A retrospective cohort study1 of people who experience non-surgical low back pain (LBP) was conducted from 2017-2019 by David Elton, DC, OptumLabs vice president of musculoskeletal R&D, and colleagues. This is yet another in a series of excellent studies from the OptumLabs team demonstrating superior effectiveness for chiropractic as first-line care that reduces costs and use of opioids.
In the study, the research team tracked 503,958 low back pain patients seeing 196,522 different health care providers (HCPs) utilizing 13 different health care services, with a total cost of $387,867,096. Their approach was to look at which provider type was the last seen by the patient to resolve their LBP. The study also tracked the first providers and provider types each patient saw on their path to resolution.
Primary care physicians (PCPs) were the first providers for 35.2% of episodes, followed by DCs (first providers for 25.9% of episodes), nurse practitioners (7.5% of episodes), radiologists (6.0%) and orthopedic surgeons (5.5%). Just over half of patients saw only one provider, with 30.2% seeking care from a second HCP, 11.8% seeking care from a third, 5.2% from a fourth and 2.5% from a fifth.
Compared to PCPs, when DCs were the initial-contact provider, they were the most likely to be the only and last one seen (84 percent of patients). DCs were also the most likely to be the last HCP when they were the second, third and fourth HCP seen. Not surprisingly, neurosurgeons were among the least likely to be the last HCP seen.
A second retrospective cohort study2 by the same team compared first-line services: chiropractic manipulative therapy (CMT), active care (AC), manual therapy (MT), and acupuncture, to see which was more efficient. The researchers looked at the number of visits, total costs and reduction in utilization of second- and third-line services like nonsteroidal anti-inflammatories (NSAIDs) and opioids.
The study followed 132,199 nonsurgical LBP patients who received initial care from 1,336 different DCs, 2,734 different PTs and 1,339 different acupuncturists (LAc), with a total cost of $62,185,930. The most common duration of care was between one and three visits. Almost half (48.2%) of CMT episodes came in at three or fewer visits, followed by MT (32.1%), AC (29.7%) and acupuncture (27.0%). This number of visits resulted in the lowest utilization of second- and third-line services.
This study concluded that "CMT was associated with lowest median total episode cost at each level of visit utilization." CMT also resulted in the lowest exposure the second- and third-line services. It was also found that "DCs were initially contacted by individuals from zip codes with higher ADI (Area Deprivation Index - median 44), lower AGI (median $67,653) and higher % NHW population (median 76.9%)."
Together, these two studies make sound arguments for beginning nonsurgical low back pain care with chiropractors. Chiropractic was shown to be the most efficient first-line care, reducing costs, as well as the use of opioids and other second- and third-line services. Payers, patients and other providers will hopefully recognize this superiority and adapt their health care decisions accordingly. When it comes to low back pain, chiropractic should be the first, not last, option.
Editor’s Note: As is the case with other recent research by Dr. Elton and colleagues reported in Dynamic Chiropractic in the past several issues, these latest two studies are preprints and have not yet been certified by peer review. They report new medical research that has yet to be evaluated and thus should not be used yet to guide clinical practice.
References
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