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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
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.
... 41 The physiotherapy-and physician-led care groups were similar in age and gender in two studies (13%), 29,30 and differed significantly in three studies (20%). 31,38,41 The 10 remaining studies (67%) did not report 36,37,39 or compare age and gender between groups. 27,28,[32][33][34][35]40 However, most considered age as a covariate in the analyses. ...
... 27,28,[32][33][34]37,40 Six of the 15 studies (40%) included persons with acute low back pain or with a new episode of low back pain after a period without insurance claims, healthcare visits, or medical diagnoses related to low back pain. 27,[30][31][32][33][34] Two studies (13%) included a mixture of persons with acute, subacute, and chronic pain, 29,41 and seven studies (47%) did not report low back pain duration. 28,[35][36][37][38]40 Only three of the 15 studies (20%) collected information on baseline disability, [38][39][40] and none reported pain intensity at baseline. ...
... All seven studies on medication use demonstrated significantly fewer prescriptions for opioid-and non-opioid-containing drugs in the physiotherapy-led care group up to one year follow-up. [27][28][29]31,33,34,40 Additionally, six out of seven studies found significantly lower use of radiography in the physiotherapy-led care group at six months 38 and one year follow-up, 27,30,31,33,35 with one study not reporting p-values. 33 The seventh study found no group differences. ...
Objective
To summarise the evidence on the effect of physiotherapy-led versus physician-led care on clinical outcomes, healthcare use, and costs in persons with low back pain.
Data sources
PubMed, Web of Science, CINAHL, Embase, and PEDro were systematically searched with the latest search performed in July 2024. Reference lists of articles were hand-searched.
Review methods
Studies comparing clinical outcomes, healthcare use, or costs between adults with low back pain first consulting a physiotherapist and those first consulting a physician were included. Methodological quality was assessed with the Newcastle-Ottawa Scale. Study design, clinical setting, patient characteristics, and group effects were extracted. Findings on outcomes assessed in two or more studies were synthesised narratively. Certainty of evidence was determined using the GRADE approach.
Results
Eighteen studies comprising 1,481,980 persons with low back pain were included. Most studies were non-randomised retrospective or prospective cohort studies. In primary care (15 studies), consistent evidence, though of mostly very low certainty, indicated that physiotherapy-led care leads to higher patient satisfaction, less use of medication, injections and imaging, fewer physician's visits, lower total healthcare costs, and less sick leave compared to physician-led care, without increased harm. In emergency care (three studies), evidence of very low certainty showed that physiotherapy-led care leads to shorter waiting and treatment times, and fewer hospital admissions.
Conclusion
Physiotherapy-led care is a clinically, time- and cost-effective care pathway for low back pain, although the certainty of evidence was overall very low. Further high-quality research with a greater focus on clinical outcomes is warranted.
... In the UK back pain is also one of the commonest reasons for prescribing a sickness certificate [14]. Prescribing physical therapy may lower utilization of high cost medical services (such as imaging and emergency care visits) as well as lower opioid use [15]. Last, non-opioid analgesics (NSAIDs or acetaminophen) have a statistically significant pain reducing effect over opioids. ...
... The four quality indicators we defined are key-messages in most guidelines [4][5][6][7]40]. The results on overall performance for these quality indicators in literature varies strongly because of difference in definition and method of analysis used [8,15,16,[41][42][43][44][45][46][47][48]. This makes comparison to previous literature difficult. ...
Background
Low back pain (LBP) is one of the most frequent reasons for encounter in general practice. Yet results from literature show adherence to clinical practice guidelines is low. Audit & feedback is a well-known strategy to improve adherence to guidelines. Benchmarking is an important step in the audit & feedback process. The objective of this study was to develop data-derived benchmarks for low back pain quality indicators.
Methods
Four electronic health record extractable quality indicators were selected from an existing indicator set developed by CEBAM, an independent, multidisciplinary and interuniversity medical scientific institute in Belgium. Data from 2021-2022 from INTEGO, a general practice morbidity registry, were used to calculate benchmarks for the four quality indicators. The Achievable Benchmark of Care methodology was used to create benchmarks based on the performance of the 10% best-performing practices.
Results
The following benchmarks were derived: 4.2% prescription for medical imaging, 12.7% prescription for opioids, 27.2% for prescription for non-steroidal anti-inflammatory drugs or acetaminophen, 37.7% prescription for physical therapy and 11.9% prescription for work absenteeism.
Conclusions
Benchmarks for four electronic health record-extractable quality indicators have been established. They can be used for an electronic audit & feedback tool in primary practice in Flanders or other quality improvement initiatives.
... 7,8 In addition, early access to PT services has been shown to improve patient outcomes and overall quality of life. 6,[9][10][11][12][13] Therefore, direct access to musculoskeletal PT services has been promoted worldwide. 14 PTs operate under direct access function as primary care providers. ...
Purpose
Direct access to physical therapy (PT) requires PTs to act as primary care providers, making differential diagnosis a critical component of patient assessment. We investigated how participation in postgraduate training in differential diagnosis and medical screening influences PTs’ confidence, self-efficacy, attitudes and beliefs about treating patients with low back pain (LBP).
Patients and Methods
This prospective, two-arm study involved 49 PTs in an intervention group and 70 in a control group. The intervention included 40-hours of training on medical screening and differential diagnosis, focusing on red flags, clinical reasoning and referral pathways, while the control group received no intervention. Clinical confidence, self-efficacy, attitudes and beliefs were measured before, immediately after, and 6-months after training. Outcomes included the Primary Care Confidence Scale (PCCS), which assesses confidence in primary care practice, detection of serious pathology, and medical screening; the Physiotherapy Self-Efficacy (PSE) questionnaire, evaluating clinical self-efficacy in assessing and treating patients with LBP; and the Attitudes to Back Pain Scale for Musculoskeletal Practitioners (ABS-mp), which measures clinicians’ attitudes and beliefs about LBP.
Results
The intervention group showed significant immediate improvements in PCCS scores (40.26 ± 5.23 to 45.24 ± 4.20, Cohen’s d = 1.08, p < 0.001) and PSE scores (51.06 ± 6.46 to 54.65 ± 5.78, Cohen’s d = 0.6, p < 0.001). At six-month, significant interaction effects were observed for PCCS (F = 17.49, Partial η² = 0.131, p < 0.001) and PSE scores (F = 5.87, Partial η² = 0.06, p < 0.05) and PSE scores (55.32 ± 6.09, p < 0.05), with the intervention group maintaining improvements while the control group showed no significant changes. No significant changes were observed in ABS-mp scores.
Conclusion
This study highlights the positive impact of training in medical screening and differential diagnosis on reducing concerns and increasing clinical confidence and self-efficacy.
... [4] Furthermore, there is evidence from observational studies indicating that non-pharmacological treatments for LBP reduce risk of future opioid use. [5][6][7] Consensus recommendations in practice guidelines, and encouraging findings from the previously cited observational studies, provide foundational support for non-pharmacological care of LBP, but there is still an urgent need for research designs that address their effectiveness. Pressing research questions about the structuring of nonpharmacologic care pathways to optimize clinical outcomes such as pain interference and physical function persist. ...
Purpose: AIM-Back is an embedded pragmatic clinical trial (ePCT) with cluster randomization designed to increase access and compare the effectiveness of two different non-pharmacological care pathways for low back pain (LBP) delivered within the Veteran Administration Health Care System (VAHCS). This manuscript describes baseline characteristics of AIM-Back participants as well as the representativeness of those referred to the AIM-Back program by sex, age, race, and ethnicity, relative to Veterans with low back pain at participating clinics.
Participants: To be eligible for AIM-Back, Veterans were referred to the randomized pathway at their clinic by trained primary care providers (Referral cohort). Veterans from the Referral cohort that participated in the study included: 1) an Electronic Health Record (EHR) sample of Veterans enrolled in the program (i.e., attended initial AIM-Back visit with no consent required) and a Survey sample of Veterans that were consented for further study. Descriptive statistics for age, race, ethnicity, sex, high-impact chronic pain (HICP), a comorbidity measure, post-traumatic stress diagnosis (PTSD) and opioid exposure were reported for the Referral cohort and by sample; mean baseline PROMIS pain interference, physical function and sleep disturbance scores were reported by sample. Additional measures of pain, mental health and social risk were reported on the Survey sample. Participation to prevalence ratios (PPRs) were calculated for sex, age, race, and ethnicity by clinic to describe representativeness of the Referral cohort.
Findings to Date: Across 17 randomized primary care clinics, the Referral cohort included 2767 unique Veterans with n=1817 in the EHR sample, n=996 in the Survey sample and n=799 of the EHR sample (44%) were also in the Survey sample. High rates of HICP were observed in the EHR and Survey samples (>59%). Mean scores (SD) based on self-reported PROMIS Pain Interference (63.2 (6.8), 63.1 (6.6)) and PROMIS Physical Function (37.1 (5.3), 38.1 (5.8)) indicated moderate impairment in the EHR sample and Survey sample respectively. Approximately 10% of the EHR sample had documented opioid use in the year leading up to the AIM-Back referral. At most clinics, older Veterans (>=65 years) were underrepresented in the Referral cohort compared to those with LBP visits at clinics (PPRs < 0.8).
Future Plans: The AIM-Back trial will conduct analysis to examine the comparative effectiveness of the two care pathways and identify individual characteristics that may improve responses to each pathway. The trial is expected to complete 12-month follow-up data collection by December 2024, with subsequent analyses and publications providing insights into optimizing non-pharmacological care for Veterans with LBP.
Trial Registration: NCT04411420 (clinicaltrials.gov)
... The remaining 129 records, along with additional 162 records identified via other methods (ie Google and Google Scholar searching and citation searching) were retrieved for full text screening. Of these, 224 papers were excluded as they did not meet the inclusion criteria, in terms of intervention (n = 192) (eg involvement of physicians and nurses 45,46 ), setting (15) (eg unspecified setting, 47 setting not limited to primary care and community-based 48 ), outcome (14) (eg acute care utilization-related outcomes were not reported separately, 49 did not measure utilization-related outcomes, 50 focused on utilization associated costs only [51][52][53], study design (2), and duplicate (1). Of the 67 included papers, two papers were based on the same RCT but focused on different outcomes; 54,55 another two papers presented findings of a study at two different follow-up times. ...
The aim of this mixed methods systematic review was to synthesize contemporary evidence on effectiveness of community-based allied health (AH) services on acute care utilizations and views from relevant stakeholders. An a priori protocol was registered with PROSPERO [CRD42023437013]. Inclusion criteria were: (a) stand-alone interventions led by practitioners/graduates from one or more target AH professions (audiology, exercise physiology, diabetes educator, nutrition and dietetics, occupational therapy, physiotherapy, podiatry, psychology, social work, and speech pathology); (b) examined acute care utilization-related outcomes with/without perceptions of relevant stakeholders; and (c) published after 2010 and in English. Eligible studies were identified from: (a) bibliographic databases (MEDLINE, Embase, EmCare, PsycINFO, CINAHL complete, and the Cochrane Library) (September 19, 2023); (b) online databases (ProQuest Central and ProQuest Dissertations & Theses Global) and theses repository (Trove) (September 20, 2023); (c) Google and Google Scholar (October 17–18, 2023); and (d) citation searching. A modified version of McMaster Critical Appraisal Tools and McGill Mixed Methods Appraisal Tool were used to assess methodological quality. Data synthesis was through convergent segregated approach. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. There were 67 included papers. The integrated quantitative and qualitative findings demonstrated mixed evidence, likely influenced by the heterogeneity of the evidence base, for the effectiveness of AH services on acute care utilizations. Patients and their carers were largely positive about these services, highlighting opportunities to build on these experiences. The certainty of evidence for patient-important outcomes was however “very low”, emphasizing cautious interpretation. The findings of this review shed light on the breadth and scope of AH in the community sector, and its potential impact on the acute sector. Further investment in, and ongoing research on, community-based AH can strengthen primary healthcare and relieve pressure on the acute sector.
Introdução: A dor lombar (DL) é uma limitação funcional e a principal causa de incapacidade em diversos países do mundo. Por se tratar de um problema global que afeta diretamente a qualidade de vida dos indivíduos, diversas formas de tratamento vêm sendo estudadas, entre elas, a fisioterapia e os analgésicos opioides. Objetivo: Revisar sistematicamente a literatura dos últimos dez anos na busca de analisar os desfechos da eficácia da fisioterapia resultando na desprescrição de opioides e diminuição de custos de saúde em pacientes com DL. Métodos: Trata-se de uma revisão sistemática de estudos de coorte retrospectivos que analisaram a eficácia do tratamento fisioterapêutico e consequente diminuição da prescrição de opioides, em artigos científicos publicados em revistas digitais entre os anos 2012 a 2022, nas bases de dados PubMed, BVS, SciELO e PEDro. Resultados: Para pessoas com DL, todos os estudos relataram que o manejo com fisioterapia precoce foi associado a uma diminuição do quadro álgico e na prescrição de opioides. Conclusão: Os estudos avaliados nesta revisão sugerem que a fisioterapia promove melhorias na qualidade de vida dos pacientes com DL, principalmente quando realizada precocemente. Ademais, essa terapia permite diminuição no custo dos serviços de saúde por diminuir a prescrição de opióides utilizados na analgesia da DL. Palavras-chave: Analgésicos opioides; custos de cuidados de saúde; dor lombar; serviços de fisioterapia.
OBJECTIVE: To identify factors associated with physical therapy (PT) attendance and self-discharge in patients with chronic pain.
DESIGN: Retrospective chart review with survey.
METHODS: Organizational reports were screened for patients with chronic pain. A retrospective review of the electronic medical record was performed, and a survey invitation was sent to the evaluating therapist. Poisson regression analyzed factors related to attendance, while logistic regression analyzed factors related to self-discharge.
RESULTS: The 200 patients had attendance and self-discharge rates of 73% and 55%, respectively. Attendance rates were lower in patients whose therapists reported higher comfort levels with treating chronic pain and slightly higher in patients with a longer duration of care. Odds of self-discharge were higher if the patient had a higher no-show rate or was seen by a therapist reporting higher comfort levels with treating chronic pain but were lower if more PT visits were completed.
CONCLUSION: In this study, attendance rates and self-discharge were related to several patient- and therapist-driven factors. Therapists should identify each patient’s potential facilitators and/or barriers to attending PT and prepare them for self-management of their condition upon discharge. JOSPT Open 2024;2(4):1-8. Epub 7 August 2024. doi:10.2519/josptopen.2024.1136
Introduction
Physical therapy (PT) is recommended as a primary treatment for low back pain (LBP), a common and impactful musculoskeletal condition after limb loss. The purpose of this brief report is to report the duration and cost of PT care, and subsequent escalation of care events, for LBP in service members with and without limb loss.
Materials and Methods
This was a retrospective cohort, descriptive study. Service members with and without limb loss (matched) who received PT for LBP at a military treatment facility from 2015 to 2017 were included. Duration of PT care, number of PT visits, and escalation of care events 1 year after PT were extracted from medical records. Escalation of care events was identified as epidural steroid injections, referrals to specialists (e.g., orthopedists, spine surgeons, and pain management), and LBP-related hospitalizations.
LBP-related PT encounters were queried; duration of care, number of visits, and cost of care were quantified. Escalation of care events, including opioid prescription, epidural steroid injections, specialty referrals, and hospitalizations, were identified up to 1 year after PT care.
Results
The average course of PT care for LBP was 12.9 more visits, 48.7 days longer, and $764.50 more expensive in service members with limb loss (n = 16) vs. those without limb loss (n = 48). Higher rates of opioid prescriptions and specialty referrals were observed in service members with limb loss.
Conclusions
This study suggests that service members with limb loss and LBP received higher quantities and longer durations of PT than those without limb loss, yielding a nearly 4 times higher cost of PT.
Study Design: Cross sectional observation study utilizing the National Ambulatory and National
Hospital Ambulatory Medical Care Surveys between 1997 and 2010.
Objective: To characterize national PT referral trends during Primary Care Provider (PCP) visits in the
United States.
Summary of Background Data: Despite guidelines recommending physical therapy (PT) for the initial
management of low back pain (LBP), national PT referral rates remain low.
Methods: Race, ethnicity, age, payer type, and PT referral rates were collected for patients aged 16 to
90 who were visiting their PCPs. Associations among demographic variables, and PT referral were
determined using logistic regression.
Results: Between 1997 and 2010, we estimated 170 million visits for LBP leading to 17.1 million PT
referrals. Average proportion of PCP visits associated with PT referrals remained stable at about 10.1%
(OR 1.00 95%CI [0.96-1.04]), despite our prior finding of increasing number of visits associated with
opioid prescriptions.
Lower PT referral rates were observed among visits by patients who were insured by Medicaid (OR
0.48 [0.33-0.69]) and Medicare (OR 0.50 [0.35-0.72]) (Table 3). Furthermore, visits not associated
with PT referrals were more likely to be associated with opioid prescriptions (OR 1.69 [1.22-2.35]).
Conclusions: Though therapies delivered by PTs are promoted as a first-line treatment for LBP, PT
referral rates continue to be steadily low. There also exists disparately lower referral rates in
populations with more restrictive health plans and simultaneous opioid prescription. Our findings
provide a broad overview to PT prescription trend and isolate concerning associations requiring further
explorations.
Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS).
Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models.
753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs.
The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.
Background/objectives:
Low back pain (LBP), a prevalent costly condition, has evidence-based pharmacological and nonpharmacological treatments. Because the prevalence of LBP and the use of opioids differ between the U.S. Census Regions, we compared the treatments used for LBP and their related costs between regions.
Methods:
Deidentified patient health claims data from persons with LBP along with treatments received were extracted from a large commercially insured data set (2007-2009; N = 1,630,438). Descriptive statistics and analyses of variance were used during data analysis.
Results:
An opioid was used by 49.8% (n = 812,479) of this sample, whereas nonpharmacological therapies were used less frequently (8%, psychological therapies; 19%, exercise therapies; 12%, physical therapy). The median costs for pharmacological and nonpharmacological treatments are variable. We found significant differences in the medications and therapies used in the U.S. Census Regions (p < .0001).
Conclusion:
Overuse of pharmacological treatment and underuse of nonpharmacological treatment are common among persons with LBP. Differences exist in the receipt of various LBP treatments geographically.
Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Importance
Low back pain (LBP) is responsible for more than 2.5 million visits to US emergency departments (EDs) annually. These patients are usually treated with nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, or skeletal muscle relaxants, often in combination.Objective
To compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.Design, Setting, and Participants
This randomized, double-blind, 3-group study was conducted at one urban ED in the Bronx, New York City. Patients who presented with nontraumatic, nonradicular LBP of 2 weeks’ duration or less were eligible for enrollment upon ED discharge if they had a score greater than 5 on the Roland-Morris Disability Questionnaire (RMDQ). The RMDQ is a 24-item questionnaire commonly used to measure LBP and related functional impairment on which 0 indicates no functional impairment and 24 indicates maximum impairment. Beginning in April 2012, a total of 2588 patients were approached for enrollment. Of the 323 deemed eligible for participation, 107 were randomized to receive placebo and 108 each to cyclobenzaprine and to oxycodone/acetaminophen. Follow-up was completed in December 2014.Interventions
All participants were given 20 tablets of naproxen, 500 mg, to be taken twice a day. They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP. They also received a standardized 10-minute LBP educational session prior to discharge.Main Outcomes and Measures
The primary outcome was improvement in RMDQ between ED discharge and 1 week later.Results
Demographic characteristics were comparable among the 3 groups. At baseline, median RMDQ score in the placebo group was 20 (interquartile range [IQR],17-21), in the cyclobenzaprine group 19 (IQR,17-21), and in the oxycodone/acetaminophen group 20 (IQR,17-22). At 1-week follow-up, the mean RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference in mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, −2.6 to 3.2; P = .77), for oxycodone/acetaminophen vs placebo, 1.3 (98.3% CI, −1.5 to 4.1; P = .28), and for oxycodone/acetaminophen vs cyclobenzaprine, 0.9 (98.3% CI, −2.1 to 3.9; P = .45).Conclusions and Relevance
Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting.Trial Registration
clinicaltrials.gov Identifier: NCT01587274
In this article, we describe twopm, a command for fitting two-part models for mixed discrete-continuous outcomes. In the two-part model, a binary choice model is fit for the probability of observing a positive-versus-zero outcome. Then, conditional on a positive outcome, an appropriate regression model is fit for the positive outcome. The twopm command allows the user to leverage the capabilities of predict and margins to calculate predictions and marginal effects and their standard errors from the combined first- and second-part models. Copyright 2015 by StataCorp LP.
Compare health care utilization and charges for low-back-pain (LBP) patients receiving advanced imaging or physical therapy as a first management strategy following a new primary care consultation.
Electronic medical record (EMR) and insurance claims data.
Retrospective analysis of propensity-matched groups.
Claims and EMR data were used. Utilization and LBP-related charges over a 1-year period were extracted from claims data.
In the propensity-matched sample (n = 406), advanced imaging recipients had higher odds of all utilization outcomes. Charges were higher with advanced imaging by an average 3,676, $5,910).
For patients with LBP whom newly consulted primary care referred for additional management, advanced imaging as a first management was associated with higher health care utilization and charges than physical therapy.
© Health Research and Educational Trust.