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.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study did not receive any funding

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Because data was de-identified or a Limited Data Set in compliance with the Health Insurance Portability and Accountability Act and customer requirements, the UnitedHealth Group Office of Human Research Affairs Institutional Review Board determined that this study was exempt from ethics review

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Data Availability

All data produced in the present work are contained in the manuscript

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