From the Journal of Occupational and Environmental Medicine comes a study that gives excellent direction to employers (and insurers) regarding the management of low back problems (LBP).1 The authors analyzed databases belonging to a large, self-insured company over the course of nine years to evaluate the direct and indirect costs of LBP for the company's employees (EEs).
The Set-Up: Study Overview / Parameters
The study had four objectives:
- Identify all active employees reporting a back problem diagnosis during the study period.
- Define and classify their initial patterns of medical care and use of Rx medication.
- Track the effect of these patterns on direct and indirect cost outcomes.
- Further stratify these treatment patterns by measures of congruence with the previously described guideline aspects for LBP care and determine the effect on cost outcomes.
Through a review of the databases, the study authors identified five specific care patterns that were typical of employee experiences:
- Information and Advice ("TalkInfo"): information gathering, office visit consults, lab tests, "imaging (X-ray, ultrasound, CT, or MRI) but no other procedures." (59 percent of employees)
- Complex Medical Management (Complex MM): "physician visits for nerve blocks, surgeries, or comparable procedures" (2 percent of employees).
- Chiropractic (Chiro): more than one visit to a DC. (11 percent of employees)
- Physical therapy (PT): more than one visit to a PT. (11 percent of employees)
- "Dabble": "episodes with at most one visit for physician, chiropractic, or PT care, or at most one visit to two or more of these categories." (17 percent of employees)
The study noted whether each care pattern showed "incongruence" or "congruence" with 11 established guidelines. These guidelines related to what procedures were used and how soon they were applied to the employee's condition.
The Findings: An Eye Opener
The study sample comprised 13,224 back episodes, of which 1,623 had neurologic findings (LBP/neuro), 7,650 had no neurologic findings (LBP/nonneuro), and 3,951 were categorized as "other back." Across the nine years of the study period, there were 44,100 prescriptions filled (which is eye opening in and of itself), but the most significant findings related to the average cost for each care pattern – for each type of low back problem – across a three-year period:
Low Back/Neuro (three-year total)
Low Back/Nonneuro (three-year total)
Other Back (three-year total)
These figures confirm that complex medical care was the most expensive care route, followed by physical therapy. Chiropractic was the least expensive care path. In fact, three years of chiropractic care proved less expensive than the first year of PT and the first two years of "TalkInfo" and "Dabble."
Other Key Findings
The study revealed other important information: including the following:
Patients chose the same care as previously: "When those EEs with more than one episode were examined, their previous initial treatment choice was highly predictive of their current initial treatment choice. In fact, they tended to start out by choosing the same approach that they had previously."
Drugs taken sooner raised costs: "Similarly, medication choices had cost consequences. With rare exception, medication use within 4 weeks of episode start date was linked to higher unadjusted cost totals than no use."
Care incorporating drugs costs more: "The Complex MM approach was linked to the highest rates of Rx fills for four of the seven drug classes – opioids, other pain medications, SSRI/SNRI/tricyclics, and anxiolytics/sedatives/hypnotics. The PT group was highest in NSAIDs, muscle relaxants, and oral steroids, whereas the Chiro group had the lowest Rx rates in all seven classes. Complex MM and PT are the two most expensive care patterns.
Care incongruent with most guidelines is more expensive: "With one exception, higher rates of guideline incongruence were linked to greater costs."
Chiro / PT care sooner saves money: "The lone exception occurred on the 'PT/Chiro within 2 weeks' measure (the practice guidelines from the American College of Physicians and the American Pain Society), where episodes that reported the first visit within the 2-week mark posted, on average, notably less costs than those episodes that refrained from having the first visit within the 2-week mark."
The authors noted: "Much added questionable expense to the employer and ultimately its EEs seems to be occurring as a result. The evidence here would seem to merit a new outreach to company health plans and providers. The focus of this outreach would be the applicability of these findings for improving the health care and productivity loss outcomes of LBP EEs/patients."
It's also important to note that doctors of chiropractic practiced more consistently with the guidelines than any of the other groups, according to the study. This dispels a long-held myth many providers, payers and other entities may still hold.
This is definitely a study you should share with employers in your community. In a health care era in which cost-containment is king, any opportunity to reign in health care costs is sure to be embraced or at least given consideration.
- Allen H, Wright M, Craig T, et al. Tracking low back problems in a major self-insured workforce. J Occup Environ Med; epub ahead of print May 21, 2014.
Click here for more information about Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher.