, decompression). ED utilization at 30- and 90-days was assessed as the primary outcome. Outpatient spine surgical clinic utilization was considered the primary predictor variable. Multivariable logistic regression was used to adjust for confounders.
Results:
Between 2006-2014, 48,868 patients met inclusion criteria. Fifteen percent (n = 7,183) presented to the ED within 30 days post-discharge. By 90 days, 29% of patients (n = 14,388) presented to an ED. The 30- and 90-day complication rates were 6% (n = 2,802) and 8% (n = 4,034), respectively, and readmission rates were 5% (n = 2,344) and 8% (n = 3,842), respectively. Use of outpatient spine clinic services significantly reduced the likelihood of ED utilization at 30- (OR 0.48; 95% CI 0.46, 0.53) and 90-days (OR 0.55; 95% CI 0.52, 0.57).
Conclusion:
Within 90-days following spine surgery 29% of patients sought care in the ED. However, only one-third of these patients had a complication recorded, and even fewer were readmitted. This suggests a high rate of unnecessary ED utilization. Outpatient utilization of spine clinics was the only factor independently associated with a reduced likelihood of ED utilization.
Level of evidence:
3.
Depression and hypertension frequently present together in clinical practice. Evaluating the interaction between depression and hypertension would help stakeholders better understand the value of depression prevention in primary care. This retrospective study aimed to evaluate the excessive burden of depression on overall health and on health care utilization expenditure among hypertensive patients. A total of 7019 hypertensive patients (ICD-9-CM: 401) were identified from the 2012 Medical Expenditure Panel Survey (MEPS 2012) data, of which 936 patients had depression (ICD-9-CM: 311). Hypertension with depression was associated with worse health status (physical component score, -3.97 [17.9% reduction]; mental component score, -9.14 [9% reduction]), higher utilization of health care services (outpatient visits, 6.4 [63.8% higher]; nights of hospitalization, 0.9 [100% higher]; medication prescription, 22.6 [76.8% higher]), and higher health care expenditures (inpatient, $1953.2 [72% higher]; prescription drugs, $1995.5 [82% higher]).
Background context:
The value of continuity of care in preventing 30-day readmissions after surgical procedures remains an issue of debate.
Purpose:
To investigate the association of being evaluated in the Emergency Room (ER) of the hospital where the original procedure was performed with 30-day readmissions for spine surgery patients.
Study design/setting:
Cohort study PATIENT SAMPLE.: 16,483 spine surgery patients being evaluated in the ED within 30-days postoperatively OUTCOME MEASURES.: 30-day post-discharge readmission METHODS.: We performed a cohort study involving patients who were evaluated in the ER within 30-days after discharge following spine surgery from 2009-2013, and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. A propensity score adjusted model was used to control for confounding.
Results:
From our patients, 11,638 (70.6%) were seen in a hospital different from the one where the original procedure was performed (12.0% readmitted), and 4845 (29.4%) were evaluated at the original hospital (10.9% readmitted). In a multivariable analysis, we demonstrated that being evaluated in the original hospital was associated with decreased rate of 30-day readmission (OR, 0.87; 95% CI, 0.77-0.97). We found similar associations in a propensity score adjusted model (OR, 0.87; 95% CI, 0.78-0.97). This corresponds to 7 patients needed to be evaluated in the hospital where the original procedure was performed to prevent one readmission. The authors have no conflicts to disclose CONCLUSIONS.: Using a comprehensive all-payer cohort of patients in New York State, who were evaluated in the ER after spine surgery, we identified an association of assessment in the hospital where the original procedure was performed with lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.
Objective
To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one of four categories of comorbid depression: no depression, unrecognized depression, asymptomatic depression, or symptomatic depression.
Research Design and Methods
Data from the 2004–2011 Medical Expenditure Panel Survey (MEPS) was used to create nationally representative estimates. The dependent variable was total healthcare expenditures for the calendar year, including office-based, hospital outpatient, emergency room, inpatient hospital, prescription, dental, and home health care expenditures. The 2004–2011 direct medical costs were adjusted to a common 2014 dollar value. The primary independent variable was four mutually exclusive depression categories created from ICD-9-CM codes and the PHQ-2 depression screening tool. Healthcare expenditures were estimated using a two-part model and were adjusted for age, sex, race, marital status, education, health insurance, metropolitan statistical area status, region, income level, and comorbidities.
Results
Based on a national sample of adults with diabetes (unweighted sample of 15,548, weighted sample of 17,465,579), 10.2 % had unrecognized depression, 13.6 % had asymptomatic depression, and 8.9 % had symptomatic depression. In the pooled sample, after adjusting for covariates, the incremental cost of unrecognized depression was $2872 (95 % CI 1660–4084), asymptomatic depression increased by $3347 (95 % CI 2568–4386), and symptomatic depression increased by $5170 (CI 95 % 3610–6731) compared to patients with no depression.
Conclusions
Adjusted analyses showed that expenditures were $2000–3000 higher for unrecognized and asymptomatic depression than no depression, and $5000 higher for symptomatic depression. Higher medical expenditures persisted over time, with only symptomatic depression showing a sustained decrease over time.
Retrospective cohort study.
Determine how psychosocial factors, particularly depression, impact lumbar fusion outcomes in a workers' compensation (WC) setting.
WC patients are less likely to return to work (RTW) after fusion. Few studies evaluate risk factors within this clinically distinct population.
A total of 2799 Ohio WC subjects were identified who underwent lumbar fusion between 1993 and 2013 using Current Procedural Terminology (CPT) procedural and International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. A total of 123 subjects were diagnosed with depression before fusion. Subjects with a smoking history, prior lumbar surgery, permanent disability, and failed back syndrome were excluded. The primary outcome was whether subjects returned to work within 2 years of fusion and sustained this RTW for more than 6 months of the following year. To determine the impact depression had on RTW status, we performed a multivariate logistic regression analysis. We also compared time absent from work and other secondary outcomes using χ and t tests.
Subjects with preoperative depression had significantly higher rates of legal representation, degenerative lumbar disease, and higher medical costs, and used opioid analgesics for considerably longer before and after fusion (P < 0.001).Depression group (10.6% [13/123]) and controls (33.0% [884/2676]) met our RTW criteria (P < 0.001). Preoperative depression was a negative predictor of RTW status (P < 0.001; odds ratio [OR]: 0.38). Additional predictors included working during same week as fusion (OR: 2.15), age more than 50 years (OR: 0.58), chronic preoperative opioid analgesia (OR: 0.58), and legal representation (OR: 0.64). After surgery, depression subjects were absent from work 184 more days compared with controls (P < 0.001).
Overall, RTW rates after fusion were low, which was especially true for those with pre-existing depression. Depression was a strong negative predictor of postoperative RTW status. Psychological screening and treatment may be beneficial in these subjects. The poor outcomes in this study may highlight a more limited role for fusion among WC subjects with chronic low back pain where RTW is the treatment goal.
3.
In this article, we describe twopm, a command for fitting two-part models for mixed discrete-continuous outcomes. In the two-part model, a binary choice model is fit for the probability of observing a positive-versus-zero outcome. Then, conditional on a positive outcome, an appropriate regression model is fit for the positive outcome. The twopm command allows the user to leverage the capabilities of predict and margins to calculate predictions and marginal effects and their standard errors from the combined first- and second-part models. Copyright 2015 by StataCorp LP.
The economic burden of depression in the United States-including major depressive disorder (MDD), bipolar disorder, and dysthymia-was estimated at $83.1 billion in 2000. We update these findings using recent data, focusing on MDD alone and accounting for comorbid physical and psychiatric disorders.
Using national survey (DSM-IV criteria) and administrative claims data (ICD-9 codes), we estimate the incremental economic burden of individuals with MDD as well as the share of these costs attributable to MDD, with attention to any changes that occurred between 2005 and 2010.
The incremental economic burden of individuals with MDD increased by 21.5% (from $173.2 billion to $210.5 billion, inflation-adjusted dollars). The composition of these costs remained stable, with approximately 45% attributable to direct costs, 5% to suicide-related costs, and 50% to workplace costs. Only 38% of the total costs were due to MDD itself as opposed to comorbid conditions.
Comorbid conditions account for the largest portion of the growing economic burden of MDD. Future research should analyze further these comorbidities as well as the relative importance of factors contributing to that growing burden. These include population growth, increase in MDD prevalence, increase in treatment cost per individual with MDD, changes in employment and treatment rates, as well as changes in the composition and quality of MDD treatment services.
© Copyright 2015 Physicians Postgraduate Press, Inc.
Considerable attention is being paid to hospital readmission as a marker of poor postdischarge care coordination. However, little is known about another potential marker: emergency department (ED) use. We examined ED visits for Medicare patients within thirty days of discharge for six common inpatient surgeries. We found that these visits were widespread and showed extensive variation across facilities. For example, 17.3 percent of these patients experienced at least one ED visit within the postdischarge period, and 4.4 percent of patients had multiple ED visits. Among those patients who were readmitted, 56.5 percent were readmitted from the ED. There was substantial variation-as much as fourfold-in hospital-level ED use for these patients across all six procedures. The variation might signify a failure in upstream coordination of care and therefore might represent a novel hospital quality indicator. In addition, the postdischarge ED visit is an opportunity to ensure that care is properly coordinated and is the last best chance to avoid preventable readmissions.
Objectives: Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities in administrative data and assess the performance of the resulting algorithms. Methods: ICD-10 coding algorithms were developed by "translation" of the ICD-9-CM codes constituting Deyo's (for Charlson comorbidities) and Elixhauser's coding algorithms and by physicians' assessment of the face-validity of selected ICD- 10, codes. The process of carefully developing ICD-10 algorithms also produced modified and enhanced ICD-9-CM coding algorithms for the Charlson and Elixhauser comorbidities. We then used data on in-patients aged 18 years and older in ICD-9-CM and ICD-10 administrative hospital discharge data from a Canadian health region to assess the comorbidity frequencies and mortality prediction achieved by the original ICD-9-CM algorithms, the enhanced ICD-9-CM algorithms, and the new ICD-10 coding algorithms. Results: Among 56,585 patients in the ICD-9-CM data and 58,805 patients in the ICD-10 data, frequencies of the 17 Charlson comorbidities and the 30 Elixhauser comorbidities remained generally similar across algorithms. The new ICD-10 and enhanced ICD9-CM coding algorithms either matched or outperformed the original Deyo and Elixhauser ICD-9-CM coding algorithms in predicting in-hospital mortality. The C-statistic was 0.842 for Deyo's ICD9-CM coding algorithm, 0.860 for the ICD-10 coding algorithm, and 0.859 for the enhanced ICD-9-CM coding algorithm, 0.868 for the original Elixhauser ICD-9-CM coding algorithm, 0.870 for the ICD-10 coding algorithm and 0.878 for the enhanced ICD-9-CM coding algorithm. Conclusions: These newly developed ICD-10 and ICD-9-CM comorbidity coding algorithms produce similar estimates of comorbidity prevalence in administrative data, and may outperform existing ICD-9-CM coding algorithms.
Large administrative databases are increasingly valuable tools for health care research. Although increased access to these databases provides valuable opportunities to study health care utilization, costs and outcomes and valid and comparable results require explicit and consistent analytic methods. Algorithms for identifying surgical and nonsurgical hospitalizations for "mechanical" low back problems in automated databases are described. Sixty-six ICD-9-CM diagnosis and 15 procedure codes that could be applied to patients with mechanical low back problems were identified. Twenty-seven diagnosis and two procedure codes identify hospitalizations for problems definitely in the lumbar or lumbosacral region. Exclusion criteria were developed to eliminate nonmechanical causes of low back pain, such as malignancies, infections, and major trauma. The use of the algorithms is illustrated using national hospital discharge data.
Cost of illness study alongside a randomized controlled trial.
To describe the costs of care for patients with low back pain (1) and to identify patient characteristics as predictors for high health care cost during a 1-year follow-up (2).
Low back pain (LBP) is one of the leading causes of high health care costs in industrialized countries (Life time prevalence, 70%). A lot of research has been done to improve primary health care and patients' prognosis. However, the cost of health care does not necessarily follow changes in patient outcomes.
General practitioners (n = 126) recruited 1378 patients consulting for LBP. Sociodemographic data, pain characteristics, and LBP-related cost data were collected by interview at baseline and after 6 and 12 months. Costs were evaluated from the societal perspective. Predictors of high cost during the subsequent year were studied using logistic regression analysis.
Mean direct and indirect costs for LBP care are about twice as high for patients with chronic LBP compared to acutely ill patients. Indirect costs account for more than 52% to 54% of total costs. About 25% of direct costs refer to therapeutic procedures and hospital or rehabilitational care. Patients with high disability and limitations in daily living show a 2- to 5-fold change for subsequent high health care costs. Depression seems to be highly relevant for direct health care utilization.
Interventions designed to reduce high health care costs for LBP should focus on patients with severe LBP and depressive comorbidity. Our results add to the economic understanding of LBP care and may give guidance for future actions on health care improvement and cost reduction.
Depression is the most common psychiatric illness in the USA and is commonly diagnosed in patients with chronic back pain. We investigated the use of mood-altering medications among spine surgery candidates and the relationship with opioid use and cost of care. We retrospectively reviewed the charts of 578 spine surgery patients who underwent surgery during 2005 to 2007 and their hospital charges. Patients were divided by type of spine surgery as follows: 154 lumbar microdiscectomies (LMD), 297 anterior cervical decompression and fusions (ACDF) and 127 lumbar decompression and fusions (LDF). We found that 25.4% of spine surgery candidates were on antidepressants, 9.3% on anxiolytics, and 41.3% on opioids were. More precisely, 26.6% of LMD, 24.6% of ACDF and 26% of LDF patients were on antidepressants; 9.1% of LMD, 7.1% of ACDF, and 15% of LDF patients were on anxiolytics; and 47.4% of LMD, 36% of ACDF, and 46.5% of LDF patients were on opioids. Of all patients, 16.8% were on two or three types of these medications. Significantly more antidepressants were used by females in the ACDF and LDF groups and more opioids were used by African Americans in the LDF group. There were significant differences (p<0.05) in the length of stay and hospital cost between patients on antidepressants and those not on antidepressants in the LDF group, especially among females. Opioids are the most commonly used psychoactive drugs among chronic back pain and spine surgery candidates followed by antidepressants and anxiolytics. Screening for antidepressant use among spine surgery patients seems reasonable on the preoperative visit. This would help adjust antidepressant medications following surgery as depression might resolve in response to pain improvement. If antidepressant medications were initially prescribed to treat pain; they also might need to be tapered off postoperatively to correspond with new pain levels. The relationship of antidepressants with increased hospital charges in this category of patients requires further investigation.
Study design:
Analysis of nationally representative survey data for spine-related health care expenditures, utilization and self-reported health status.
Objective:
To study trends from 1997 to 2006 in per-user expenditures for spine-related inpatient, outpatient, pharmacy, and emergency services; and to compare these trends to changes in health status.
Summary of background data:
Although prior work has shown overall spine-related expenditures accounted for $86 billion in 2005, increasing 65% since 1997, the study did not report per-user expenditures. Understanding population-level per-user expenditure for specific services relative to changes in the health status may help assess the value of these services.
Methods:
We analyzed data from the Medical Expenditure Panel Survey, a multistage survey sample designed to produce unbiased national estimates of health care utilization and expenditure. Spine-related hospitalizations, outpatient visits, prescription medications and emergency department visits were identified using ICD-9-CM diagnosis codes. Regression analyses controlling for age, sex, comorbidity, and time (years) were used to examine trends from 1997 to 2006 in inflation-adjusted per-user expenditures, and utilization, and self-reported health status.
Results:
An average of 1774 respondents with spine problems was surveyed per year; the proportion suggested an increase in the number of people who sought treatment for spine problems in the United States from 14.8 million in 1997 to 21.9 million in 2006. From 1997 to 2006, the mean adjusted per-user expenditures were the largest component of increasing total costs for inpatient hospitalizations, prescription medications, andemergency department visits, increasing 37% (from $13,040 in 1997 to $17,909 in 2006), 139% (from $166 to $397), and 84% (from $81 to $149), respectively. A 49% increase in the number of patients seeking spine-related care (from 12.2 million in 1997 to 18.2 million in 2006) was the largest contributing factor to increased outpatient expenditures. Population measures of mental health and work, social, and physical limitations worsened over time among people with spine problems.
Conclusion:
Expenditure increases for spine-related inpatient, prescription, and emergency services were primarily the result of increasing per-user expenditures, while those related to outpatient visits were primarily due to an increase in the number of users of ambulatory services.
To develop a measure of the burden of comorbid disease from the MED-ECHO data base (Québec), the so-called Charlson index was adapted to International Classification of Disease (ICD-9) codes. The resulting comorbidity index was applied to the study of inpatient death in 33,940 patients with ischemic heart disease. Multiple logistic regression was used to relate inpatient death to its predictors, including gender, principal diagnosis, age, and the comorbidity index. Various transformations of the comorbidity score were performed, and their effect on the predictive accuracy was assessed. The comorbidity index was constantly and strongly associated with death. From a statistical viewpoint, the best results were obtained when the index was transformed into four dummy independent variables (the area under the receiver-operating curve is then 0.87). In a validation analysis performed on 1990-1991 MED-ECHO data (36,012 admissions with ischemic heart disease), the comorbidity index has the same statistical properties. We conclude that the Charlson index may be an efficient approach to risk adjustment from administrative data bases, although it should be tested on other conditions.
Health economists often use log models to deal with skewed outcomes, such as health utilization or health expenditures. The literature provides a number of alternative estimation approaches for log models, including ordinary least-squares on ln(y) and generalized linear models. This study examines how well the alternative estimators behave econometrically in terms of bias and precision when the data are skewed or have other common data problems (heteroscedasticity, heavy tails, etc.). No single alternative is best under all conditions examined. The paper provides a straightforward algorithm for choosing among the alternative estimators. Even if the estimators considered are consistent, there can be major losses in precision from selecting a less appropriate estimator.
This study ascertained the odds of diagnosed depression in individuals with diabetes and the relation between depression and health care use and expenditures.
First, we compared data from 825 adults with diabetes with that from 20,688 adults without diabetes using the 1996 Medical Expenditure Panel Survey (MEPS). Second, in patients with diabetes, we compared depressed and nondepressed individuals to identify differences in health care use and expenditures. Third, we adjusted use and expenditure estimates for differences in age, sex, race/ethnicity, health insurance, and comorbidity with analysis of covariance. Finally, we used the Consumer Price Index to adjust expenditures for inflation and used SAS and SUDAAN software for statistical analyses.
Individuals with diabetes were twice as likely as a comparable sample from the general U.S. population to have diagnosed depression (odds ratio 1.9, 95% CI 1.5-2.5). Younger adults (<65 years), women, and unmarried individuals with diabetes were more likely to have depression. Patients with diabetes and depression had higher ambulatory care use (12 vs. 7, P < 0.0001) and filled more prescriptions (43 vs. 21, P < 0.0001) than their counterparts without depression. Finally, among individuals with diabetes, total health care expenditures for individuals with depression was 4.5 times higher than that for individuals without depression ($247,000,000 vs. $55,000,000, P < 0.0001).
The odds of depression are higher in individuals with diabetes than in those without diabetes. Depression in individuals with diabetes is associated with increased health care use and expenditures, even after adjusting for differences in age, sex, race/ethnicity, health insurance, and comorbidity.
The objective of this study is to determine whether depression is an independent risk factor for onset of an episode of troublesome neck and low back pain. There is growing evidence that pain problems increase the risk of depression. However, the evidence about the role of depression as a risk factor for onset of pain problems is contradictory. This lack of consistency in research findings may be due in part to methodological weaknesses in existing studies, for example, use of an inappropriate study design and inadequate consideration of confounding. A population-based random sample of adults was surveyed and followed at 6 and 12 months. Individuals at risk of troublesome (intense and/or disabling) neck or low back pain are the subjects of this report (n=790). We used Cox proportional hazards models to measure the time-varying effect of depressive symptoms on the onset of troublesome neck and low back pain. Our multivariable analysis considered the possible confounding effects of demographic and socio-economic factors, health status, co-morbid medical conditions and injuries to the neck or low back. We found an independent and robust relationship between depressive symptoms and onset of an episode of pain. In comparison with the lowest quartile of scores (the least depressed), those in the highest quartile of depression scores had a four-fold increased risk of troublesome neck and low back pain (adjusted HRR 3.97; 95% CI 1.81-8.72). Depression is a strong and independent predictor for the onset of an episode of intense and/or disabling neck and low back pain.
The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together.
A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate).
Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level.
Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone.
Socioeconomic factors are important risk factors for lumbar pain and disability. The total costs of low-back pain in the United States exceed $100 billion per year. Two-thirds of these costs are indirect, due to lost wages and reduced productivity. Each year, the fewer than 5% of the patients who have an episode of low-back pain account for 75% of the total costs. Because indirect costs rely heavily on changes in work status, total costs are difficult to calculate for many women and students as well as elderly and disabled patients. These methodologic challenges notwithstanding, the toll of lumbar disc disorders is enormous, underscoring the critical importance of identifying strategies to prevent these disorders and their consequences.
Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: a systematic review
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