Background
Methods/design
BOLD registry
Overview
Participating centers
Institutional review board (IRB) approval
Subject eligibility
Inclusion Criteria
| |
1. | Age ≥ 65 years |
2. | Primary care visit for back pain based on ICD9 code (Table 2) |
Exclusion criteria:
| |
1. | Health care encounter for back pain within 6 months |
2. | Previously contacted for registry participation |
3. | Prior lumbar spine surgery |
4. | Developmental spine deformities |
5. | Inflammatory spondyloarthropathy |
6. | Spinal malignancy or infection |
7. | History of cancer within past 5 years excluding non-melanomatous skin cancer |
8. | History of HIV within past 5 years |
9. | No telephone |
10. | Planning on leaving Health System within the next 12 months |
11. | Unable to understand English |
12. | Severe mental impairment that would interfere with answering questions |
Patient identification
Inclusion Diagnoses | Exclusion Diagnoses | ||
---|---|---|---|
ICD9 Code | Description | ICD9 Code | Description |
307.89 | Psychogenic backache | V66.7 | Encounter for palliative care |
721.3 | Lumbosacral spondylosis w/o myelopathy | 042, 079.53 | HIV within the last five years |
140-239.9 (except 173, 210–229) | Cancer other than non-melanoma skin cancer within the last 5 years and benign neoplasms | ||
721.5 | Kissing spine (Baastrup Disease) | 290.0–290.4 | Dementia |
721.6 | Ankylosing vertebral hyperostosis | 324.1 | Intraspinal abscess |
721.7 | Traumatic spondylopathy | 331.0 | Alzheimer’s disease |
721.8 | Other allied disorders of spine | 630–676 | Pregnancy-related diagnoses |
721.9 | Spondylosis of unspecified site w/o myelopathy | 720.0–720.9 | Inflammatory spondyloarthropathies |
721.90 | Spondylosis of unspecified site w/o myelopathy | 730–730.99 | Osteomyelitis |
722.1 | Displacement of thoracic or lumbar disc w/o myelopathy | 737.30–737.39 737.40–737.43 | Developmental spine deformities |
722.10 | Displacement of lumbar disc w/o myelopathy | 733.8, 733.81–733.8InternalRef>) | Non-union/mal-union of fracture |
722.11 | Displacement of thoracic disc w/o myelopathy | 805–806.9 | Fractures of spinal column |
722.2 | Degeneration of intervertebral disc, site unspecified | 839–839.59 | All vertebral dislocations |
722.3 | Schmorl’s nodes | E800-E849.9 | Vehicular accidents |
722.31 | Schmorl’s nodes- thoracic region | 03.09; 80.50 | Prior lumbar surgery: |
722.32 | Schmorl’s nodes- lumbar region | 80.51; 80.52; | ·Laminectomy |
722.5 | Degeneration of thoracic or lumbar intervertebral disc | 80.59; 81.00; | ·Discectomy |
722.51 | Degeneration of thoracic or thoracolumbar intervertebral disc | 81.06–81.09; | ·Fusion |
722.52 | Degeneration of lumbar or lumbosacral intervertebral disc | 03.02; 03.6; | ·Other |
722.6 | Degeneration of intervertebral disc, site unspecified | 78.69 | |
722.9 | Other and unspecified disc disorder | ||
722.90 | Other and unspecified disc disorder of unspecified region | ||
722.92 | Other and unspecified disc disorder of thoracic region | ||
722.93 | Other and unspecified of lumbar region | ||
724 | Other and unspecified disorders of back | ||
724.0 | Spinal stenosis, not cervical | ||
724.00 | Spinal stenosis of unspecified region | ||
724.01 | Spinal stenosis- thoracic | ||
724.02 | Spinal stenosis- lumbar | ||
724.03 | Spinal stenosis- lumbar with neurogenic claudication | ||
724.09 | Spinal stenosis- other region | ||
724.1 | Pain in thoracic spine | ||
724.2 | Lumbago | ||
724.3 | Sciatica | ||
724.4 | Back pain w/radiation, unspec | ||
724.5 | Backache, unspecified | ||
724.6 | Disorders of sacrum (including Lumbosacral junction) | ||
733.1 | Pathologic fractures: | ||
733.10, | ·unspecified site, | ||
733.13 | ·vertebrae | ||
733.95 | Stress fracture of other bone | ||
738.4 | Acquired spondylolisthesis | ||
738.5 | Other acquired deformity of back or spine | ||
739.2 | Nonallopathic lesions- thoracic, not elsewhere classified | ||
739.3 | Nonallopathic lesions, lumbar, not elsewhere classified | ||
739.4 | Nonallopathic lesions, sacral, not elsewhere classified | ||
756.11 | Spondylolysis | ||
756.12 | Spondylolisthesis | ||
846.0 | Lumbosacral sprain | ||
846.1 | Sacroiliac (ligament) sprain | ||
846.2 | Sacrospinatus (ligament) sprain | ||
846.3 | Sacrotuberous (ligament) sprain | ||
846.8 | Other specified sites of sacroiliac region sprain | ||
846.9 | Unspecified site of sacroiliac region sprain | ||
847.1 | Thoracic sprain | ||
847.2 | Lumbar sprain | ||
847.3 | Sacral sprain | ||
847.9 | Sprain- unspecified site of back |
Patient enrollment
1. | Previously contacted for registry participation |
2. | Severe cognitive impairment that would interfere with answering questions |
3. | Tumor/cancer related to the spine |
4. | Any history of cancer within past 5 years, other than non-melanomatous skin cancer |
5. | Spine abscess |
6. | Ankylosing spondylitis |
7. | Spine deformity from childhood |
8. | Spine fracture |
9. | Vehicular accident as cause of back pain |
10. | Prior lumbar spine surgery |
11. | No telephone, or planning to leave health system within next 12 months |
12. | Unable to understand English |
Data collection
Follow-up
Baseline and follow-up measures
Baseline descriptive measures
Primary outcome measure
Additional patient-reported measures
Pain Interference
Patient Health Questionnaire-4 Depression and Anxiety Screen
EQ-5D
Additional data
INDEX VISIT | INSURANCE |
---|---|
Date | Medicare |
ICD-9 codes (primary, secondary) | Medicaid |
Encounter type | Commercial |
Encounter subtype | Private Pay |
Facility code | Drug coverage |
Provider specialty | Co-pay |
Provider age | |
Provider gender | |
Provider ordering patterns | |
IMAGING
|
LABORATORY DATA
|
Date | Date |
Ordering physician specialty | Lab test |
Indication for image | Result |
Image Result (diagnosis) | Normal range |
CPT code | |
DICOM images de-identified | |
PHARMACY (All medications that we will subsequently categorize relatedness to back pain)
|
PROCEDURES
|
Date | Date |
Generic name | CPT code |
Brand name | Indication for procedure |
Supply | Referring physician specialty |
Amount | Performing physician specialty |
Specialty of treating physician | |
Number times refilled | |
PROVIDER VISITS
|
VITAL SIGNS
|
Date | Height |
ICD-9 codes (primary, secondary) | Weight |
Encounter code/type | Blood pressure |
Encounter subtype | |
Provider specialty |
COMORBIDITY INDEX
|
Primary Care | Quan score |
Specialty Care | Charlson score |
Urgent Care | Elixhauser score |
Emergency room | |
PT | |
Chiropractor | |
Massage | |
Acupuncture |
Data management
Analytic approach
Observational cohort of early imaging
Subject eligibility
Analytic approach to the observational cohort of early imaging
Matching
Primary analysis
Secondary analyses
Diagnostic | Therapeutic- Percutaneous | Therapeutic- Open Surgical |
---|---|---|
1. Myelography | 1. Epidural steroid injections | 1. X-stop |
2. Arthrography | 2. Facet injection | 2. Laminectomy/ discectomy/ decompression |
3. Biopsy | 3. Trigger point injection | 3. Posterior fusion or T-PLIF |
4. Anterior fusion | ||
5. Anterior and posterior fusion |
Economic analysis
Sample size
Index Case Prevalence | ||||
---|---|---|---|---|
2% | 3% | 5% | 10% | |
Number of Cases
| 100 | 150 | 250 | 500 |
Effect Size (D)
| ||||
RDQ†
| ||||
1.5 | - | - | 61% | 88% |
2.0 | - | 63% | 84% | 98% |
2.5 | 65% | 82% | 96% | 99% |
Pain NRS†
| ||||
0.7 | - | 52% | 74% | 96% |
1.0 | 65% | 82% | 96% | 99% |
1.3 | 87% | 96% | 99% | 99% |
Incremental Cost per QALY Gain < $50,000††
| ||||
$500 / 0.03 D QALY | - | - | - | 38% |
$500 / 0.06 D QALY | 45% | 61% | 82% | 98% |
$800 / 0.03 D QALY | - | - | - | 21% |
$800 / 0.06 D QALY | 36% | 51% | 72% | 95% |
Rare Events (Surgery, Complication, or Binary Event Rate)**
| ||||
2% Incidence Rate | ||||
RR = 1.5 | - | - | - | - |
RR = 2.0 | - | - | - | 62% |
RR = 2.5 | - | - | 60% | 88% |
5% Incidence Rate | ||||
RR = 1.5 | - | - | - | 51% |
RR = 2.0 | - | 51% | 73% | 95% |
RR = 2.5 | - | 79% | 95% | 99% |