Background/Purpose:  Musculoskeletal (MSK) pain syndromes are common and the most prevalent type of chronic pain in the pediatric population. The chronic pain syndromes include central pain sensitization conditions such as Reflex Neurovascular Dystrophy, Reflex Sympathetic Dystrophy, Juvenile Fibromyalgia, Allodystrophy, and Complex Regional Pain Syndrome. The mean annual cost per child of care with chronic pain at tertiary pain centers was estimated at $11,787. To our knowledge, there is no robust data characterizing pediatric patients with chronic MSK pain syndromes prior to diagnosis at non-specialized pain centers. We describe the length to diagnosis, the healthcare utilization patterns, and economic burden of chronic MSK pain syndromes in pediatric populations. We hypothesized that the cost of MSK pain syndromes prior to diagnosis is similarly burdensome due to delayed diagnosis.

Methods: A retrospective chart review was conducted at a general pediatric rheumatology clinic at Nationwide Children’s Hospital (NCH) in Columbus, OH. We included subjects with a diagnosis of primary chronic musculoskeletal (MSK) pain including Juvenile-Onset Fibromyalgia, RSD, and CRPS seen between 2010 and 2014. We excluded patients with primary rheumatologic disorders, with a chronic MSK pain syndrome diagnosed outside of the Nationwide Children’s Hospital system or by a non-rheumatologic specialist. Of 118 with a primary diagnosis of chronic MSK pain 80 met inclusion criteria and were analyzed. We only evaluated visits within the NCH system. Data relating to MSK pain prior to diagnosis were collected from the NCH electronic medical records: date of symptom onset and diagnosis, number of emergency visits, number of hospital admissions, length of hospital admissions, number of outpatient visits, medications used, and imaging studies. Pain scores rated on a visual analogue scale (VAS) from 1-10 and functional disability using the Childhood Health Assessment Questionnaire (CHAQ) scores were recorded at the initial visit and at the time of diagnosis. The Medical Expenditure Panel Survey (MEPS) provided nationally representative data on health care service unit costs. Specifically we used the MEPS annual total expenses per visit mean estimates for office based visits, emergency room visits and inpatient admissions.

Results: The mean (±SD) age was 14.6 ±3.0 years. 89% were female and 86% were white. The average length of time from symptom onset to diagnosis was 18.2 ± 24.9 months. At diagnosis mean pain intensity was 6.45± 2.7 and mean CHAQ score were 0.74± 0.6. 29% went to the emergency room at least 1 time and 52% of those with 1 visit had diagnostic laboratory testing. 5% were admitted as inpatients. 81 % sought out one specialty consultation, 38% sought out two specialty consultations, and 35% sought out 3 or more specialty consultations. The most commonly visited specialist was rheumatology followed by orthopedics prior to a diagnosis. The mean cost estimate hospital, ED and office visits between 2009-2014 was $1910.66 ± 3807.6 (range: 213 -21216). 53% had xrays and 21% had MRI’s while other imaging studies were not as frequently performed. 65% were prescribed Nsaids and 15% were prescribed Narcotics. There were no strong correlations between length of time diagnosis and costs.

Conclusion: Children with chronic MSK pain are undiagnosed for greater than 12 months and utilize multiple health services, undergo diagnostic testing and use several medications resulting in high costs even before diagnosis. Our estimate is likely an underestimate as our data only represented data from one site when many of children are being seen in multiple health care systems. Healthcare providers must be attuned to this diagnosis in patients with a long history of chronic MSK pain, high pain scores, and who are seen frequently by healthcare professionals.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/chronic-pain-in-children-seen-at-a-rheumatology-clinic-healthcare-utilization-patterns/