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Biomedical subjects

Richard A Deyo

Publications and source records attributed to Richard A Deyo.

At least 19 recordsLinked to original sources
PubMed2007

Release from prison--a high risk of death for former inmates.

BACKGROUND: The U.S. population of former prison inmates is large and growing. The period immediately after release may be challenging for former inmates and may involve substantial health risks. We studied the risk of death among former inmates soon after their release from Washington State prisons. METHODS: We conducted a retrospective cohort study of all inmates released from the Washington State Department of Corrections from July 1999 through December 2003. Prison records were linked to the National Death Index. Data for comparison with Washington State residents were obtained from the Wide-ranging OnLine Data for Epidemiologic Research system of the Centers for Disease Control and Prevention. Mortality rates among former inmates were compared with those among other state residents with the use of indirect standardization and adjustment for age, sex, and race. RESULTS: Of 30,237 released inmates, 443 died during a mean follow-up period of 1.9 years. The overall mortality rate was 777 deaths per 100,000 person-years. The adjusted risk of death among former inmates was 3.5 times that among other state residents (95% confidence interval [CI], 3.2 to 3.8). During the first 2 weeks after release, the risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with a markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186). The leading causes of death among former inmates were drug overdose, cardiovascular disease, homicide, and suicide. CONCLUSIONS: Former prison inmates were at high risk for death after release from prison, particularly during the first 2 weeks. Interventions are necessary to reduce the risk of death after release from prison.

Adolescent↗
PubMed2006

The impact of disability compensation on long-term treatment outcomes of patients with sciatica due to a lumbar disc herniation.

STUDY DESIGN: Prospective, observational study. OBJECTIVE: To compare long-term disability and health-related quality of life outcomes of individuals receiving or not receiving workers' compensation at baseline evaluation. SUMMARY OF BACKGROUND DATA: Disability compensation has long been associated with poor clinical outcomes. However, most studies have assessed outcomes over short time periods using unvalidated measures without controlling for potential confounders. METHOD: Patients with sciatica due to a herniated lumbar disc were treated by physicians in community based orthopedic, neurosurgical, and occupational medicine practices throughout Maine. Outcomes assessed included disability compensation and work status, and health-related quality of life, controlling for initial treatment received and factors predicting initial workers' compensation status. RESULTS: Among 440 eligible patients, 172 (86%) receiving workers' compensation and 222 (92%) not receiving workers' compensation at baseline evaluation completed at least one follow-up between 5 and 10 years (80% completed 10-year). Baseline demographics, past back history, imaging findings, symptoms, functional status, and expectations significantly differed according to the patient's baseline workers' compensation status. After 5-10 years, most patients, regardless of baseline workers' compensation status (yes or no), were not receiving disability compensation (83% vs. 96%, respectively) and were employed (78% for both groups). However, workers' compensation patients were significantly more likely to be receiving disability compensation and had worse symptoms, functional status, and satisfaction outcomes. Outcome differences diminished in magnitude after controlling for baseline differences among patients receiving workers' compensation or not but continued to favor those not initially receiving workers' compensation. Initial treatment received, either surgical or nonsurgical, did not influence these findings. CONCLUSIONS: Long-term employment and disability outcomes were favorable for most patients with a disc herniation, regardless of initial workers' compensation status. However, individuals initially receiving workers' compensation had worse disability and quality of life outcomes compared to individuals not receiving workers' compensation. Despite these differences, long-term work outcomes were similarly favorable.

Adult↗
PubMed2006

Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial.

CONTEXT: Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial. OBJECTIVE: To assess the efficacy of surgery for lumbar intervertebral disk herniation. DESIGN, SETTING, AND PATIENTS: The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks. INTERVENTIONS: Standard open diskectomy vs nonoperative treatment individualized to the patient. MAIN OUTCOME MEASURES: Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status. RESULTS: Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes. CONCLUSIONS: Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00000410.

Adult↗
PubMed2006

Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort.

CONTEXT: For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care. OBJECTIVE: To compare the treatment effects of diskectomy and usual care. DESIGN, SETTING, AND PATIENTS: Prospective observational cohort of surgical candidates with imaging-confirmed lumbar intervertebral disk herniation who were treated at 13 spine clinics in 11 US states and who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003. INTERVENTIONS: Standard open diskectomy vs usual nonoperative care. MAIN OUTCOME MEASURES: Changes from baseline in the Medical Outcomes Study Short-Form Health Survey (SF-36) bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons/MODEMS version). RESULTS: Of the 743 patients enrolled in the observational cohort, 528 patients received surgery and 191 received usual nonoperative care. At 3 months, patients who chose surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6-19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences narrowed somewhat at 2 years: bodily pain (mean change: surgery, 42.6 vs nonoperative care, 32.4; treatment effect, 10.2; 95% CI, 5.9-14.5), physical function (mean change: surgery, 43.9 vs nonoperavtive care 31.9; treatment effect, 12.0; 95% CI; 7.9-16.1), and Oswestry Disability Index (mean change: surgery -37.6 vs nonoperative care -24.2; treatment effect, -13.4; 95% CI, -17.0 to -9.7). CONCLUSIONS: Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00000410.

Adult↗
PubMed2006

Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.

STUDY DESIGN: Review and analysis of data from two U.S. national surveys in 2002. OBJECTIVES: To examine the prevalence of back pain and physician visits for back pain in the United States. SUMMARY OF BACKGROUND DATA: National data on the prevalence of back pain become available only intermittently. METHODS: We summarized published data from the 2002 National Health Interview Survey (NHIS) on the prevalence of back pain and compared it with earlier surveys. We also analyzed the 2002 National Ambulatory Medical Care Survey (NAMCS) to determine physician visit rates for back pain. RESULTS: In the 2002 NHIS, there were 31,044 adult respondents. Low back pain lasting at least a whole day in the past 3 months was reported by 26.4% of respondents, and neck pain was reported by 13.8%. Among racial groups, American Indians and Alaska Natives had the highest prevalence of low back pain, and Asian Americans had the lowest. Prevalence generally declined with greater levels of education and increasing income. Prevalence estimates were consistent with those from previous surveys, although methodologic differences limited comparisons. NAMCS data suggested that the proportion of all physician visits attributable to low back pain (2.3% in 2002) has changed little since the early 1990s. CONCLUSIONS: About one fourth of U.S. adults report low back pain in the past 3 months; the proportion of physician visits attributed to back pain has changed little in the past decade.

Adult↗
PubMed2006

Population-based trends in volumes and rates of ambulatory lumbar spine surgery.

STUDY DESIGN: Sequential cross-sectional study. OBJECTIVES: To quantify patterns of outpatient lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Outpatient lumbar spine surgery patterns are undocumented. METHODS: We used CPT-4 and ICD-9-CM diagnosis/procedure codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUP's State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates. RESULTS: Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000. CONCLUSIONS: While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.

Adult↗
PubMed2006

Towards standardized measurement of adverse events in spine surgery: conceptual model and pilot evaluation.

BACKGROUND: Independent of efficacy, information on safety of surgical procedures is essential for informed choices. We seek to develop standardized methodology for describing the safety of spinal operations and apply these methods to study lumbar surgery. We present a conceptual model for evaluating the safety of spine surgery and describe development of tools to measure principal components of this model: (1) specifying outcome by explicit criteria for adverse event definition, mode of ascertainment, cause, severity, or preventability, and (2) quantitatively measuring predictors such as patient factors, comorbidity, severity of degenerative spine disease, and invasiveness of spine surgery. METHODS: We created operational definitions for 176 adverse occurrences and established multiple mechanisms for reporting them. We developed new methods to quantify the severity of adverse occurrences, degeneration of lumbar spine, and invasiveness of spinal procedures. Using kappa statistics and intra-class correlation coefficients, we assessed agreement for the following: four reviewers independently coding etiology, preventability, and severity for 141 adverse occurrences, two observers coding lumbar spine degenerative changes in 10 selected cases, and two researchers coding invasiveness of surgery for 50 initial cases. RESULTS: During the first six months of prospective surveillance, rigorous daily medical record reviews identified 92.6% of the adverse occurrences we recorded, and voluntary reports by providers identified 38.5% (surgeons reported 18.3%, inpatient rounding team reported 23.1%, and conferences discussed 6.1%). Trained observers had fair agreement in classifying etiology of 141 adverse occurrences into 18 categories (kappa = 0.35), but agreement was substantial (kappa > or = 0.61) for 4 specific categories: technical error, failure in communication, systems failure, and no error. Preventability assessment had moderate agreement (mean weighted kappa = 0.44). Adverse occurrence severity rating had fair agreement (mean weighted kappa = 0.33) when using a scale based on the JCAHO Sentinel Event Policy, but agreement was substantial for severity ratings on a new 11-point numerical severity scale (ICC = 0.74). There was excellent inter-rater agreement for a lumbar degenerative disease severity score (ICC = 0.98) and an index of surgery invasiveness (ICC = 0.99). CONCLUSION: Composite measures of disease severity and surgery invasiveness may allow development of risk-adjusted predictive models for adverse events in spine surgery. Standard measures of adverse events and risk adjustment may also facilitate post-marketing surveillance of spinal devices, effectiveness research, and quality improvement.

Humans↗
PubMed2006

Trends and variations in the use of spine surgery.

Examining trends and geographic variations in clinical care offers insights into changes in clinical decision making. We summarized data on spine surgical rates, trends, and variations in the United States to highlight areas of professional uncertainty and questions for future research. The United States has the highest rate of spine surgery in the world, but spine surgery shows wider geographic variations than most other procedures. For example, Medicare data for 2001 showed sixfold variations in spine surgery rates among United States cities, and 10-fold variations in spine fusion rates. United States spine surgery rates rose 55% in the 1980s. In the 1990s, studies of surgical rates became more difficult because 20% of discectomies shifted to an out-patient setting. Extrapolations from states with ambulatory surgery data suggest overall lumbar surgery rates continued to rise throughout the 1990s. The most rapid increase was for spinal fusion, which tripled during the 1990s and accounted for an increasing proportion of all spine procedures. Some increases coincided with the introduction of new surgical implants. Despite new technologies, rates of repeat surgery after fusion were no lower than the rates after decompression alone. As new technology for spine surgery is introduced at an accelerating pace, we anticipate substantial changes in surgery patterns. Analysis of population-based data may be useful for surveillance of changes and their impacts.

Humans↗
PubMed2005

Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial.

BACKGROUND: Chronic low back pain is a common problem that has only modestly effective treatment options. OBJECTIVE: To determine whether yoga is more effective than conventional therapeutic exercise or a self-care book for patients with chronic low back pain. DESIGN: Randomized, controlled trial. SETTING: A nonprofit, integrated health care system. PATIENTS: 101 adults with chronic low back pain. INTERVENTION: 12-week sessions of yoga or conventional therapeutic exercise classes or a self-care book. MEASUREMENTS: Primary outcomes were back-related functional status (modified 24-point Roland Disability Scale) and "bothersomeness" of pain (11-point numerical scale). The primary time point was 12 weeks. Clinically significant change was considered to be 2.5 points on the functional status scale and 1.5 points on the bothersomeness scale. Secondary outcomes were days of restricted activity, general health status, and medication use. RESULTS: After adjustment for baseline values, back-related function in the yoga group was superior to the book and exercise groups at 12 weeks (yoga vs. book: mean difference, -3.4 [95% CI, -5.1 to - 1.6] [P < 0.001]; yoga vs. exercise: mean difference, -1.8 [CI, -3.5 to - 0.1] [P = 0.034]). No significant differences in symptom bothersomeness were found between any 2 groups at 12 weeks; at 26 weeks, the yoga group was superior to the book group with respect to this measure (mean difference, -2.2 [CI, -3.2 to - 1.2]; P < 0.001). At 26 weeks, back-related function in the yoga group was superior to the book group (mean difference, -3.6 [CI, -5.4 to - 1.8]; P < 0.001). LIMITATIONS: Participants in this study were followed for only 26 weeks after randomization. Only 1 instructor delivered each intervention. CONCLUSIONS: Yoga was more effective than a self-care book for improving function and reducing chronic low back pain, and the benefits persisted for at least several months.

Adult↗
PubMed2005

Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors.

STUDY DESIGN: Prospective cohort study of randomly selected Veterans Affairs out-patients without baseline low back pain (LBP). OBJECTIVE: To determine predictors of new LBP as well as the 3-year incidence of magnetic resonance imaging (MRI) findings. SUMMARY OF BACKGROUND DATA: Few prospective studies have examined clinical and anatomic risk factors for the development of LBP, or the incidence of new imaging findings and their relationship to back pain onset. METHODS: We randomly selected 148 Veterans Affairs out-patients (aged 35 to 70) without LBP in the past 4 months. We compared baseline and 3-year lumbar spine MRI. Using data collected every 4 months, we developed a prediction model of back pain-free survival. RESULTS: After 3 years, 131 subjects were contacted, and 123 had repeat MRI. The 3-year incidence of pain was 67% (88 of 131). Depression had the largest hazard ratio (2.3, 95% CI = 1.2-4.4) of any baseline predictor of inci-dent back pain. Among baseline imaging findings, central spinal stenosis and nerve root contact had the highest, though nonsignificant, hazard ratios. We did not find an association between new LBP and type 1 endplate changes, disc degeneration, annular tears, or facet degeneration. The incidence of new MRI findings was low, with the most common new finding being disc signal loss in 11 (9%) subjects. All five subjects with new disc extrusions and all four subjects with new nerve root impingement had new pain. CONCLUSION: Depression is an important predictor of new LBP, with MRI findings likely less important. New imaging findings have a low incidence; disc extrusions and nerve root contact may be the most important of these findings.

Adult↗
PubMed2005

United States trends in lumbar fusion surgery for degenerative conditions.

STUDY DESIGN: Retrospective cohort study using national sample administrative data. OBJECTIVES: To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures. SUMMARY OF BACKGROUND DATA: Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery. METHODS: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection. RESULTS: In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses. CONCLUSIONS: Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.

Cohort Studies↗
PubMed2005

The role of alternative medical providers for the outpatient treatment of insured patients with back pain.

STUDY DESIGN: Analysis of health insurance claims from 2 large Washington State companies. OBJECTIVE: To evaluate the prevalence and cost of complementary and alternative medicine (CAM) provider use for back pain treatment. SUMMARY OF BACKGROUND DATA: Washington State requires all commercial insurance to cover licensed CAM providers. METHODS: Outpatient claims for the treatment of back pain were analyzed by the International Classification of Disease-9 codes and provider type. The number of visits and expenditures associated with different forms of treatments were calculated. RESULTS: Back pain accounted for 15% of all outpatient visits, and these companies spent more than $52 million on 652,593 claims submitted by 104,358 adults. Most people used only CAM (43%) or only conventional providers (45%) for back pain treatment, with merely 12% using both. Patients who saw only CAM providers had fewer comorbidities than the other 2 groups and made approximately twice as many visits as "conventional only" users (median 4 vs. 2). Average amount allowed per outpatient low back pain claim was lower for CAM visits (mean $50, SD $28) than for conventional visits (mean $128, SD $173). Total outpatient costs for the treatment of back pain were highest for the group using both CAM and conventional care (mean $1079, SD $1185), and lowest for the group using CAM only (mean $342, SD $429). CONCLUSION: Many people with back pain use only CAM for their treatment. Although less expensive, this group also appears to be less severely ill. Because of the high prevalence of this condition, cost-effectiveness studies that include CAM therapies are still warranted.

Adolescent↗
PubMed2005

A survey of training and practice patterns of massage therapists in two US states.

BACKGROUND: Despite the growing popularity of therapeutic massage in the US, little is known about the training or practice characteristics of massage therapists. The objective of this study was to describe these characteristics. METHODS: As part of a study of random samples of complementary and alternative medicine (CAM) practitioners, we interviewed 226 massage therapists licensed in Connecticut and Washington state by telephone in 1998 and 1999 (85% of those contacted) and then asked a sample of them to record information on 20 consecutive visits to their practices (total of 2005 consecutive visits). RESULTS: Most massage therapists were women (85%), white (95%), and had completed some continuing education training (79% in Connecticut and 52% in Washington). They treated a limited number of conditions, most commonly musculoskeletal (59% and 63%) (especially back, neck, and shoulder problems), wellness care (20% and 19%), and psychological complaints (9% and 6%) (especially anxiety and depression). Practitioners commonly used one or more assessment techniques (67% and 74%) and gave a massage emphasizing Swedish (81% and 77%), deep tissue (63% and 65%), and trigger/pressure point techniques (52% and 46%). Self-care recommendations, including increasing water intake, body awareness, and specific forms of movement, were made as part of more than 80% of visits. Although most patients self-referred to massage, more than one-quarter were receiving concomitant care for the same problem from a physician. Massage therapists rarely communicated with these physicians. CONCLUSION: This study provides new information about licensed massage therapists that should be useful to physicians and other healthcare providers interested in learning about massage therapy in order to advise their patients about this popular CAM therapy.

Adult↗
PubMed2005

A prospective cohort study of surgical treatment for back pain with degenerated discs; study protocol.

BACKGROUND: The diagnosis of discogenic back pain often leads to spinal fusion surgery and may partly explain the recent rapid increase in lumbar fusion operations in the United States. Little is known about how patients undergoing lumbar fusion compare in preoperative physical and psychological function to patients who have degenerative discs, but receive only non-surgical care. METHODS: Our group is implementing a multi-center prospective cohort study to compare patients with presumed discogenic pain who undergo lumbar fusion with those who have non-surgical care. We identify patients with predominant low back pain lasting at least six months, one or two-level disc degeneration confirmed by imaging, and a normal neurological exam. Patients are classified as surgical or non-surgical based on the treatment they receive during the six months following study enrollment. RESULTS: Three hundred patients discogenic low back pain will be followed in a prospective cohort study for two years. The primary outcome measure is the Modified Roland-Morris Disability Questionnaire at 24-months. We also evaluate several other dimensions of outcome, including pain, functional status, psychological distress, general well-being, and role disability. CONCLUSION: The primary aim of this prospective cohort study is to better define the outcomes of lumbar fusion for discogenic back pain as it is practiced in the United States. We additionally aim to identify characteristics that result in better patient selection for surgery. Potential predictors include demographics, work and disability compensation status, initial symptom severity and duration, imaging results, functional status, and psychological distress.

Back Pain↗
PubMed2005

Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study.

STUDY DESIGN: A prospective observational cohort study. OBJECTIVE: To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically. SUMMARY OF BACKGROUND DATA: The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments. METHODS: Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years. RESULTS: Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment. CONCLUSIONS: Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

Aged↗
PubMed2005

Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To assess 10-year outcomes of patients with sciatica resulting from a lumbar disc herniation treated surgically or nonsurgically. SUMMARY OF BACKGROUND DATA: There is little information comparing long-term outcomes of surgical and conservative therapy of lumbar disc herniation in contemporary clinical practice. Prior studies suggest that these outcomes are similar. METHODS: Patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Primary analyses were based on initial treatment received, either surgical or nonsurgical. Secondary analyses examined actual treatments received by 10 years. Outcomes included patient-reported symptoms of leg and back pain, functional status, satisfaction, and work and disability compensation status. RESULTS: Of 507 eligible consenting patients initially enrolled, 10-year outcomes were available for 400 of 477 (84%) surviving patients; 217 of 255 (85%) treated surgically, and 183 of 222 (82%) treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. By 10 years, 25% of surgical patients had undergone at least one additional lumbar spine operation, and 25% of nonsurgical patients had at least one lumbar spine operation. At 10-year follow-up, 69% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 61% of those initially treated nonsurgically (P = 0.2). A larger proportion of surgical patients reported that their low back and leg pain were much better or completely gone (56% vs. 40%, P = 0.006) and were more satisfied with their current status (71% vs. 56%, P = 0.002). Treatment group differences persisted after adjustment for other determinants of outcome in multivariate models. Change in the modified Roland back-specific functional status scale favored surgical treatment, and the relative benefit persisted over the follow-up period. Despite these differences, work and disability status at 10 years were comparable among those treated surgically or nonsurgically. CONCLUSIONS: Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with nonsurgically treated patients over 10 years. Nevertheless, improvement in the patient's predominant symptom and work and disability outcomes were similar regardless of treatment received. For patients in whom elective discectomy is a treatment option, an individualized treatment plan requires patients and their physicians to integrate clinical findings with patient preferences based on their symptoms and goals.

Adult↗
PubMed2005

Development and validation of the effectiveness of [corrected] auditory rehabilitation scale.

OBJECTIVE: To develop a new scale of hearing-related function and quality of life in patients with hearing aids that addresses overlooked concerns, such as hearing-aid comfort, convenience, and cosmetic appearance, that may influence hearing-aid adherence while maintaining brevity and sensitivity to clinical change. DESIGN: Prospective, multicenter instrument validation. SETTING: Four diverse sites in Washington State, including 2 private practices, 1 university setting, and 1 Veterans Affairs hospital. PATIENTS: Seventy-eight patients with hearing aids. INTERVENTIONS: We created 2 modules in the Effectiveness of Auditory Rehabilitation (EAR) scale. The first module (Inner EAR) covers intrinsic hearing issues such as hearing in quiet and hearing in noise and is administered both before and after treatment. The second module (Outer EAR) covers extrinsic (hearing-aid related) issues such as comfort, appearance, and convenience and is administered after hearing-aid fitting. MAIN OUTCOME MEASURES: Both scales were developed and validated in 3 stages. Stage 1 used a qualitative approach from multiple data sources to develop preliminary instruments. Stage 2 used approaches from classic test theory to reduce the number of items and psychometrically validate the instruments. Stage 3 examined the responsiveness or sensitivity to clinical change. RESULTS: A 10-item Inner EAR module and a 10-item Outer EAR module were created and validated. Internal consistency of individual domains (Cronbach alpha = 0.85 and 0.72, respectively) and test-retest reliability (intraclass correlation coefficients = 0.76 and 0.81, respectively) were excellent. Evidence of construct validity included concurrent validity with other hearing scales and global visual analog scales, discriminant validity with dizziness handicap, correlation with hearing-aid adherence, and confirmatory factor analyses. Both scales had strong evidence of responsiveness (sensitivity to change), with higher effect sizes and Guyatt responsiveness statistics than the 2 widely used hearing scales in this study. The scales took an average of 5 minutes to complete. CONCLUSIONS: The EAR scale is a valid and reliable measure of the effectiveness of amplification in the treatment of sensorineural hearing loss. It addresses the range of issues that are of importance to hearing-aid patients. The scales have excellent psychometric properties, are more responsive than several widely used hearing scales, and are minimally burdensome for patients to complete. The EAR may be a valuable outcome measure in future studies of both existing hearing aids and newer hearing-aid technologies, such as bone-anchored aids or middle ear implants.

Factor Analysis, Statistical↗