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D C Cherkin

Publications and source records attributed to D C Cherkin.

At least 37 records · Page 2Linked to original sources
PubMed1996

An agenda for primary care research on low back pain.

In October 1995, an International Forum for Primary Care Research on Low Back Pain was held in Seattle, Washington. The Forum focused on the broad range of decisions that patients and their primary care providers make concerning how to best manage low back pain. In addition to providing a venue for summarizing the current state of knowledge about these issues, a major goal of the Forum was to draft an agenda for future primary care research on low back pain. Previous efforts to delineate priority areas for research in this field have emphasized the concerns of basic scientists, pain specialists, and surgeons while ignoring the major concerns of patients and providers in the primary care setting, where the majority of patients with back pain are seen. This article describes the group consensus process used to draft an agenda, presents the items included, and contrasts this primary care agenda with agendas for back pain research developed primarily by specialists. This agenda identifies for the first time the clinical and methodologic issues that primary care experts on back pain consider to be of highest priority. Hopefully, it will help focus future primary care research and encourage funding agencies to give priority to the issues identified.

Humans↗
PubMed1996

Predicting poor outcomes for back pain seen in primary care using patients' own criteria.

STUDY DESIGN: A prospective cohort study of patients seen in primary care for low back pain. OBJECTIVES: A new measure of back pain outcomes is used to describe the status of back problems at various intervals after visits to primary care physicians and to identify subsets of patients with worse prognoses. SUMMARY OF BACKGROUND DATA: Most previous studies of the prognosis of back pain in primary care have failed to provide clinically useful information. METHODS: Baseline data were collected from 219 patients making an initial visit for an episode of low back pain to a primary care clinic. A measure of how patients reported they would feel if they had their current back symptoms for the rest of their lives ("Symptom Satisfaction") was used to distinguish good from poor outcomes. Patient outcomes were assessed 1, 3, 7, and 52 weeks after the index visit. RESULTS: Only 67% of patients reported good outcomes after 7 weeks, and only 71% were satisfied with their condition 1 year later. After controlling for the effects of other variables measured during the initial physician visit, only younger age, depression, and pain below the knee were significant predictors of poor outcome at 7 weeks, and only pain below the knee and depression were significant predictors at 1 year. CONCLUSIONS: The proportion of primary care patients with back pain who have poor outcomes appears to be higher than generally recognized. Ways of improving how primary care responds to patients with persisting pain should be investigated.

Adult↗
PubMed1996

Pitfalls of patient education. Limited success of a program for back pain in primary care.

STUDY DESIGN: Low back pain patients seen in primary care were allocated randomly to one of two educational interventions or to usual care. OBJECTIVE: To evaluate educational interventions designed to improve the outcomes of primary care for low back pain. SUMMARY OF BACKGROUND DATA: Patients with back pain are frequently dissatisfied with their medical care and identify lack of information as the most insufficient aspect. METHODS: In a large Health Maintenance Organization clinic, 293 subjects were allocated randomly to receive usual care, an educational booklet, or a 15-minute session with a clinic nurse, including the booklet and a follow-up telephone call. Outcome measures included satisfaction with care, perceived knowledge, participation in exercise, functional status, symptom relief, and health care use. Outcomes were assessed 1, 3, 7, and 52 weeks after the intervention. RESULTS: The nurse intervention resulted in higher patient satisfaction than usual care (P < 0.001) and higher perceived knowledge (P < 0.001). Self-reported exercise participation was also higher in the nurse intervention group after a 1-week follow-up period (97% vs. 65% in the other groups; P < 0.0001). There were no significant differences among the three groups in worry, symptoms, functional status, or health care use at any follow-up interval. Differences in self-reported exercise and perceived knowledge were no longer significant after 7 weeks. CONCLUSIONS: These findings challenge the value of purely educational approaches in reducing functional impact or health care use related to back pain and also challenge the value of fitness exercise in the most acute phase of back pain.

Adult↗
PubMed1996

Measurement of overall and disease-specific health status: does the order of questionnaires make a difference?

OBJECTIVES: This study was designed to detect any effect of order when modules on disease-specific and overall health status are combined in an outcomes research questionnaire. METHODS: Men with symptomatic benign prostatic hyperplasia (BPH) were prospectively enrolled in a clinical trial of an educational intervention in Group Health Cooperative of Puget Sound, a prepaid group practice. Within the trial, 392 consecutive men were randomized to one of two versions of a baseline questionnaire. One had a 38-item module on BPH-specific health status first, followed by a 30-item module on overall health status; the other had the modules in reverse order. Scores were compared for three BPH-specific scales and eight scales measuring overall health. Data were collected in the form of self-administered questionnaires. RESULTS: Comparing the groups assigned the two versions of the questionnaire, no significant differences in scores on any of the health status scales were found. CONCLUSIONS: In this dataset, we could find no evidence of an order effect when modules on BPH-specific and overall health status were combined in different sequences.

Group Practice, Prepaid↗
PubMed1995

Physician views about treating low back pain. The results of a national survey.

STUDY DESIGN: Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain. OBJECTIVE: To document physician beliefs about the efficacy of specific treatments and the extent to which these beliefs correspond to current knowledge. SUMMARY OF BACKGROUND DATA: Little is known about physician beliefs regarding the efficacy of specific back pain treatments. METHODS: A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders. RESULTS: Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acute or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorities of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use. CONCLUSIONS: The lack of consensus among physicians could be attributable to the absence of clear evidence-based clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy, or a tendency to discount the efficacy of competing treatments.

Adult↗
PubMed1995

Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey.

STUDY DESIGN: This study is an analysis of national survey data from 5 sample years. OBJECTIVES: The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty. SUMMARY OF BACKGROUND DATA: Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty. METHODS: Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980-81, 1985, 1989-90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician specialty. RESULTS: There were almost 15 million office visits for "mechanical" low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visits in all three time periods. Nonspecific diagnostic labels were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management. CONCLUSIONS: Back pain remains a major reason for all physician office visits. This study describes visit, referral, and management patterns among specialties providing the most care.

Adolescent↗
PubMed1994

Outcome measures for studying patients with low back pain.

There is growing recognition in the treatment of back pain that patient perspectives are essential in judging the results of treatment. Improving the patient's "quality of life" is often the main goal of therapy. Thus, although clinical research in the past has focused on physiologic outcomes, such as range of motion, muscle strength, or neurologic deficits, increasing attention is being given to the rigorous measurement of symptoms, functional status, role function, satisfaction with treatment, and health care costs. In many cases, these so-called "soft" outcomes can be measured with a level of reproducibility similar to more conventional clinical data such as imaging test results. Because symptoms and functional outcomes are sometimes only loosely associated with physiologic phenomena, the former outcomes should be measured directly. Modern questionnaires for measuring patient quality of life combine the expertise of social scientists and clinicians and have demonstrated validity. Furthermore, they have some important advantages over simple ratings of "excellent, good, fair, and poor" outcomes, or work status alone. Several modern instruments for measuring health-related quality of life in patients with low back pain are reviewed briefly, describing their content and length. Wider use of these instruments would help to increase clinician familiarity with their meaning and avoid duplication of effort in questionnaire development.

Health Status Indicators↗
PubMed1994

Strategies for outcome research in spinal disorders. An introduction.

The evaluation of the clinical utility of the clinical diagnostic tests and procedures, what works in spinal disorders, and for whom and how treatment affects a patient's symptoms and function are key questions of outcomes research. This paper describes the advantages and limitations of the main study approaches used. Examples from the spine literature on spinal stenosis are used for illustration.

Female↗
PubMed1994

Therapeutic trials for low back pain.

Little consensus exists regarding the indications for and effectiveness of many back pain treatments. This clinical uncertainty arises because most back pain research has been flawed by poor methodology. The authors discuss strategies for improving the quality of back pain research on treatment efficacy. Design features, including randomized treatment allocation, independent outcome assessors, comprehensive outcome measures, appropriate statistical analyses, and close patient follow-up can increase study validity. Complete descriptions of enrollment criteria, patient characteristics, and clinical interventions can increase the generalizability of results. Although large scale trials often involve university centers, community-based researchers can collaborate on randomized trials or conduct valuable cohort studies.

Clinical Trials as Topic↗
PubMed1994

Analysis of automated administrative and survey databases to study patterns and outcomes of care.

Large computerized databases often arise from national surveys, insurance claims, and statewide health care registries. These databases are increasingly used to examine patterns of medical care and certain outcomes of care and may be helpful in planning clinical trials. They are highly representative of defined populations, but have limited clinical information. Methods have been developed to identify episodes of low back pain and to quantify the severity of unrelated, comorbid medical conditions. Pitfalls in analysis are discussed, including limitations of diagnosis and procedure coding, cross-sectional nature of most data, limited clinical detail, and the necessarily observational (not experimental) nature of any group comparisons. There is growing interest in expanding the clinical information in such databases, for both quality improvement and research purposes.

Cross-Sectional Studies↗
PubMed1994

An international comparison of back surgery rates.

SUMMARY OF BACKGROUND DATA: Although high geographic variation in back surgery rates within the United States have been documented, international comparisons have not been published. METHODS: The authors compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher: 1) in the United States than in other developed countries, 2) in countries with more neurologic and orthopaedic surgeons per capita, and 3) in countries with higher rates of other surgical procedures. Data on back surgery rates and physician supply were obtained from health agencies within these eleven countries. Country-specific rates of other surgical procedures were available from published sources. RESULTS: The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy. CONCLUSIONS: These findings illustrate the potentially large impact of health system differences on rates of back surgery. Better outcome studies, however, are needed to determine whether Americans are being subjected to excessive surgery or if those in other developed countries are suffering because back surgery is underutilized.

Australia↗
PubMed1994

Low back pain hospitalization. Recent United States trends and regional variations.

STUDY DESIGN: This study describes recent United States trends and regional variations in the management of low back pain. OBJECTIVES: The authors investigated recent temporal trends and compared practices in different geographic regions. SUMMARY OF BACKGROUND DATA: Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. METHODS: National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. RESULTS: Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. CONCLUSIONS: Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems.

Algorithms↗
PubMed1994

Physician variation in diagnostic testing for low back pain. Who you see is what you get.

OBJECTIVE: This study examined patterns of diagnostic test use for patients with low back pain. Three specific questions were addressed: 1) What tests do physicians recommend for patients with 3 common types of low back pain? 2) Do physicians in various specialties differ in the tests they would order? and 3) How appropriate are physicians' choices of tests, based on current medical knowledge and expert recommendations? METHODS: A stratified national random sample of 2,604 physicians in 8 specialties was mailed questionnaires asking about the tests they would order for hypothetical patients with acute back pain, sciatica, or chronic low back pain. Physicians were also asked which procedures they generally used to evaluate suspected lumbar nerve root compression. These responses were compared with guidelines that have been suggested by the Quebec Task Force on Spinal Disorders, based on comprehensive evaluation of the scientific literature. RESULTS: Approximately 1,100 physicians responded to the survey (43% response rate). Magnetic resonance imaging was the most frequently used procedure for evaluating suspected lumbar nerve root compression, although a majority of neurosurgeons would still use myelography. Neurosurgeons and neurologists were twice as likely as other specialists to order an imaging study for patients with acute nonradiating pain or chronic back pain. Physiatrists and neurologists were more than 3 times as likely as other specialists to order electromyograms for acute back pain with sciatica or chronic back pain. Rheumatologists were almost twice as likely as other specialists to order laboratory tests for both acute and chronic back pain. The reported use of imaging and electrodiagnostic tests was generally premature and more extensive than that recommended by the Quebec Task Force. CONCLUSION: There is little consensus, either within or among specialties, on the use of diagnostic tests for patients with back pain. Thus, the diagnostic evaluation depends heavily on the individual physician and his or her specialty, and not just the patient's symptoms and findings. Furthermore, many physicians may be ordering imaging studies too early and for patients who do not have the appropriate clinical indications. These results suggest a need for additional clinical guidelines as well as better adherence to existing guidelines.

Diagnostic Tests, Routine↗
PubMed1994

Managing low back pain: attitudes and treatment preferences of physical therapists.

BACKGROUND AND PURPOSE: We surveyed physical therapists about their attitudes, beliefs, and treatment preferences in caring for patients with different types of low back pain problems. SUBJECTS AND METHODS: Questionnaires were mailed to all 71 therapists employed by a large health maintenance organization in western Washington and to a random sample of 331 other therapists licensed in the state of Washington. RESULTS: Responses were received from 293 (74%) of the therapists surveyed, and 186 of these claimed to be practicing in settings in which they treat patients who have back pain. Back pain was estimated to account for 45% of patient visits. The McKenzie method was deemed the most useful approach for managing patients with back pain, and education in body mechanics, stretching, strengthening exercises, and aerobic exercises were among the most common treatment preferences. There were significant variations among therapists in private practice, hospital-operated, and health maintenance organization settings with respect to treatment preferences, willingness to take advantage of the placebo effect, and mean number of visits for patients with back pain. CONCLUSIONS AND DISCUSSION: These variations emphasize the need for more outcomes research to identify the most effective treatment approaches and to guide clinical practice.

Adult↗
PubMed1993

Nonsurgical hospitalization for low-back pain. Is it necessary?

In 1988, the Diagnosis-Related Group for "Medical Back Problems" was the seventh leading reason for all U.S. hospitalizations. The authors sought to describe the content of these hospitalizations and consider the potential for shifting nonsurgical care to the outpatient setting. Three complementary data sources (the 1988 National Hospital Discharge Survey, a statewide Washington hospital discharge registry, and medical records) were used to examine the diagnoses, tests, treatments, resource use, and subsequent care associated with these hospitalizations. Nationally, nonspecific back pain and herniated discs were the most common diagnoses. Nearly half the hospitalizations were for diagnostic tests (especially myelography) and the other half for pain control. In Washington state, 43% of patients were admitted by family physicians or internists, and 40% by orthopedic or neurologic surgeons. Twenty percent of patients underwent subsequent back surgery within 1 year (most within 3 months), suggesting that many hospitalizations were "presurgical." Most of the tests and treatments identified are known to be safe in the outpatient setting. Focused medical record review indicated frequent psychosocial problems or complicating factors, including obesity, substance abuse, prior back surgery, psychologic diagnoses, or lack of a caregiver at home. The findings support other evidence that many hospitalizations for "medical back problems" are unnecessary, but also suggest a need for improved outpatient and home-based alternatives to hospitalization.

Ambulatory Care↗
PubMed1993

Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population.

Regional variations in lumbar spinal fusion rates suggest a poor consensus on surgical indications. Therefore, complications, costs, and reoperation rates were compared for elderly patients undergoing surgery with or without spinal fusion. Subjects were Medicare recipients who underwent surgery in 1985, with 4 years of subsequent follow-up. There were 27,111 eligible patients, of whom 5.6% had fusions. Mean age was 72 years. Patients undergoing fusion had a complication rate 1.9 times greater than those who had surgery without fusion. The blood transfusion rate was 5.8 times greater, nursing home placement rate 2.2 times greater, and hospital charges 1.5 times higher (all P < 0.0005). Six-week mortality was 2.0 times greater for patients undergoing fusions (P = 0.025). Reoperation rates at 4 years were no lower for patients who had fusion surgery and results were similar in most diagnostic subgroups. Indications for fusion among older patients require better definition, preferably based on outcomes from prospective controlled studies.

Aged↗
PubMed1992

Is magnitude of co-payment effect related to income? Using census data for health services research.

This study: (1) describes and evaluates a method for estimating household income using home addresses in conjunction with census data, and (2) uses this method in a study designed to determine if the introduction of copayments caused primary care office visit rates to decrease more for lower income enrollees than for higher income enrollees of a large health maintenance organization (HMO). Each step in the process of linking income estimates for small census units (block groups) to specific home addresses is described and the validity and precision of these estimates is assessed through comparisons of estimated income with self-reported income for residents of the Puget Sound area of Washington state. Although subject to considerable measurement error, this approach provided valid income estimates. This method was then used to estimate the incomes of over 20,000 households of HMO enrollees in a controlled study of the relationship between copayment effect on visit rates and enrollee income. Copayments were found to have a similar effect on higher and lower income enrollees.

Adult↗