Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain

The Impact of Chiropractic Care on Opioid Prescriptions in Veterans Health Administration Patients Receiving Low Back Pain Care

BACKGROUND

Key nonpharmacologic therapies, including those routinely provided by chiropractors, are recommended first-line treatments for low back pain (LBP). Little is known on whether such care provided in the Veterans Health Administration (VA) has a downstream effect on the use of other healthcare services, including opioid prescriptions.

OBJECTIVE

To evaluate the impact of chiropractic care on receipt of opioid prescriptions within 365 days of an incident primary care provider (PCP) visit for LBP among opioid-naïve VA patients.

DESIGN

Cross-sectional analysis with longitudinal follow-up.

PARTICIPANTS

Patients had an LBP visit with a VA PCP between 10/1/2015 and 9/30/2020, without any VA LBP visit in the preceding 18 months, and then 2 subsequent VA LBP visits in the following 12 months.

MAIN MEASURES

VA electronic health record data including outpatient visits, prescriptions, and comorbid diagnoses.

KEY RESULTS

A total of 128,377 patients met study criteria. The hazard ratio for opioid prescription in a propensity-matched sample was 0.77 (95% CI 0.71-0.83), indicating a significantly lower risk for receipt of an opioid prescription among chiropractic care users in the 365-day follow-up adjusting for potential confounders. The cumulative incidence of opioid prescriptions was 13.0% for chiropractic care users and 16.8% for non-users and the number needed to treat was 27.

CONCLUSIONS

The results of this study show that nonpharmacologic chiropractic care can be an important component of opioid sparing strategies for VHA patients with LBP.

Inequities time-to-follow-up care and administrative action after low back pain diagnosis in active duty service members

ABSTRACT

As healthcare systems adopt data-driven methods to determine resource allocation for treating low back pain (LBP), it is critical to evaluate equity in time-to-follow-up care after an index visit and long-term occupational outcomes. This retrospective observational study included medical records of 525,252 active duty US service members who received an LBP index diagnosis from June 2016 to February 2022. Poisson generalized additive models evaluated time-to-LBP follow-up visit (primary outcome) and administrative action receipt (eg, disability evaluation; secondary outcome). Service members assigned female in the medical record compared to service members assigned male had lower cumulative hazards of follow-up visit at 1-week, but higher hazards by 4 weeks. Asian and Pacific Islander, Black, and Latino service members compared to white service members had lower cumulative hazards of follow-up visit during the acute/subacute period (up to 7, 19, 31, weeks, respectively), then higher cumulative hazards. Service members whose race and ethnicity was recorded as Other had lower hazards across time. Service members assigned female in the medical record compared to service members assigned male had lower cumulative hazards of administrative action receipt, as did Asian and Pacific Islander, Black, and Latino service members and service members whose race and ethnicity was recorded as Other compared to white service members. Overall, inequities in LBP follow-up visit timing warrant system-level programming to mitigate healthcare barriers acutely and subacutely after an LBP index visit, as well as system-level evaluation of pathways to administration action receipt.

Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review

BACKGROUND

The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain.

METHODS

A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators.

RESULTS

The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures.

CONCLUSION

Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

Longitudinal Care Patterns and Utilization Among Patients With New-Onset Neck Pain by Initial Provider Specialty

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare utilization patterns for patients with new-onset neck pain by initial provider specialty.

SUMMARY OF BACKGROUND DATA

Initial provider specialty has been associated with distinct care patterns among patients with acute back pain; little is known about care patterns among patients with acute neck pain.

METHODS

De-identified administrative claims and electronic health record data were derived from the Optum Labs Data Warehouse, which contains longitudinal health information on over 200M enrollees and patients representing a mixture of ages and geographical regions across the United States. Patients had outpatient visits for new-onset neck pain from October 1, 2016 to September 30, 2019, classified by initial provider specialty. Utilization was assessed during a 180-day follow-up period, including subsequent neck pain visits, diagnostic imaging, and therapeutic interventions.

RESULTS

The cohort included 770,326 patients with new-onset neck pain visits. The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%). Initial provider specialty was strongly associated with the receipt of subsequent neck pain visits with the same provider specialty. Rates and types of diagnostic imaging and therapeutic interventions during follow-up also varied widely by initial provider specialty. While uncommon after initial visits with chiropractors (≤2%), CT, or MRI scans occurred in over 30% of patients with initial visits with emergency physicians, orthopedists, or neurologists. Similarly, 6.8% and 3.4% of patients initially seen by orthopedists received therapeutic injections and major surgery, respectively, compared with 0.4% and 0.1% of patients initially seen by a chiropractor.

CONCLUSION

Within a large national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain. Compared with patients initially seen by physician providers, patients treated initially by chiropractors or therapists received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions during follow-up.

LEVEL OF EVIDENCE

3.