OBJECTIVE To assess the relationship between depression and anxiety comorbidity on pain intensity, pain-related disability, and health-related quality of life (HRQL). METHODS Analysis of baseline data from the Stepped Care for Affective disorders and Musculoskeletal Pain (SCAMP) Study. All patients (N = 500) had chronic pain (≥ 3 months duration) of the low back, hip or knee. Patients with depression were over-sampled for the clinical trial component of SCAMP and thus represented 50% of the study population. Patients were categorized according to pain comorbid with depression, anxiety, or both. We used ANOVA and MANOVA models to asess relationships between independent and dependent variables. RESULTS Participants had a mean age of 59 years; were 55% women, 56% white and 40% black. Fifty-four percent (n=271) reported pain only, 20% (n=98) had pain and depression, 3% (n=15) had pain and anxiety, and 23% (n=116) had pain, depression, and anxiety. Patients with pain and both depression and anxiety experienced the greatest pain severity (p < .0001) and pain-related disability (p < .0001). Psychiatric comorbidity was strongly associated with disability days in the past 3 months (p < .0001), with 18.1 days reported by patients with pain only, 32.2 days by those with pain and anxiety, 38.0 days by those with pain and depression, and 42.6 days in those with all three conditions. We found a similar pattern of poorer HRQL (p <.0001) in those with pain, depression, and anxiety. CONCLUSIONS The added morbidity of depression and anxiety with chronic pain is strongly associated with more severe pain, greater disability, and poorer HRQL.

Context Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs.Objective To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. Design, Setting, and Patients Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 communitybased clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score Ն10).Intervention Patients were randomly assigned to the intervention (n=123) or to usual care (n=127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3).Main Outcome Measures Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months.Results At 12 months, 46 of the 123 intervention patients (37.4%) had a 50% or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (Ն30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]). ConclusionOptimized antidepressant therapy followed by a pain selfmanagement program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability.

BACKGROUND: Inadequate pain assessment is a barrier to appropriate pain management, but single-item "pain screening" provides limited information about chronic pain. Multidimensional pain measures such as the Brief Pain Inventory (BPI) are widely used in pain specialty and research settings, but are impractical for primary care. A brief and straightforward multidimensional pain measure could potentially improve initial assessment and followup of chronic pain in primary care. OBJECTIVES:To develop an ultra-brief pain measure derived from the BPI.DESIGN: Development of a shortened three-item pain measure and initial assessment of its reliability, validity, and responsiveness. PARTICIPANTS:We used data from 1) a longitudinal study of 500 primary care patients with chronic pain and 2) a cross-sectional study of 646 veterans recruited from ambulatory care.RESULTS: Selected items assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G). Reliability of the threeitem scale (PEG) was α=0.73 and 0.89 in the two study samples. Overall, construct validity of the PEG was good for various pain-specific measures (r=0.60-0.89 in Study 1 and r=0.77-0.95 in Study 2), and comparable to that of the BPI. The PEG was sensitive to change and differentiated between patients with and without pain improvement at 6 months. DISCUSSION:We provide strong initial evidence for reliability, construct validity, and responsiveness of the PEG among primary care and other ambulatory clinic patients. The PEG may be a practical and useful tool to improve assessment and monitoring of chronic pain in primary care.

BACKGROUND-Current methods of risk adjustment rely on diagnoses recorded in clinical and administrative records. Differences among providers in diagnostic practices could lead to bias.

Background Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals. Study design Using the national Medicare database, we identified patients undergoing one of 4 inpatient procedures in 2005 (coronary artery bypass, hip fracture repair, back surgery, and colectomy). For each procedure, price-standardized Medicare payments from the date of admission for the index procedure to 30 days post discharge were assessed and categorized by payment type (hospital, physician, and post-acute care) and sub-type. Results Average total payments for inpatient surgery episodes varied from $26,515 for back surgery to $45,358 for CABG. Hospital payments accounted for the largest share of total payments (60-80%, depending on procedure), followed by physician payments (13-19%) and post-acute care (7-27%). Overall episode payments for hospitals in the lowest and highest payment quartiles differed by $16,668 for CABG, $18,762 for back surgery, $10,615 for hip fracture repair, and $12,988 for colectomy. Payments to hospitals accounted for the largest share of variation in payments. Among specific types of payments, those associated with 30-day readmissions, and post-acute care varied most substantially across hospitals. Conclusions Fully bundled payments for inpatient surgical episodes would need to be dispersed among many different types of providers. Hospital payments—both overall and for specific services—vary considerably and might be reduced by incentives for hospitals and physicians to improve quality and efficiency.

Per capita Medicare spending is more than twice as high in New York City and Miami than in places like Salem, Oregon. How much of these differences can be explained by Medicare's paying more to compensate for the higher cost of goods and services in such areas? To answer this question, we analyzed Medicare spending after adjusting for local price differences in 306 Hospital Referral Regions. The price-adjustment analysis resulted in less variation in what Medicare pays regionally, but not much. The findings suggest that utilization—not local price differences—drives Medicare regional payment variations, along with special payments for medical education and care for the poor.

OBJECTIVE:To evaluate the effectiveness of a community pharmacist-based home blood pressure (BP) monitoring program. DESIGN:Trial of a high-intensity (HI) versus low-intensity (LI) intervention randomized in 12 community pharmacies. The HI intervention comprised 4 face-to-face visits with a trained pharmacist. Pharmacists provided patient-specific education about hypertension. Following the first and third visits, patients were provided with a home BP monitoring device and instructed to measure their BP at least once daily for the next month. Home BP readings were used by the pharmacists to develop treatment recommendations for the patient's physician. Recommendations were discussed with the physician and, if approved, implemented by the pharmacist. In the LI intervention, pharmacists measured patients BP in the pharmacy and referred them to their physician for evaluation. PARTICIPANTS:Patients with uncontrolled BP at baseline. MEASUREMENTS:The main outcomes were the differences in systolic and diastolic BP (SBP and DBP) from baseline to follow-up between the HI and LI patients. RESULTS:The study enrolled 125 patients, 64 in the HI and 61 in the LI group. From baseline, SBP declined 13.4 mmHg in the HI group and 9.0 mmHg in the LI group. At the final visit, the difference in SBP/DBP change between the HI and LI group was À 4.5/ À 3.2 mmHg (P =.12 for SBP and P =.03 for DBP). CONCLUSIONS:The HI intervention achieved a lower DBP and this model could be a strategy for patients with hypertension.

BACKGROUND: Most estimates of short‐ and long‐term survival after hepatic resection of colorectal cancer metastases are derived from surgical case series. For the current report, the authors used Medicare data to investigate operative mortality and long‐term survival in a national sample and examined the factors associated with survival. METHODS: Data were analyzed from Medicare enrollees (age ≥65 years) who were admitted to hospital between January 1, 2000 and December 31, 2004 with a primary diagnosis of colorectal cancer with resection. The sample was restricted to patients who subsequently underwent hepatic resection for liver metastases. The Medicare Denominator File was used to determine operative mortality and long‐term survival and the factors that were associated with those outcomes. RESULTS: Of the 306,061 Medicare beneficiaries who were diagnosed with colorectal cancer, 3957 patients were identified who underwent hepatic resection for liver metastases. The crude 30‐day and 90‐day mortality rates were 4% and 8.2%, respectively, and the 5‐year survival rate was 25.5%. Advancing age (hazards ratio [HR], 1.83; 95% confidence interval [95% CI], 1.32‐2.53 for age ≥80 years vs ages 65‐69 years), comorbid disease (HR, 1.40; 95% CI, 1.06‐1.85 for Charlson ≥5 vs Charlson 0), and synchronous colon/hepatic resection (HR, 2.46; 95% CI, 1.89‐3.20 for synchronous vs metachronous resection) were associated with worse 90‐day mortality. Similarly, long‐term mortality was associated with age (HR, 1.36; 95% CI, 1.18‐1.56), comorbid disease (HR, 1.51; 95% CI, 1.36‐1.69), and synchronous colon/hepatic resection (HR, 1.37; 95% CI, 1.24‐1.51 for synchronous vs metachronous resection). CONCLUSIONS: In this national study, short‐ and long‐term survival was worse than that reported in surgical case series. Subgroups at high risk for worse outcomes include the extreme elderly and those undergoing synchronous colon and hepatic resection. Cancer 2009. © 2009 American Cancer Society.