Dataset Information

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review.

ABSTRACT:

Objective

The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain.

Methods

Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of low back pain by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure.

Results

A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared to patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent.

Conclusions

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with low back pain. High-quality randomized controlled trials are needed to confirm our findings.

Impact

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with low back pain. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists,within primary health care systems.

Lay summary

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with low back pain. High-quality randomized controlled trials are needed to confirm these findings.

SUBMITTER: Zouch J

PROVIDER: S-EPMC10071499 | biostudies-literature | 2022 Nov

REPOSITORIES: biostudies-literature

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Publications

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review.

Zouch James J Comachio Josielli J Bussières André A Ashton-James Claire E CE Dos Reis Ana Helena Salles AHS Chen Yanyu Y Ferreira Manuela M Ferreira Paulo P

Physical therapy 20221201 12

<h4>Objective</h4>The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP).<h4>Methods</h4>Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened tit ...[more]

PMID: 36317766

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Project description:BackgroundDiagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs.MethodsUsing national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics.ResultsAmong 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5093) or primary care physician ($5660), and highest when starting with an orthopedist ($9434) or acupuncturist ($9205).ConclusionThe first provider seen by individuals with LBP was associated with large differences in health care utilization, opioid prescriptions, and cost while there were no differences in delays in diagnosis of serious illness.

Project description:BackgroundLow back pain (LBP) is the most common medical cause of disability among adults 65 or older. No previous study has characterized health care costs and treatment patterns of LBP among Medicare beneficiaries.MethodsThis retrospective cohort study quantifies health care utilization costs among Medicare beneficiaries with newly diagnosed LBP, compares costs between patients managed operatively and nonoperatively, identifies costs associated with treatment guideline nonadherence, and characterizes opioid prescribing patterns. Patients were queried via ICD codes from a 20% random sample of Medicare claims records. Patients with concomitant or previous "red flag" diagnoses, neurological deficits, or diagnoses that could cause nondegenerative LBP were excluded. Total costs of care in the year of diagnosis were calculated and stratified by operative versus nonoperative management. To assess for guideline adherence, utilization and costs of different services were tabulated. Opioid prescription patterns were characterized by quantity, cost, duration, and medication type.ResultsAbout 1,269,896 patients were identified; 23,919 (1.8%) underwent surgery. These accounted for 7% of the cohort's total cost ($514 million total, $21,496 per person). Patients treated nonoperatively accounted for over $7 billion in costs ($5,880 per person; p<.001). Within the nonoperative cohort, 626,896 (50.3%) patients were nonadherent to current guidelines for conservative management of LBP. Guideline nonadherence increased total annual costs by $4,012 per person ($7,873 for nonadherent vs. $3,861 for adherent patients, p<.001). About 460,867 opioid prescriptions were filled for 303,796 unique patients (23.9%) within 30 days of LBP diagnosis. Within the nonsurgical cohort, patients nonadherent to imaging guidelines were more likely to have an opioid prescription within this window than adherent patients (26.5% vs. 21.2%; p<.001).ConclusionsNonoperative management of LBP is associated with significantly lower costs per patient. Early imaging and opioid prescription are significant drivers of excess cost. Adherence to proposed treatment guidelines can save over $2.8 billion in total health care costs.

Project description:BackgroundChronic low back pain is a costly condition and the leading cause of disability worldwide. A recent call to action identified the overuse of low-value health care as ineffective and potentially harmful in the context of back pain. Interdisciplinary pain programs (IPPs) incorporate physical therapy and behavioral pain treatments with the goal of empowering patients to actively use skills to self-manage pain, decreasing stress, disability, and reliance on low-value care. While IPPs are deemed "cost-effective," few studies elaborate upon the patterns of healthcare utilizations among patients who complete IPPs with attention to valued-based care. The aim of this study was to describe healthcare patterns of patients participating in a interdisciplinary pain program (IPP) for chronic low back pain.MethodsThis observational cohort study describes the healthcare utilization of a group of adult patients (N=143) who participated in an IPP for chronic back pain compared to patients who did not complete the entire program (N=112), and those who were eligible for the program but chose not to participate (N=76). Patterns of healthcare utilization were evaluated in a 12-month period before and after IPP participation. Healthcare utilization categories included outpatient resources, specialist visits, imaging, pain interventional procedures, and acute care utilization. Opioid use was also extracted based on inpatient and outpatient orders, as well as days on opioids within 2 weeks following an emergency department visit or hospitalization. Utilization was defined as a health care visit in which the primary or secondary diagnosis or procedure reason was back pain related. Relative value units (RVUs) measure value used in Medicare reimbursement for physician services.ResultsOverall, healthcare utilization was not markedly different in the 12 months before and after IPP across the 3 groups (graduates, drop-outs, or no participation). However, sub-grouping analyses revealed significant reductions in opioid prescriptions, x-rays, and ED visits in the IPP group for the 12 months after the program, as well as an increased utilization of behavioral pain management.ConclusionsAdult patients who participated in an IPP for chronic low back pain demonstrated significant reductions in utilization in opioid prescriptions, x-rays and ED visits, while also showing increased participation in active therapies such as behavioral pain management. These findings suggest that participation in a IPP could influence future value-based healthcare decisions, in turn also influencing cost.

Project description:ObjectiveThis study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).DesignA retrospective cohort study of patients with new-onset LBP from 2008 to 2013.SettingThe study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.Participants216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance.ExposuresThe primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).Main outcome measuresShort-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months).ResultsShort-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).ConclusionsInitial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Project description:ImportanceLow back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery.ObjectivesTo assess use of health care resources for LBP and LEP management and analyze associated costs.Design, setting, and participantsThis cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019.ExposuresNewly diagnosed LBP or LEP.Main outcomes and measuresThe primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated.ResultsA total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy.Conclusions and relevanceThe findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.

Project description:BackgroundOpioid prescriptions for Veterans with low back pain (LBP) persist despite the availability of PT, a lower medical risk treatment option. Patterns of treatment and subsequent healthcare utilization for Veterans with LBP are unknown. The purpose of this study was to evaluate the association of physical therapy (PT) and opioids and outcomes of spinal surgery and chronic opioid use for Veterans with incident LBP.MethodsWe conducted a retrospective cohort study identifying Veterans with a new diagnosis of LBP using ICD codes from the Veterans Administration national database from 2012 to 2017. Veterans were classified into three treatment groups based on the first treatment received within 30 days of incident LBP: receipt of PT, opioids, or neither PT nor opioids. Outcomes, events of spinal surgery and chronic opioid use, were identified beginning on day 31 up to one year following initial treatment. We used propensity score matching to account for the potential selection bias in evaluating the associations between initial treatment and outcomes.ResultsThere were 373,717 incident cases of LBP between 2012 and 2017. Of those 28,850 (7.7%) received PT, 48,978 (13.1%) received opioids, and 295,889 (79.2%) received neither PT or opioids. Pain, marital status and the presence of cardiovascular, pulmonary, or metabolic chronic conditions had the strongest statistically significant differences between treatment groups. Veterans receiving opioids compared to no treatment had higher odds of having a spinal surgery (2.04, 99% CI: 1.67, 2.49) and progressing to chronic opioid use (11.8, 99% CI: 11.3, 12.3). Compared to Veterans receiving PT those receiving opioids had higher odds (1.69, 99% CI: 1.21, 2.37) of having spinal surgery and progressing to chronic opioid use (17.8, 99% CI: 16.0, 19.9).ConclusionInitiating treatment with opioids compared to PT was associated with higher odds of spinal surgery and chronic opioid use for Veterans with incident LBP. More Veterans received opioids compared to PT as an initial treatment for incident LBP. Our findings can inform rehabilitation care practices for Veterans with incident LBP.

Dataset Information

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review.

Objective

Methods

Results

Conclusions

Impact

Lay summary

Publications

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review.

Similar Datasets

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