Background: For individuals with low back pain (LBP), in the absence of serious pathology clinical practice guidelines (CPG) recommend a stepped approach to management with first-line emphasis on natural history, self-care, and non-pharmaceutical therapies. For individuals with non-surgical LBP initially contacting a chiropractor (DC), physical therapist (PT), or licensed acupuncturist (LAc), the purpose of this retrospective cohort study was to examine the dose response association between the number of visits of chiropractic manipulative therapy (CMT), active care (AC), manual therapy (MT), or acupuncture, the exposure to second- and third-line services and total episode cost. Methods: A national sample of individuals with a single episode of non-surgical LBP occurring in 2017-2019 was analyzed using episode of care as the unit of analysis. The primary independent variables were initial contact with either a DC, PT, or LAc, and the number of visits of CMT, AC, MT, or acupuncture. Dependent measures included rate and timing of use of 14 types of health care services and total episode cost. Results: 132,199 continuously insured individuals aged 18 years and older initially contacted 21,336 different DCs, 2,734 PTs and 1,339 LAcs for a single episode of non-surgical LBP. These individuals were associated with $62,185,930 in expenditures. The most common number of visits was 1 to 3 - CMT (48.2% of episodes), AC (29.7%), MT (32.1%), and acupuncture (27.0%). For each service, having 1 to 3 visits was associated with the lowest rate of exposure to second- and third-line services although rate differences between visit dose categories were generally not significant or clinically meaningful due in part to small sample sizes. Episode total cost and duration increased significantly with increasing number of visits. CMT was associated with lowest median total episode cost at each level of visit utilization. Conclusions: For non-surgical LBP episodes initially contacting a DC, PT or LAc, 1 to 3 visits of CMT, AC, MT, or acupuncture was the most common level of utilization, associated with the lowest exposure to second- and third-line services and lowest total episode cost. Among, CMT, AC, MT, and acupuncture, CMT was associated with the lowest total episode cost at each level of utilization. A higher number of visits of CMT, AC, MT or acupuncture was associated with significantly higher total cost, without meaningful impact on exposure to second- or third-line services. Unmeasured clinical benefits may be associated with higher visit counts and warrants further study.

Background: Variability in the management of LBP has been extensively studied, however the degree to which this variability is associated with patient gender is less well understood. The purpose of this retrospective cohort study was to examine variability in the management of LBP associated with patient gender in commercially insured (CI) and Medicare Advantage (MA) cohorts before and after the COVID-19 pandemic. Methods: A US national sample of LBP episodes with a duration of less than 91 days experienced during 2019-2021 was analyzed. Independent variables included patient gender, whether an individual had CI or MA coverage, and the timing of LBP onset during pre-, early, and late COVID time periods. Dependent measures included the percent of individuals initially contacting eighteen types of health care provider (HCP) and receiving twenty-two types of health care services, and total episode cost. Measures associated with female patients were compared with a male patient baseline to examine patient gender related differences. Results: The study included 222,043 CI and 466,125 MA complete episodes of LBP. 114,322 (51.5%) of the CI and 281,597 (60.4%) of MA episodes were associated with female patients. Individual home address zip code population attributes were nearly identical in both CI and MA cohorts. During the pre-, early, and late COVID time periods, in both CI and MA cohorts, female patients were less likely than male patients to initially contact DCs (risk ratio (RR) CI pre-COVID 0.88, CI early COVID 0.90, CI late COVID 0.86, MA pre 0.70, MA early 0.70, MA late 0.73) and were more likely to initially contact rheumatologists (2.72, 2.62, 3.20, 2.15, 2.59, 2.08). In the CI cohort during the pre-, early, and late COVID time periods female patients more likely than male patients to initially contact physical therapists (PT) (RR pre-COVID 1.24, early COVID 1.17, late COVID 1.16) and licensed acupuncturists (LAC) (1.75, 1.53, 2.21). In both the CI and MA cohorts plain film radiology was the most provided service for both female (32-40% of episodes) and male (31-40%) patients. During all time periods in both CI and MA cohorts female patients were less likely than male patients to receive spinal surgery (risk ratio (RR) CI pre-COVID 0.53, CI early COVID 0.54, CI late COVID 0.53, MA pre- 0.45, MA early 0.46, MA late 0.42), prescription oral steroids (0.75, 0.73, 0.77, 0.82, 0.79, 0.83), and chiropractic manipulative therapy (CMT) (0.87, 0.89, 0.85, 0.70, 0.71, 0.73). In the CI cohort during all time periods female patients more likely than male patients to receive acupuncture (RR pre- 1.41, early 1.48, late 1.48). Conclusions: In both CI and MA cohorts, and compared to males, females with LBP were less likely to seek treatment from DCs and more likely to seek treatment from Rheumatologists. In the CI cohort females were more likely than males to seek treatment from PTs and LAcs. Females with LBP were less likely than males to undergo spinal surgery, receive a prescription oral steroid, or receive CMT.

Background: Physician specialists (PS) are often the type of healthcare provider initially contacted by an individual with low back pain (LBP). LBP clinical practice guidelines (CPG) recommend a stepped approach to management with an emphasis on first-line non-pharmaceutical and non-interventional services. Objective: Examine the association between the incorporation of CPG recommended first-line services, exposure to second- and third-line services and total episode cost for individuals with non-surgical LBP initially contacting a PS. Design: Retrospective observational study with identical design to previous study focused on primary care physicians. Setting/Patients: National sample of individuals with non-surgical LBP occurring in 2017-2019. Measurements: Independent variables were initial contact with a PS, and the timing of incorporation of five types of first-line services. Dependent measures included exposure to thirteen types of health care services and total episode cost. Results: 91,096 individuals were associated with 98,992 episodes of non-surgical LBP. 36.2% of the 33,277 PS initially contacted for an episode of LBP incorporated any first-line service at any time during an episode. A first-line service was provided in 24.0% of episodes with active care (19.5% of episodes), manual therapy (13.7%) and chiropractic manipulative therapy (6.5%) the most common. 7.3% of non-surgical LBP episodes included a first-line service within seven days of initial contact with a PS. These episodes were associated with a reduction in the use of prescription skeletal muscle relaxants (risk ratio 0.88) and opioids (0.55), spinal injections (0.84), and CT scans (0.71), with no impact on the use of prescription NSAIDs, radiography, or MRI scans. First-line services were associated with an increase in total episode cost at any time of incorporation with chiropractic manipulation associated with the lowest cost increase. Younger individuals from zip codes with higher adjusted gross income were more likely to receive a first-line service in the first seven days of an episode. Limitations: As a retrospective observational analysis of associations there are numerous potential confounders and limitations. Conclusions: Individuals with non-surgical LBP initially contacting a PS infrequently receive a CPG recommended first-line service. If a first-line service is provided it is often later in an episode and typically in addition to second- and third-line services. There is an opportunity to improve concordance with LBP CPGs for individuals with LBP initially contacting a PS.

Background: Neck pain (NP) is prevalent and costly. NP clinical practice guidelines are similar to those for low back pain (LBP), emphasizing non-pharmaceutical and non-interventional first-line approaches. Primary care providers (PCP) are frequently consulted by individuals with NP. Objective: Examine the association between guideline concordant incorporation of non-pharmaceutical therapies, use of imaging, pharmaceutical, and interventional services, and total episode cost for individuals with NP initially contacting a PCP. Design: Retrospective cohort study using identical methods to a previous LBP study Setting/Patients: National sample of individuals with non-surgical NP occurring in 2017-2019. Measurements: Independent variables were initial contact with a PCP, and the timing of incorporation of 5 types of non-pharmaceutical therapies. Dependent measures included use of 13 types of health care services and total episode cost. Results: 70,252 PCPs were initially contacted by 124,780 individuals with 137,274 episodes of non-surgical NP. 30.9% of PCPs and 22.1% of episodes included at least one of five non-pharmaceutical services at any time during an episode. Active care (13.7% of episodes), manual therapy (10.8%), and chiropractic manipulative therapy (9.4%) were the most common non-pharmaceutical services. 7.4% of episodes included a non-pharmaceutical service during the first 7 days with these episodes associated with a modest reduction (risk ratio 0.28 to 0.78) in the use of prescription pharmaceuticals. Younger individuals from ZIP codes with higher adjusted gross income were more likely to receive a non-pharmaceutical service in the first 7 days of an episode. When included during an episode, non-pharmaceutical services were associated with an increase in total episode cost with the smallest increase associated with chiropractic and osteopathic manipulation. Limitations: As a retrospective observational analysis of associations there are numerous potential confounders and limitations. Conclusions: Non-pharmaceutical services are infrequently provided to individuals with non-surgical NP initially contacting a PCP. For these individuals, non-pharmaceutical services, if provided, are most commonly introduced later in an episode after receiving pharmaceutical, imaging, and interventional services. For individuals with NP initially contacting a PCP there is an opportunity to increase the guideline concordant incorporation of non-pharmaceutical services early in an episode.

BackgroundNeck pain (NP) clinical practice guidelines (CPG) generally emphasize natural history, self-care, and non-pharmaceutical therapies. For non-pharmaceutical therapies provided for NP, like chiropractic manipulative treatment (CMT), active care (AC), manual therapy (MT), or acupuncture, little is known about the dose/response relationship with use of other services and total cost. The purpose of this retrospective cohort study of individuals with NP was to examine the dose response association between the number of visits of CMT, AC, MT, or acupuncture, the exposure to pharmaceutical, imaging, and interventional services, and total episode cost.MethodsEpisode of care was used to analyze a national sample of individuals 18 years and older with a single episode of non-surgical NP occurring in 2017-2019 and initially contacting a chiropractor (DC), physical therapist (PT), or licensed acupuncturist (LAc). The number of visits of CMT, AC, MT, or acupuncture were the primary independent variables. Rate and timing of use of 13 types of health care services and total episode cost were the primary dependent measures.ResultsA total of 91,805 continuously insured individuals initially contacted a DC, PT, or LAc for a single episode of non-surgical NP. These individuals initially contacted 19,387 different DCs, 1,828 PTs and 1,153 LAcs. There were $39,150,944 in total expenditures. The most common number of visits was 1 to 3 for CMT (47.8% of episodes), AC (31.8%), and MT (35.0%), and 4 to 6 for acupuncture (27.5%). Different levels of utilization intensity of CMT, AC, MT, and acupuncture were generally not associated with statistically or clinically meaningful differences in exposure to pharmaceutical, imaging, or interventional services. Total episode cost increased with higher numbers of visits of CMT, AC, MT, and acupuncture with CMT associated with the lowest median total episode code at each level of visit utilization.ConclusionsFor individuals with non-surgical NP initially contacting a DC, PT or LAc, 1 to 3 visits of CMT, AC, or MT, and 4 to 6 visits of acupuncture were the most common levels of utilization. A higher number of visits of CMT, AC, MT or acupuncture was associated with significantly higher total cost, without clinically or statistically meaningful differences in exposure to pharmaceutical, imaging, or interventional services. CMT was associated with the lowest total episode cost at each level of utilization. Higher visit counts of CMT, AC, MT, or acupuncture may have been associated with unmeasured clinical benefits and warrants further study.