Expenditures Associated with Lower Back, Lower Extremity Pain Diagnoses

A recent study into expenditures following a first-time diagnosis of lower back pain or lower extremity pain found failure to follow guidelines and receiving surgery before exhausting therapy options can lead to a significant economic burden.

Despite finding that just 1.2% of newly diagnosed patients receive surgery in the first 12 months, that group accounted for more than 25% of total expenditures within the study.

Investigators used the Truven Health MarketScan Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases to collect data from between Jan. 1, 2007 to Dec. 31, 2016. Investigators designed a retrospective longitudinal cohort study that included patients 18 or older who were newly diagnosed with LBP or LEP between 2008 and 2015.

The primary outcome was a continuous variable denoting total health care depending at 6 and 12 months following a new diagnosis of LBP or LEP. Investigators reported costs according to whether patients received spinal surgery, patterns of conservative management, and types of health care services used. Investigators defined costs as total eligible charges prior to reductions, including both patient and health plan share of payments. The terms nonsurgical spending and surgical spending refer to aggregate costs from the nonsurgical and surgical cohorts.

Investigators included a total of 2,498,013 opiate naive-patients in their study. Investigators noted both cohorts included young, privately insured patients as most of those included in the trial had 0 or 1 preexisting comorbidity. A majority (98.8%) of patients did not receive surgery with 12 months of diagnosis. Patients who received surgery were slightly older and more likely to be male.

After analyses, investigators found that 55.7% of all study patients received no intervention. Patients within the nonsurgical cohort were less likely to visit primary care practitioners (69.7% versus 93%) and physical therapists (6.9% versus 26%) but more likely to visit chiropractors (12.5% versus 9.3%). Patients within the surgical cohort received more imaging, including lumbar computed tomography (12.3% versus 1%), MRI (85.9% versus 12%), and radiography 72.9% versus 30%). They also received more epidural steroid injections (ESI) (40.1% versus 3.5%) and physical therapy (41.3% versus 13.6%). While the nonsurgical cohort formed 98.8% of the study population, they only accounted for 70.8% of total spending at 12 months.

Despite multiple published guidelines stating imaging should not be obtained within 30 days of diagnosis, 32.3% of patients in the nonsurgical cohort received imaging within 30 days of diagnosis. Adjusted 12 month costs for patients who received imaging were more than double the costs for patients who did not receive early imaging ($1194 versus $556).

Within the nonsurgical cohort, 56.3% of patients did not receive physical therapy, imaging, or ESI and they accounted for 26.3% ($498 million) of expenditures. The 27.6% of patients who received imaging only accounted for 27.7% and 19.6% of total 12-month cost in the nonsurgical and entire cohorts, respectively ($525 million). The mean spending per patient increased with greater use of services (physical therapy, imaging, and ESI: $5868, physical therapy and imaging: $2056, physical therapy only: $1090, imaging only: $770, and none: $359.

Investigators performed the same analysis for the surgical cohort to analyze expenditures, except only physical therapy and ESI were included. A total of 38.7% of that cohort did not receive either of those interventions. These patients had health care expenditures of $265 million as a group in the first 12 months after diagnosis. Aggregate costs for patients who underwent surgery and physical therapy only (21.1%) amounted to $166 million, a per-patient cost of $25,590. Patients who underwent surgery and received ESI without physical therapy (20.0%) had a total 12-month cost of $169 million, a per-patient cost of $27,578. Those who had both PT and ESI (20.1%) spent $183 million as a group during the first 12-month period, a per-patient cost of $299,000.

In their conclusion, authors noted that failure to adhere to management guidelines resulted in increased expenditures among many patients within the study. Patients that received early imaging or receive surgery for LBP and LEP accounted for a disproportionate amount of total costs associated with these conditions.