Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US

Performance of ChatGPT on NASS Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain: A Comparison Study

STUDY DESIGN

Comparative analysis.

OBJECTIVE

To evaluate Chat Generative Pre-trained Transformer (ChatGPT's) ability to predict appropriate clinical recommendations based on the most recent clinical guidelines for the diagnosis and treatment of low back pain.

BACKGROUND

Low back pain is a very common and often debilitating condition that affects many people globally. ChatGPT is an artificial intelligence model that may be able to generate recommendations for low back pain.

MATERIALS AND METHODS

Using the North American Spine Society Evidence-Based Clinical Guidelines as the gold standard, 82 clinical questions relating to low back pain were entered into ChatGPT (GPT-3.5) independently. For each question, we recorded ChatGPT's answer, then used a point-answer system-the point being the guideline recommendation and the answer being ChatGPT's response-and asked ChatGPT if the point was mentioned in the answer to assess for accuracy. This response accuracy was repeated with one caveat-a prior prompt is given in ChatGPT to answer as an experienced orthopedic surgeon-for each question by guideline category. A two-sample proportion z test was used to assess any differences between the preprompt and postprompt scenarios with alpha=0.05.

RESULTS

ChatGPT's response was accurate 65% (72% postprompt, P =0.41) for guidelines with clinical recommendations, 46% (58% postprompt, P =0.11) for guidelines with insufficient or conflicting data, and 49% (16% postprompt, P =0.003*) for guidelines with no adequate study to address the clinical question. For guidelines with insufficient or conflicting data, 44% (25% postprompt, P =0.01*) of ChatGPT responses wrongly suggested that sufficient evidence existed.

CONCLUSION

ChatGPT was able to produce a sufficient clinical guideline recommendation for low back pain, with overall improvements if initially prompted. However, it tended to wrongly suggest evidence and often failed to mention, especially postprompt, when there is not enough evidence to adequately give an accurate recommendation.

Chiropractic spinal manipulation and likelihood of tramadol prescription in adults with radicular low back pain: a retrospective cohort study using US data

OBJECTIVES

Patients receiving chiropractic spinal manipulation (CSM) for low back pain (LBP) are less likely to receive any opioid prescription for subsequent pain management. However, the likelihood of specifically being prescribed tramadol, a less potent opioid, has not been explored. We hypothesised that adults receiving CSM for newly diagnosed radicular LBP would be less likely to receive a tramadol prescription over 1-year follow-up, compared with those receiving usual medical care.

DESIGN

Retrospective cohort study.

SETTING

US medical records-based dataset including >115 million patients attending academic health centres (TriNetX, Inc), queried 9 November 2023.

PARTICIPANTS

Opioid-naive adults aged 18-50 with a new diagnosis of radicular LBP were included. Patients with serious pathology and tramadol use contraindications were excluded. Variables associated with tramadol prescription were controlled via propensity matching.

INTERVENTIONS

Patients were divided into two cohorts dependent on treatment received on the index date of radicular LBP diagnosis (CSM or usual medical care).

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk ratio (RR) for tramadol prescription (primary); markers of usual medical care utilisation (secondary).

RESULTS

After propensity matching, there were 1171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the CSM cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p<0.0001). A cumulative incidence graph demonstrated that the reduced incidence of tramadol prescription in the CSM cohort relative to the usual medical care cohort was maintained throughout 1-year follow-up. Utilisation of NSAIDs, physical therapy evaluation and lumbar imaging was similar between cohorts.

CONCLUSIONS

This study found that US adults initially receiving CSM for radicular LBP had a reduced likelihood of receiving a tramadol prescription over 1-year follow-up. These findings should be corroborated by a prospective study to minimise residual confounding.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers

BACKGROUND

Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period.

METHODS

A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES.

RESULTS

67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up.

CONCLUSIONS

These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review

BACKGROUND

The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain.

METHODS

A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators.

RESULTS

The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures.

CONCLUSION

Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain

Objective

To determine associations between post-emergency department (ED) management pathways and downstream opioid prescriptions in patients seeking care for incident neck and/or back pain.

Patients and Methods

We identified patients seeking first-time ED care for neck and/or back pain from January 1, 2013, through November 6, 2017. We reported demographic characteristics and opioid prescriptions across management pathways using descriptive statistics and assessed the relative risk of any opioid prescription 12 months post-ED visit among 5 different post-ED management pathways using Poisson regression adjusted for patient demographic characteristics.

Results

Within 12 months after the index ED visit, 58.0% (n=10,949) were prescribed an opioid, with most patients prescribed an opioid within the first week (average daily morphine milligram equivalents of 6.8 mg (SD 9.6 mg). The morphine milligram equivalents decreased to 0.7 mg (SD 8.2 mg) by week 4 and remained consistently less than 1 mg between week 4 and 12 months. Compared with the ED to primary care provider pathway, the relative risk of opioid prescription between 7 days and 12 months after the index ED visit was similar for the ED to physical therapy pathway, higher for both the ED to hospital admission or repeat ED visit pathway (30% increase; relative risk (RR), 1.3; 95% CI, 1.17-1.44) and the ED to specialist pathway (19% increase; RR, 1.19; 95% CI, 1.07-1.33), and lower in the ED with no follow-up visits pathway (41% decrease; RR, 0.59; 95% CI, 0.54-0.65).

Conclusion

In general, more conservative care was associated with lower opioid prescription rates, and escalated care was associated with higher opioid prescription rates.

Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data

OBJECTIVES

Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up.

DESIGN

Retrospective cohort study.

SETTING

US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023.

PARTICIPANTS

Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year.

INTERVENTIONS

Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

OR for gabapentin prescription.

RESULTS

After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference.

CONCLUSIONS

Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.