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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

By |May 28, 2022|Cost-Effectiveness of Chiropractic, Initial Provider|

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

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SOURCE:   BMC Health Serv Res 2022 (May 23); 22 (1): 694

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Kenneth J. Harwood, Jesse M. Pines, C. Holly A. Andrilla & Bianca K. Frogner

College of Health and Education,
Marymount University,
Arlington, VA, USA.



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 ($5,093) or primary care physician ($5,660), and highest when starting with an orthopedist ($9,434) or acupuncturist ($9,205).

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Characteristics of Older Adults with Back Pain Associated with Choice of First Primary Care Provider: A Cross-sectional Analysis from the BACE-N Cohort Study

By |January 20, 2022|Initial Provider, Medicare|

Characteristics of Older Adults with Back Pain Associated with Choice of First Primary Care Provider: A Cross-sectional Analysis from the BACE-N Cohort Study

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SOURCE:   BMJ Open 2021 (Sep 17); 11 (9): e053229

Ørjan Nesse Vigdal, Kjersti Storheim, Rikke Munk Killingmo, Milada Cvancarova Småstuen, and Margreth Grotle

Department of Physiotherapy,
Oslo Metropolitan University,
Oslo, Norway



Objectives:   To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor).

Design:   Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study.

Setting:   Norwegian GP, PT and chiropractic primary care centres.

Participants:   Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor.

Primary and secondary outcome measures:   For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses.

Results:   Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05).

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Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain

By |July 3, 2021|Initial Provider, Opioid Epidemic|

Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain

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SOURCE:   Archives of Phys Med and Rehabilitation 2020 (Aug)

Christopher J. Louis, PhD, Carolina-Nicole S. Herrera, MA, et. al.

Department of Health Law, Policy, and Management,
Boston University School of Public Health,
Boston, Massachusetts.


Objective:   To determine whether the initial care provider for neck pain was associated with opioid use for individuals with neck pain.

Design:   Retrospective cohort study.

Setting:   Marketscan research databases.

Participants   : Patients (N=427,966) with new-onset neck pain from 2010-2014.

Main outcome measures:   Opioid use was defined using retail pharmacy fills. We performed logistic regression analysis to assess the association between initial provider and opioid use. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using bootstrapping logistic models. We performed propensity score matching as a robustness check on our findings.

Results:   Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%–91% less likely to fill an opioid prescription in the first 30 days, and between 41%–87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47–3.69; P<.001).

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