Wednesday, September 10, 2008

Back pain tx: Great work if ya can get it.

Expenditures increase while improvement is, well, have you looked at the stock market lately?

Expenditures and health status among adults with back and neck problems. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, SullivanSD. JAMA. 2008 Feb 13;299(6):656-64.

Well, I was looking into another topic, and came across this January JAMA article.

Martin and colleagues use some wide-ranging hospital data to calculate expenses for back pain. Along with this, the cool thing is they are able to look at the benefits of this treatment.
The data set was: the Medical Expenditures Panel Survey. Or, MEPS.

MEPS is carried out year after year. A big federal attempt to describe where you and I spend our health care dollar, and for what problem or symptom. Questions are asked about problems and symptoms, and the researchers also try to figure out what you paid to treat the problem. This is a big study, folks, with many people looking over the shoulder of the design and implementation, as well as sample sizes well beyond 10,000. So, this is no "Dewey Beats Truman" poll. (Although it could be in the future, depending upon how they transition to cell phone recruitment).

Now, either you are a current back pain patient, or you are a "pre-consumer." Either way: ask yourself: for my current or future back pain, as I spend money on my care, what do I want for my dollar? what are the outcomes I am concerned about?

This is what the researchers evaluated. This JAMA-published MEPS study compares results from 1997 to 2005 -- almost a decade.

Here are the outcomes. "Physical functioning:" Can you rake the yard? Load the dishwasher? Reach the top shelf? "Work:" are you able to get back to the same job you had before back pain treatment? "School:" Are you able to get back to scholastic pursuits, if any, that were interrupted by the back pain?

The answer:
Costs (as proper, dollars adjusted for inflation) increased per patient from $4700 in 1997 to $6100 in 2005.
Outcomes: the same. These people spent more to arrive at the same outcome.

Because this is an amazing finding, and because ink is cheap on the internet, let me repeat:
These people spent more to arrive at the same outcome.

So, if practicing back pain treatment, and a patient asks about empirical evidence for outcomes, what do you tell them? "I will carry out the recognized interventions, but chances are that you will not get better"?

To be honest, that seems to be the answer.

This is consistent with an extensive body of knowledge that has indicated that: results for back pain treatment, notably medication and surgery, are not great; and a decent, satisfactory body of evidence indicating that physical therapy and almost-mandatory emphases on activity do achieve results, but the pills and surgery lead to both worse outcomes, and to the sad result of a patient who sees the answer solely in terms of the right pill or the right surgery.

Some day soon I will put together a handful of info for this blog on the lousy outcomes for traditional, recognized, reimbursed back pain interventions, and also share some of the evidence showing the unorthodox but encouraging evidence for appropriate physical therapy, including where this concept parallels Pilates and yoga, and also for the benefits of more psychological-type interventions like social involvement and psychotherapy.

Speaking of pain and orthodoxy, there has even been a small but decent emphasis on evaluating yoga intervention for carpal tunnel syndrome.

Meds Vs Therapy for back pain. Therapy continues to lead on this one.
Frankly, having resolved my own lower back pain, at no expense, and hearing similar successes of others, plus having done training rotations in "pain/aneasthisiology," (and binging on the free lunches as the new meds and devices emerged), and having read a bunch on the topic, including Block specifically but Cochrane as well, this topic just seems ready to declare: stick-a-fork-in-me.

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