Low back pain service utilization and costs: association with timing of first-line services for individuals initially contacting a primary care provider. A retrospective cohort study

Abstract

Background: Low back pain (LBP) is prevalent, costly, and a common reason for a visit to a primary care provider (PCP). Guidelines recommend a stepped approach to management. Objective: For individuals with LBP initially contacting a PCP, examine the association between the incorporation of first-line therapies, use of second- and third-line services and total episode cost. Design: Retrospective cohort study Setting/Patients: National sample of individuals with non-surgical LBP occurring in 2017-2019. Measurements: Independent variables were initial contact with a PCP, and the timing of incorporation of 5 types of first-line therapies. Dependent measures included use of 14 types of health care services and total episode cost. Results: 8.5% of 118,503 PCPs initially contacted by 308,790 individuals with 347,627 episodes of non-surgical LBP were associated with an episode including any first-line service at any time. 17.5% of episodes included any first-line service at any time. Active care (11.6% of episodes), manual therapy (8.0%) and chiropractic manipulative therapy (7.0%) were the most common first line services. 5.4% of episodes included a first-line service during the first 7 days. These episodes were associated with a modest reduction in the use of prescription pharmaceuticals, with no impact on the use of imaging or spinal injection. First-line services were associated with an increase in total episode cost with the smallest increase associated with chiropractic and osteopathic manipulation. Younger individuals from ZIP codes with higher adjusted gross income were more likely to receive a first-line service in the first 7 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 PCP infrequently receive a first-line service, and if received, it is typically in addition to second- and third-line pharmaceutical, imaging, and interventional services. There is an opportunity to improve concordance with the stepped approach to management described in LBP guidelines.

Neck pain service utilization and costs: association with timing of non-pharmaceutical services for individuals initially contacting a primary care provider. A retrospective cohort study

“…First, an identical study of individuals with LBP initially contacting a PCP also found low rates of incorporation of AC, MT, CMT, OMT, and Acu. 47 Second, a previous study found a low proportion of individuals with NP initially contacting a PCP have timely incorporation of guideline-concordant non-pharmacologic and non-interventional therapies. 35 This study expands on this to explore more detailed distribution of episodes by timing of incorporation of AC, MT, CMT, OMT, and Acu.…”

“…The study design was identical to a previous study of LBP conducted by the same author group. 47 De-identified enrollment records and administrative claims data for individuals with NP were included in an enrollee database. HCP de-identified demographic information and professional licensure status was included in a HCP database.…”

“…The timing of incorporation of AC, MT, CMT, OMT, or Acu services was based on the number of days after the initial visit with a PCP when a non-pharmaceutical service was first billed by any HCP. 11,35,47 The PCP HCP category consisted of Family Practice, Internal Medicine, General Medicine, and OBGYN physician types, along with Nurse Practitioner and Physician Assistant HCPs. The study cohort was able to access all PCP HCP types directly without a referral.…”

“…ETG ® and ERG ® have been reported as a valid measurement for comparison of HCPs based on cost of care 56 , with previous studies finding a low risk of misclassification bias associated with the episode of care unit of analysis. 11,35,47 Complete episodes, defined as having at least 91-day pre-and 61-day post-episode clean periods, were included in the analysis. Incomplete episodes were excluded.…”

“…[39][40][41][42][43][44][45][46] These barriers include coverage limitations 39,45 , inconvenient access 40,45 , cost 40,41,45 , lack of familiarity and communication [42][43][44] , limited time to make a referral 45 , and concerns about possible adverse events. 46 The aim of this retrospective, observational study was to replicate the methods used in an earlier study of LBP 47 to examine the associations between frequency and timing of incorporation of active care (AC), manual therapy (MT), chiropractic manipulative therapy (CMT), osteopathic manipulative therapy (OMT), or acupuncture (Acu) services, utilization of other healthcare services, and total episode cost for individuals with non-surgical NP initially contacting a PCP. Like the previous LBP study 47 the hypothesis was that early incorporation of one or more non-pharmaceutical services would be associated with lower rates of imaging, pharmaceutical and interventional service use, and lower total episode cost.…”