Back pain is the 6th most costly condition in the United States and is responsible for the most workdays lost. Approximately 33 million American adults suffered from back and neck problems in 2005. The societal cost of chronic back pain (CBP) has not been calculated from a US perspective. Longitudinal data files from Panels 12, 13, and 14 of the Medical Expenditure Panel Survey (MEPS) were used to estimate excess direct (ambulatory visits, inpatient admissions, emergency room visits, and prescription medication) costs and indirect (lost productivity) costs for persons 18 years and older reporting CBP compared to those not reporting back pain. Persons were included in the CBP group if they reported back pain (ICD-9-CM codes 720, 721, 722, 723, 724, 737, 805, 806, 839, 846, 847) in at least 3 consecutive interview rounds. The complex sampling design of MEPS was taken into account to get accurate national estimates. All costs were adjusted to 2011 using Consumer Price Indices. All mean costs were computed using age-stratified regression models, after adjusting for demographic and clinical covariates. Utilization of provider-based complementary and alternative medicine (CAM) among CBP patients was studied, and differences in costs between CAM users and non-users examined. Based on this analysis, the prevalence of CBP in the adult US population was estimated to be 3.76%. Total all-cause costs for CBP patients were estimated to be $187 billion over 2 years (direct costs = $176 billion, indirect cost = $11 billion). Overall estimates of excess costs of CBP over 2 years per person for direct medical costs were $37,129 ($25,273 vs. $48,984; p<0.001). This breaks down to $11,711 ($14,929 vs. $3,219; p<0.001) for ambulatory visits; $3,560 ($6,514 vs. $2,914; p<0.001) for inpatient admissions; $300 ($690 vs. $390; p<0.001) for emergency department visits; and $19,849 ($23,873 vs. $4,024; p<0.001) for prescription medications. Excess indirect costs for CBP patients were $1,668 ($2,329 vs. $661; p<0.001). Thirty-seven percent of CBP patients reported at least one CAM visit. There was no significant difference in overall costs between CAM users and non-users. The high cost of chronic back pain in the US population has potential implications for prioritizing policy, and in attempting to improve care and outcomes for these patients. / text

Introduction: More than half of all patients seeking care for chest pain do not have a cardiac cause for this pain. Despite recurrent episodes of chest pain, many patients are discharged without a clear explanation of the cause for their pain. A lack of explanation may result in a misinterpretation of the pain as being cardiac-related, causing worry and uncertainty, which in turn leads to substantial use of healthcare resources. Psychological distress has been associated with non-cardiac chest pain (NCCP), but there is limited research regarding the relationship between different psychological factors and their association with healthcare utilization. There is a need for interventions to support patients to manage their chest pain, decrease psychological distress, and reduce healthcare utilization and costs. Aim: The overall aim of this thesis was to improve care for patients with  non-cardiac chest pain by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention. Designs and methods: This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. The studies used the same initial cohort. Patients were consecutively approached within 2 weeks from the day of discharge from a general hospital in southeast Sweden. In study I, 267 patients participated (131 with NCCP, 66 with acute myocardial infarction (AMI), and 70 with angina pectoris (AP)). Out of these, 199 patients (99 with NCCP, 51 with AMI, 49 with AP) participated in study II. Participants were predominantly male (about 60 %) with a mean age of 67 years. Data was collected on depressive symptoms (Study I), healthcare utilization (Study I, II), and societal costs (Study II). Study III had a cross-sectional explorative and descriptive design. Data was collected consecutively on depressive symptoms, cardiac anxiety and fear of body sensations in 552 patients discharged with diagnoses of NCCP (51 % women, mean age 64 years) from four hospitals in southeast Sweden. Patients were approached within one month from the day of discharge. Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years, who were randomly assigned to an intervention (n=7) or control group (n=8). The intervention consisted of a four-session guided Internet-delivered cognitive behavioural therapy (CBT) program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. Data was collected on chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. Results: Depressive symptoms were prevalent in 20 % (Study IV) and 25 % (Study I, III) of the patients, and more than half of the patients still experienced depressive symptoms one year later (Study I). There were no significant differences in prevalence and severity of depressive symptoms between patients diagnosed with NCCP, AMI or AP. Living alone and younger age were independently related to more depressive symptoms (Study I). Cardiac anxiety was reported by 42 % of the patients in study III and 67 % of the patients in study IV. Fear of body sensations was reported by 62 % of the patients in study III and 93 % of the patients in study IV. On average, patients with NCCP had 54 contacts with primary care or the outpatient clinic per patient during the two-year study period. This was comparable to the number of contacts among patients with AMI (50 contacts) and AP (65). Patients with NCCP had on average 2.6 hospital admissions during the two years, compared to 3.6 for patients with AMI and 3.9 for patients with AP (Study II). Four out of ten patients reported seeking healthcare at least twice during the last year due to chest pain (Study III). On average, 14 % of patients with NCCP were on sick-leave annually, compared to 18 % for patient with AMI and 25 % for patient with AP. About 11-12 % in each group received a disability pension. The mean annual societal costs for patients with NCCP, AMI and AP were €10,068, €15,989 and €14,737 (Study II). Depressive symptoms (Study I, III), cardiac anxiety (Study III) and fear of body sensations (Study III) were related to healthcare utilization. Cardiac anxiety was the only variable independently associated with healthcare utilization (Study III). In the intervention study (Study IV), almost all patients in both the intervention and control groups improved with regard to chest pain  frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. There was no significant difference between the groups. The intervention was perceived as feasible and easy to manage, with comprehensible language, adequate and varied content, and  manageable homework assignments. Conclusions: Patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain. A short guided Internet-delivered CBT program seems to be feasible. In the pilot study, patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. Larger studies with longer follow-up are needed to evaluate both the short and long- term effects of this intervention.