LBP Update

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  • Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis & stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  • Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis & stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  • Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis & stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  • Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis & stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  • Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis & stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  • Tried to use colors to show “dose effect” across categories - ekr
  • LBP Update

    1. 1. Oh, the Aching Backs! Low Back Pain: Eric Robertson, PT, A Current State ofK.AffairsDPT, OCS Eric Robertson, PT, DPT, OCS, FAAOMPT University of Texas at El Paso Continuing Education Series, Spring 2014
    2. 2. Our Objectives  Review current epidemiology of LBP  Review current clinical guidelines for managing patients with LBP  Discuss psychologically informed practice as it relates to patients with LBP  Discuss optimal care pathways for patients with LBP
    3. 3. Relative Healthcare Costs Cost in Billions 800 700 600 500 400 300 200 100 0 Cardiovascular Disease
    4. 4. Relative Healthcare Costs Cost in Billions 350 300 Cardiovascular Disease 250 200 150 100 50 0 Cancer Diabetes LBP All Arthritis
    5. 5. Relative Healthcare Costs Cost in Billions 800 700 CHRONIC PAIN! 600 500 400 300 200 100 0 Cardiovascular Disease
    6. 6. Which of the following are predictors of LBP? • Bulging disc without herniation or root contact • Bulging disc without herniation but with nerve root contact • Herniated/Prolapsed discs • End plate changes / Shmorl‘s nodes • Foraminal or canal stenosis Physical findings / Imaging • History of depression • History of occupational-related LBP • Fearful beliefs about work as reported in a survey Psychosocial findings
    7. 7. How did you do?  Physically:  Only disc contact with nerve root has been shown to be a WEAK predictor of LBP  Psychosocial:  Depression, occupational injuries, and fearavoidance are all STRONG predictors of LBP Implications in terms of pain?
    8. 8. Summary of LBP Predictors ? Physical Psychosocial
    9. 9. Guideline Adherence for LBP Adherent Non-adherent
    10. 10. Worsening Trends in the Management and Treatment of Back Pain Malfi et al. JAMA Int Med, 2013 ―Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID or acetaminophen use and no change in physical therapy referrals. With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care.‖
    11. 11. Things we know about LBP:  Incidence  Second only to the common cold for reasons to see a doctor  25% of US population has had back pain within last 3 months at any given time.  Common Dx in PT Clinics everywhere!  Prognosis  Favorable prognosis for simple, acute LBP! Di Fabio & Boissonault (1998)
    12. 12. We have a problem… According to Martin, Deyo et al., (2008 JAMA) “…spine-related expenses have risen exponentially from 1997 – 2005 without evidence of improvement of selfassessed health status.”  Healthcare costs related to low back pain are climbing  Outcomes for low back pain are falling
    13. 13. Why?  Cause of LBP is unclear  Surgical Interventions  Imaging  Chronic LBP costs are high as a sub-group
    14. 14. Evolution of a Paradigm  Historically, the diagnosis of LBP has closely matched the tools with which we have had at our disposal to examine it.  1900‘s – Nerve etiologies  1920‘s – Muscle etiologies  1950‘s – Bony etiologies (radiographs)  1980‘s – Disc etiologies (MRI) –  However, this was discovered in 1938! Back Pain Diagnoses in the 20th Century, Lutz et al., 2003
    15. 15. The percentage of low back pain of a non-specific nature.
    16. 16. So what about that imaging anyway?
    17. 17. MRI‘s in Healthy Individuals % of people 120 100 80 60 40 20 0 All Healthy Sign Anatom HNP Facet Combined
    18. 18. Findings on MRI Do not predict who has LBP in either the chronic or acute state • Caragee et al, 2005, 2006; Borenstein et al, 2001; Savage et al, 1997 Lead to higher rates of surgical intervention • Jarvik et al, 2003 Do not predict success or nonsuccess in rehabilitation or future disability • Caragee et al, 2005; Kleinsteuck et al, 2006
    19. 19. Inappropriate Imaging?  66% of CT and MRI ordered by primary MD‘s in an HMO inapprop.  28-38% of California workers‘ comp. MRI‘s inappropriate  Higher use when MD owns imaging facility  All imaging tests increased 40% from 2000-2003; now $100 billion/year
    20. 20. Pharmaceuticals: 180% increase! Martin, Deyo et al, JAMA, 2008
    21. 21. Deyo R, AAOMPT 2009
    22. 22. Deyo R, AAOMPT 2009
    23. 23. Spinal Instability?  "Spinal instability is routinely given as a diagnosis to these patients with chronic lower-back pain. It is a term used to justify an operation. And it‗s a great diagnosis, because it can't be directly disproved."
    24. 24. Deyo R, AAOMPT
    25. 25. Spinal Fusion Surgery Annual number of spinal-fusion operations rose by 77 percent between 1996 and 2001. In contrast, TKA and THA increased by 13 to 14 percent during the same interval Spinal-Fusion Surgery - The Case for Restraint Deyo RA et al. NEJM. 2004 350, Iss. 7; 722
    26. 26. Financial Interests in Spine Surgery Pedicle Screws at $13,000 per instrumented fusion surgery. • $4 billion per year! Manufactures acknowledge giving surgeons millions in royalties, speaking fees, and research grants. • On-going government investigation of device makers Government investigating illegal kickbacks. • Medtronic paid $40million in settlement Ableson R, Peterson M; New York Times, 2003
    27. 27. Quote: Dr. Seth Waldman:  "There will be a lot of people doing the wrong thing for back pain for a long time, until we finally figure it out. I just hope that we don't hurt too many people in the process."
    28. 28. Clinical Guidelines Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Chou et al., 2007
    29. 29. Clinical Guideline: APS - APC Chou et al., 2007 Annals of Internal Medicine
    30. 30. Clinical Guideline: APS - APC Chou et al., 2007 Annals of Internal Medicine
    31. 31. Clinical Guideline: APS - APC Chou et al., 2007 Annals of Internal Medicine
    32. 32. Clinical Guideline: APS - APC Chou et al., 2007 Annals of Internal Medicine
    33. 33. Clinical Guideline: APS - APC Chou et al., 2007 Annals of Internal Medicine
    34. 34. Clinical Guideline: APS - APC Chou et al., 2007 Annals of Internal Medicine •Spinal Manipulation •Exercise •Yoga •Acupuncture •CBT •Spinal manipulation
    35. 35. 635 Billion Reasons Or, why addressing chronic pain is in everyone’s best interest.
    36. 36. PAIN #1 cause of adult disability in the US
    37. 37. PAIN 1 in 6 People live with chronic pain.
    38. 38. PAIN Total annual direct costs for pain >$635B.
    39. 39. Relative Healthcare Costs Cost in Billions 350 300 Cardiovascular Disease 250 200 150 100 50 0 Cancer Diabetes LBP All Arthritis
    40. 40. Relative Healthcare Costs Cost in Billions 800 700 CHRONIC PAIN! 600 500 400 300 200 100 0 Cardiovascular Disease
    41. 41. Summary of LBP Predictors ? Physical Psychosocial
    42. 42. Implications in terms of pain?  It might not be as much of a physical thing as we think!  We need to consider the cognitive components!
    43. 43. Nociception
    44. 44. Nociceptive Input Mechanical / Proprioceptive Input C/Adelta A-beta T-Cells Signal in 2nd order Neurons dominated by A-beta input
    45. 45. Nociception Noci means danger! Detecting danger. All the way to thalmus is nociception. The thalmus is determining what should we tell the brain  Nociception can activate protective responses without us knowing about it…think withdrawal reflex from a hot stove Nociception is NOT Pain Perception.
    46. 46. The perception of pain creates pain! CRPS EXAMPLE Neurology, 2005- touching a mirror image of the non-painful hand creates pain and swelling in the painful side.
    47. 47. The perception of pain creates pain! Also:  Phantom limb pain  Severity of Whiplash inversely related to initial pain perception  Battlefield injuries: little pain reported  So…you don‘t need nociception to feel pain.
    48. 48. Nociception Pain Outside of awareness Aware Input Small picture Without emotion Relatively Simple Output Big picture With emotion Relatively Complex Pain the conscious version of nociception
    49. 49. Pain is… Modern Pain Model: The Neuromatrix Paradigm  Nociceptive signals are processed in the brain, mixed with other sensory, emotional, cognitive, planning, and motor signals in the brain, and the resultant output is the pain perception.
    50. 50. How do we change pain perception? What can we change  Sensory input from body  Social work environment  Expected consequences  Beliefs, knowledge What can’t we change  Previous experience  Cultural Factors
    51. 51. Chronic Pain Models  We speak of pain processing primarily in terms of acute pain. Physical  Pain that persists beyond nociceptive input is difficult to understand if you forget that pain is an output.  Chronic pain models can influence the way we treat patients. Psychosocial
    52. 52. Concept: The Body-self Large loops of neurons between the thalamus and the cortex which allow parallel processing and permit:  An awareness of the body and unique and separate from the world  An orientation of the self as a point of awareness
    53. 53. Neuromatrix Paradigm  The collection of structures creating the body-self is called the neuromatrix.  The continuous output from this system is a neurosignature  The neurosignature is always present and allows us to perceive normal  We detect when it‘s abnormal = pain Melzack, Acta Anaesthesiol Scand 1999; 43: 880–884
    54. 54. Neuromatrix Paradigm  Explains how pain can be felt without nociception  Explains chronic pain  Explains how the brain changes in response to pain  Up-regulation, increased receptor fields, more efficient pain processing
    55. 55. Neuromatrix Paradigm BodySelf Pain?
    56. 56. 57 From: Gifford, LS 1998
    57. 57. Identifying Patients at Risk for Chronic Pain Originally:  Waddell‘s Non-organic Signs and Symptoms Bottom Line: •None of the non-organic tests served as effective screening measures to predict development of chronic LBP •Alternative screening tools are required Fritz et al., 2000
    58. 58. Identifying Patients at Risk for Chronic Pain George & Zepperi, JOSPT, July- 2009  Fear-avoidance model of musculoskeletal pain (FAM) (Measured by FABQ)  Factors influencing pain perception  Anxiety  Fear of re-injury  Catastrophizing Confrontation Anxiety Fear of re-injury Catastrophizing Avoidance Anxiety Fear of re-injury Catastrophizing
    59. 59. Graded Exposure for Patients with Chronic Pain George & Zepperi, JOSPT, July2009
    60. 60. L E V E L P A I N Injury! Adapted from Butler & Mosely, 2008, ―Explain Pain‖ H E A L I N G R E S P ON SE
    61. 61. FDAQ – A Measurement George & Zepperi, JOSPT, July- 2009 George et al., PTJ, July- 2009
    62. 62. General Principles 1. Chronic pain is not a local anatomical problem. 2. Pain perception influenced by common psychological conditions (FAB, depression).
    63. 63. General Principles 3. True psychogenic causes of pain are so rare as to not even be discussed much in rehab settings. Most patients we see have a reason to have pain (i.e. injury) and it is the processing of the pain that is altered. 4. Overt malingering is rare and cannot be detected by physical therapists (i.e. variation in maximum effort does not equal lack of effort).
    64. 64. General Principles 5. Graded approaches are a good way for PT's to incorporate cognitive-behavioral principles. The key is to focus on activity tolerance, NOT pain reduction. 6. If you are seeing a lot of chronic pain, consider a multidisciplinary approach, as that is where the evidence points to increased effectiveness.
    65. 65. Establishing a Baseline Therapist: ‗How long can you walk before you flare-up?‘ Patient: ‗I can walk for 30 min but I pay for it the next day‘ Therapist: ‗Can you walk for 20 min without flaring up?‘ Patient: ‗No, but I have‘ Therapist: ‗Can you walk for 10 min without flaring up?‘ Patient: ‗Probably not — definitely not up hills‘ Therapist: ‗5 min on a flat surface?‘ Patient: ‗Probably‘ Therapist: ‗3 min on a flat surface?‘ Patient: ‗Definitely‘
    66. 66. Continuous Progression  ‗every day you do more than you did yesterday, but not much more‘…at least initially.  Setting clear measurable goals and objectives!
    67. 67. KEY POINTS  Pain is not nociception  The representation of the body in the human brain  The brain changes as the pain persists  Body-brain is a 2 way street  Training the brain for people in Pain
    68. 68. Patient Education Perhaps your most powerful analgesic tool is the ability to educate your patient about pain physiology. Physical Therapists We are the intersection of physiology & psychology!
    69. 69. A = Baseline Chronic Pain B = Following HEP C = Following Pain Education
    70. 70. One more thing… Is spinal manipulation appropriate for people with chronic pain?
    71. 71. Response to Thoracic Spine Manipulation: fMRI Pre-Manipulation Post-Manipulation Sparks et al, JOSPT 2013
    72. 72. Timing of Referral and Adherence to Best Practice for LBP: Does It Matter? John D. Childs, PT, PhD, MBA
    73. 73. Non-invasive Interventions for Acute LBP Intervention Net benefit Level of evidence Spinal manipulation Small/Moderate Fair Exercise therapy No benefit Good Back schools Unclear Poor Acupuncture Unclear Poor Massage Unclear Poor Interferential therapy, shortwave diathermy, ultrasound, lumbar supports, TENS Unclear Poor
    74. 74. Non-invasive interventions for Chronic or Subacute LBP Intervention Net benefit Level of evidence Behavioral therapy Moderate Good Exercise therapy Moderate Good Interdisciplinary rehabilitation Moderate Good Spinal manipulation Moderate Good Acupuncture Moderate Fair Massage Moderate Fair Yoga Moderate Fair (for Viniyoga) Back schools Small Fair
    75. 75. Arch Intern Med. 2010;170(3):271-277
    76. 76. Methods • Care provided in 3,533 patient visits to GPs for a new episode of LBP was mapped to key recommendations in treatment guidelines • The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004)
    77. 77. Results • Despite recommendations to the contrary • > 25% patients referred for imaging • Only 20.5% and 17.7% received care limited to advice and simple analgesics, respectively • Analgesics provided were typically NSAIDs (37.4%) and opioids (19.6%) • This pattern of care was the same in the periods before and after the release of the local guideline
    78. 78. The timing of care matters. 2011;41(11):838846 Fuhrmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. WSJ. 2007:1/12.
    79. 79. Methods • National 20% sample of CMS outpatient claims (Medicare) • Treatment for LBP between 2003-2004 (n=439,195). • Patients with prior visit for back pain, lumbosacral injection, or lumbar surgery within the previous year were excluded • Referral to physical therapy classified as • Acute – 0-4 weeks • -Subacute – 4 weeks – 3 months • Chronic – 3 months – 1 year
    80. 80. Gellhorn et al. 2012; 37: 775 – 782 0.47 (95% CI, 0.44–0.50) 0.46 (95% CI, 0.44–0.49) 0.38 (95% CI, 0.36–0.41) There was a lower risk of subsequent medical service among patients who received PT early after an episode of acute LBP relative to those who received PT later.
    81. 81. Purpose • Examine the cost implications of the decision to refer patients with a new episode of LBP from primary care providers to physical therapy and examine the influence of the timing of referral (early vs. delayed) and the content of the care (adherent vs. non adherent) received by physical therapists
    82. 82. Subjects SETTING Data extracted from Mercer HealthOnline® a database of members of employeesponsored health plans.
    83. 83. Subjects 32,070 patients with a new primary care consultation for LBP from November 1, 2007 - January 31, 2009. 756.11 Spondylolysis, lumbosacral region 756.11 Spondylolesthesis 722.1 Lumbar disk displacement 722.93 Other disk disorder lumbar region 846.0 Sprain lumbosacral 722.73 Lumbar disk deease with myelopathy 846.8 Sprain – other sacroilliac region 721.3 Lumbosacralspondylosis without myelopathy 846.1 Sprain sacroilliac ,sprain - sacrum 722.52 Lumbar / lumbosacral disc displacement 724.02 Spinal stenosis - lumbar 724.5 Backache, unspecified 847.2 Sprain lumbar region 847.3 sprain other specified sites of sacroiliac region 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis 724.3 Lumbago
    84. 84. Data Abstraction • Patients meeting definition of new LBP episode visiting a primary care provider from November 1, 2007 through January 31, 2009 • Eligible patients had to be continuously eligible within the database for 6 months before and 18 months after the index date • All healthcare visits, procedures, tests, prescription medications, etc. and associated billed charges • CPT codes for each visit if patient received physical therapy
    85. 85. Inclusion/Exclusion • Age 18-60 years old at index primary care visit • No prior spinal surgery • No evidence of non-musculoskeletal cause of LBP diagnosis (e.g., infectious process, kidney stones, gall stones, urinary tract infection, cancer, osteomyelitis, etc.)
    86. 86. Groups Timing: 1. Early Physical Therapy - 1-14 days from first Dr. visit (53%) 2. Delayed Physical Therapy - 15-90 days (47%) Content: 1. Adherent - Active physical therapy based on CPT codes (22%) 2. Non adherent – Passive physical therapy (78%)
    87. 87. Covariates Examined • Age and gender • Amount of co-payment for the index visit • Insurance plan (Point-of-service, Preferred Provider Organization, Health Maintenance Organization , High deductible health plan, Other) • Employment status (Active, Retiree, Long-term disability, Other) • Geographic region (Northeast, South, Midwest, West)
    88. 88. Comorbidities • Co-morbid healthcare conditions in 6-month period prior to index date • Number unique ICD-9 diagnoses recorded in any setting • Number of unique medications • If a hospitalization occurred • If narcotic medications were prescribed • Total allowed costs for all services (inpatient, outpatient and prescription) • Presence of co-morbid health conditions that may influence prognosis for individuals with LBP • Mental health conditions (depression, anxiety, bipolar or other psychotic disorders) • Concomitant neck or thoracic spine pain • Fibromyalgia
    89. 89. Phase 1: 1st 14 days of Episode of Care ACTIVE CODES 97110 97350 97535 Therapeutic Exercise Therapeutic Activity Self Care Management Training PASSIVE CODES ALLOWED CODES PT Evaluation PT ReEvaluation 97035 Ultrasound 97001 97010 Hot or Cold Pack 97002 G0283, 97032 Electrical Stimulation 99070 Miscellaneo us Supplies 97112 Neuromuscul ar Re97012 Education Mechanical Traction 97750 Physical Performanc e Test/Measu re 97150 Group Therapeutic Procedures Massage Therapy 97140 Manual Therapy PHASE I 97124 97113 97116 Aquatic Therapy with Exercise Gait Training Therapy
    90. 90. Phase 2: >14 days ACTIVE CODES 97110 97350 97535 PHASE II PASSIVE CODES Therapeutic 97140 Exercise Therapeutic 97035 Activity Self Care Management 97010 Training ALLOWED CODES Manual Therapy 97001 Ultrasound 97002 Hot or Cold Pack 99070 97112 Neuromuscul G0283, ar Re97032 Education Electrical Stimulation 97750 97150 Group Therapeutic Procedures 97012 Mechanical Traction 97113 97124 Massage Therapy 97116 PT Evaluation PT ReEvaluation Miscellaneo us Supplies Physical Performanc e Test/Measu re Aquatic Therapy with Exercise Gait Training Therapy
    91. 91. Determination of Adherence • Number of active and passive CPT codes at each visit within each phase recorded • % of active to passive codes calculated as • Number of active codes/(number of active codes + number of passive codes) x 100% • Adherent care defined as % of active to passive codes at least 75%, with each visit including at least 1 active code • Comparisons of costs between adherent vs. non-adherent care
    92. 92. All Patients (n=32,070) Timing of Physical Therapy (n=2,077) Early Delayed (n=1,102) (n=975) Content of Physical Therapy (n=1,917) NonAdherent Adherent (n=413) (n=1504) Advanced Imaging (MRI or CT) 18.9% 29.4% 54.9% 38.7% 43.9% Physician Specialist Visits 44.1% 52.6% 81.0% 64.4% 68.8% Lumbar Spine Surgery 2.5% 4.7% 9.9% 5.1% 8.1% Lumbar Spinal Injections 7.1% 10.1% 21.2% 12.6% 17.8% Narcotic 49.1% Medication Use 49.1% 55.3% 49.6% 53.2% Table 2. Utilization of specific services for low back pain in the 18 month period following the index primary care visit
    93. 93. All Patients (n=32,070) Timing of Physical Therapy (n=2,077) Early (n=1,102) Delayed (n=975) Content of Physical Therapy (n=1,917) NonAdherent Adherent (n=413) (n=1504) Imaging Procedures $291.12 (5.42) $473.32 $807.20 $513.84 $701.14 (63.92) (42.12) (46.82) (52.32) Physician Visits $209.54 (1.48) $259.62 $411.76 $295.52 $357.15 (9.76) (11.89) (14.33) (9.86) Surgical/ Injection Procedures $740.44 $1018.88 $2760.62 $1445.23 $1965.72 (36.84) (170.65) (381.27) (486.37) (229.42) Inpatient NonSurgical Procedures $79.28 (11.13) $65.00 (30.58) $231.79 $162.31 $142.99 (64.52) (90.20) (37.81) Table 3. Costs incurred over the 18 month period following the index primary care visit. Values represent mean (standard error).
    94. 94. All Patients (n=32,070) Timing of Physical Therapy (n=2,077) Early Delayed (n=1,102) (n=975) Content of Physical Therapy (n=1,917) Adherent Non-Adherent (n=413) (n=1504) Emergency Room Visits $19.83 (0.87) $26.21 (4.89) $25.22 (4.59) $24.87 (6.94) $28.61 (4.36) Prescription Medication $104.23 (3.01) $80.41 (10.22) $116.83 (11.27) $76.43 (9.85) $98.85 (9.61) Other LBP-related $437.89 $1225.04 $1531.3 $1090.64 Costs (8.11) (52.10) (67.01) (89.06) $1651.73 (53.07) Total LBP costs $1882.33 $3148.49 $5884.71 $3608.83 (44.58) (228.90) (429.92) (533.49) $4946.18 (277.19) Non-LBP healthcare costs $7892.53 $7169.22 $8430.44 $7254.82 (108.75) (472.39) (761.80) (1155.66) $7511.44 (402.09) Table 3. Costs incurred over the 18 month period following the index primary care visit. Values represent mean (standard error).
    95. 95. Utilization of Services Early PT Delayed PT 53% 81% 49% 55% 10% 21% 4.7% 9.9% 29% 55%
    96. 96. Figure 2. Likelihood of receiving specific services during the 18 month follow-up period based on non adherent physical therapy care.
    97. 97. $3,000.00 Total Costs: $2,500.00 $3148 $5884 $2,000.00 $1,500.00 $1,000.00 $500.00 $0.00 Early PT Delayed PT
    98. 98. Total Costs: $7,000 $3148 $5884 $6,000 Other LBP-related Costs $5,000 Prescription Medication Emergency Room Visits $4,000 Inpatient Non-Surgical Procedures Surgical/ Injection Procedures $3,000 Physician Visits Imaging Procedures $2,000 $1,000 $0 Early Physical Therapy Delayed Physical Therapy
    99. 99. Implications of Timing and Quality of Physical Therapy on Low Back Pain Utilization and Costs in the Military Health System John D. Childs, PT, PhD, MBA Samuel S. Wu, PhD Eric Robertson, PT, DPT Forest S. Kim PhD, MHA, MBA Robert S. Wainner, PT, PhD Timothy W. Flynn, PT, PhD Steven Z. George, PT, PhD Julie M. Fritz, PT, PhD
    100. 100. Background • Back pain & arthritis the most costly conditions requiring rehabilitation in the U.S. • Over $200 billion per year, exceeding total costs associated with spinal cord injury, traumatic brain injury, stroke, multiple sclerosis, and limb loss • Studies demonstrate that the vast majority of costs are incurred early in the care process • Many studies demonstrate lack of adherence to practice guidelines for managing LBP • Previous work has demonstrated that timing of referral and adherence to practice guidelines reduces utilization and costs • Military Health System offers compelling opportunity to expand this work because a single payer system
    101. 101. Methods • Extract LBP ICD-9 codes from Jan 1, 2007 through Dec 31, 2009 • Extract full history of these cases from Jan 1, 2006-Dec 31, 2011 • Determine previous medical history for 1-year preceding the index visit • Conduct 2-year follow-up from index visit • Newly consulting LBP defined as no claims with a LBP-related ICD-9 code for 6 months preceding the index date
    102. 102. Inclusion/Exclusion • Age between 18-60 years of age at index date • Continuously eligible within database 12 months before (to capture comorbidities and previous history) and 24 months after index date • No co-morbid diagnosis within 4 weeks of index date that could be nonmusculoskeletal source of LBP (e.g, kidney stones, urinary tract infection, etc .) • No prior history of spinal surgery or trauma (ie. fx) based on the presence of related current procedural terminology (CPT) codes at any time prior to the index date • Only the first eligible index date for an individual patient included to avoid overlap in episodes of care. (ie – individual patients can only appear once in dataset)
    103. 103. Analysis • Considered 90-day period after the primary care index date to identify PT utilization • If a PT visit occurred with a LBP-related ICD-9 during this period, patient defined as utilizing PT • Early PT defined as utilizing PT within 14 days from primary care index date • All PT episodes without a primary care index date (ie, direct access) classified as early • Late PT defined as utilizing PT between 15-90 days from index date • Patients with both PT and chiropractic utilization for LBP excluded • Adherence determined using the same algorithm previously published (Fritz, Spine, 2012) • Controlled for co-morbidities similar to previous research (Fritz, Spine, 2012)
    104. 104. Inclusion and Exclusion Criteria 883,969 continuously eligible patients with primary care for low back pain. Age <18 & >60 years (n=13,992) Low back pain claim in the past 6 months (n=38,955) Possible nonmusculoskeletal low back pain (n=154,729) Prior surgery for low back pain (n=148) 676,145 patients included in analysis
    105. 105. Groups and Demographics Age (mean, sd) Gender (% female) Common Beneficiary Category Spouse/families Retired Other Active Duty Timing of PT Adherence All PT Users Adheren Patients Early Delayed Non‐Adher (n=158,2 t (n=676,14 (n=59,4 (n=98,8 ent (n=23,5 71) 16) 55) 5) (n=32,750) 50) 33.8 33.3 32.2 34.0 34.8 36.1 (11.2) (10.5) (10.4) (10.6) (11.3) (11.2) 39.10% 34.10% 32.80% 34.90% 41.80% 45.30% 19.80% 10.10% 12.80% 57.30% 14.50% 13.10% 15.30% 20.60% 7.30% 5.80% 8.10% 11.20% 8.80% 8.00% 9.30% 13.20% 69.50% 73.10% 67.20% 55.00% 22.80% 11.70% 14.90% 50.70%
    106. 106. Additional Covariates Timing of PT All Patients PT Users Early Delayed (n=676,145 (n=158,271 (n=59,416 (n=98,855 ) ) ) ) Number of LBP diagnosis codes 1.5 1.4 1.4 1.4 (mean, sd) (1.8) 1.5) (1.2) (1.6) Number of prescription 13.6 15.2 12.9 16.5 medications (10.3) (10.8) (9.9) (11.0) (mean, sd) Co‐morbid mental health condition 0.082 0.084 0.078 0.088 Co‐morbid fibromyalgia diagnosis 0.019 0.017 0.016 0.018 Co‐morbid neck/thoracic spine 0.108 0.118 0.129 0.111 condition Narcotic use prior to index visit 34.10% 35.20% 34.10% 35.90% Hospitalization prior to index visit 7.20% 7.10% 6.90% 7.20% Total medical costs prior to index $3608.26 $3704.36 $3617.90 $3756.35 visit (8017.10) (7795.80) (8189.26) (7548.91) (mean, sd) Adherence Adherent Non‐Adhere (n=23,550 nt ) (n=32,750) 1.5 1.7 (1.7) (1.9) 15.9 (11.1) 16.4 (11.3) 0.09 0.02 0.088 0.023 0.116 0.142 37.50% 8.40% $4119.76 (10271.64 ) 38.40% 8.50% $4069.42 (7558.78)
    107. 107. Adjusted Odds Ratios & 99% CIs Advanced Imaging E vs. D .47 (.45, .49) A vs. NA .68 (.64, .72) Lumbar surgery .52 (.47, .56) .80 (.71, .91) Spinal injection .47 (.45, .49) .78 (.73, .83) Opioid use .48 (.47, .50) .93 (.89, .98)
    108. 108. Utilization of Services – Timing of Care Early Delayed Advanced imaging (MRI or CT) 12% 23% Lumbar spine surgery 3% 4% 8% 17% 59% 75% Lumbar spinal injections Opioid medication use
    109. 109. Utilization of Services – Guideline Adherence Adherent Non-adherent Advanced imaging (MRI or CT) Lumbar spine surgery Lumbar spinal injections Opioid medication use 23% 30% 2% 4% 14% 18% 71% 73%
    110. 110. Utilization of Services – Timing & Guideline Adherence E/A E/NA D/A D/NA Advanced imaging (MRI or CT) Lumbar spine surgery Lumbar spinal injections Opioid medication use 13% 20% 27% 35% 2% 3% 4% 5% 9% 13% 17% 21% 61% 64% 77% 78%
    111. 111. Total Costs Incurred Over 2-year Follow-up $1,400 $1,200 $859 $1,000 $800 $733 $983 $600 $400 $200 $0 Prescription meds E/A E/NA L/A L/NA $1,145
    112. 112. Total Costs Incurred Over 2-year Follow-up $16,000 $14,000 $12,000 $11,407 $13,030 $10,521 $10,000 $8,000 $6,000 $4,000 $2,000 $0 Inpatient E/A E/NA L/A L/NA $13,506
    113. 113. Total Costs Incurred Over 2-year Follow-up $5,000 $4,340 $4,500 $3,670 $4,000 $3,500 $2,784 $3,000 $2,500 $2,110 $2,000 $1,500 $1,000 $500 $0 Total LBP E/A E/NA L/A L/NA
    114. 114. Total Costs Incurred Over 2-year Follow-up $12,000 $10,000 $10,380 $8,470 $8,459 $8,000 $6,000 $4,000 $2,000 $0 Non LBP-related E/A E/NA L/A L/NA $10,589
    115. 115. Low quality physical therapy delivered early is better than current standard of care for back pain management in the U.S.
    116. 116. High quality physical therapy delivered early is even better
    117. 117. Acknowledgements • This study is funded in part by the following organizations: • U.S. Air Force Medical Service Intramural Grant Program • Texas State University Faculty Grant
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