Low back pain care pathways - is the last provider seen more important than the first: A retrospective cohort study

BackgroundThe associations between the type of health care provider (HCP) initially contacted by an individual with low back pain (LBP), guideline concordance, and cost of care are well understood. Less is known about types of HCP that become involved after the initial HCP, particularly the last HCP seen. The purpose of this retrospective cohort study was to examine sequence patterns in the types of HCP involved in an episode of LBP, exposure to 13 types of services, and total cost. MethodsA US national sample of commercially insured individuals with a single episode of non-surgical LBP occurring in 2017-2019 was analyzed using episode of care unit of analysis. The primary independent variable was the type of initial contact HCP. Dependent measures included types of subsequent HCPs involved in an episode of LBP, rate of use of 13 types of health care services, and total cost. Results503,958 individuals aged 18 years and older initially contacted 196,522 different HCPs for an episode of non-surgical LBP. 30.2% of individuals saw a second HCP, 11.8% a third, 5.2% a fourth and 2.5% a fifth. Compared to primary care providers (PCP) (71.0% of episodes), when chiropractors (DC) were the initial contact HCP they were the most likely to be the only and last HCP seen (84.0% of episodes) (risk ratio 1.18, 95% confidence interval 1.18-1.19). DCs were also the most likely to be the last HCP seen when the second HCP in an episode (72.7%) (1.10, 1.09-1.12), the third HCP (67.7%) (1.10, 1.08-1.13), or the fourth HCP (61.6%) (1.13, 1.08-1.17). Physical therapists (PT), while less likely than PCPs to be the only and last HCP seen (60.0%) (0.84, 0.83-0.86), were more likely than PCPs to be the last HCP when the second (70.9%) (1.08, 1.06-1.09), third (63.2%) (1.03, 1.00-1.06), or fourth HCP (60.7%) (1.11, 1.06-1.16) seen during an episode. PTs were the only type of HCP involved in more episodes as the second HCP (7,344) than as the initial HCP (5,114). ConclusionsDCs are the most likely to be the last HCP seen for an episode of non-surgical LBP. PTs are as likely as DCs to be the last HCP seen except when initially contacted by an individual with LBP. There are numerous potential confounders and limitations to consider when interpreting this novel finding.