BackgroundLow back pain (LBP) is prevalent, costly, and a common reason for a visit to a primary care provider (PCP). Guidelines recommend a stepped approach to management.

ObjectiveFor individuals with LBP initially contacting a PCP, examine the association between the incorporation of first-line therapies, use of second- and third-line services and total episode cost.

DesignRetrospective cohort study

Setting/PatientsNational sample of individuals with non-surgical LBP occurring in 2017-2019.

MeasurementsIndependent variables were initial contact with a PCP, and the timing of incorporation of 5 types of first-line therapies. Dependent measures included use of 14 types of health care services and total episode cost.

Results8.5% of 118,503 PCPs initially contacted by 308,790 individuals with 347,627 episodes of non-surgical LBP were associated with an episode including any first-line service at any time. 17.5% of episodes included any first-line service at any time. Active care (11.6% of episodes), manual therapy (8.0%) and chiropractic manipulative therapy (7.0%) were the most common first line services. 5.4% of episodes included a first-line service during the first 7 days. These episodes were associated with a modest reduction in the use of prescription pharmaceuticals, with no impact on the use of imaging or spinal injection. First-line services were associated with an increase in total episode cost with the smallest increase associated with chiropractic and osteopathic manipulation. Younger individuals from ZIP codes with higher adjusted gross income were more likely to receive a first-line service in the first 7 days of an episode.

LimitationsAs a retrospective observational analysis of associations there are numerous potential confounders and limitations.

ConclusionsIndividuals with non-surgical LBP initially contacting a PCP infrequently receive a first-line service, and if received, it is typically in addition to second- and third-line pharmaceutical, imaging, and interventional services. There is an opportunity to improve concordance with the stepped approach to management described in LBP guidelines.

/pdf/low-back-pain-service-utilization-and-costs-association-with-bbsmgvs0.pdf

Low back pain service utilization and costs: association with timing of first-line services for individuals initially contacting a primary care provider. A retrospective cohort study

ABSTRACT Background Active duty service members (ADSMs) of the U.S. Armed Forces are uniquely at risk for musculoskeletal injuries (MSKIs) of the Head/Neck region, including the eye and face, from training with head gear, donning Kevlar, operating aircraft, and maintaining sitting or standing postures for prolonged durations. The purposes of this descriptive study were to report the prevalence/incidence, health care utilization, and health care costs attributable to Head/Neck MSKIs across the Services from fiscal years (FYs) 2016 to 2021. Methods This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Head/Neck MSKIs, associated health care utilization, and private sector costs were obtained by querying electronic health records from military treatment facilities, private sector care (PC) claims, and theater medical data from October 1, 2015 to September 30, 2021 (FYs 16–21), using the Military Health System Data Repository. Utilization associated with Head/Neck MSKIs in both the direct care and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC costs related to Head/Neck MSKIs were captured for each year. Results In FY21, 109,683 ADSMs sought care for Head/Neck MSKIs, representing 7.3% of the U.S. Armed Forces. The prevalence of Head/Neck MSKIs ranged from 6.9 to 7.8% during FY16–21, with the highest annual prevalence among the Air Force (8.0–9.4%) and Army (7.9–8.8%). Within direct care across the services, Soldiers presented for the highest proportion (45.9–47.9%) of outpatient encounters for Head/Neck MSKI annually. The Air Force relied most heavily on PC for outpatient Head/Neck MSKI care, which accounted for $9,134,741 in PC costs and comprised 37.2% of all PC encounters in FY21. Conclusions This retrospective, descriptive study established prevalence/incidence, health care utilization, and PC costs for Head/Neck MSKIs across the services from FY16–21, emphasizing the burden of Head/Neck MSKIs among the U.S. Armed Forces, with PC costs amounting to $42,912,940 in FY21 alone. 

Musculoskeletal Head and Neck Injuries in U.S. Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016–2021

Background: Physician specialists (PS) are often the type of healthcare provider initially contacted by an individual with low back pain (LBP). LBP clinical practice guidelines (CPG) recommend a stepped approach to management with an emphasis on first-line non-pharmaceutical and non-interventional services. Objective: Examine the association between the incorporation of CPG recommended first-line services, exposure to second- and third-line services and total episode cost for individuals with non-surgical LBP initially contacting a PS. Design: Retrospective observational study with identical design to previous study focused on primary care physicians. Setting/Patients: National sample of individuals with non-surgical LBP occurring in 2017-2019. Measurements: Independent variables were initial contact with a PS, and the timing of incorporation of five types of first-line services. Dependent measures included exposure to thirteen types of health care services and total episode cost. Results: 91,096 individuals were associated with 98,992 episodes of non-surgical LBP. 36.2% of the 33,277 PS initially contacted for an episode of LBP incorporated any first-line service at any time during an episode. A first-line service was provided in 24.0% of episodes with active care (19.5% of episodes), manual therapy (13.7%) and chiropractic manipulative therapy (6.5%) the most common. 7.3% of non-surgical LBP episodes included a first-line service within seven days of initial contact with a PS. These episodes were associated with a reduction in the use of prescription skeletal muscle relaxants (risk ratio 0.88) and opioids (0.55), spinal injections (0.84), and CT scans (0.71), with no impact on the use of prescription NSAIDs, radiography, or MRI scans. First-line services were associated with an increase in total episode cost at any time of incorporation with chiropractic manipulation associated with the lowest cost increase. Younger individuals from zip codes with higher adjusted gross income were more likely to receive a first-line service in the first seven days of an episode. Limitations: As a retrospective observational analysis of associations there are numerous potential confounders and limitations. Conclusions: Individuals with non-surgical LBP initially contacting a PS infrequently receive a CPG recommended first-line service. If a first-line service is provided it is often later in an episode and typically in addition to second- and third-line services. There is an opportunity to improve concordance with LBP CPGs for individuals with LBP initially contacting a PS.

/pdf/low-back-pain-service-utilization-and-costs-association-with-1c2ykx36.pdf

Low back pain service utilization and costs: association with timing of first-line services for individuals initially contacting a physician specialist. A retrospective cohort study

Introduction: Worldwide many countries provide direct access in physiotherapy. The aim of this scoping review was to synthesize the available evidence on the quality of primary care musculoskeletal physiotherapy from different perspectives. Methods: Systematic searches were conducted in three databases up to September 2022. Studies were included when regarding assessment of at least one of the following perspectives: patient (quality of Life, patient satisfaction, pain, functioning, adverse events), provider (treatment compliance, responsibility, liability, status, prestige, job satisfaction), and society (number of referrals, amount of medical imaging, medication use, number of sessions needed for rehabilitation, and overall costs and cost-effectiveness). Selection and methodological quality assessment of systematic reviews were performed. Data extraction and analysis were performed separately for systematic reviews and individual primary studies. Results: Five systematic reviews as well as 17 primary studies were included. From a patient perspective, no significant effect of direct access was found for pain and a tendency in favour of direct access was found for quality of life, functioning, and well-being. Concerning providers, higher treatment compliance was found in direct access to physiotherapy and decision-making was more accurate. From a societal perspective, significant differences in favour of direct access physiotherapy were found for waiting time, prescribed medication, and medical imaging. In addition, there was a tendency towards lower health care costs. 

Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review from a patient, provider, and societal perspective

<title>Abstract</title> This research investigates the equitable distribution of healthcare resources and its impact on patient outcomes, along with the relationship between resource allocation strategies and operational efficiency in Taiwan's healthcare system. Using a mixed-methods approach, the study explores these strategies through qualitative data from semi-structured interviews analyzed with NVIVO software and quantitative data collected via surveys from hospital administrators, safety teams, and financial personnel. A sequential random sampling method selected healthcare institutions based on size, location, and specialty services. The findings reveal a strong correlation between the adoption of AI techniques, healthcare quality, patient care service utilization, and improved patient outcomes, although resource allocation alone does not directly affect patient outcomes. Operational efficiency plays a mediating role, contributing to better patient results. The study emphasizes the need for integrating efficient resource management and operational practices to enhance patient outcomes, providing actionable insights for healthcare administrators to improve care quality and accessibility. It also highlights the importance of developing tailored resource management strategies that consider regional and organizational differences within Taiwan’s healthcare system. 

‘Technology Alone Is Not Enough: The Role of Operational Efficiency in Bridging AI and Patient Outcomes’ – Insights from Taiwanese Healthcare Facilities"

INTRODUCTION
Spine pain is one of the largest and costliest burdens to our healthcare systems. While evidence-based guidelines for spine pain have been established, and continue to evolve, the actual management of this condition continues to burden the healthcare system. This has led to increased costs due to inefficient entry to healthcare, utilization of treatments unsupported by clinical guidelines, and patient navigation through our healthcare systems. The purpose of this study was to assess the healthcare utilization and related outcomes for Active Duty Service Members (ADSM) receiving healthcare services in a novel acute spine pain clinic (ASPC) during the first 5 years of operation at a large Military Treatment Facility.


MATERIALS AND METHODS
In 2014 the Physical Medicine and Rehabilitation and Physical Therapy (PT) services designed a novel acute spine clinic intended to directly receive ADSM with acute spine symptoms for an initial evaluation by a Physical Therapist. The inclusion criteria into the ASPC were: ADSM, pain less than or equal to 7 days, no more than three prior episodes of acute spine pain in the past 3 years, and not currently receiving care from Chiropractic, Pain Management, or PT services. The exclusion criteria were: significant and/or progressive neurological deficits, bowel or bladder dysfunction, unstable vital signs or fever, hematuria or extensive trauma.


RESULTS
A total of 1,215 patients presented to the ASPC for evaluation between 2014 and 2019. The most common chief complaint was acute pain in the lumbar spine (73%), followed by cervical spine pain (15%), and thoracic spine pain (12%) represented the fewest. The average number of PT visits per patient was 3.5 (range 1-13) with 61.1% utilizing three or fewer visits. Over 95% of cases returned to work the same day as their initial evaluation. Sixty-six percent returned to work without restriction the same day as their initial evaluation. Light duty recommendations were provided to 412 (33.9%) patients ranging from one to 30 days, with greater than 85% of the light duty being less than 14 days. Recommendations to not return to work (sick-in-quarters) were issued to 56 (4.6%) patients. The sick-in-quarters recommendations were for a 24-hour period in 48 cases, 48 hours for seven cases, and 72 hours for one case. All encounters in which the patient first sought care at the ASPC for low back pain met the Healthcare Effectiveness Data Set standard for low back pain care of having no imaging within 28 days of the first encounter for nonspecific low back pain. A medical record review of 100 randomly selected patients within 12 months of the initial evaluation demonstrated decreased utilization of medication, imaging, and referral to surgical services.


CONCLUSIONS
This innovative approach demonstrates the potential benefits of rapid access to treatment and education for patients with acute spine pain by a Physical Therapist. Modeling this approach at Military Treatment Facilities may lead to decreased utilization of medications, radiology services, specialty care referrals, and reduced cost of care provided to individuals with acute spine pain.

Improving Access and Decreasing Healthcare Utilization for Patients With Acute Spine Pain: Five-Year Results of a Direct Access Clinic.

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Improving Access and Decreasing Healthcare Utilization for Patients With Acute Spine Pain: Five-Year Results of a Direct Access Clinic.