This document discusses the timing of physical therapy for patients with low back pain. It finds that early utilization of physical therapy (within 4 weeks) is associated with decreased future health care costs and utilization compared to physical therapy received later (after 4 weeks). Specifically, early physical therapy is linked to fewer physician visits, imaging tests like MRIs, spinal injections, and lumbar surgery. The document also notes that a chronic care model that focuses on self-management may be more effective for low back pain than an acute care model. Overall, receiving physical therapy earlier in the treatment process leads to better health outcomes and lower costs for managing low back pain.

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Associations of the timing of physical
therapy utilization and subsequent health
care costs and utilization in care pathway
for patients with low back pain
Julie M. Fritz, PT, PhD
Professor, Department of Physical Therapy
University of Utah
Why Low Back Pain?
• About 26% of adults in U.S. experience LBP at
least 1 day in past 3 months.
• 2nd most common reason for physician visits
– Estimated 44.4 million physician visits for back pain
in 2006 (US Bone Jt Decade)
• Estimated $193 billion total direct medical costs
in 2004
– Increase of 49% since 1996
Source: Deyo et al. Overtreating low back pain Am Board Fam Phys. 2009
Chronic LBP Prevalence in North Carolina Residents
From Freburger et al, Archives Int Med, 2009
percentage
• Clinicians often apply acute care model to chronic LBP
and expect a “cure”.
• Motivates more imaging, operations, injections and opioids
for LBP
– unlikely to improve outcomes
• A “chronic care model” would acknowledge LBP as a
chronic condition to be managed.
– Focus on prevention (secondary vs. primary)
– Emphasis on self-management strategies
Improvement in Health Outcomes
Should be the preeminent goal in health care because it is what
ultimately matters to its customers (patients) and unites the
interests of all system actors. Porter & Teisburg, Harvard Business Review, 2006
Money Spent
Value =
Created by a full cycle of care, not any single provider or
intervention
Based on delivering the right care to the right patient at the
right time

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Process
Entry
Point
Value is created by a full cycle of care, not any single
provider or intervention.
Womack & Jones
Patient with
LBP decides
to seek care
Process
Process ProcessHealth
Outcome
Cycle
Complete
• Many decisions are preference sensitive –
– Multiple management strategies exist
– Often no clearly “correct” decision for an individual patient
– Chronic condition for which self-management should be the
focus on initial care strategies
Why is Value Difficult to Achieve for Back Pain?
 Poor decision-making in areas of preference-sensitive care
Enthusiasm for unproven methods ...
Over-use, mis-use, under-use based on provider preferences...
Quality = spare no expense ...
More care is always better…
• Examined Medicare enrollees (2003-2004) receiving
treatment for LBP with no treatment in prior year.
(n=431,195)
• Treatment received within 1-year of physician visit
– Physical Therapy: 16.1%
– Lumbosacral Injections: 11.9%
– Lumbar Surgery: 3.1%
• Timing of Physical Therapy Utilization:
– 52.0% within 4 weeks (acute)
– 18.1% 4 weeks - 3 months (subacute)
– 29.9% >90 days (chronic)
“Early PT use was strongly associated with decreased
use of lumbosacral injections, physician office visits for
LBP and lumbar surgery, when compared with PT that
occurred at later times.”
SETTING
Data extracted from Mercer HealthOnline® a database of
members of employee-sponsored health plans.
PATIENTS
32,070 patients with a new primary care consultation for
LBP from November 1, 2007 - January 31, 2009.

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STUDY SAMPLE
• Age 18-60 at the index visit date
• No claims related to LBP for 6 months preceding index date.
• Continuously eligible in database 6 months prior and 18
months after the index visit date.
• Excluded patients with likely non-musculoskeletal cause for
LBP based on ICD-9 codes. (e.g. kidney stones, UTI, cauda
equina syndrome, osteomyelitis, cancer, prior spinal surgery)
PHYSICAL THERAPY UTILIZATION
Evaluated in the 90-period after the index visit:
– Recorded if a physical therapy visit occurred.
– Categorized the timing of physical therapy based on days from
index visit to first PT visit:
 EARLY (0-14 days)
 DELAYED (15-90 days)
31,474
Age <18 or >60
76,967
Continuously-eligible patients with
primary care visit for LBP
10,266
Prior care in past 6 months
2,077
Non-musculoskeletal cause
222
Prior spine surgery
32,070
2,234 (7.0%)
Utilized PT within 90 days
1,102 (53.1%)
EARLY PT
975 (46.9%)
DELAYED PT
Likelihood of Utilization for Delayed vs. Early Physical Therapy
Odds Ratio (95%confidence interval)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
Advanced Imaging
Lumbar Surgery
Spinal Injection
Narcotic Use
Physician Visits
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

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Methods
• Extract LBP ICD-9 codes from: Jan 1, 2007 - 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
Percentageofpatients
24-month utilization outcomes
Meanvalues($)
24-month cost outcomes PURPOSE
• Evaluate the utilization and timing of physical therapy
in the care of newly consulting patients with LBP
enrolled with University Health Plan.
– Enrollees in either Medicaid or Commercial insurance plan
• Examine relationships between physical therapy
timing and subsequent LBP-related costs and
utilization
METHODS
• Retrospective review of claims data
• Newly consulting patients with LBP-related ICD 9 code.
– 90-day wash out period
– 180-day follow-up window
– Excluded patients with fracture diagnosis or systemic disease
• Health care costs associated with LBP computed
during follow-up window
• Utilization of specific services (MRI, injections, surgeon
visits, surgery) were recorded.
RESULTS
MEDICAID (n=817) COMMERCIAL (n=607)
Mean age = 43.7 years Mean age = 40.1%
70% female 62% female
PT utilizers = 16.2% PT utilizers = 21.9%
Predictors of Early PT: Initial Provider:
PMR 38%, PCP 12%, ED 8%
Predictors of Early PT: Initial Provider:
PMR 41%, PCP 16%
Early PT associated with ↓ risk of:
MRI, surgeon visit, injection
Early PT associated with ↓ risk of:
surgeon visit, injection, surgery
Cost difference: $441 (95% CI: $182, $700) Cost difference: $2,015 (95% CI: $1039, $2990)
63.2%
EARLY PT
36.8%
DELAYED PT
67.9%
EARLY PT
32.1%
DELAYED PT

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Summary
 Similar to other settings, early use of physical
therapy was associated with decreased future
health care utilization and costs.
 Overall utilization of PT was higher, and the
percentage of early PT utilizers was greater for
Health Plan enrollees.
 Physical therapy utilization predicted by initial
provider type.
Thank you