Examining medical claims data on the utilization of chiropractic services for treatment of low back pain to determine risk of treatment escalation Brian Anderson DC, MPH, MS Assistant Professor and Clinician- National University of Health Sciences PhD student- Northern Illinois University
Presenter disclosures Brian Anderson • The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: 1. Educational scholarship from NCMIC foundation
Background • 2016 Global Burden of Disease study • Back pain is the leading cause of disability in every country considered “high income” • Incidence of back pain has increased by 18% over the past decade • Dieleman 2016 JAMA • examined health care spending on 155 different conditions in the US from 1996-2013. Low back and neck pain ranked third in spending at $87.6 billion in 2013
Inappropriate care • Friedly 2010- • 307% increase in the use of lumbar MRI studies in the Medicare population from 1994-2004 • 50% of patients initially presenting with LBP are prescribed opioids • ESI’s increased 3-fold from 1994-2001 • spinal fusion surgery increased by 40% from 1998-2004 • Allen et.al 2014- • “incongruence with clinical treatment guidelines” • $5500 increased cost/episode in pts treated with incongruent care
Treatment escalation • Describes the process of increasing the complexity of care for patients • literature on this topic is mainly related to end-of-life care, critical care, and pharmaceutical dose escalations. • Can be applied to MSK care, where the most basic intervention would be PCP office visits and the most invasive intervention would be surgery.
Methods • Using medical claims data from a large, self-insured company, the utilization of DC services for LBP was examined to answer the following question: • Does DC care for an episode of LBP result in decreased risk of treatment escalation vs. PCP care? • Hypothesis …… it does! • Over a 5 year period, 4156 members initiated care with a DC for an episode of LBP, and were compared to 5305 members who initiated care with a PCP
Treatment escalation model Alias Description 1 CHIR Chiropractic care 2 INJC Injections 3 EMRG Emergency room visits 4 IMAGE X-ray, MRI or comparable image 5 SURG Surgery
Results YEAR VARIABLE PCP DC 2012 ALLOWED $ 2,035,431 515,318 CASES 1,229 897 PCPY 1,656 574 2013 ALLOWED $ 2,643,692 848,449 CASES 1,174 951 PCPY 2,252 892 2014 ALLOWED $ 1,278,225 566,642 CASES 1,063 847 PCPY 1,202 669 2015 ALLOWED $ 1,318,020 436,847 CASES 889 681 PCPY 1,483 641 2016 ALLOWED $ 1,836,999 509,573 CASES 1,002 728 PCPY 1,833 700
Highest level of escalation Escalation PCP DC Escalation PCP DC Therapies 3.67% 78.66% Therapies 71 1460 Injections 20.70% 5.33% Injections 400 99 Emergency 19.51% 2.26% Emergency 377 42 Imaging 38.20% 9.11% Imaging 738 169 Surgery 17.91% 4.63% Surgery 346 86 Grand Grand Total 100.00% 100.00% Total 1932 1856
Are DC vs MD seeking patients comparable? • 2 studies indicating YES • Allen (2016) • the most significant predictor of the type of provider chosen was previous experience with that same type of provider • The authors could not substantiate a hypothesis that patients with more intensive back pain would self-select into more medically intensive strategies • Houweling (2015) • evaluated patient characteristics who choose between MD and DC care in the Swiss medical system. • age, sex, pain location, number of complaints, pain duration, pain rating and mode of onset were essentially identical between the two treatment groups
Are DC vs MD seeking patients comparable? • 2 studies indicating NO • Haas (2005) • examined patient characteristics suffering from acute and chronic low back pain who choose MD vs DC care • MD patient had the higher pain intensity, functional disability, and comorbidities, and lower physical and mental health scores on the SF-12 scores • Fritz (2016) • Examined characteristics and co-morbidities of patients seeking care from PCP, DC, physical medicine and PT • Those seeking primary care were more likely to have chronic pain (12.5% vs 2.4%), mental health comorbidities (39.9% vs 34.3%) and prior spine surgery (1.2% vs 0%) vs those seeking chiropractic care.
Conclusion • The hypothesis that self-selection of DC care for LBP episodes would lead to lower levels of treatment escalation, as well as cost savings, was confirmed in this study. • Members utilizing DC care were most likely to avoid costly imaging studies and invasive procedures.
Bibliography • GBD Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 14 Sept 2017: 390;1151–210. • Dieleman, J. L. et al. US Spending on Personal Health Care and Public Health, 1996-2013. JAMA 316, 2627– 2646 (2016). • Friedly, J., Standaert, C. & Chan, L. Epidemiology of spine care: the back pain dilemma. Phys. Med. Rehabil. Clin. N. Am. 21, 659–677 (2010). • Allen, H. et al. Tracking Low Back Problems in a Major Self-Insured Workforce: Toward Improvement in the Patient ’ s Journey. J. Occup. Environ. Med. 56, 604–620 (2014). • Houweling, T. A. W. et al. First-Contact Care With a Medical vs Chiropractic Provider After Consultation With a Swiss Telemedicine Provider: Comparison of Outcomes, Patient Satisfaction, and Health Care Costs in Spinal, Hip, and Shoulder Pain Patients. J. Manipulative Physiol. Ther. 38, 477–483 (2015). • Haas, M., Sharma, R. & Stano, M. Cost-Effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain. J. Manipulative Physiol. Ther. 28, 555–563 (2005). • Fritz, JM et.al. Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs. Journal of Evaluation in Clinical Practice 22 (2016) 247–252
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