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Depp S, Brown L, Quatman-Yates C, Foraker R, Patterson ES, Vasileff WK, Di Stasi S. Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial. Musculoskelet Sci Pract 2024; 73:103154. [PMID: 39116761 DOI: 10.1016/j.msksp.2024.103154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 07/25/2024] [Accepted: 07/27/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown. HYPOTHESIS OBJECTIVE To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain. STUDY DESIGN Observational feasibility study of a randomized controlled trial. METHODS Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes. RESULTS Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001). CONCLUSIONS An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.
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Affiliation(s)
- Sarah Depp
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Lindsey Brown
- Feasibility Informatics, Medpace, Inc., Cincinnati, OH, USA
| | - Catherine Quatman-Yates
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA; Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Randi Foraker
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA
| | - Emily S Patterson
- Division of Health Information Management and Systems, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - W Kelton Vasileff
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Orthopaedics, The Ohio State University, Columbus, OH, USA
| | - Stephanie Di Stasi
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA; Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Kosakowski H, Rone-Adams S, Boissonnault WG, Harmon-Matthews L, Kuczynski J, Martin M, Briggs MS. Financial impact associated with implementation of the low back pain clinical practice guideline in outpatient physical therapist practice at a large academic medical center. Physiother Theory Pract 2024; 40:746-754. [PMID: 36567617 PMCID: PMC10290726 DOI: 10.1080/09593985.2022.2160940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Low back pain (LBP) is the top health condition requiring rehabilitation in the United States. The financial burden of managing LBP is also amongst the highest in the United States. Clinical practice guidelines (CPGs) provide management recommendations and have the potential to lower health costs. Limited evidence exists on the impact of CPG implementation on downstream medical costs. OBJECTIVE To examine the impact of CPG implementation in physical therapist (PT) practice on direct and downstream costs for patients with LBP. METHODS A retrospective observational study examined billing data from 270 patients with LBP who were treated at multiple sites within one large academic medical center by PTs who participated in a multifaceted CPG implementation program. Costs were analyzed for direct PT services, downstream medical services, and PT utilization from September 2017 to March 2018 (pre-implementation group) and compared with costs from June 2018 to December 2018 (post-implementation group). RESULTS Direct PT costs were significantly lower post-implementation than pre-implementation mean: $2,863 USD (SD: $1,968) vs. $3,459 USD (SD: $2,838), p = .05, 95% CI [11, 1182]. All downstream costs were lower post-implementation with statistically significant lower costs found in downstream imaging: p = .04, 95% CI [32, 1,905]; pharmacy: p = .03, 95% CI [70, 1,217]; surgery: p = .03, 95% CI [446, 9,152], and "other": p = .02, 95% CI [627, 7,920]. CONCLUSION Implementing the LBP CPG in outpatient PT practice can have a positive impact on lowering downstream costs and the potential to increase the value of PT services.
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Affiliation(s)
- Heidi Kosakowski
- World Physiotherapy, Unit 17 Empire Square, London, SE1 4NA United Kingdom
| | - Shari Rone-Adams
- Nova Southeastern University, 3200 S. University Drive, Fort Lauderdale, FL 33328
| | - William G. Boissonnault
- University of Wisconsin-Madison, Department of Orthopedics, 1300 University Avenue, Madison, WI 53706
| | - Lindsay Harmon-Matthews
- Jameson Crane Sports Medicine Institute, Ohio State University, Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH, 43202
| | - J.J. Kuczynski
- James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, 410 W. 10 Avenue, Columbus, OH 43210
| | - Michael Martin
- Richard M. Ross Heart Hospital, Ohio State University Wexner Medical Center, 452 W 10 Avenue, Suite 1255, Columbus, OH 43210
| | - Matthew S. Briggs
- Jameson Crane Sports Medicine Institute, Ohio State University, Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH, 43202
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Zheng P, Ewing S, Tang A, Black D, Hue T, Lotz J, Peterson T, Torres-Espin A, O’Neill C. Predictors of response in PROMIS-global in a chronic low back pain specialty clinic: STarTBack and chronic overlapping pain conditions. J Back Musculoskelet Rehabil 2024; 37:909-920. [PMID: 38427463 PMCID: PMC11307069 DOI: 10.3233/bmr-230067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Tools, such as the STarTBack Screening Tool (SBT), have been developed to identify risks of progressing to chronic disability in low back pain (LBP) patients in the primary care population. However, less is known about predictors of change in function after treatment in the specialty care population. OBJECTIVE We pursued a retrospective observational cohort study involving LBP patients seen in a multidisciplinary specialty clinic to assess which features can predict change in function at follow-up. METHODS The SBT was administered at initial visit, and a variety of patient characteristics were available in the chart including the presence of chronic overlapping pain conditions (COPCs). Patient Reported Outcomes Measurement Information System-10 (PROMIS-10) global physical health (PH) and global mental health (MH) were measured at baseline and at pragmatic time points during follow-up. Linear regression was used to estimate adjusted associations between available features and changes in PROMIS scores. RESULTS 241 patients were followed for a mean of 17.0 ± 7.5 months. Mean baseline pain was 6.7 (SD 2.1), PROMIS-10 global MH score was 44.8 (SD 9.3), and PH score was 39.4 (SD 8.6). 29.7% were low-risk on the SBT, 41.8% were medium-risk, and 28.5% were high-risk. Mean change in MH and PH scores from baseline to the follow-up questionnaire were 0.86 (SD 8.11) and 2.39 (SD 7.52), respectively. Compared to low-risk patients, high-risk patients had a mean 4.35 points greater improvement in their MH score (p= 0.004) and a mean 3.54 points greater improvement in PH score (p= 0.006). Fewer COPCs also predicted greater improvement in MH and PH. CONCLUSIONS SBT and the presence of COPC, which can be assessed at initial presentation to a specialty clinic, can predict change in PROMIS following treatment. Effort is needed to identify other factors that can help predict change in function after treatment in the specialty care setting.
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Affiliation(s)
- Patricia Zheng
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Susan Ewing
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Angelina Tang
- School of Medicine, University of California, San Francisco, CA, USA
| | - Dennis Black
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Trisha Hue
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Jeffrey Lotz
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Thomas Peterson
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | - Abel Torres-Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Conor O’Neill
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
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Vomer RP, Larick RS, Bent A, Fungwe C, Contractor PS, York E. Improving Patient Access to Musculoskeletal Treatments and Medical Student Musculoskeletal Education via Free Clinic Services. Cureus 2023; 15:e47996. [PMID: 38034178 PMCID: PMC10685178 DOI: 10.7759/cureus.47996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Homeless patients are at higher risk for musculoskeletal conditions but have limited access to treatments. Physical therapy (PT) and osteopathic manual therapy (OMT) are treatments for acute and chronic musculoskeletal conditions. Here, we outline establishing a free specialty clinic to provide PT and OMT to underserved patients. Methods At Eastern Virginia Medical School's Health Outreach Partnership of EVMS Students (HOPES) free clinic, we established a volunteer student, resident, and attending-led specialty clinic to provide exercise therapy, manual therapy, and injections to underserved patients. Results Student volunteering resulted in significant improvement in student confidence with musculoskeletal physical exam skills and their ability to diagnose musculoskeletal conditions. Patients of the clinic reported significant improvement in pain and mobility. Discussion This clinic is a novel activity that improves student musculoskeletal medical education and patient access to musculoskeletal condition treatments. Exposing students to PT and OMT services increased student awareness of the PT scope of practice, OMT's use as a component for patient treatment increased confidence in the appropriate applications of OMT for patient care. Implementing a free PT and OMT clinic at an established free clinic can improve musculoskeletal medical education and enhance patient care for underserved populations.
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Affiliation(s)
- Rock P Vomer
- Family Medicine, Avance Care, Raleigh, USA
- Family Medicine Research, Mayo Clinic - Jacksonville, Jacksonville, USA
| | - Rayghan S Larick
- Physical Medicine and Rehabilitation, Eastern Virginia Medical School, Norfolk, USA
| | - Abigail Bent
- Family and Community Medicine, Eastern Virginia Medical School, Norfolk, USA
| | - Chris Fungwe
- Family and Community Medicine, Eastern Virginia Medical School, Norfolk, USA
| | | | - Emma York
- Family and Preventive Medicine, Prisma Health University of South Carolina, Columbia, USA
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Murphy DR, Justice BD, Borkan J. Using medical storytelling to communicate problems and solutions in the low back pain conundrum: an evidence-based tale of twins. Chiropr Man Therap 2023; 31:25. [PMID: 37553703 PMCID: PMC10410981 DOI: 10.1186/s12998-023-00499-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/14/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES Low back pain (LBP) is the number one cause of disability world-wide. It is also the most expensive area in healthcare. Patient-centered innovations are needed. This paper uses medical storytelling to illustrate the common problems that often lead to unnecessary suffering for patients, and costs to society. We present innovative solutions, including narrative interventions. METHODS We use medical storytelling to present a scenario in which hypothetical twin patients with identical LBP episodes enter the healthcare system, with one twin managed in an appropriate manner, and the other inappropriately. RESULTS One twin becomes a chronic LBP sufferer, while the other experiences quick resolution, despite identical conditions. Recommendations are made to de-implement inappropriate action and to implement a more productive approach. CONCLUSIONS Many patients with LBP descend into chronic pain. This is rarely inevitable based on clinical factors. Much of chronic LBP results from how the condition is handled within the healthcare system. Medical narrative may be one innovation to illustrate the problem of current LBP management, recommend solutions and foster changes in clinical behavior. PRACTICAL IMPLICATIONS The starkly different outcomes for each identical twin are illustrated. Recommendations are made for reframing the situation to de-implement the inappropriate and to implement a more appropriate approach.
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Affiliation(s)
- Donald R Murphy
- Department of Family Medicine, Alpert Medical School of Brown University, 133 Dellwood Road, Cranston, RI, 02920, USA.
| | - Brian D Justice
- Excellus BlueCross BlueShield, 165 Court Street, Rochester, NY, 14647, USA
| | - Jeffrey Borkan
- Department of Family Medicine, Alpert Medical School of Brown University, 111 Brewster St, Pawtucket, RI, 02860, USA
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Short S, Tuttle M, Youngman D. A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy. Int J Sports Phys Ther 2023; 18:262-271. [PMID: 36793565 PMCID: PMC9897024 DOI: 10.26603/001c.67936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/03/2022] [Indexed: 02/05/2023] Open
Abstract
Symptom modification techniques have been recently dichotomously labeled as either passive or active therapies. Active therapy such as exercise has been rightfully advocated for while "passive" therapies, mainly manual therapy have been regarded as low value within the physical therapy treatment spectrum. In sporting environments where physical activity and exercise are inherent to the athletic experience, the utilization of exercise-only strategies to manage pain and injury can be challenging when considering the demands and qualities of a sporting career which include chronically high internal and external workloads. Participation may be impacted by pain and its influence on related factors such as training and competition performance, career length, financial earning potential, educational opportunity, social pressures, influence of family, friends, and other key stakeholders of their athletic activity. Though highly polarizing viewpoints regarding different therapies create black and white "sides," a pragmatic gray area regarding manual therapy exists in which proper clinical reasoning can serve to improve athlete pain and injury management. This gray area includes both historic positive reported short-term outcomes and negative historical biomechanical underpinnings that have created unfounded dogma and inappropriate overutilization. Applying symptom modification strategies to safely allow the continuation of sport and exercise requires critical thinking utilizing not only the evidence-base, but also the multi-factorial nature of sports participation and pain management. Given the risks associated with pharmacological pain management, the cost of passive modalities like biophysical agents (electrical stimulation, photobiomodulation, ultrasound, etc), and the indications from the evidence-base when combined with active therapies, manual therapy can be a safe and effective treatment strategy to keep athletes active. Level of Evidence 5.
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7
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Jin MC, Jensen M, Zhou Z, Rodrigues A, Ren A, Barros Guinle MI, Veeravagu A, Zygourakis CC, Desai AM, Ratliff JK. Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain. JAMA Netw Open 2022; 5:e2222062. [PMID: 35816312 PMCID: PMC9280399 DOI: 10.1001/jamanetworkopen.2022.22062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain. OBJECTIVE To understand health care utilization in patients with new-onset idiopathic neck pain. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022. MAIN OUTCOMES AND MEASURES The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used. RESULTS In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were $24 267.55 per surgical patient and $515.69 per nonsurgical patient. Across all health care services, $95 379 949 was accounted for by nonsurgical patients undergoing early imaging who did not receive any additional conservative therapy or epidural steroid injections, for a mean (SD) of $477.53 ($1375.60) per patient and median (IQR) of $120.60 ($20.70-$452.37) per patient. On average, patients not undergoing surgery, physical therapy, chiropractic manipulative therapy, or epidural steroid injection, who underwent either early advanced imaging (magnetic resonance imaging or computed tomography) or both early advanced and radiographic imaging, accumulated significantly elevated health care costs ($850.69 and $1181.67, respectively). Early conservative therapy was independently associated with 24.8% (95% CI, 23.5%-26.2%) lower health care costs. CONCLUSIONS AND RELEVANCE In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael Jensen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Zeyi Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Adrian Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Alexander Ren
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | | | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Acharya M, Chopra D, Smith AM, Fritz JM, Martin BC. Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas. J Chiropr Med 2022; 21:67-76. [PMID: 35774633 PMCID: PMC9237579 DOI: 10.1016/j.jcm.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 12/30/2022] Open
Abstract
Objective The objective of this study was to estimate the association between early use of physical therapy (PT) or chiropractic care and incident opioid use and long-term opioid use in individuals with a low back pain (LBP) diagnosis. Methods A retrospective cohort study was conducted using data from Arkansas All Payers' Claims Database. Adults with incident LBP diagnosed in primary care or emergency departments between July 1, 2013, and June 30, 2017, were identified. Participants were required to be opioid naïve in the 6-month baseline period and without cancer, cauda equina syndrome, osteomyelitis, lumbar fracture, and paraplegia/quadriplegia in the entire study period. PT and chiropractic treatment were documented over the ensuing 30 days starting on the date of LBP. Any opioid use and long-term opioid use (LTOU) in 1-year follow-up were assessed. Multivariable logistic regressions controlling for covariates were estimated. Results A total of 40 929 individuals were included in the final sample, with an average age of 41 years and 65% being women. Only 5% and 6% received PT and chiropractic service, respectively, within the first 30 days. Sixty-four percent had incident opioid use, and 4% had LTOU in the follow-up period. PT was not associated with incident opioid use (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.98-1.18) or LTOU (OR, 1.19; 95% CI, 0.97-1.45). Chiropractic care decreased the odds of opioid use (OR, 0.88; 95% CI, 0.80-0.97) and LTOU (OR, 0.56; 95% CI, 0.40-0.77). Conclusion In this study we found that receipt of chiropractic care, though not PT, may have disrupted the need for opioids and, in particular, LTOU in newly diagnosed LBP.
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Affiliation(s)
- Mahip Acharya
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Divyan Chopra
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Allen M. Smith
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Julie M. Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah
| | - Bradley C. Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Corresponding author: Bradley C. Martin, PharmD, PhD, 4301 West Markham Street, Slot 522, Little Rock, AR 72205
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Crowell MS, Mason JS, McGinniss JH. Musculoskeletal Imaging for Low Back Pain in Direct Access Physical Therapy Compared to Primary Care: An Observational Study. Int J Sports Phys Ther 2022; 17:237-246. [PMID: 35136693 PMCID: PMC8805092 DOI: 10.26603/001c.31720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Overutilization of diagnostic imaging is associated with poor outcomes and increased costs. Physical therapists demonstrate the ability to order diagnostic imaging safely and appropriately, and early access to physical therapy reduces unnecessary imaging, lowers healthcare costs, and improves outcomes. HYPOTHESIS/PURPOSE The primary purpose of this study was to compare rates of compliance with the National Committee for Quality Assurance - Healthcare Effectiveness Data and Information Set (HEDIS) recommendations for diagnostic imaging in low back pain between physical therapists and primary care providers in young, athletic patients. STUDY DESIGN Retrospective cohort study. METHODS Military Health System Data Repository (MDR) data from January 2019 to May 2020 was reviewed for compliance with the low back pain HEDIS recommendation. The low back pain imaging HEDIS measure identifies the percentage of patients who did not have an imaging study (plain X-ray, MRI, CT Scan) ordered on the first encounter with a diagnosis of low back pain or in the 28 days following that first diagnosis. Chi-square tests compared HEDIS compliance rates, with α = 0.05 set a priori. RESULTS From January 2019 to May 2020, in patients age 18-24, the MDR database identified 1,845 total visits for LBP identified in the Physical Therapy Clinic and 467 total visits for LBP in the Primary Care Clinic. In the Physical Therapy Clinic, 96.7% of encounters did not have imaging ordered within the first 28 days of onset of symptoms, compared with 82.0% in the Primary Care Clinic (p < .001). CONCLUSIONS Utilizing data from a national standardized healthcare performance measure, physical therapists practicing in a direct-access setting were significantly more likely than primary care providers to adhere to guidelines for low back pain imaging in young, athletic patients. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Michael S Crowell
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - John S Mason
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - John H McGinniss
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
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Ding Y, Liu C. Alternative payment models and physician treatment decisions: Evidence from lower back pain. JOURNAL OF HEALTH ECONOMICS 2021; 80:102548. [PMID: 34763199 DOI: 10.1016/j.jhealeco.2021.102548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 10/20/2021] [Accepted: 10/23/2021] [Indexed: 06/13/2023]
Abstract
The capitated payment model has been used to address the high cost of health care. Under capitation, physicians are compensated with a fixed amount per patient, regardless of the services generated. We provide new evidence on how the capitation payment model changes physicians behaviors by studying the treatment of lower back pain, as this type of treatment provides substantial scope for physicians discretion. We use data from 2003 to 2006 from a large database of employer-sponsored health insurance claims and leverage capitation variation within the plan and physician to mitigate selection concerns. The results show that the treatment intensity-primarily derived from therapy and diagnostic testing -of patients under a capitation system is 7-12% lower than that of similar patients in a non-capitated plan. Furthermore, we find no evidence of increased relapse rates for patients in a capitated plan.
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Affiliation(s)
- Yu Ding
- Department of Economics, University of Wisconsin at Madison, United States.
| | - Chenyuan Liu
- Department of Economics, School of Economics and Management, Tsinghua University, Beijing 100084, China.
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Contribution of COMT and BDNF Genotype and Expression to the Risk of Transition From Acute to Chronic Low Back Pain. Clin J Pain 2021; 36:430-439. [PMID: 32079998 PMCID: PMC7211115 DOI: 10.1097/ajp.0000000000000819] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES A number of factors, including heritability and the environment, contribute to risk of transition from acute low back pain to chronic low back pain (CLBP). The aim of this study was to (1) compare somatosensory function and pain ratings at low back pain (LBP) onset between the acute low back pain and CLBP conditions and (2) evaluate associations between BDNF and COMT polymorphisms and expression levels at LBP onset to acute and chronic pain burden and risk for transition to the chronic pain state. METHODS In this longitudinal study, 220 participants were enrolled following recent onset of LBP and data were collected until the LBP resolved or until the end of the study at 6 months. Forty-two participants' pain resolved before 6 weeks from onset and 42 participants continued to have pain at 6 months. Patient-reported pain burden, somatosensory function (quantitative sensory testing), and blood samples were collected at each study visit. RESULTS CLBP is associated with greater pain burden and somatosensory hypersensitivity at the time of LBP onset. COMT rs4680 genotype (GG) was associated with acute cold pain sensitivity and with the risk for transition to CLBP while COMT expression was independently associated with risk for transition. DISCUSSION CLBP was characterized by higher reported pain burden and augmented hypersensitivity at LBP onset. COMT expression and genotype were associated with acute pain burden and likelihood of transition to CLBP.
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Blokzijl J, Dodd RH, Copp T, Sharma S, Tcharkhedian E, Klinner C, Maher CG, Traeger AC. Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study. Emerg Med J 2021; 38:529-536. [PMID: 34045266 DOI: 10.1136/emermed-2020-210345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/02/2020] [Accepted: 04/25/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Overuse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential. AIM To explore factors that might influence overuse of lumbar imaging in the Emergency Department. METHODS Participants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds. RESULTS Patients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients' perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care. CONCLUSION AND KEY FINDINGS We found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.
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Affiliation(s)
- Johan Blokzijl
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Centre Utrecht Brain Centre, Utrecht, Netherlands.,Institute for Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Rachael H Dodd
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Institute for Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | | | - Christiane Klinner
- Institute for Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia .,Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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14
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Magel JS, Gordon AJ, Fritz JM, Kim J. The Influence of an Opioid Use Disorder on Initiating Physical Therapy for Low Back Pain: A Retrospective Cohort. J Addict Med 2021; 15:226-232. [PMID: 33074851 PMCID: PMC8050136 DOI: 10.1097/adm.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Low back pain (LBP) is common among patients with an opioid use disorder (OUD). The extent to which patients with an OUD initiate physical therapy for LBP is unknown. The aim of this study was to examine the association between a history of an OUD and initiation of physical therapy for LBP within 60 days of a primary care provider (PCP) visit for this condition. METHODS Claims from a single state-wide all payer claims database from June 30, 2013 and August 31, 2015 were used to establish a retrospective cohort of patients who consulted a PCP for a new episode of LBP. The outcome measure was patients who had at least 1 physical therapy claim within 60-days after the PCP visit. After propensity score matching on covariates, logistic regression was used to compare the outcome of patients with a history of an OUD to patients without an OUD. RESULTS Propensity score matching resulted in 1360 matched pairs of participants. The mean age was 47.2 years (15.9) and 55.9% were female. Compared to patients without an OUD, patients with an OUD were less likely to initiate physical therapy for LBP (adjusted odds ratio = 0.65, 95% confidence intervals:0.49-0.85). CONCLUSIONS After a visit to a PCP for a new episode of care for LBP, patients with a history of an OUD are less likely to initiate physical therapy.
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Affiliation(s)
- John S Magel
- Department of Physical Therapy and Athletic Training, University of Utah, UT (JSM, JMF, JK); Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA) and Greater Intermountain Node (GIN), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (AG)
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Alhowimel A, Alodaibi F, Alotaibi M, Alamam D, Alsobayel H, Fritz J. Development of a Logic Model for a Programme to Reduce the Magnetic Resonance Imaging Rate for Non-Specific Lower Back Pain in a Tertiary Care Centre. Healthcare (Basel) 2021; 9:healthcare9020238. [PMID: 33672242 PMCID: PMC7926309 DOI: 10.3390/healthcare9020238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 11/16/2022] Open
Abstract
Tertiary care centres continue to experience over-utilisation of diagnostic imaging services for lower back pain cases that may not be required. Moreover, these services may require additional time and consequently delay access to services that offer conservative management, i.e., physiotherapy, and hence, increase the direct and indirect costs with no added quality of care. A logic model was developed based on qualitative and quantitative studies that explains the plan and process evaluation strategies to reduce imaging for lower back pain in tertiary hospitals. Logic models are useful tools for defining programme components. The delivery of the components is ensured by well-defined process evaluations that identify any needed modifications. The proposed logic model provides a road map for spine clinics in tertiary care hospitals to decrease the number of patient referrals for magnetic resonance imaging and waiting times for consultations and services and promote early access to physiotherapy services.
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Affiliation(s)
- Ahmed Alhowimel
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia;
- Correspondence:
| | - Faris Alodaibi
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Mazyad Alotaibi
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia;
| | - Dalyah Alamam
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Hana Alsobayel
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT 84112, USA;
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Schaaf S, Huang W, Perera S, Conley Y, Belfer I, Jayabalan P, Tremont K, Coelho P, Ernst S, Cortazzo M, Weiner D, Vo N, Kang J, Sowa G. Association of Protein and Genetic Biomarkers With Response to Lumbar Epidural Steroid Injections in Subjects With Axial Low Back Pain. Am J Phys Med Rehabil 2021; 100:48-56. [PMID: 32576742 PMCID: PMC8128510 DOI: 10.1097/phm.0000000000001514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this observational study was to examine the association of protein and genetic biomarkers with pain and pain-related disability in individuals with axial low back pain undergoing epidural steroid injections. DESIGN Forty-eight adults with axial low back pain undergoing an epidural steroid injection were recruited from an academic medical center. Blood samples were assayed at baseline and follow-up for plasma proteins and functional single-nucleotide polymorphisms associated with pain. Data regarding pain and function were collected at baseline and follow-up. The characteristics of responders (defined as 50% improvement in pain score) and nonresponders were compared, and the association between response and baseline biomarkers was examined. RESULTS Thirty-five percent of subjects were responders to injection. Responders had lower baseline plasma levels of chondroitin sulfate 846 and higher neuropeptide Y and serotonin levels than nonresponders, and baseline neuropeptide Y level correlated with change in disability levels. In addition, subjects with the variant allele for the catechol-O-methyltransferase single-nucleotide polymorphism demonstrated increased odds of responding to the injection. CONCLUSIONS These data identify candidates who may have utility for patient selection for spinal procedures and provide support for exploration in prospective studies to assess and validate their predictive ability.
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Affiliation(s)
- Stephen Schaaf
- From the Departments of Physical Medicine and Rehabilitation (SS, WH, PJ, KT, PC, SE, MC, GS), Medicine (SP, DW), and Orthopaedic Surgery (NV), University of Pittsburgh/UPMC, Pittsburgh, Pennsylvania; School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania (YC); National Institutes of Health, Bethesda, Maryland (IB); Shirley Ryan AbilityLab, Northwestern Feinberg School of Medicine, Chicago, Illinois (PJ); and Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts (JK)
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Hudson D, Knapp K, Benwell M. An evaluation of MRI lumbar spine scans within a community-based diagnostic setting. Musculoskeletal Care 2020; 19:384-395. [PMID: 33278329 DOI: 10.1002/msc.1529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND With an ongoing move towards more management of patients within the community setting, demand for magnetic resonance imaging (MRI) is increasing and commonly used in lower back conditions. There is well recorded overuse of MRI in this scenario which goes against evidence-based practice and adds to rising healthcare costs. METHODS The study was a retrospective review of lumbar spine MRI scans performed within a community-based setting over an 18-month period. The review took a randomised purposive sample of patients (n = 450); looking at adherence to, and relevance of, guidelines in managing lower back conditions. Data extracted provided information on demographics and prevalence of clinical presentation and report observations. RESULTS There is variation in practice and utlisation of MRI with this patient group which warrants further exploration. Results support inappropriate use, lacking adherence to guidelines and pathways, leading to unnecessary imaging. 46% of referrals were considered clinically justified with 38% of report findings considered abnormal and of clinical relevance. Chi-square and binomial logistic regression were used to assess the significance and relationship of any factors on referral justification and report outcome. No difference was found between type of referrer, with patient age and leg symptoms being significant factors. CONCLUSION The study highlights the opportunity to integrate better referral criteria to improve referral quality, its suitability and the relevance of final reports. In the current climate this would help manage appropriate use of imaging resources during the post COVID-19 pandemic recovery phase, as well as support recommendations regarding diagnostic reform and a move towards more community-based diagnostics.
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Affiliation(s)
| | - Karen Knapp
- Medical Imaging, College of Medicine and Health, Exeter University, Exeter, UK
| | - Martin Benwell
- Medical Imaging, College of Medicine and Health, Exeter University, Exeter, UK
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Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine. J Gen Intern Med 2020; 35:3605-3612. [PMID: 32989711 PMCID: PMC7728897 DOI: 10.1007/s11606-020-06181-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Contrary to guidelines, magnetic resonance imaging (MRI) is often ordered in the first 6 weeks of new episodes of uncomplicated non-specific low back pain. OBJECTIVE To determine the downstream consequences of early imaging. DESIGN Retrospective matched cohort study using data from electronic health records of primary care clinics of the U.S. Department of Veterans Affairs. PARTICIPANTS Patients seeking primary care for non-specific low back pain without a red flag condition or an encounter for low back pain in the prior 6 months (N = 405,965). EXPOSURE MRI of the lumbar spine within 6 weeks of the initial primary care visit. MAIN MEASURES Covariates included patient demographics, health history in the prior year, and baseline pain. Outcomes were lumbar surgery, prescription opioid use, acute health care costs, and last pain score recorded within 1 year of the index visit. KEY RESULTS Early MRI was associated with more back surgery (1.48% vs. 0.12% in episodes without early MRI), greater use of prescription opioids (35.1% vs. 28.6%), a higher final pain score (3.99 vs. 3.87), and greater acute care costs ($8082 vs. $5560), p < 0.001 for all comparisons. LIMITATIONS Reliance on data gathered in normal clinical care and the potential for residual confounding despite the use of coarsened exact matching weights to adjust for baseline differences. CONCLUSIONS The association between early imaging and increased utilization was apparent even in a setting largely unaffected by incentives of fee-for-service care. Reduced imaging cost is only part of the motivation to improve adherence with guidelines for the use of MRI. Early scans are associated with excess surgery, higher costs for other care, and worse outcomes, including potential harms from prescription opioids.
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Alhowimel A, Alotiabi M, Coulson N, Radford K. Feasibility study and process evaluation of MRI plus physiotherapy vs. physiotherapy alone in non-specific chronic low back pain among patients in Saudi Arabia. Pilot Feasibility Stud 2020; 6:188. [PMID: 33292710 PMCID: PMC7702682 DOI: 10.1186/s40814-020-00731-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/18/2020] [Indexed: 11/12/2022] Open
Abstract
Aim To determine the feasibility of conducting a definitive randomised control trial (RCT) to answer the following questions: (1) Is early physiotherapy treatment acceptable and feasible for patients and direct healthcare providers? and (2) Is early physiotherapy intervention associated with better disability and psychosocial outcomes compared with the practice of routine MRIs? Methods In a feasibility RCT in Riyadh City from 01 March 2018 until 29 July 2018, chronic low back pain (CLBP) patients presenting to spine clinics were randomised to receive an MRI (intervention) plus physiotherapy rehabilitation or physiotherapy alone (control group). The acceptability of randomisation to the control group (non-MRI) was tested during the recruitment by qualitatively interviewing study participants and referring physicians. Moreover, interviews with study participants explored the broader social, political, economic, and environmental (context) aspects that may influence trial delivery and intervention implementation. Results The recruitment target was not met: 16/24 (66%) participants were recruited in 4 months (12.4% of those screened); 33% declined. The process evaluation identified numerous factors that may affect the success of a definitive RCT in Saudi Arabia. These were research resources, the lack of research infrastructure to support recruitment to trials, limited research capacity in terms of knowledge and skills of the healthcare team, and limited funding. Conclusion A definitive RCT to test the influence of MRI diagnosis on the psychosocial and disability outcomes in people with CLBP treated with physiotherapy in Saudi Arabia is feasible. However, the lack of research infrastructure, research capacity, the impact of MRI on patient outcomes, and a lack of clinical equipoise in the treatment and management of CLBP in Saudi Arabia pose major barriers to clinical trials.
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Affiliation(s)
- Ahmed Alhowimel
- Physical Therapy and Rehabilitation Science Department, Prince Sattam Bin AbdulAziz University, Alkarj, Saudi Arabia.
| | - Mazyad Alotiabi
- Physical Therapy and Rehabilitation Science Department, Prince Sattam Bin AbdulAziz University, Alkarj, Saudi Arabia
| | - Neil Coulson
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kathryn Radford
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
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Barnett PG, Jacobs JC, Jarvik JG, Chou R, Boothroyd D, Lo J, Nevedal A. Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System. JAMA Netw Open 2020; 3:e2010343. [PMID: 32658287 PMCID: PMC7358914 DOI: 10.1001/jamanetworkopen.2020.10343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Magnetic responance imaging (MRI) of the lumbar spine that is not concordant with treatment guidelines for low back pain represents an unnecessary cost for US health plans and may be associated with adverse effects. Use of MRI in the US Department of Veterans Affairs (VA) primary care clinics remains unknown. OBJECTIVE To assess the use of MRI scans during the first 6 weeks (early MRI scans) of episodes of nonspecific low back pain in VA primary care sites and to determine if historical concordance can identify clinicians and sites that are the least concordant with guidelines. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of electronic health records from 944 VA primary care sites from the 3 years ending in 2016. Data were analyzed between January 2017 and August 2019. Participants were patients with new episodes of nonspecific low back pain and the primary care clinicians responsible for their care. EXPOSURES MRI scans. MAIN OUTCOMES AND MEASURES The proportion of early MRI scans at VA primary care clinics was assessed. Clinician concordance with published guidelines over 2 years was used to select clinicians expected to have low concordance in a third year. RESULTS A total of 1 285 405 new episodes of nonspecific low back pain from 920 547 patients (mean [SD] age, 56.7 [15.8] years; 93.6% men) were attributed to 9098 clinicians (mean [SD] age, 52.1 [10.1] years; 55.7% women). An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%). Historical concordance was better than a random draw in selecting the 10% of clinicians who were subsequently the least concordant with published guidelines. For primary care clinicians, the area under the receiver operating characteristic curve was 0.683 (95% CI, 0.658-0.701). For primary care sites, the area was under this curve was 0.8035 (95% CI, 0.754-0.855). The 10% of clinicians with the least historical concordance were responsible for just 19.2% of the early MRI scans performed in the follow-up year. CONCLUSIONS AND RELEVANCE VA primary care clinics had low rates of use of early MRI scans. A history of low concordance with imaging guidelines was associated with subsequent low concordance but with limited potential to select clinicians most in need of interventions to implement guidelines.
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Affiliation(s)
- Paul G. Barnett
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Josephine C. Jacobs
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Jeffrey G. Jarvik
- Department of Radiology, University of Washington, Seattle
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics, Oregon Health & Science University, Portland
- Department of Medicine, Oregon Health & Science University, Portland
| | - Derek Boothroyd
- Quantitative Research Unit, Stanford University Medical School, Stanford, California
| | - Jeanie Lo
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
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Framework for improving outcome prediction for acute to chronic low back pain transitions. Pain Rep 2020; 5:e809. [PMID: 32440606 PMCID: PMC7209816 DOI: 10.1097/pr9.0000000000000809] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 12/23/2022] Open
Abstract
Clinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.
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Chevan J, Heath AE. Developing core education principles for rehabilitation professionals in response to the opioid crisis: an example from physical therapy education. Disabil Rehabil 2019; 43:2227-2232. [PMID: 31774705 DOI: 10.1080/09638288.2019.1696416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE We describe how educators in one state developed a set of core principles for the education of Doctor of Physical Therapy students in response to the opioid crisis, and we present these principles as a model for educators globally. METHODS In Massachusetts, a working group from the physical therapy program directors developed a model for opioid education based on a review of the literature, of curricula and of the accreditation standards. RESULTS The "Core Principles for the Education of Physical Therapy Professionals in the Context of the U.S. Opioid Emergency" provide a model that recognizes the profession's role in care and prevention; a role that engages the profession with patients who have painful conditions and are at risk for substance and/or opioid misuse, patients who have painful conditions and opioid use disorder, and patients who have opioid use disorder as a primary diagnosis. The principles ensure that graduates have the skills and knowledge to provide care that minimizes the social stigma and biases that individuals with opioid use disorder may face. DISCUSSION The Core Principles provide a roadmap for educational programs. Health professions educators can assume a role of leadership in the opioid crisis and ensure that students and clinical instructors are prepared for care provision and advocacy.IMPLICATIONS FOR REHABILITATIONIn light of the opioid crisis, students in the rehabilitation professions should have education targeted specifically to opioid use and opioid use disorder that incorporates pharmacology, pain science, behavioral and socio-political perspectives.The Core Education Principles document posits that physical therapy education around opioid use should focus on three patient populations, people who have painful conditions and are at risk for substance and/or opioid misuse, people who have painful conditions and opioid use disorder, and people who have opioid use disorder as a primary diagnosis.Within each of the patient populations there are curricular implications in terms of teaching about screening and prevention, movement system interventions, and interprofessional care activities.
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Affiliation(s)
- Julia Chevan
- Department of Physical Therapy, Springfield College, Springfield, MA, USA
| | - Amy E Heath
- Department of Physical Therapy Department, Western Michigan University, Kalamazoo, MI, USA
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Lentz TA, Goode AP, Thigpen CA, George SZ. Value-Based Care for Musculoskeletal Pain: Are Physical Therapists Ready to Deliver? Phys Ther 2019; 100:621-632. [PMID: 31764990 PMCID: PMC7439230 DOI: 10.1093/ptj/pzz171] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/23/2019] [Accepted: 08/18/2019] [Indexed: 12/22/2022]
Abstract
Early physical therapy models hold great promise for delivering high-value care for individuals with musculoskeletal pain. However, existing physical therapist practice and research standards are misaligned with value-based principles, which limits the potential for growth and sustainability of these models. This Perspective describes how the value proposition of early physical therapy can be improved by redefining harm, embracing a prognostic approach to clinical decision making, and advocating for system-wide guideline-adherent pain care. It also outlines the need to adopt a common language to describe these models and embrace new, rigorous study designs and analytical approaches to better understand where and how early physical therapy delivers value. The goal is to define a clear path forward to ensure physical therapists are aligned within health care systems to deliver on the American Physical Therapy Association's vision of high-value care in a rapidly changing health care environment.
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Affiliation(s)
- Trevor A Lentz
- Duke Clinical Research Institute, Duke University, and Department of Orthopaedic Surgery, Duke University, 200 Morris St, Durham, NC 22701 USA,Address all correspondence to Dr Lentz at:
| | - Adam P Goode
- Duke Clinical Research Institute, Department of Orthopedic Surgery, and Department of Population Health Sciences, Duke University
| | - Charles A Thigpen
- ATI Physical Therapy, Greenville, South Carolina, and Center for Effectiveness Research in Orthopaedics, University of South Carolina, Greenville, South Carolina
| | - Steven Z George
- FAPTA, Duke Clinical Research Institute, and Department of Orthopedic Surgery, Duke University
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Comment on "The Relationship of the Amount of Physical Therapy to Time Lost From Work and Costs in the Workers' Compensation System". J Occup Environ Med 2019; 62:e80-e81. [PMID: 31714375 DOI: 10.1097/jom.0000000000001759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Akindele M, Rabiu M, Useh E. Assessment of the awareness, adherence, and barriers to low back pain clinical practice guidelines by practicing physiotherapists in a low‐resourced country. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 25:e1811. [DOI: 10.1002/pri.1811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/27/2019] [Accepted: 08/25/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Mukadas Akindele
- Department of Physiotherapy, Faculty of Allied Health SciencesBayero University Kano Nigeria
| | - Mubasshir Rabiu
- Department of Physiotherapy, Faculty of Allied Health SciencesBayero University Kano Nigeria
| | - Efe Useh
- Lifestyle Diseases Research Entity, Faculty of Health SciencesNorth West University Mahikeng South Africa
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Walston Z, Niles P, Spiker L, Yake D. Use of cognitive behavioural therapy with usual physical therapy intervention for individuals who are unemployed secondary to chronic low back pain: A case series. Musculoskeletal Care 2019; 17:269-273. [PMID: 31373424 DOI: 10.1002/msc.1422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/12/2019] [Accepted: 07/13/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Low back pain (LBP) is a leading cause of work absence and may influence the development of fear-avoidance behaviours. The purpose of this case series was to examine the use of cognitive behavioural therapy (CBT) with physical therapy (PT) for the treatment of fear-avoidance behaviours in patients with chronic LBP who are disabled or in a period of work absence. CASE DESCRIPTION Four patients with high-irritability chronic LBP who were considered as being on work absence or disability were treated in outpatient PT clinics. The intervention consisted of fundamental CBT concepts utilized in combination with a traditional PT intervention. OUTCOMES Patients were treated until the achievement of functional goals and normalized movement patterns. Pain, disability and function were measured via a numerical pain rating scale, the Oswestry Disability Index and Focus on Therapeutic Outcomes. All patients achieved the minimally clinically important difference for these measures. Fear-avoidance behaviours decreased, as observed by an average 15-point change in Fear-Avoidance Behaviour Questionnaire (Physical Activity) outcomes. Patients on work absence returned to work. DISCUSSION This case series describes the use of CBT in combination with a traditional PT intervention for the treatment of high-irritability, fear-avoidant individuals who are on disability or in a period of work absence. The results indicated that CBT may be a useful and feasible adjunct to PT and may positively influence a return to work. Further studies are needed to determine effectiveness, including randomized controlled trials.
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Affiliation(s)
| | - Paige Niles
- PT Solutions Physical Therapy, Atlanta, Georgia
| | - Lisa Spiker
- PT Solutions Physical Therapy, Atlanta, Georgia
| | - Dale Yake
- PT Solutions Physical Therapy, Atlanta, Georgia
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Gross DP, Emery DJ, Long A, Reese H, Whittaker JL. A descriptive study of physiotherapist use of publicly funded diagnostic imaging modalities in Alberta, Canada. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2018.1505947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Douglas P. Gross
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
| | - Derek J. Emery
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Audrey Long
- Bonavista Physiotherapy Clinic, Calgary, Canada
| | - Hilary Reese
- LifeMark at Academy Place Physiotherapy Clinic, Edmonton, Canada
| | - Jackie L. Whittaker
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Canada
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Arnold E, La Barrie J, DaSilva L, Patti M, Goode A, Clewley D. The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review. Arch Phys Med Rehabil 2019; 100:1324-1338. [DOI: 10.1016/j.apmr.2018.11.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/23/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
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Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:937-950. [DOI: 10.1007/s00586-019-05918-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/18/2019] [Accepted: 02/10/2019] [Indexed: 12/21/2022]
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Ramirez MM, Brennan GP. Using the value-based care paradigm to compare physical therapy access to care models in cervical spine radiculopathy: a case report. Physiother Theory Pract 2019; 36:1476-1484. [PMID: 30776939 DOI: 10.1080/09593985.2019.1579878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The efficiency and effectiveness of multiple physical therapy care delivery models can be measured using the value-based care paradigm. Entering physical therapy through direct access can decrease health-care utilization and improve patient outcomes. Limited evidence exists which compares direct access physical therapy to referral using the value-based care paradigm specific to cervical spine radiculopathy. Case Description: The patient was a 39-year-old woman who presented to physical therapy through physician referral with the diagnoses of acute cervical radiculopathy. The patient was evaluated, provided guideline adherent treatment and discharged with a home exercise program. Sixteen months from being discharged, the same patient returned through direct access due to an acute onset of cervical spine symptoms and was evaluated and provided treatment that same morning. Outcomes: Direct access physical therapy saved the patient and third-party payer $434.30 and $3264.75 respectively. A 5×'s higher efficiency per visit and a 6.2×'s higher value in reducing disability was demonstrated when the patient accessed physical therapy directly. Physician referral and direct access entry pathways demonstrated neck disability index improvements of 6% and 16%, respectively. Discussion: This case report describes a clinical example of previous research that demonstrates improved cost efficiency, outcomes, and increased value with a patient who presented to physical therapy with cervical radiculopathy through two different access to care models. The results of this case demonstrate a clinical example of the use of the value-based care paradigm in comparing value and efficiency of two access to care models in a patient with cervical radiculopathy without other neurological deficits.
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Affiliation(s)
- Michelle M Ramirez
- Department of Sports Medicine and Rehabilitation, AdventHealth Orlando-Adventist Health System , Orlando, FL, USA
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Service Utilization and Costs of Patients at a Cash-Based Physical Therapy Clinic. Health Care Manag (Frederick) 2019; 38:37-43. [PMID: 30640238 DOI: 10.1097/hcm.0000000000000247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cash-based physical therapy, a model in which the clinicians do not accept insurance payments and accept only direct payment, is quickly becoming an enticing option for clinicians who own their own practice. The purpose of this study was to describe service utilization for a single cash-based physical therapy clinic. Forty-eight charts of patients who had been discharged between 2013 and 2016 were randomly selected. The data were deidentified prior to the researchers gaining access. Chronic diagnoses were predominately prevalent (n = 28). The lumbo/pelvic region of diagnoses (39.6%) and knee/leg region of diagnoses (29.2%) encompassed the majority of the diagnoses. The mean physical therapy utilization for the cohort per episode of care was 8.0 ± 8.1 visits per episode of care, total cost of $780.19 ± 530.30 per episode of care, and $97.52 per visit. This study is the first to present data regarding costs, utilization, and patient demographics for a cash-based physical therapy clinic.
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Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ. Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain. JAMA Netw Open 2018; 1:e185909. [PMID: 30646297 PMCID: PMC6324326 DOI: 10.1001/jamanetworkopen.2018.5909] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States. OBJECTIVE To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018. MAIN OUTCOMES AND MEASURES Opioid use between 91 and 365 days after the index date. RESULTS Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P < .001), and low back pain (OR, 0.93; 95% CI, 0.88-0.98; P = .004). For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain (-9.7%; 95% CI, -18.5% to -0.8%; P = .03), knee pain (-10.3%; 95% CI, -17.8% to -2.7%; P = .007), and low back pain (-5.1%; 95% CI, -10.2% to 0.0%; P = .046), but not for neck pain (-3.8%; 95% CI, -10.8% to 3.3%; P = .30). CONCLUSIONS AND RELEVANCE Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined.
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Affiliation(s)
- Eric Sun
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California
| | - Jasmin Moshfegh
- Center for Health Policy, Stanford University School of Medicine, Stanford, California
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Chris A. Rishel
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California
| | - Chad E. Cook
- Duke Clinical Research Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Adam P. Goode
- Duke Clinical Research Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Steven Z. George
- Duke Clinical Research Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
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Horn ME, Fritz JM. Timing of physical therapy consultation on 1-year healthcare utilization and costs in patients seeking care for neck pain: a retrospective cohort. BMC Health Serv Res 2018; 18:887. [PMID: 30477480 PMCID: PMC6258489 DOI: 10.1186/s12913-018-3699-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients seek care from physical therapists for neck pain but it is unclear what the association of the timing of physical therapy (PT) consultation is on 1-year healthcare utilization and costs. The purpose of this study was to compare the 1-year healthcare utilization and costs between three PT timing groups: patients who consulted a physical therapist (PT) for neck pain within 14 days (early PT consultation), between 15 and 90 days (delayed PT consultation) or between 91 and 364 days (late PT consultation). METHODS A retrospective cohort of 308 patients (69.2% female, ages 48.7[±14.5] years) were categorized into PT timing groups. Descriptive statistics were calculated for each group. In adjusted regression models, 1-year healthcare utilization of injections, imaging, opioids and costs were compared between groups. RESULTS Compared to early PT consultation, the odds of receiving an opioid prescription (aOR = 2.79, 95%CI: 1.35-5.79), spinal injection (aOR = 4.36, 95%CI:2.26-8.45), undergoing an MRI (aOR = 4.68, 95%CI:2.25-9.74), X-ray (aOR = 2.97, 95%CI:1.61-5.47) or CT scan (aOR = 3.36, 95%CI: 1.14-9.97) were increased in patients in the late PT consultation group. Similar increases in risk were found in the delayed group (except CT and Opioids). Compared to the early PT consultation group, mean costs were $2172 ($557, $3786) higher in the late PT contact group and $1063 (95%CI: $ 138 - $1988) higher in the delayed PT consultation group. DISCUSSION There was an association with the timing of physical therapy consultation on healthcare utilization and costs, where later consultation was associated with increases costs and healthcare utilization. This study examined the association of timing of physical therapy consultation on costs and healthcare utilization, but not the association of increased access to physical therapy consultation. Therefore, the findings warrant further investigation to explore the effects of increased access to physical therapy consultation on healthcare utilization and costs in a prospective study.
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Affiliation(s)
- Maggie E Horn
- Department of Orthopaedic Surgery, Doctor of Physical Therapy Division, Duke University, Box 104002, Durham, NC, 27708, USA.
| | - Julie M Fritz
- Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA
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Garber AM, Azad TD, Dixit A, Farid M, Sung E, Vail D, Bhattacharya J. Medicare savings from conservative management of low back pain. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e332-e337. [PMID: 30325195 PMCID: PMC9810112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP. STUDY DESIGN We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis. METHODS We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management. RESULTS Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more. CONCLUSIONS Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.
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Clewley D, Rhon D, Flynn T, Koppenhaver S, Cook C. Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain. PLoS One 2018; 13:e0201348. [PMID: 30067844 PMCID: PMC6070259 DOI: 10.1371/journal.pone.0201348] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 07/13/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders. METHODS A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables. RESULTS The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70). CONCLUSION Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.
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Affiliation(s)
- Derek Clewley
- Rocky Mountain University of Health Professions, Provo, Utah, United States of America
- Duke University School of Medicine, Department of Orthopaedics, Division of Physical Therapy, Durham, North Carolina, United States of America
| | - Dan Rhon
- Center for the Intrepid, San Antonio, Texas, United States of America
- Baylor University, Doctor of Physical Therapy Program, Waco, Texas, United States of America
| | - Timothy Flynn
- South College, School of Physical Therapy, Knoxville, Tennessee, United States of America
| | - Shane Koppenhaver
- Baylor University, Doctor of Physical Therapy Program, Waco, Texas, United States of America
| | - Chad Cook
- Duke University School of Medicine, Department of Orthopaedics, Division of Physical Therapy, Durham, North Carolina, United States of America
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Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM. Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Serv Res 2018; 53:4629-4646. [PMID: 29790166 DOI: 10.1111/1475-6773.12984] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To compare differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist (PT) at the first point of care, at any time during the episode or not at all. DATA SOURCES Commercial health insurance claims data, 2009-2013. STUDY DESIGN Retrospective analyses using two-stage residual inclusion instrumental variable models to estimate rates for opioid prescriptions, imaging services, emergency department visits, hospitalization, and health care costs. DATA EXTRACTION Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period. PRINCIPAL FINDINGS Compared to patients who saw a PT later or never, patients who saw a PT first had lower probability of having an opioid prescription (89.4 percent), any advanced imaging services (27.9 percent), and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization (all p < .001). These patients also had significantly lower out-of-pocket costs, and costs appeared to shift away from outpatient and pharmacy toward provider settings. CONCLUSIONS When LBP patients saw a PT first, there was lower utilization of high-cost medical services as well as lower opioid use, and cost shifts reflecting the change in utilization.
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Affiliation(s)
- Bianca K Frogner
- Department of Family Medicine, University of Washington Center for Health Workforce Studies, Seattle, WA
| | - Kenneth Harwood
- Health Care Quality Program, The George Washington University, Washington, DC
| | - C Holly A Andrilla
- Department of Family Medicine, University of Washington Center for Health Workforce Studies, Seattle, WA
| | - Malaika Schwartz
- Department of Family Medicine, University of Washington, Seattle, WA
| | - Jesse M Pines
- Center for Health Innovation and Policy Research, The George Washington University, Washington, DC
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Liu X, Hanney WJ, Masaracchio M, Kolber MJ, Zhao M, Spaulding AC, Gabriel MH. Immediate Physical Therapy Initiation in Patients With Acute Low Back Pain Is Associated With a Reduction in Downstream Health Care Utilization and Costs. Phys Ther 2018; 98:336-347. [PMID: 29669083 DOI: 10.1093/ptj/pzy023] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 11/19/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND Physical therapy is an important treatment option for patients with low back pain (LBP). However, whether to refer patients for physical therapy and the timing of initiation remain controversial. OBJECTIVE The objective of this study was to evaluate the impact of receiving physical therapy and the timing of physical therapy initiation on downstream health care utilization and costs among patients with acute LBP. DESIGN The design was a retrospective cohort study. METHODS Patients who had a new onset of LBP between January 1, 2009, and December 31, 2013, in New York State were identified and grouped into different cohorts on the basis of whether they received physical therapy and the timing of physical therapy initiation. The probability of service use and LBP-related health care costs over a 1-year period were analyzed. RESULTS Among 46,914 patients with acute LBP, 40,246 patients did not receive physical therapy and 6668 patients received physical therapy initiated at different times. After controlling for patient characteristics and adjusting for treatment selection bias, health care utilization and cost measures over the 1-year period were the lowest among patients not receiving physical therapy, followed by patients with immediate physical therapy initiation (within 3 days), with some exceptions. Among patients receiving physical therapy, those receiving physical therapy within 3 days were consistently associated with the lowest health care utilization and cost measures. LIMITATIONS This study was based on commercial insurance claims data from 1 state. CONCLUSIONS When referral for physical therapy is warranted for patients with acute LBP, immediate referral and initiation (within 3 days) may lead to lower health care utilization and LBP-related costs.
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Affiliation(s)
- Xinliang Liu
- Department of Health Management and Informatics, University of Central Florida, 4000 Central Florida Blvd, HPA II - 204, Orlando, FL 32816-2205 (USA)
| | | | | | - Morey J Kolber
- Department of Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida
| | - Mei Zhao
- Department of Health Administration, University of North Florida, Jacksonville, Florida
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Meghan H Gabriel
- Department of Health Management and Informatics, University of Central Florida
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Abstract
An estimated 116 million Americans suffer from chronic pain, at a cost of over $600 billion per year, or roughly $2000 per person per year. In this Viewpoint, the authors highlight the challenges of the current opioid epidemic and outline strategies that the physical therapy profession may adopt to be part of the solution. These strategies include facilitating and providing patient education, early access to physical therapy services, and the promotion of health, wellness, and prevention. J Orthop Sports Phys Ther 2018;48(5):349-353. doi:10.2519/jospt.2018.0606.
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Clewley D, Rhon D, Flynn T, Koppenhaver S, Cook C. Physical therapists familiarity and beliefs about health services utilization and health seeking behaviour. Braz J Phys Ther 2018; 22:336-343. [PMID: 29503116 DOI: 10.1016/j.bjpt.2018.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/05/2018] [Accepted: 02/09/2018] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Physical therapists' familiarity, perceptions, and beliefs about health services utilization and health seeking behaviour have not been previously assessed. OBJECTIVES The purposes of this study were to identify physical therapists' characteristics related to familiarity of health services utilization and health seeking behaviour, and to assess what health seeking behaviour factors providers felt were related to health services utilization. METHODS We administered a survey based on the Andersen behavioural model of health services utilization to physical therapists using social media campaigns and email between March and June of 2017. In addition to descriptive statistics, we performed binomial logistic regression analysis. We asked respondents to rate familiarity with health services utilization and health seeking behaviour and collected additional characteristic variables. RESULTS Physical therapists are more familiar with health services utilization than health seeking behaviour. Those who are familiar with either construct tend to be those who assess for health services utilization, use health services utilization for a prognosis, and believe that health seeking behaviour is measurable. Physical therapists rated need and enabling factors as having more influence on health services utilization than predisposing and health belief factors. CONCLUSION Physical therapists are generally familiar with health services utilization and health seeking behaviour; however, there appears to be a disconnect between what is familiar, what is perceived to be important, and what can be assessed for both health services utilization and health seeking behaviour.
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Affiliation(s)
- Derek Clewley
- Rocky Mountain University of Health Professions, Provo, United States; Duke University, Division of Physical Therapy, Department of Orthopaedics, Durham, United States.
| | - Dan Rhon
- Center for the Intrepid, San Antonio, United States; Baylor Doctoral Physical Therapy Program, Waco, United States
| | - Tim Flynn
- South College, Department of Physical Therapy, Knoxville, United States
| | | | - Chad Cook
- Duke University, Duke Clinical Research Institute, Division of Physical Therapy, Department of Orthopaedics, Durham, United States
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Mitchell JM, Hadley J. Treatments and Health Outcomes of Medicare Patients With Back Pain. Med Care Res Rev 2018; 77:121-130. [PMID: 29298545 DOI: 10.1177/1077558717751209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Back pain treatments are costly and frequently involve use of procedures that may have minimal benefit on improving patients' functional status. Two recent studies evaluated adverse outcomes (mortality and major medical complications) following receipt of spinal surgery but neither examined whether such treatments affected functional ability. Using a sample composed of Medicare patients with persistent back pain, we examined whether functional ability improved after treatment, comparing patients treated with back surgery or spinal injections to nonrecipients. We analyzed four binary variables that measure whether the ability to perform routine tasks improved. We used instrumental variables analysis to address the nonrandom selection of treatment received due to unobservable confounding. Contrary to the observational results, the instrumental variable estimates suggest that receipt of either back surgery or spinal injections does not improve back patients' functional ability. Failure to account for selection into treatment can lead to overestimating the benefits of specific treatments.
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Graham JE, Middleton A, Roberts P, Mallinson T, Prvu-Bettger J. Health Services Research in Rehabilitation and Disability-The Time is Now. Arch Phys Med Rehabil 2018; 99:198-203. [PMID: 28782540 PMCID: PMC5748255 DOI: 10.1016/j.apmr.2017.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/23/2017] [Accepted: 06/28/2017] [Indexed: 01/17/2023]
Abstract
Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.
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Affiliation(s)
- James E Graham
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX.
| | - Addie Middleton
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | | | - Trudy Mallinson
- School of Medicine & Health Sciences, George Washington University, Washington, DC
| | - Janet Prvu-Bettger
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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Horn ME, George SZ, Fritz JM. Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain. Mayo Clin Proc Innov Qual Outcomes 2017; 1:226-233. [PMID: 30225421 PMCID: PMC6132197 DOI: 10.1016/j.mayocpiqo.2017.09.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To examine patients seeking care for neck pain to determine associations between the type of provider initially consulted and 1-year health care utilization. Patients and Methods A retrospective cohort of 1702 patients (69.25% women, average age, 45.32±14.75 years) with a new episode of neck pain who consulted a primary care provider, physical therapist (PT), chiropractor (DC), or specialist from January 1, 2012, to June 30, 2013, was analyzed. Descriptive statistics were calculated for each group, and subsequent 1-year health care utilization of imaging, opioids, surgery, and injections was compared between groups. Results Compared with initial primary care provider consultation, patients consulting with a DC or PT had decreased odds of being prescribed opioids within 1 year from the index visit (DC: adjusted odds ratio [aOR], 0.54; 95% CI, 0.39-0.76; PT: aOR, 0.59; 95% CI, 0.44-0.78). Patients consulting with a DC additionally demonstrated decreased odds of advanced imaging (aOR, 0.43; 95% CI, 0.15-0.76) and injections (aOR, 0.34; 95% CI, 0.19-0.56). Initiating care with a specialist or PT increased the odds of advanced imaging (specialist: aOR, 2.96; 95% CI, 2.01-4.38; PT: aOR, 1.57; 95% CI, 1.01-2.46), but only initiating care with a specialist increased the odds of injections (aOR, 3.21; 95% CI, 2.31-4.47). Conclusion Initially consulting with a nonpharmacological provider may decrease opioid exposure (PT and DC) over the next year and also decrease advanced imaging and injections (DC only). These data provide an initial indication of how following recent practice guidelines may influence health care utilization in patients with a new episode of neck pain.
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Key Words
- ACP, American College of Physicians
- CDC, Centers for Disease Control and Prevention
- DC, chiropractor
- ICD-9, International Classification of Diseases, Ninth Revision
- IQR, interquartile range
- MRI, magnetic resonance imaging
- PCP, primary care provider
- PT, physical therapist
- UUHP, University of Utah Health Plans
- aOR, adjusted odds ratio
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Affiliation(s)
- Maggie E Horn
- Department of Orthopaedic Surgery, Physical Therapy Division, Duke University, Durham, NC
| | - Steven Z George
- Duke Clinical Research Institute, Duke University, Durham, NC.,Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Julie M Fritz
- Department of Physical Therapy, College of Health, University of Utah, Salt Lake City, UT
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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45
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Tousignant-Laflamme Y, Longtin C, Brismée JM. How radiological findings can help or hinder patients' recovery in the rehabilitation management of patients with low back pain: what can clinicians do? J Man Manip Ther 2017; 25:63-65. [PMID: 28559664 DOI: 10.1080/10669817.2017.1309345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Yannick Tousignant-Laflamme
- Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, Canada.,Research Center of the Centre hospitalier universitaire de Sherbrooke (CRCHUS), Sherbrooke, Canada
| | - Christian Longtin
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Jean-Michel Brismée
- Doctor of Science Program in Physical Therapy, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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46
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Maeng DD, Graboski A, Allison PL, Fisher DY, Bulger JB. Impact of a value-based insurance design for physical therapy to treat back pain on care utilization and cost. J Pain Res 2017; 10:1337-1346. [PMID: 28615965 PMCID: PMC5459966 DOI: 10.2147/jpr.s135813] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To assess the impact of a value-based insurance design providing enhanced access to physical therapy (PT) for treatment of back pain on treatment patterns and cost of care. STUDY DESIGN A retrospective analysis of claims data obtained from Geisinger Health Plan (GHP). In April 2013, GHP began offering "PT bundle" - i.e., a bundle of up to five PT visits for a single one-time copay that can be renewed for another bundle of five PT visits - for its employer-based plan members with back pain. METHODS A cohort of GHP members who were preauthorized for the PT bundle were compared against a contemporaneous cohort of GHP members who were preauthorized for PT under the standard per-visit copay arrangement between January 2013 and October 2014. RESULTS Among the PT bundle cohort, the PT visit rate during the first 9 months since the PT preauthorization date had dramatically increased and then gradually decreased in subsequent months. The PT bundle was also associated with 29%-35% short-term reductions in emergency department visits and with 12%-20% reductions in primary care visits after 6 months. No significant impact on hospitalization or cost was observed. CONCLUSION Implementation of the PT bundle appears to have led to a change in the treatment pattern of back pain that is more consistent with the recommended guidelines to use more conservative management such as PT as the first-line treatment for back pain.
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Affiliation(s)
- Daniel D Maeng
- Department of Epidemiology and Health Services Research, Geisinger Health System
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47
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Physical Therapy and Hospitalization Among Medicare Beneficiaries With Low Back Pain: A Retrospective Cohort Study. Spine (Phila Pa 1976) 2016; 41:1515-1522. [PMID: 26998645 DOI: 10.1097/brs.0000000000001571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to evaluate associations between receipt and quantity of outpatient physical therapy (PT) during an episode of care and 30-day and 180-day hospital admissions for any condition and lumbar spine conditions. SUMMARY OF BACKGROUND DATA Low back pain (LBP) is a common cause of hospitalization and the most common reason Medicare beneficiaries utilize outpatient PT. The association between PT and hospitalization among patients with LBP is unknown. METHODS A national sample of Medicare Fee-for-Service claims included 413,608 beneficiaries with an International Classification of Disease 9th revision (ICD-9) code of LBP and 1,415,037 episodes of care between June 1, 2010, and June 30, 2011. Episodes were classified as PT episodes or non-PT episodes. Relative risk of hospitalization from the episode start date was caldulated, adjusting for health status (Charlson comorbidity index), prior care utilization (number of prior hospitalizations and total number of episodes), an indicator of LBP severity (number of LBP ICD-9 codes), and demographics (sex, race/ethnicity, age). RESULTS The proportion of 30-day hospitalization for any condition was 3.42% for PT episodes of care and 6.54% for non-PT episodes. For 180-day hospitalization, proportions were 15.45% (PT) and 21.65% (non-PT). The adjusted relative risk reduction of PT (vs. non-PT) was 41% for 30 days [99% confidence interval (CI) 38-44] and 22% for 180 days (20-24). For admitting diagnoses of lumbar spine, reductions were 65% at 30 days and 32% at 180 days. More PT treatment days showed greater 30-day risk reductions. For any condition, compared with non-PT, reductions were 24% for 1 to 2 treatment days (lowest tertile), 45% for 3 to 7 days, and 65% for more than 8 days (highest tertile). Stronger effects were found for lumbar spine admissions. Associations between PT quantity and 180-day hospitalization were less consistent. Limitations of Medicare claims include the potential for inaccuracies, limited knowledge about disease severity, and which PT interventions were conducted. CONCLUSION Receipt of PT during an episode had a 22% to 65% reduced relative risk of hospitalization, with greater short-term reductions for more PT treatment days. LEVEL OF EVIDENCE 3.
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48
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Horn ME, Brennan GP, George SZ, Harman JS, Bishop MD. A value proposition for early physical therapist management of neck pain: a retrospective cohort analysis. BMC Health Serv Res 2016; 16:253. [PMID: 27405318 PMCID: PMC4942887 DOI: 10.1186/s12913-016-1504-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neck pain is one of the most common reasons for entry into the healthcare system. Recent increases in healthcare utilization and medical costs have not correlated with improvements in health. Therefore there is a need to identify management strategies for neck pain that are effective for the patient, cost efficient for the payer and provided at the optimal time during an episode of neck pain. METHODS One thousand five hundred thirty-one patients who underwent physical therapist management with a primary complaint of non-specific neck pain from January 1, 2008 to December 31, 2012 were identified from the Rehabilitation Outcomes Management System (ROMS) database at Intermountain Healthcare. Patients reporting duration of symptoms less than 4 weeks were designated as undergoing "early" management and patients with duration of symptoms greater than 4 weeks were designated as receiving "delayed" management. These groups were compared using binary logistic regression to examine odds of achieving Minimal Clinically Important Difference (MCID) on the Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS). Separate generalized linear modeling examined the effect of timing of physical therapist management on the metrics of value and efficiency. RESULTS Patients who received early physical therapist management had increased odds of achieving MCID on the NDI (aOR = 2.01, 95 % CI 1.57, 2.56) and MCID on the NPRS (aOR = 1.82, 95 % CI 1.42, 2.38), when compared to patients receiving delayed management. Patients who received early management demonstrated the greatest value in decreasing disability with a 2.27 percentage point change in NDI score per 100 dollars, best value in decreasing pain with a 0.38 point change on the NPRS per 100 dollars. Finally, patients receiving early management were managed more efficiently with a 3.44 percentage point change in NDI score per visit and 0.57 point change in NPRS score per visit. CONCLUSIONS These findings suggest that healthcare systems that provide pathways for patients to receive early physical therapist management of neck pain may realize improved patient outcomes, greater value and higher efficiency in decreasing disability and pain compared to delayed management. Further research is needed to confirm this assertion.
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Affiliation(s)
- Maggie E Horn
- Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, 1200 N Stonewall Ave, Oklahoma, OK, 73117, USA.
| | - Gerard P Brennan
- Director of Clinical Quality and Outcomes Research, Intermountain Healthcare, 389 South 900 East, Salt Lake, UT, 84102, USA
| | - Steven Z George
- Department of Physical Therapy, University of Florida, UFHSC, Box 100154, Gainesville, FL, 32610, USA
| | - Jeffrey S Harman
- Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL, 32606, USA
| | - Mark D Bishop
- Department of Physical Therapy, University of Florida, UFHSC, Box 100154, Gainesville, FL, 32610, USA
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49
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Abstract
The Journal of Orthopaedic & Sports Physical Therapy (JOSPT) requires the use of robust research reporting guidelines for all research report submissions, including the newly adopted RECORD (REporting of studies Conducted using Observational Routinely-collected health Data) statement. We remind authors submitting research to JOSPT to identify the appropriate guideline and checklist for their study design, and to submit a completely and accurately completed checklist with their manuscript. J Orthop Sports Phys Ther 2016;46(3):130. doi:10.2519/jospt.2016.0105.
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50
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Starkweather AR, Lyon DE, Kinser P, Heineman A, Sturgill JL, Deng X, Siangphoe U, Elswick RK, Greenspan J, Dorsey SG. Comparison of Low Back Pain Recovery and Persistence: A Descriptive Study of Characteristics at Pain Onset. Biol Res Nurs 2016; 18:401-10. [PMID: 26883808 DOI: 10.1177/1099800416631819] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Persistent low back pain is a significant problem worldwide. Early identification and treatment of individuals at high risk for persistent low back pain have been suggested as strategies to decrease the rate of disability associated with this condition. PURPOSE To examine and compare demographic, pain-related, psychological, and somatosensory characteristics in a cohort of participants with acute low back pain who later went on to experience persistent low back pain or whose pain resolved within the first 6 weeks after initial onset. METHODS A descriptive study was conducted among men and women 18-50 years of age who had an acute episode of low back pain. Study questionnaires were administered to collect demographic information and measures of pain, coping, reactivity, mood, work history and satisfaction, and disability. A standardized protocol of quantitative sensory testing was performed on each participant at the painful area of their low back and at a remote site on their arm. RESULTS The sample consisted of 48 participants, of whom 19 went on to develop persistent low back pain and 29 resolved. Compared to the resolved group, the persistent low back pain group was significantly older and had a lower level of educational attainment, a higher body mass index, and higher mean "least" pain score on the Brief Pain Inventory-Short Form. Significantly higher thermal detection thresholds at the painful and remote sites as well as signs of central sensitivity differentiated the persistent pain group from the resolved group during the acute stage of low back pain.
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Affiliation(s)
| | - Debra E Lyon
- College of Nursing, University of Florida, Gainesville, FL, USA
| | | | - Amy Heineman
- Virginia Commonwealth University, Richmond, VA, USA
| | | | - Xiaoyan Deng
- Virginia Commonwealth University, Richmond, VA, USA
| | | | - R K Elswick
- Virginia Commonwealth University, Richmond, VA, USA
| | - Joel Greenspan
- School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Susan G Dorsey
- School of Nursing, University of Maryland, Baltimore, MD, USA
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