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

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

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