The Effect of Comorbidity on Care Seeking for Back Problems in the United States

doi:10.1016/S1047-2797(98)00059-3

Annals of Epidemiology

Volume 9, Issue 4, May 1999, Pages 262-270

https://doi.org/10.1016/S1047-2797(98)00059-3 Get rights and content

Abstract

PURPOSE: We assess the effect of comorbidity on self-reported use of health care for back problems in the United States.

METHODS: Data from the 1989 National Health Interview Survey (NHIS) were used to perform cross-sectional analyses of adults who reported a back-related condition. The presence of one or more nonback-related conditions (and associated disability and health care) were the primary predictor variables. Weighted logistic regression modeling was performed to estimate odds ratios (ORs) adjusted for the effects of covariates.

RESULTS: The 1989 NHIS included 84,572 adults, of which 4790 (5.7%) reported at least one back-related condition. Of these, 931 (19.6%) sought health care for their back condition during the 2-week reference period. Among all adults with reported back problems, those with disabling comorbidities and those who sought care for their comorbidities during the reference period were less likely to have sought back care than were those with no comorbidities. Subjects with back-related disabilities who reported nondisabling comorbidities without associated health care were much more likely to have sought back care than were similar subjects without any comorbidities.

CONCLUSIONS: The decision to seek care for a back problem is a complex process that depends upon the presence and impact of other conditions and the use of care for these conditions. Comorbid back problem sufferers may not seek back care when afflicted with other disabling conditions or conditions that may be perceived to be more amenable to care.

Introduction

Low-back pain is one of the most prevalent and costly health problems facing the workplace and health-care communities (1). Seventy to eighty percent of the U.S. adult population will experience low-back pain at least once in their lives (2), and about 50% experience at least some pain each year (3). Back pain results in greater costs and more frequent disability than any other ailment among working-age adults 4, 5, and it is the second most frequent primary complaint reported by patients seeking medical care (6). In addition to an annual direct expenditure for diagnosis and treatment of approximately $33 billion (7), indirect costs, including personal suffering and production losses, probably push the economic impact of low-back pain much higher 7, 8.

The decision to seek health care in general has been related to health status (“need”), sociodemographic factors (e.g., sex, education, income), access to care (e.g., availability of providers, health-insurance coverage), expectation of treatment outcome, patterns of illness behavior, and anxiety and emotional distress 9, 10, 11, 12, 13. Recent studies of health-care utilization among back-pain populations have shown that race (14), duration of pain (14), pain severity 14, 15, number of bed days (15), sciatica (14), and the belief that back pain would be a lifelong problem (16) were predictors of seeking care. Age, sex, and health-insurance status were not predictive of seeking health care for chronic or acute low-back pain 14, 15.

Although there is a large body of literature on the effect of depression and other affective disorders on general care seeking 17, 18, 19, there is little known about how people make decisions regarding care for a specific condition when they are faced with multiple conditions. We are unaware of any studies that address the effect of comorbidity on the use of care for back pain or other back problems. Persons with back problems as well as other conditions may utilize health services differently than do persons with back problems alone. The severity and type of comorbidity may also influence back-related care-seeking behavior. Back pain sufferers afflicted with multiple conditions may have to prioritize their ailments and decide which to seek care for based on their relative severity, cost, perceived benefit, or other reasons. This situation may be exacerbated under certain managed health-care delivery systems where patients are discouraged from seeking care for more than one problem during each visit.

This study uses data from the 1989 National Health Interview Survey (NHIS) to assess the relationship between reported comorbid conditions and reported use of back-related health care during the previous 2 weeks among persons with back pain. The NHIS is conducted annually by the National Center for Health Statistics. The major research questions are two. First, is back-related care seeking influenced by the presence of one or more comorbid conditions? Second, does the use of back care depend upon the type of comorbidity or on related disability or health care?

Section snippets

Data Source

This study uses data from adult respondents of the 1989 NHIS, which collected comprehensive information about demographics, disability, health status, and health-care utilization for 116,929 members of the civilian noninstitutionalized population (including 84,572 adults). The survey uses a multistage sampling process that results in 52 weekly replicated samples that are pooled at the end of the calendar year to provide data on about 48,000 different U.S. households. This pooled sample is fully

Back-Related Conditions and Health Care

Of the 84,572 adults interviewed in the 1989 NHIS, 4790 (5.7% of the U.S. adult population) reported at least one back-related condition. Proxy responses were obtained for 1054 (22%) subjects. The majority of the conditions were chronic traumatic or nontraumatic impairments involving the back (NHIS code X80). Other commonly reported conditions, in order of frequency, were thoracic or lumbar disc displacement, curvature of spine, sciatic nerve lesion or sciatica, sprain or strain of back,

Discussion

This is the first study using a representative sample of the civilian noninstitutionalized U.S. population to compare adults with back conditions with and without comorbidities with respect to back-care use. The results indicate that about 25% of adults with back conditions reported one comorbid condition, and another 37% reported having multiple comorbid conditions. Forty-seven percent of the subjects reported comorbidity-related activity limitations or restricted-activity days. Disability and

Conclusions

Despite its limitations, we believe this study contributes to our understanding of back care in the United States. This study demonstrates that comorbidity is associated with the use of back care, controlling for health status and other potential confounders. We hypothesize that the back problem may compete with other conditions in persons with multiple problems. Back-problem sufferers with other, more serious conditions or conditions perceived as more amenable to care may decide to employ

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Mortality and adverse joint outcomes following septic arthritis of the native knee: a longitudinal cohort study of patients receiving arthroscopic washout
2020, The Lancet Infectious Diseases
Citation Excerpt :
Patients with a pre-existing diagnosis of osteoarthritis or rheumatoid arthritis were at increased risk of having subsequent arthroplasty, as would be expected. Patients with a high comorbidity index or diabetes were at reduced risk of subsequent arthroplasty, and this finding could be a result of patients with more comorbidities or diabetes being less likely to either seek or access arthroplasty.34 Progression of osteoarthritis appeared to be accelerated in patients with a history of septic arthritis, as evidenced by the rate of knee arthroplasty at age 40–49 years being increased by up to 27 times the annual rate in the general population of the same age.
The short-term and long-term consequences of septic arthritis are uncertain. We aimed to determine risk of mortality and adverse joint outcomes following septic arthritis of the native knee.
We did a retrospective cohort study in patients who received arthroscopic knee washout for septic arthritis in England between April 1, 1997, and March 31, 2017, using data in the national Hospital Episode Statistics database. Patients with previous knee surgery to the same knee were excluded. Mortality within 90 days, adverse joint outcomes (arthrodesis, amputation, arthroplasty) within 1 year, and arthroplasty within 15 years were determined. Mortality in patients with a primary admitting diagnosis of septic arthritis (ICD-10) was compared with that in patients in whom septic arthritis was a secondary diagnosis.
12 132 patients were included (mean age 56·6 years [SD 24·9]) of whom 4307 (36%) were female. In 10 195 (84%) patients with septic arthritis as the primary admitting diagnosis, 90-day mortality was 7·05% (95% CI 6·56–7·57; 719 patients), rising to 22·69% (20·80–24·68; 418 patients) in 1842 patients older than 79 years. Secondary septic arthritis diagnosis versus primary diagnosis was associated with an adjusted odds ratio for mortality of 2·10 (95% CI 1·79–2·46; p<0·0001). In 11 393 patients with at least 1 year follow-up, the 1 year rates were 0·13% (95% CI 0·07–0·22; 15 patients) for arthrodesis, 0·40% (0·30–0·54; 46 patients) for amputation, and 1·33%; (1·13–1·56; 152 patients) for arthroplasty. Within 15 years, 159 (8·76%; 95% CI 7·50–10·15) of 1816 patients had received arthroplasty, corresponding to an annual risk of arthroplasty that was about six times that of the general population (risk ratio 6·14, 95% CI 4·95–7·62; p<0·0001).
The consequences of septic knee arthritis in patients undergoing arthroscopic knee washout are serious. These findings highlight the potentially devastating outcomes associated with sepsis from musculoskeletal joint infection.
National Institute for Health Research.
Patient-reported disability in the general Japanese population was associated with medical care visits for low back pain, regardless of pain intensity
2015, Journal of Orthopaedic Science
Race/ethnicity is known to affect pain severity and the emotional aspects of pain, with medical care visits also reported to differ according to race/ethnicity. It has been hypothesized that there is an interactive relationship between pain intensity and patient-reported disability and that the interactive relationships are related to medical care visits. However, it remains unclear whether the association between patient-reported disability and medical care visits for low back pain (LBP) are dependent on the pain intensity. The aims of this study were to examine the prevalence of medical care visits among members of the Japanese general population and to analyze the association between patient-reported disability and medical care visits for LBP patients, regardless of the pain intensity.
From a random sample of the general Japanese population (n = 2962), we focused on those who experienced LBP within the past month. Subjects were asked about the number of medical care visits (medical clinic or complementary/alternative medical clinic) for LBP. Patient- reported disability was assessed using the Roland-Morris disability questionnaire (RDQ). Pain intensity of LBP was assessed by visual analog scale. To examine the association between RDQ and medical care visits among people with LBP, we used multiple logistic regression analysis and the trend analysis for the RDQ.
Of 841 reporting LBP in the past month, 285 (33.9 %) visited a medical care facility. After adjusting for pain intensity and other confounding factors, the odds ratios for the RDQ categories 1-5, 6-10, 11-15, and > 16 were compared with the RDQ categories 0, 1.13 (95 % CI 0.731.73), 2.05 (95 % CI 1.17-3.60), 2.21 (95 % CI 1.06-4.62), and 4.0 (95 % CI 1.60-9.98), respectively (p for trend < 0.01).
Patient-reported disability was associated with medical care visits for LBP, regardless of the pain intensity, with the results similar to those obtained for other races/ethnicities.
Is it all about a pain in the back?
2013, Best Practice and Research: Clinical Rheumatology
Multisite musculoskeletal pain is common among people suffering from low back pain. Although the mechanisms behind co-occurrence of multiple somatic symptoms and musculoskeletal pain are still unknown, patients with co-morbidities and co-occurring musculoskeletal symptoms tend to have worse functional status, a poorer prognosis and respond less favourably to treatment. Evidence also suggests that the more pain sites a patient reports, the more reduced their physical and mental function will be regardless of location of pain. At the same time, evidence suggests that strategies for diagnosis and treatment of low back pain and other musculoskeletal disorders such as neck pain and lower limb osteoarthritis are very similar. In this chapter, we discuss the prevalence, consequences, and implications of commonalities between low back pain, pain in other sites and co-occurring pain. In addition, we propose a conceptual framework for a common stepwise approach to the diagnosis and management of back and musculoskeletal pain.
Epidemiology: Spinal manipulation utilization
2012, Journal of Electromyography and Kinesiology
Citation Excerpt :
Health services researchers have investigated socio-demographic and health-related factors that differentiate users from non-users of chiropractic services for the past 30 years or so; however, studies addressing predictors of spinal manipulation use vs. other treatment modalities are few and far between. Compared to non-users, chiropractic patients have been shown to be middle-aged (Shekelle and Brook, 1991; Ni et al., 2002) or older (Cleary, 1982; Mugge, 1984), high school (Shekelle and Brook, 1991; Shekelle et al., 1995; Hurwitz and Morgenstern, 1997) or college educated (Ni et al., 2002), married (Shekelle and Brook, 1991), single (Hurwitz and Morgenstern, 1997), female (Mugge, 1984; Ni et al., 2002), male (Shekelle et al., 1995; Hurwitz and Morgenstern, 1997), white (Mugge, 1984; Deyo and Tsui-Wu, 1987; Shekelle and Brook, 1991; Pedersen et al., 1993; Shekelle et al., 1995; Hurwitz and Morgenstern, 1997; Hawk and Long, 1999; Ni et al., 2002; Mikuls et al., 2003; Graham et al., 2005; Quan et al., 2008), non-Hispanic (Mugge, 1984; Ni et al., 2002; Najm et al., 2003; Graham et al., 2005), living in a rural (Hawk and Long, 1999; Lafferty et al., 2006; Lind et al., 2009; Sibbritt et al., 2006) vs. urban (Côté et al., 2001) area or in the West (Deyo and Tsui-Wu, 1987; Hurwitz and Morgenstern, 1997), more acculturated (Lee et al., 2010), and employed (Hurwitz and Morgenstern, 1997); to have worse overall health status (Palinkas and Kabongo, 2000; Coulter et al., 2002) including mental (Coulter et al., 2002) and emotional (Palinkas and Kabongo, 2000) health, better overall health status (Carey et al., 1995; Hurwitz and Morgenstern, 1999), multiple chronic health conditions (Cleary, 1982) including chronic fatigue syndrome (Jones et al., 2007), better social and physical function (Côté et al., 2001), more activity limitations (Mugge, 1984), fewer disabling comorbidities and restricted-activity days (Hurwitz and Morgenstern, 1997) and bed days (Hurwitz and Morgenstern, 1999), longer term pain (Hurwitz, 1994; Hurwitz and Morgenstern, 1997; Smith and Stano, 1997; Sibbritt and Adams, 2010), less severe pain (Carey et al., 1995), recent personal injury (Sibbritt et al., 2006); to be high users of conventional medical care (Cleary, 1982; Hurwitz and Morgenstern, 1997; Ni et al., 2002; Sibbritt et al., 2006; Sibbritt and Adams, 2010) and complementary care (Sibbritt and Adams, 2010); and to have difficulty accessing medical doctors (Cleary, 1982) or to have adequate health insurance (Carey et al., 1995) (Table 1). A comprehensive analysis of chiropractic and general practice patients in North America revealed that compared with GP only patients in the US and Canada, chiropractic patients tend to be under 65 and white, with arthritis and disabling back or neck pain.
The objectives of this article are to (1) describe spinal manipulation use by time, place, and person, and (2) identify predictors of the use of spinal manipulation. We conducted a systematic review of the English-language literature published from January 1, 1980 through June 30, 2011. Of 822 citations identified, 213 were deemed potentially relevant; 75 were included after further consideration. Twenty-one additional articles were identified from reference lists. The literature is heavily weighted toward North America, Europe, and Australia and thus largely precludes inferences about spinal manipulation use in other parts of the world. In the regions covered by the literature, chiropractors, osteopaths, and physical therapists are most likely to deliver spinal manipulation, often in conjunction with other conservative therapies. Back and neck pain are the most frequent indications for receiving spinal manipulation; non-musculoskeletal conditions comprise a very small percentage of indications. Although spinal manipulation is more commonly used in adults than children, evidence suggests that spinal manipulation may be more likely used for non-musculoskeletal ailments in children than in adults. Patient satisfaction with spinal manipulation is very high.
Factors related to seeking health care among adolescents with musculoskeletal pain
2011, Pain
Citation Excerpt :
Our study also supports this finding. Moreover, adults with nondisabling comorbidities were more likely to seek care for a disabling back problem in a study by Hurwitz and Morgenstern [28], also in accordance with our results. In addition to other reasons to seek care, adolescents with any chronic disease may have become used to seeking care for health problems or preferred access to the health care system, which, in turn, may increase their likelihood to seek care for musculoskeletal pain.
Musculoskeletal pain is common among adolescents, but little is known about the factors that affect seeking health care for the problem. We examined the care-seeking pattern among adolescents reporting musculoskeletal pain. The study consisted of adolescents aged 16 years from the 1986 Northern Finland Birth Cohort who responded to a mailed questionnaire in 2001 and reported musculoskeletal pain over the preceding 6 months (n = 5052). Logistic regression analyses were performed to assess whether enabling resources, need factors, personal health habits, and psychological problems were associated with seeking health care for musculoskeletal pain. Musculoskeletal pain during the preceding 6 months was reported by 68% of boys and 83% of girls in the study population. Only 16% of boys and 20% of girls reporting pain had sought medical care. Among both boys and girls, care-seeking was associated with being a member of a sports club (boys, odds ratio [OR] 2.1; girls, OR 1.5) and having one (boys, OR 2.1; girls, OR 1.8) or at least 2 (boys, OR 2.2; girls, OR 2.1) other health disorders. In addition, it was associated with a high physical activity level (OR 1.5) and low self-rated (OR 1.5) health among girls. Reporting pain in other anatomical areas decreased the likelihood of seeking care for pain among both genders. In conclusion, relatively few adolescents with musculoskeletal pain had consulted a health professional for the problem. Being physically active (trauma), participating in organized sport (accessibility of care), and having other health problems may explain why an adolescent seeks care for musculoskeletal pain.
Factors defining care-seeking in low back pain - A meta-analysis of population based surveys
2010, European Journal of Pain
Citation Excerpt :
The literature search yielded 3721 hits, of which 3390 titles were excluded mainly due to inappropriate methodology or inappropriate population, according to our inclusion criteria. Of the remaining 331 titles, 11 articles reporting on 10 population based surveys met our inclusion criteria based on abstract and full paper assessment and were included in the review (Carey et al., 1995, 1996; Waxman et al., 1998; Hurwitz and Morgenstern, 1999; Cote et al., 2001, 2005; Bassols et al., 2002; Vingard et al., 2002; Jacob et al., 2003; Mortimer et al., 2003; Walker et al., 2004). Included studies yielded a total of 13,486 subjects with non-specific LBP distributed in two well-defined groups of health care-seekers and non-seekers.
Little is known about factors determining health care-seeking behavior in low back pain. While a number of studies have described general characteristics of health care utilization, only a few have aimed at appropriately assessing determinants of care-seeking in back pain, by comparing seekers and non-seekers. The objective of this systematic review was to identify determinants of health care-seeking in studies with well-defined groups of care-seekers and non-seekers with non-specific low back pain.
A search was conducted in Medline, AMED, Cinahl, Web of Science, PsycINFO, National Research Register, Cochrane Library and LILACS looking for population- based surveys of non-specific low back pain patients older than 18 years, published since 1966. To be included in the review, studies needed to report on characteristics of well-defined groups of care-seekers and non-seekers. Methodological quality was assessed using a criteria list based on sampling, response rate, data reproducibility, power calculation and external validity. Risk estimates were expressed as odd ratios (95% confidence intervals). When possible, meta-analyses were performed, using a random effects model.
Eleven studies were included in the review. Pooled results show that women are slightly more likely to seek care for their back pain as are patients with a previous history of back pain. Pain intensity was only slightly associated with care-seeking, whereas patients with high levels of disability were nearly eight times more likely to seek care than patients with lower levels of disability.

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^☆: Supported by a grant from the Agency for Health Care Policy and Research (1RO3 HS07968-01).

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Original reportsThe Effect of Comorbidity on Care Seeking for Back Problems in the United States☆

Abstract

Introduction

Section snippets

Data Source

Back-Related Conditions and Health Care

Discussion

Conclusions

Orthop Clin North Am.

Am J Med.

Cost, controversy, crisisLow-back pain and the health of the public

Ann Rev Pub Health.

Back pain and sciatica

New Engl J Med.

A new clinical model for the treatment of low back pain

Musculoskeletal DisordersTheir Frequency of Occurrence and Their Impact on the Population of the United States

Characteristics of physician visits for back symptomsA national perspective

Am J Pub Health.

Low back painA twentieth-century health-care enigma

Spine.

Indicators and predictors of health services utilization

Illness behavior, social adaptation, and the management of illness

J Nerv Ment Dis.

The experience and reporting of common physical complaints

J Health Soc Behav.

Distress syndrome, illness behavior, acccess to care, and medical utilization in a defined population

Med Care.

The effect of psychological distress on physician utilizationA prospective study

J Health Soc Behav.

Acute severe low back painA population-based study of prevalence and care seeking

Spine.

Care seeking among individuals with chronic low back pain

Spine.

Original reports
The Effect of Comorbidity on Care Seeking for Back Problems in the United States☆