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The American Journal of Managed Care February 2017
Synchronized Prescription Refills and Medication Adherence: A Retrospective Claims Analysis
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Addressing the Chronification of Disease
Michael E. Chernew, PhD, Co-Editor-in-Chief, The American Journal of Managed Care
Economic Burden of Hypoglycemia With Basal Insulin in Type 2 Diabetes
Vivian Fonseca, MD; Engels Chou, MS; Hsing-Wen Chung, PhD; and Charles Gerrits, PhD, PharmD
Treating Medicaid Patients With Hepatitis C: Clinical and Economic Impact
Zobair Younossi, MD; Stuart C. Gordon, MD; Aijaz Ahmed, MD; Douglas Dieterich, MD; Sammy Saab, MD; and Rachel Beckerman, PhD
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Cindy Reistroffer, DSc; Larry R. Hearld, PhD; and Jeff M. Szychowski, PhD
Sustained Participation in a Pay-for-Value Program: Impact on High-Need Patients
Dori A. Cross, BSPH; Genna R. Cohen, PhD; Christy Harris Lemak, PhD; and Julia Adler-Milstein, PhD
Value-Based Contracting Innovated Medicare Advantage Healthcare Delivery and Improved Survival
Aloke K. Mandal, MD, PhD; Gene K. Tagomori, BSc; Randell V. Felix, BSc; and Scott C. Howell, DO, MPH&TM
Community-Based Asthma Education
Rohini Rau-Murthy, BA; Leslie Bristol, RRT, AE-C; and David Pratt, MD, MPH
Perceptions of the Medical Home by Parents of Children With Chronic Illnesses
Emily B. Vander Schaaf, MD, MPH; Elisabeth P. Dellon, MD, MPH; Rachael A. Carr, BA; Neal A. deJong, MD; Asheley C. Skinner, PhD; and Michael J. Steiner, MD, MPH
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Patient Characteristics and Healthcare Utilization of a Chronic Pain Population Within an Integrated Healthcare System
Robert J. Romanelli, PhD; Sonali N. Shah, RPh, MBA, MPH; Laurence Ikeda, MD; Braden Lynch, PharmD, MS, CPEHR; Terri L. Craig, PharmD, CPEHR; Joseph C. Cappelleri, PhD, MPH, MS; Trevor Jukes, MS; and D

Patient Characteristics and Healthcare Utilization of a Chronic Pain Population Within an Integrated Healthcare System

Robert J. Romanelli, PhD; Sonali N. Shah, RPh, MBA, MPH; Laurence Ikeda, MD; Braden Lynch, PharmD, MS, CPEHR; Terri L. Craig, PharmD, CPEHR; Joseph C. Cappelleri, PhD, MPH, MS; Trevor Jukes, MS; and D
This study describes the patient characteristics and healthcare utilization of a chronic pain population within an integrated healthcare system in northern California.
ABSTRACT

Objectives: We sought to characterize the chronic pain (CP) population and healthcare utilization across types of CP within a community-based healthcare system. 
 
Study Design: Cross-sectional study of electronic health records data from 2012. 
 
Methods: Patients 18 years or older with at least 2 encounter diagnoses for CP conditions in 2012 were included in the study. Patients were categorized into non–mutually exclusive CP types: arthritis/joint pain, back/cervical pain, neuropathies/neuralgias, headaches/migraines, and unclassified pain. 
 
Results: Of 1,784,114 patients, 120,481 (6.8%) met the criteria for the CP study cohort. Within the cohort, the most common types of CP were arthritis/joint pain (57%), back/cervical pain (49%), and neuropathy/neuralgias (40%). Patients with neuropathies/neuralgias were older than patients with other pain types and had more comorbidities (for neuropathies/neuralgias: mean age, 59 years; Charlson Comorbidity Index score >3, in 28% of patients). Patients with unclassified pain were most likely to be female (82%). Rates of office and emergency department (ED) visits were highest in patients with unclassified pain (5136 events and 209 events per 1000 patients, respectively). Rates of hospitalizations and 30-day hospital readmissions were highest in patients with neuropathies/neuralgias (70 events and 287 events per 1000 patients, respectively). An increased number of CP types was linearly associated with higher rates of office, ED, and hospital visits.
 
Conclusions: Based on prevalence, comorbidities, and healthcare utilization, several types of CP, including neuropathies/neuralgias, arthritis/joint pain, and unclassified pain, appear to be most impactful. Health systems can use these findings to target efforts to improve the management of patients with CP, particularly those with multiple pain-related conditions. 

Am J Manag Care. 2017;23(2):e50-e56
Take-Away Points

Patients with chronic pain (CP) are not a homogeneous population; they differ in terms of age, sex, overall chronic disease burden, and their use of health resources. 
  • Certain CP conditions appear to impact the healthcare system more than others, including neuropathies/neuralgias, arthritis/joint pain, and unclassified pain. 
  • Patients with multiple CP conditions, regardless of type of condition, used more healthcare resources than patients with fewer CP conditions. 
  • Health systems can use these findings to target efforts to improve the management of patients with CP.
In the United States, approximately 100 million adults are affected by noncancer chronic pain (CP).1 CP causes substantial disability and has an impact on an individual’s productivity, functional status, and mood/mental health.2-4 A report from the Institute of Medicine (now the National Academy of Medicine) estimated that the annual direct and indirect costs of CP in the United States were $635 billion (in 2010 dollars)—which exceeds the costs of heart disease, cancer, and diabetes.1 

CP has received much attention in recent years due to its prevalence, economic impact, and burden on patients’ quality of life; additionally, an aging population has a greater propensity to develop painful conditions. Patients with CP tend to be high utilizers of healthcare resources, and painful conditions (eg, osteoarthritis, joint disorders, back pain) represent some of the most common reasons for healthcare encounters in the United States.5 Annual healthcare expenditures are, on average, nearly $5000 higher for patients with CP than for those without.1 

Patients with CP are not a homogenous population,6 as CP is associated with multiple disease states and patients often have more than 1 type of CP, which introduces complexity to pain management. Accordingly, targeted initiatives are needed to better identify, oversee, and coordinate care for patients with CP within the healthcare system and to direct these patients to appropriate resources to manage pain symptoms.

Few studies have evaluated how different types of CP impact the healthcare system. In this study, we sought to characterize the CP population within a community-based healthcare delivery system and to quantify healthcare utilization across types of CP within this population.

METHODS

Study Design and Setting

This study was conducted as a retrospective cross-sectional analysis of Sutter Health electronic health record (EHR) data from January 1 to December 31, 2012. Sutter Health is a community-based, nonprofit, open-network healthcare delivery system that provides ambulatory (primary and specialty care) and inpatient services across northern California. In 2013, the system served more than 3 million patients, with a total of 10 million outpatient visits; 800,000 emergency department (ED) visits; and nearly 200,000 hospital discharges. The EHR system, EpicCare, is integrated across ambulatory clinics and hospitals, which allows a clinician to view patient information throughout the continuum of care. The clinical population is generally representative of the underlying geographic area with respect to age, sex, and race/ethnicity.

This study was approved by the Institutional Review Board of the Palo Alto Medical Foundation Research Institute. All data were de-identified in accordance with the Health Insurance Portability and Accountability Act standards. 

Study Cohort

Patients were included in the study cohort if they were 18 years or older, had at least 2 International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) encounter diagnoses for a CP condition in 2012 that were at least 30 days apart, and had at least 1 encounter of any type prior to 2010 to confirm prior health system contact. Patients were excluded if they had an encounter or problem list diagnosis for a malignancy (other than nonmelanoma skin cancer) in the 2 years prior to 2012 or had surgery in the 3 months prior to the first CP encounter in 2012. 

Patients were grouped into 20 non–mutually exclusive CP conditions based on ICD-9-CM diagnoses, which were further categorized into 5 types of CP: 1) arthritis/joint pain (arthropathy, osteoarthritis, rheumatoid arthritis, joint pain); 2) back/cervical pain (back pain, cervical radioculopathy, lumbar radiculopathy, spinal cord injury); 3) neuropathies/neuralgias (postherpetic neuropathy, diabetic neuropathy, neuropathy, neuralgia, surgically induced pain, limb pain); 4) headaches/migraines; and 5) unclassified pain (pelvic pain, abdominal pain, general pain, fibromyalgia).

The ICD-9-CM codes for CP conditions were based on well-described criteria from a recent study of CP in a single large healthcare delivery system.6 The 5 CP types were based on the anatomic location and pain pathophysiology of CP conditions.  These CP types are also based on previous research4,7 and were developed with input from both Sutter and Pfizer investigators, including clinical pharmacists and a physician, with the specific exclusion of cancer pain and acute pain that may be due to surgery. The ICD-9-CM codes for each CP condition are provided in eAppendix Table 1 (eAppendices available at ajmc.com). 

Data Collection

Patient demographics, clinical characteristics, and healthcare encounters (office visits, ED visits, hospitalizations, and 30-day hospital readmissions) were obtained retrospectively from the clinical EHR and from administrative databases containing medical claims. We did not restrict encounters to those only related to pain. Race/ethnicity data are from patient self-reports collected as a part of routine clinical practice and were categorized as non-Hispanic white (NHW), African American, East/Southeast Asian (Chinese, Japanese, Korean, Filipino, or Vietnamese), South Asian (Asian Indian), Hispanic (of any race), other (Pacific Islander, American Indian/Alaskan Native, of multiple races, or race reported as “other”), and unknown.

Disease burden was calculated by the Charlson Comorbidity Index (CCI) score.8 Insurance type was categorized as commercial (fee-for-service [FFS], preferred provider organization [PPO], health maintenance organization, point of service), Medicare, Medicaid, multiple payers (combination of commercial, Medicare, and/or Medicaid), other, self-pay, or unknown.

Data Analysis

Descriptive statistics were used to summarize continuous variables (means, medians) and binary or categorical variables (relative frequency distributions) for the 5 CP types, as well as for each of the 20 CP conditions. Rates of healthcare resource utilization were calculated as the number of events per 1000 patients in 2012. We applied negative binomial regression models to assess the relationship between the primary outcome of interest, healthcare utilization (counts of office visits, ED visits, hospitalizations, or 30-day hospital readmissions in 2012), and the main predictor of interest: the number of CP types per patient taken as a nominally measured predictor (ie, total number of CP types per patient, with the reference category as 1 CP type).9

Patient demographics and characteristics were included as covariates in all models for statistical adjustment (age, sex, race/ethnicity, insurance payer, prior counts of utilization, and geographic region of the clinical catchment area). In the same type of model, we further examined the linear association between healthcare utilization rates and the number of CP types by taking the latter as an ordinally—instead of nominally—measured predictor. Relative rates of each outcome were expressed as incident rate ratios (IRRs) with 95% confidence intervals (CI). A P value <.05 was considered statistically significant. 

RESULTS

Chronic Pain Cohort Selection

We identified 1,784,114 patients who were 18 years or older and had at least 1 EHR encounter of any type in 2012; of these, 23% had at least 1 CP encounter and 11% had at least 2 CP encounters at least 30 days apart (Figure 1). Altogether, 120,481 patients (6.8%) met eligibility criteria for the CP cohort.

Chronic Pain Cohort Characteristics

CP patients were, on average, aged 56 years; the majority was female (66%) and NHW (63%) (Table). Most patients with CP (60%) had more than 1 type (median = 2), 57% had arthritis/joint pain, 49% had back/cervical pain, 40% had neuropathies/neuralgias, 23% had headaches/migraines, and 20% had unclassified pain. 

Patients with headaches/migraines and unclassified pain were, on average, younger (mean = 49 and 54 years, respectively) than those with other types of CP and were more likely to be female (81% and 82%, respectively) (Table). Patients with arthritis/joint pain and neuropathies/neuralgias tended to have the highest burden of comorbidity (CCI >3 in 25% and 28% of patients, respectively) compared with patients with other types of CP. Patients with headaches/migraines were the most likely to be commercially insured beneficiaries (65%) and the least likely to be Medicare beneficiaries (6%). No racial/ethnic differences were found across the types of CP. Patients with unclassified pain were most likely to have more than 1 type of CP (88%), with a median of 3 unique types. 

The relative frequency distribution of each CP condition among all CP types is shown in Figure 2. Joint pain was the most common CP condition (41%), followed by back pain (39%). Comorbidity burden by each CP condition is provided in eAppendix Figure 1

Healthcare Utilization

Patients with unclassified pain had the highest rates of crude (unadjusted) office visits (5136 per 1000 patients) followed by those with neuropathies/neuralgias (4865 per 1000 patients) (Figure 3). Crude ED visit rates were highest among patients with unclassified pain (209 per 1000 patients), followed by those with headaches/migraines (180 per 1000 patients).

Crude hospitalization rates were highest among patients with neuropathies/neuralgias (70 per 1000 patients), followed by those with unclassified pain (67 per 1000 patients). Among approximately 5% of patients with CP with a hospitalization in 2012, rates of 30-day readmissions were highest among patients with neuropathies/neuralgias (287 per 1000 patients), followed by those with unclassified pain (255 per 1000 patients).

The crude rates of healthcare utilization for each of the 20 CP conditions are provided in eAppendix Figures 2 through 5. Highest rates of office visits per 1000 patients were found among those with lumbar radiculopathy (6409), surgical pain (6265), neuralgia (6093), fibromyalgia (5434), and general pain (5433) (eAppendix Figure 2). Highest rates of ED visits per 1000 patients were found among those with spinal cord injury (347), general pain (226), pelvic pain (226), headaches (206), and surgical pain (205) (eAppendix Figure 3). Highest hospitalization rates per 1000 patients were found among those with spinal cord injury (179), diabetic neuropathy (130), postherpetic neuropathy (84), neuropathy (82), and osteoarthritis (80) (eAppendix Figure 4). Among patients with a hospitalization in 2012, the highest rates of 30-day readmissions per 1000 patients were found among those with neuralgia (490), diabetic neuropathy (370), rheumatoid arthritis (346), general pain (315), and neuropathy (270) (eAppendix Figure 5). 

 
Copyright AJMC 2006-2017 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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