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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

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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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... A growing body of literature has found significant variation in LBP health care utilization and costs associated with the providers initiating care, suggesting that provider role and ordering in the care pathway may be important factors when considering methods to reduce costs. Frogner and colleagues [11] examined 2009-2013 private health insurance claims data from the Health Care Cost Institute (HCCI) in six Pacific Northwest states. The researchers found that adult, non-elderly individuals with LBP who were seen by a physical therapist (PT) first, as compared to individuals who saw a PT later or never, had an 89% lower probability of receiving an opioid prescription, 28% lower probability of having any advanced imaging services, and 15% lower probability of emergency department (ED) visits. ...
... Where other studies used propensity score matching to control for selection bias, [12,13] we applied a well-known econometric technique for causal inference called a twostage residual inclusion (2SRI) estimation approach, which is an instrumental variable (IV) approach best suited for non-linear models while controlling for selection bias inherent in observational studies [15]. A related study used "differential distance", defined as the difference in the distance between the patient and the provider seen versus the patient and a hypothetical alternative provider, as their instrument to control for selection bias in their 2SRI model and predict downstream health care utilization and costs for LBP care on choice of first provider [11]. In this study, we examine whether copay for the initial visit to a provider is a suitable alternative instrument to predict the initial choice of provider, and conduct a sensitivity analysis of results using differential distance as the instrument. ...
... We used the copay associated with the index date as our "instrument". For a sensitivity analysis, we also tested differential distance, an instrument used in a previous study, [11] defined as: 1) the distance between an individual and the first provider of choice, and 2) the distance between an individual and the closest alternative provider (see S2 for further discussion about measures and S2 Table A and Table B for first stage results). ...
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Background Diagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs. Methods Using national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics. Results Among 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5093) or primary care physician ($5660), and highest when starting with an orthopedist ($9434) or acupuncturist ($9205). Conclusion The first provider seen by individuals with LBP was associated with large differences in health care utilization, opioid prescriptions, and cost while there were no differences in delays in diagnosis of serious illness.
... A recent policy brief [30] details the licensed professionals trained to deliver non-pharmacologic pain interventions. Among these professionals are occupational therapy and physical therapy practitioners, whose evidence-based pain treatments [48] reduce healthcare expenditures [49], decrease the duration of prescription opioid use [50], and most importantly prioritize ADL, IADL, and cognitive functioning. Patients' pain severity should be monitored along with their ability to independently perform ADL and IADL that are critical for successfully managing their daily health, navigating the community to access health services, and participating as an active and social member within their environment. ...
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Background Opioid analgesics are commonly used to manage pain; however, it is unclear how they affect patient function. This study examines the association between opioid analgesics and incident limitations in activities of daily living (ADL), instrumental activities of daily living (IADL), and cognitive functioning among community-dwelling older adults. Methods Data included 10,003 participants of the 2016 and 2018 waves of the Health and Retirement Study, which sampled US adults aged 51–98 years. The primary exposure was self-reported opioid pain medication use in 2016. Outcomes included incident limitations in ADL, IADL, and cognitive functioning in 2018. Statistical methods adjusted for confounding using multivariable logistic regressions, inverse probability of treatment weighting, and propensity scores. Results Opioid use (adjusted odds ratio [aOR]: 1.34, 95% confidence interval [CI] 1.07–1.68) was associated with a statistically significant higher odds of incident ADL limitation in multivariable regression and in propensity score adjustment (aOR: 1.41, 95% CI 1.13–1.76). The association between opioid use and ADL and IADL limitations was modified by age. Adults aged < 65 years had a higher odds of incident ADL (aOR: 1.83, 95% CI 1.38–2.42) and IADL (aOR: 1.42, 95% CI 1.06–1.90) limitations compared with those aged ≥ 65 years. Conclusions Community-dwelling adults using opioid analgesics to manage pain may be at risk for incident ADL limitations. Middle-aged adults, compared with those older than 65 years of age, experienced the greatest odds for incident ADL and IADL limitations following opioid use. According to sensitivity analyses, our findings were robust to unmeasured confounding.
... In addition to barriers to accessing occupational therapy interventions for pain, there is limited evidence demonstrating the effectiveness of occupational therapy as an intervention for acute or subacute pain capable of producing lasting benefits. Small trials and large observational studies show that nonpharmacologic pain interventions, such as occupational and physical therapy, improve quality of life and reduce high-risk opioid consumption (Frogner et al., 2018;Pritchard et al., 2021;Simon & Collins, 2017). However, randomized control trials are needed to demonstrate the role of early occupational therapy in mitigating pain while improving function, particularly for adults over 65 years, the only age group with an increasing rate (10.5%) of prescription opioid-related mortality (Scholl et al., 2019). ...
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Occupational therapy is beneficial among adults with chronic pain; however, occupational therapy interventions addressing earlier phases of pain have not been clearly explicated. This systematic review characterized acute and subacute interventions billable by occupational therapy after hip or knee replacement to improve pain and function. Seven articles met inclusion criteria. Six articles had a low risk of bias. Three intervention types were found: task-oriented exercise, water-based, and modalities. Only task-oriented interventions improved both pain and function one-year after surgery. There are long-term benefits to early task-oriented exercise. Further research is needed to contextualize occupational therapy's role in early pain interventions.
... 10 Importantly, evidence shows that early referral to PT for non-pharmacological pain management can enable patients to avoid a firsttime opioid prescription. [11][12][13] Over the past 60 years, advances in both laboratory and clinical research have enabled physiotherapists to provide evidence-informed care. At the macro level, these advances include significant developments in pain science and an understanding of the multidimensional and complex nature of pain. ...
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Purpose: The Pain Science Division (PSD) is a special interest group of the Canadian Physiotherapy Association that serves physiotherapists who have an interest in better understanding and managing patients’ pain. The PSD developed evidence-based resources for its members with the goal of improving patient care by supporting professional development. However, online metrics tracking access to these resources indicated that access was low. The purpose of this study was to identify the barriers PSD members encountered to the use of PSD resources and to recommend interventions to address these barriers guided by the Theory and Techniques Tool (TTT). Method: We distributed an online survey to PSD members across Canada. We used the TTT, a knowledge translation tool, to guide the design of the questionnaire and identify actionable findings. Results: Response rates from 621 non-student members and 1,470 student members were 26.9% and 1.4%, respectively. Based on the frequency of practicing physiotherapists’ ( N = 167) agreement with items in the TTT, the primary barriers to use of the PSD resources were forgetting that the resources were available and forgetting to use them. Conclusions: The TTT can be used to identify barriers to use of professional development tools.
... Exercise reduces pain and disability in patients with lower back, neck problems, and improves the quality of life (CalvoMuñoz et al., 2013;Groeneweg et al., 2017;Rushton et al., 2015). Frogner et al. stated that people with low back pain who received physical therapist support in the first part of their treatment used fewer opioids as well as less need for high-cost medical services (Frogner et al., 2018). Telerehabilitationbased exercises for nonspecific low back pain provide more cost savings than clinical exercise (Fatoye et al., 2020). ...
... To implement IV estimation within the framework of the Tobit model, the 2SRI approach was used, which was proposed by Terza and has been widely adopted in health economics (Basu et al., 2018;Frogner et al., 2018). Simulations have shown that the 2SRI estimator can generate consistent estimates in nonlinear models (Terza and Rathouz, 2008). ...
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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.
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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
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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 $4,793 (95 percent CI: $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.