Primary care utilization among veterans with chronic musculoskeletal pain: a retrospective chart review

Abstract

Objective: Patients with chronic pain have been shown to be more frequent utilizers of primary care, a contributor to increased health care costs. This study aimed to clarify which patient factors predict primary care utilization among veterans with chronic pain.

Design: Data were gathered from the electronic medical records of veterans who used Veterans Affairs primary care services from 2003 to 2009 in upstate New York. Chronic pain cases (N = 792) were those veterans diagnosed with a musculoskeletal condition of the hip, knee, or lower back during two or more primary care encounters over a period ≥ 3 months. Cases were frequency matched by age to controls, or those veterans who did not have a chronic musculoskeletal condition of the hip, knee, or lower back. Demographic information, medical and psychiatric diagnoses, medication use, and other health-related factors were used in regression models to predict primary care utilization.

Results: Cases consistently accrued more primary care encounters than controls during each year of the observation period. Cases also accrued more encounters from specialty medicine clinics, chronic pain clinics, and behavioral health clinics co-located in primary care. The contribution of mental health factors to care utilization differed by case-control status. Diagnosis of depression and substance use disorders were predictors of care utilization only among controls, whereas anxiety disorders, use of anxiolytics, and adjustment disorders were predictors only among cases. Cases with a co-occurring anxiety disorder had a greater than twofold increased risk (odds ratio = 2.36, 95% confidence interval = 1.32-4.22) of being in the top 10% of the distribution of total primary care utilization.

Conclusions: Mental health conditions that commonly co-occur with chronic musculoskeletal pain contribute to greater health care utilization. Improved screening and early intervention for these disorders in primary care may improve patient outcomes and stem high rates of care utilization of veterans.

Keywords: Chronic Pain; Comorbidity; Health Care Utilization; Mental Health; Musculoskeletal Diseases; Primary Health Care.