Low back pain service utilization and costs: association with timing of first-line services for individuals initially contacting a primary care provider. A retrospective cohort study

BackgroundLow back pain (LBP) is prevalent, costly, and a common reason for a visit to a primary care provider (PCP). Clinical practice guidelines (CPG) recommend a stepped approach to management. ObjectiveFor individuals with LBP initially contacting a PCP, examine the association between the incorporation of first-line therapies, use of second- and third-line services and total episode cost. DesignRetrospective cohort study Setting/PatientsNational sample of individuals with non-surgical LBP occurring in 2017-2019. MeasurementsIndependent variables were initial contact with a PCP, and the timing of incorporation of 5 types of first-line therapies. Dependent measures included use of 13 types of health care services and total episode cost. Results8.5% of 118,503 PCPs initially contacted by 308,790 individuals with 347,627 episodes of non-surgical LBP were associated with an episode including any first-line service at any time. 17.5% of episodes included any first-line service at any time. Active care (11.6% of episodes), manual therapy (8.0%) and chiropractic manipulative therapy (7.0%) were the most common first-line services. 5.4% of episodes included a first-line service during the first 7 days with these episodes associated with a modest reduction (risk ratio 0.34 to 0.89) in the use of prescription pharmaceuticals. First-line services were associated with an increase in total episode cost with the smallest increase associated with chiropractic and osteopathic manipulation. Younger individuals from ZIP codes with higher adjusted gross income were more likely to receive a first-line service in the first 7 days of an episode. LimitationsAs a retrospective observational analysis of associations there are numerous potential confounders and limitations. ConclusionsIndividuals with non-surgical LBP initially contacting a PCP infrequently receive a first-line service, and if received, it is typically in addition to second- and third-line pharmaceutical, imaging, and interventional services. There is an opportunity to improve concordance with the stepped approach to management described in LBP CPGs.