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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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Michael E. Chernew, PhD, Co-Editor-in-Chief, The American Journal of Managed Care
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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 Denis Ishisaka, PharmD, MS

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 Denis Ishisaka, PharmD, MS
This study describes the patient characteristics and healthcare utilization of a chronic pain population within an integrated healthcare system in northern California.
After statistical adjustment for important covariates, an increased number of CP types per patient was associated with a higher rate of office visits (P <.001 for all levels vs 1 CP type), ED visits (P <.001 for all levels vs 1 CP type), and hospitalizations (P <.001 for 2 or 3 CP types vs 1 CP type), but not 30-day hospital readmissions (Figure 4). Linear trends for the relationship between healthcare utilization rates and number of CP types per patients were statistically significant (P <.001 each for office visits, ED visits, and hospitalizations). Unadjusted and adjusted point estimates for categorical and linear trends are provided in eAppendix Table 2.


In this large, cross-sectional analysis of patients with noncancer CP from a community-based healthcare delivery system in northern California in 2012, we found that the most common type of CP was arthritis/joint pain, with more than half of all patients with CP having a diagnosis of this type (57%). Among the 20 individual CP conditions, the most common were joint pain (41%), back pain (39%), limb pain (27%), osteoarthritis (23%), and cervical radiculopathy (17%). We also found that the majority of patients with CP had more than 1 type of pain (60%), with a median of 2 unique CP types per patient; those with unclassified pain were most likely to have multiple CP types. Furthermore, patients across the various types of CP were heterogeneous with respect to age, sex, and disease burden, but were largely similar by race/ethnicity. In terms of healthcare utilization, patients with unclassified pain had the highest crude rates of office visits and ED visits, and patients with neuropathies/neuralgias had the highest crude rates of hospitalizations and 30-day hospital readmissions.

Regardless of CP type, an increased number of types of CP per patient was linearly associated with higher rates of office visits, ED visits, and hospitalizations, but not hospital readmissions. The relationship between the number of conditions and utilization rates was observed even after controlling for important drivers of resource use, including age and prior healthcare utilization. The magnitude of this relationship was most pronounced for office visits and ED visits, but was less for hospitalizations, especially for patients with all 5 CP types. We noted that less than 1% of patients had all 5 CP types (0.77%). Thus, there was limited power to detect statistically significant differences in outcomes between this group and others, particularly for relatively rare events, such as hospitalization or hospital readmissions.

Studies of CP have been previously performed in a variety of healthcare system settings6,7,10; most, however, have focused on assessing disease prevalence for individual CP conditions. Lamerato and colleagues recently showed that among patients in an integrated healthcare delivery network, the overall prevalence of CP in 2010 was approximately 10% to 12% and that the most common CP conditions were joint pain, limb pain, back pain, and osteoarthritis.6 These data are largely consistent with our findings, using a similar definition of CP; however, in their study, Lamerato and colleagues did not exclude patients with cancer-related pain or acute pain due to surgery. Nevertheless, similar to our study, the authors demonstrated that patients with CP are heterogeneous with regard to age and sex, but are largely similar across racial/ethnic groups.6 The results of ours and other studies have shown that females are disproportionately affected by CP conditions; in particular, headaches/migraines and unclassified pain, which is inclusive of pelvic pain and fibromyalgia.6,7,10-12 

Our study adds to the current body of knowledge by further demonstrating that patients across various types of CP differ with regard to overall chronic disease burden and rates of healthcare utilization. We also show that the number of concurrent CP types is linearly associated with the incident rates of office visits, ED visits, and hospitalizations. To our knowledge, our study is the first to characterize the relative use of healthcare resources across patients with different types of CP. 

Several CP types are potentially the most impactful to the healthcare system, including neuropathies/neuralgias (eg, diabetic neuropathy, neuralgia, postherpetic pain), arthritis/joint pain (eg, osteoarthritis, rheumatoid arthritis), and unclassified pain (eg, general pain, fibromyalgia). Notably, these types of CP are impactful for different reasons. Arthritis and joint pain are highly prevalent conditions, affecting a large number of patients.  However, unclassified pain affects fewer patients, who, on average, have more concurrent types of painful conditions and use more outpatient and ED services. On the other hand, neuropathies/neuralgias are relatively prevalent, but more often affect the elderly and are associated with a greater burden of comorbidity, which ostensibly drives higher hospitalization rates and readmissions.

In a 2014 study of Medicare beneficiaries, Johnston and colleagues reported higher average comorbidity index scores among patients with pain from diabetic neuropathy (mean = 3.4) compared with patients with postherpetic neuralgia or fibromyalgia (mean = 1.3, for each). The authors also found that total annual healthcare costs due to inpatient admissions, outpatient services, and outpatient prescriptions were highest among patients with diabetic neuropathy.13 Total annual healthcare costs in 2010 US dollars for patients with diabetic neuropathy were $24,740 compared with $18,320 and $16,579 for patients with fibromyalgia and postherpetic neuralgia, respectively. Approaches to mitigating the burden of CP conditions on the healthcare system will likely require individualized strategies. 


The findings of this study should be interpreted in the context of several limitations. This was a cross-sectional analysis of patients with prevalent, non–mutually exclusive types of CP. We did not have comprehensive information on disease history; thus, variation across CP types, in terms of disease comorbidity and healthcare utilization rates, may be attributable to differences in disease onset and progression.

In our analysis, approximately 7% of all patients within the healthcare system in 2012 had at least 1 of 20 CP conditions based on our eligibility criteria. Our observed point prevalence (7%) is lower than that reported by Lamerato and colleagues (10%-12%) among continuously enrolled patients from a managed-care health system in Detroit, Michigan.6 Although geographic or demographic differences between study populations may explain this discrepancy, we recognize that our cohort was different as it was derived from an open-network healthcare system with primarily FFS/PPO beneficiaries. Therefore, the prevalence of CP reported herein may be underestimated.

Identifying the appropriate “denominator” in an open-network healthcare system is problematic and requires further validation since it is difficult to determine the true annual population based on those who have utilized services. We used rather strict eligibility criteria to ensure that patients had previous contact with our health system. Although relaxing these criteria would increase the point prevalence (Figure 1), we chose higher specificity over sensitivity. Through an Internet-based nationally representative sample of adults in the United States in 2010, the prevalence of CP was estimated at 30.7%,14 which is much higher than that reported in our study and in the Lamerato study.6 This may be due to inherent methodological biases when data are collected from surveys compared with EHR or administrative claims. For example, the detection of patients with CP through encounter diagnoses is dependent on conditions being sufficiently painful to warrant medical services and the healthcare provider to appropriately code the condition.

In this study, we did not take into account reasons for healthcare encounters; thus, utilization rates across different types of CP do not necessarily reflect treatment for specific diagnoses. The use of EHR data from an open-network healthcare system may have also underestimated overall healthcare utilization rates, as patients may have received care outside of the system. However, we do not believe that use of outside resources would be different across the various types of CP. Lastly, the generalizability of the findings to other regions in the United States and to other healthcare systems (eg, closed managed-care systems or the Veterans Affairs system) is unknown.


The management of CP is of growing interest to healthcare organizations due to its prevalence, economic impact, and burden on patients’ quality of life. Several CP types including neuropathies/neuralgias, arthritis/joint pain, and unclassified pain are potentially the most impactful to the healthcare system. Health systems can learn from these findings to target efforts to improve the management of patient with CP, particularly those with multiple pain conditions.

Author Affiliations: Palo Alto Medical Foundation Research Institute (RJR), Palo Alto, CA; Clinical Outcomes Research, Clinical Integration Department, Sutter Health (RJR, TJ, DI), Sacramento, CA; Pfizer Inc (SNS, LI, BL, TLC, JCC), New York, NY
Source of Funding: This study was sponsored by Pfizer. Sutter Health received financial support from Pfizer in connection with this study and the development of this manuscript.
Author Disclosures: Dr Romanelli and Mr Jukes are employees of Sutter Health, and paid consultants to Pfizer in connection with this study and the development of this manuscript. Dr Ishisaka was an employee of Sutter Health at the time the study was conducted and is currently an employee of Blue Shield of California. Drs Shah, Ikeda, Lynch, Craig, and Cappelleri are employees of Pfizer. 
Authorship Information: Concept and design (RJR, SNS, LI, BL, TLC, JCC, TJ, DI); acquisition of data (TJ); analysis and interpretation of data (RJR, SNS, LI, BL, TLC, JCC, TJ, DI); drafting of the manuscript (RJR, SNS, TJ, DI); critical revision of the manuscript for important intellectual content (RJR, SNS, LI, BL, TLC, JCC, DI); statistical analysis (RJR, JCC); obtaining funding (LI, BL, TLC, DI); administrative, technical, or logistic support (BL, TLC, DI); and supervision (BL, TLC, DI). 
Address Correspondence to: Robert J. Romanelli, PhD, Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Ames Bldg, Palo Alto, CA 94301. E-mail: 

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