Welcome back to Spine IQ’s BackBlog! This week, we would like to discuss findings summarized in a recent briefing from the Center for Health Workforce Studies at the University of Washington titled “Opioid prescriptions, radiography, and costs for self-limited ‘one-and-done’ lower back pain visits in a commercially insured population.”¹ There is a lot of interest in healthcare right now, not only about what treatments are being delivered but who is delivering treatment for low back pain. This author group sought to address that question by analyzing a large dataset of commercially insured patients. We hope you find this research as interesting as we did!

Objective and Methods

Low back pain is the leading cause of disability and poses a large economic burden on the healthcare system.² The incidence of low back pain is high with about 30% of people expected to suffer an episode of low back pain in a year.⁴ In order to mitigate public health crisis, researchers and health systems are trying to identify the most effective and cost-efficient care pathways for patients. The goal is to discover what treatments and providers are able to best improve outcomes while decreasing healthcare waste and overuse.³ About 50% of people that suffer an episode of low back pain seek healthcare, some of whom will only have a single encounter with a clinician. Researchers focused on this population, using a large insurance claims database to measure opioid prescription rates, imaging rates, and costs of care.

Opioid prescriptions were divided into 2 groups: 1) early opioid use that was prescribed and filled within 30 days of the healthcare session or 2) long-term opioid use, which included patients that filled prescriptions for 120 days or more within one year or filled prescriptions for 90 days and had ten or more refills in one year. Imaging included x-ray, MRI, or CT scans within one year of the healthcare encounter. Costs were divided into 2 outcomes: 1) total costs and 2) out-of-pocket costs paid by patients.

Results

A total of 189,205 unique “one-and-done” healthcare encounters were included in the study. Providers inlcuded family/internal medicine physicians (55%), chiropractors (21.7%), emergency medicine physicians (8.3%), orthopedic physicians (6.0%), physical medicine physicians (3.6%), registered nurses (3.4%), physical therapists (1.4%), and acupuncturists (0.6%).

Early opioid was most common in patients seeking care from physical medicine physicians (8.0%), emergency medicine (7.6%), family/internal medicine physicians (6.7%), registered nurses (5.4%), and orthopedic physicians (4.8%). Only 0.6% and 0.3% of patients seeing physical therapists or chiropractors received early opioid prescriptions. Since chiropractors and physical therapists cannot prescribe, it is likely that these prescriptions were filled by another healthcare visit not seen in this dataset. Long term opioid prescription was rare for all patients in this cohort.

Plain-film imaging was most in patients seeking care from orthopedic physicians (41.2%) followed by physical medicine physicians (13.7%), emergency medicine physicians (8.9%), chiropractors (7.9%), registered nurses (6.8%), family/internal medicine physicians (6.0%), and physical therapists (0.6%). MRI or CT scan’s were not common and most likely to be associated with care delivered by orthopedic physicians (1.8%).

The total cost of one healthcare encounter was highest for patients seeking care from emergency medicine physicians ($478) followed by physical medicine physicians ($248), registered nurses ($224), orthopedic physicians ($211), acupuncturists ($206), physical therapists ($160), and chiropractic ($91). Out-of-pocket costs were highest for patients seeking care from emergency medicine ($202) followed by acupuncturists ($110), physical medicine physicians ($103), registered nurses ($90), physical therapists ($90), family/internal medicine physicians ($61), and chiropractic ($57).

Conclusion

This data has a lot of very interesting findings for the conservative spine clinician. First, it is important to note that chiropractic was the healthcare profession that delivered the second highest amount of healthcare encounters. This demonstrates that patients with low back pain commonly seek treatment from chiropractors. Second, there is clear evidence that patients seeking care from conservative spine clinicians receive significantly less opioid prescriptions. Third, imaging tends to be lower for patients seeking care from conservative spine clinicians compared to other physicians. Finally, the cost of total care on the health system and out-of-pocket cost for the patient is lowest for patients seeking care from chiropractors. This type of data will become increasingly more important as payers, employers and health systems move more towards value-based care models, with a greater focus on cost, outcomes and satisfaction (The Triple Aim) when making payment and access to care decisions.

References:

1. Pines JM, Harwood K, Andrilla CH, Frogner BK. Opioid Prescriptions, Radiography, and Costs for Self-Limited “One-and-Done” Lower Back Pain Visits  in a Commercially Insured Population. :7.
2. Blyth FM, Briggs AM, Schneider CH, Hoy DG, March LM. The Global Burden of Musculoskeletal Pain—Where to From Here? Am J Public Health. 2019;109(1):35-40. doi:10.2105/AJPH.2018.304747
3. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-2388. doi:10.1016/S0140-6736(18)30488-4
4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X