Impact of patient gender on low back pain management before and after the COVID-19 pandemic in commercially insured and Medicare Advantage cohorts. A retrospective cohort study

BackgroundVariability in the management of LBP has been extensively studied, however the degree to which this variability is associated with patient gender is less well understood. The purpose of this retrospective cohort study was to examine variability in the management of LBP associated with patient gender in commercially insured (CI) and Medicare Advantage (MA) cohorts before and after the COVID-19 pandemic. MethodsA US national sample of LBP episodes with a duration of less than 91 days experienced during 2019-2021 was analyzed. Independent variables included patient gender, whether an individual had CI or MA coverage, and the timing of LBP onset during pre-, early, and late COVID time periods. Dependent measures included the percent of individuals initially contacting eighteen types of health care provider (HCP) and receiving twenty-two types of health care services, and total episode cost. Measures associated with female patients were compared with a male patient baseline to examine patient gender related differences. ResultsThe study included 222,043 CI and 466,125 MA complete episodes of LBP. 114,322 (51.5%) of the CI and 281,597 (60.4%) of MA episodes were associated with female patients. Individual home address zip code population attributes were nearly identical in both CI and MA cohorts. During the pre-, early, and late COVID time periods, in both CI and MA cohorts, female patients were less likely than male patients to initially contact DCs (risk ratio (RR) CI pre-COVID 0.88, CI early COVID 0.90, CI late COVID 0.86, MA pre 0.70, MA early 0.70, MA late 0.73) and were more likely to initially contact rheumatologists (2.72, 2.62, 3.20, 2.15, 2.59, 2.08). In the CI cohort during the pre-, early, and late COVID time periods female patients more likely than male patients to initially contact physical therapists (PT) (RR pre-COVID 1.24, early COVID 1.17, late COVID 1.16) and licensed acupuncturists (LAC) (1.75, 1.53, 2.21). In both the CI and MA cohorts plain film radiology was the most provided service for both female (32-40% of episodes) and male (31-40%) patients. During all time periods in both CI and MA cohorts female patients were less likely than male patients to receive spinal surgery (risk ratio (RR) CI pre-COVID 0.53, CI early COVID 0.54, CI late COVID 0.53, MA pre-0.45, MA early 0.46, MA late 0.42), prescription oral steroids (0.75, 0.73, 0.77, 0.82, 0.79, 0.83), and chiropractic manipulative therapy (CMT) (0.87, 0.89, 0.85, 0.70, 0.71, 0.73). In the CI cohort during all time periods female patients more likely than male patients to receive acupuncture (RR pre-1.41, early 1.48, late 1.48). ConclusionsIn both CI and MA cohorts, and compared to males, females with LBP were less likely to seek treatment from DCs and more likely to seek treatment from Rheumatologists. In the CI cohort females were more likely than males to seek treatment from PTs and LAcs. Females with LBP were less likely than males to undergo spinal surgery, receive a prescription oral steroid, or receive CMT.