Management of Neck or Back Pain in Ambulatory Care

Abstract

Background/Objective: In recent years, 2 circumstances have changed provider-patient interactions in ambulatory care: (1) the replacement of virtual for in-person visits and (2) the COVID-19 pandemic. We studied the potential impact of each event on provider practice and patient adherence by comparing the frequency of the association of provider orders, and patient fulfillment of those orders, by visit mode and pandemic period, for incident neck or back pain (NBP) visits in ambulatory care. Methods: Data were extracted from the electronic health records of 3 Kaiser Permanente regions (Colorado, Georgia, and Mid-Atlantic States) from January 2017 to June 2021. Incident NBP visits were defined from ICD-10 coded as primary or first listed diagnoses on adult, family medicine, or urgent care visits separated by at least 180 days. Visit modes were classified as virtual or in-person. Periods were classified as prepandemic (before April 2020 or the beginning of the national emergency) or recovery (after June 2020). Percentages of provider orders for, and patient fulfillment of orders, were measured for 5 service classes and compared on: virtual versus in-person visits, and prepandemic versus recovery periods. Comparisons were balanced on patient case-mix using inverse probability of treatment weighting. Results: Ancillary services in all 5 categories at each of the 3 Kaiser Permanente regions were substantially ordered less frequently on virtual compared with in-person visits in both the prepandemic and recovery periods (both P ≤ 0.001). Conditional on an order, patient fulfillment within 30 days was high (typically ≥70%) and not likely meaningfully different between visit modes or pandemic periods. Conclusions: Ancillary services for incident NBP visits were ordered less frequently during virtual than in-person visits in both prepandemic and recovery periods. Patient fulfillment of orders was high, and not significantly different by mode or period.

Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period?

“…In other studies, we found that order likelihood is lower for virtual than for in-person visits. 16,17 In this study, we found that 3 moderators that might influence patient treatment adherence did little to account for fulfillment disparities by visit mode.…”

“…An incident NBP visit was defined as: a completed visit (ie, cancelled appointments and opened but incomplete visits were excluded); with an ICD-10 diagnosis identified as primary or principal; be provided as routine or urgent ambulatory care (defined by the department of service – such as the department of family medicine, general internal medicine, or urgent or after hours care or an equivalent virtual visit program such as KPCO synchronous chats or KPMAS “house calls”), provided to a patient 19 years or older of age, and, with no NBP visit within the prior 180 days 16. An incident UTI visit was similarly defined, except the interval between visits was set at 90 days 17…”

“…In prior analyses, we studied whether visit mode was associated with patient fulfillment of ancillary services orders and found a modestly-sometimes significantly-lower frequency with virtual versus in-person visits for neck or back pain (NBP) or urinary tract infection (UTI). 16,17 Our primary study objective was to evaluate if any of these 3 factors moderated the likelihood of patient fulfillment of ancillary services ordered by a physician on an ambulatory care visit differed by visit mode (virtual vs. in-person) or COVID-19 period [prepandemic (before beginning of the national emergency in April 2020) or recovery (after June 2020)].…”

“…Following the access to care framework of Aday, Andersen, and colleagues,13–15 we examined 3 factors—or moderators—of ancillary services order fulfillment: distance from residence to clinic, level of cost-sharing in service fulfillment defined by insurance plan benefits, and prior experience with pharmacy mail-order fulfillment as an alternative to facility-based fulfillment. In prior analyses, we studied whether visit mode was associated with patient fulfillment of ancillary services orders and found a modestly—sometimes significantly—lower frequency with virtual versus in-person visits for neck or back pain (NBP) or urinary tract infection (UTI) 16,17. Our primary study objective was to evaluate if any of these 3 factors moderated the likelihood of patient fulfillment of ancillary services ordered by a physician on an ambulatory care visit differed by visit mode (virtual vs. in-person) or COVID-19 period [prepandemic (before beginning of the national emergency in April 2020) or recovery (after June 2020)].…”

Assessing the Impact of Telemedicine Implementation in Diverse Health Care Systems

“…The KP research studies also tackle new areas in telemedicine research by comparing the impact of telemedicine and in-person visits on ancillary services utilization, including medication, laboratories, and imaging, for urinary tract infections7 neck and back pain,8 and depression 9. These studies found that although ancillary service orders resulting from telemedicine visits were generally high, orders from telemedicine encounters were not placed as often as in-person encounters for urinary tract infections, 7 neck and back pain, 8 but there were no significant changes in patient fulfillment of ordered antidepressant medications 9. The KP findings highlight the importance of prior use of mail-order pharmacy options in promoting the fulfillment of prescribed medication orders, irrespective of visit mode 10.…”