Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

BackgroundLow back pain (LBP) is prevalent, management benefits from high-quality clinical practice guidelines, and yet LBP is a common source of low value care. The purpose of this retrospective cohort study was to examine the association between the type of initial contact health care provider (HCP), service utilization, and total episode cost for the management of LBP. MethodsEpisode of care was used to analyze a US national sample of LBP episodes completed in 2017-2019. A combined surgical and non-surgical (pooled) sample and a non-surgical sample were separately analyzed. The primary independent variable was the type of the initial contact HCP. Dependent measures included rate and timing of use of 14 types of health care services and total episode cost. The association between initial contact HCP, total episode cost and rate of prescription opioid and NSAID use was tested using a mixed effects model. ResultsThe study included 616,766 continuously insured individuals aged 18 years and older with 756,631 episodes of LBP involving 386,795 HCPs and incurring $1,010,495,291 in expenditures. A primary care or specialist HCP was initially contacted in 62.0% of episodes, with these episodes associated with early use of low-value services such as imaging, pharmacologic, and interventional services. A non-prescribing HCP was initially contacted in 32.5% of episodes with these episodes associated with early use of guideline recommended first line services. Each type of HCP emphasized different initial services with little indication of a stepped approach to managing LBP. Following adjustment for covariates chiropractors were associated with the lowest total episode cost. As an observational study of associations, numerous confounders may have impacted results. ConclusionsAn individual with LBP has different experiences based on the type of HCP initially contacted. Initial contact with primary care or specialist HCPs is associated with second- and third-line services provided before first line services, with little indication of a guideline recommended stepped approach to managing LBP. Increasing the likelihood of guideline- concordant, high-value care for LBP may require systemic changes to the health care delivery system. In the absence of red flags these changes may include increasing the proportion of individuals receiving early non-pharmacological treatment, either through improving direct access to non-prescribing HCPs or increasing timely referrals from primary care and specialist health care providers.