J Eval Clin Pract. 2016 (Apr); 22 (2): 247–252 ~ FULL TEXT
Julie M. Fritz PhD PT FAPTA, Jaewhan Kim PhD, and Josette Dorius BSN MPH
Department of Physical Therapy,
College of Health,
University of Utah,
Salt Lake City, UT, USA.
This article is the perfect example of how mis-leading an Abstract can be,
when it fails to reflect what the study actually reveals. (see it below)
The RESULTS portion of this Abstract only partially discusses the findings, comparing 3 different professions' treatment, costs, and outcomes for low back pain.
In it they only mention the costs associated with medical management, while in reviewing chiropractic care vs. physical thereapy portions, they choose to emphasize:
Entry in chiropractic was associated with
an increased episode of care duration
Entry in physical therapy
no patient entering in physical therapy had surgery.
That *seems* to suggest that physical therapy *may* entail less expense, or shorter durations of care, or that chiropractic patients are more likely to end up with surgery. None of that is true. Their own Table 2 plainly reveals that chiropractic care was the least expensive form of care provided to the 3 groups.
More recently Blanchette et al.  found, while reviewing 5,511 cases of workers who received compensation, that:
“The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, while physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system.”
Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation
for Occupational Back Pain
Journal of Occupational Rehabilitation 2017 (Sep); 27 (3): 382–392
In case you are wondering what's bugging me, meta-analyses and other types of reviews always start by looking for Abstracts that fulfill their search criteria. This abstract does NOT suggest that chiroptactic is less costly (even though it was).
Even more insultingly, in the DISCUSSION section, they slip in just a bit more deception:
“More specifically, existing studies suggest there may be reduced exposure to expensive and invasive procedures and lower costs when a non-doctor provider such as a physical therapist or chiropractor is the initial provider...”
Can you hear my blood boil yet? The proper terminology for a chiropractor is “Doctor of Chiropractic”, not a “non-doctor provider such as a physical therapist”
Clearly they smell blood in the water.
In the future, some profession WILL become the Gatekeeper for patients with low back pain, and this article tries to suggest that PTs should stand, hand-in-hand, with chiropractors in that doorway.
I don't think so.
Chiropractors take almost 1000 hours of classes devoted spinal manipulation techniques, out of a 4,200 hour doctoral program. How many hours did they recieve, and who did they recieve it from?
The University of Utah Department of Physical Therapy website does not say. Hmmm?
RATIONALE, AIMS AND OBJECTIVE: Low back pain (LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs.
METHODS: A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting.
RESULTS: 747 patients were identified (mean age = 38.2 (± 10.7) years, 61.2% female). Entry setting was primary care (n = 409, 54.8%), chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%).
Relative to primary care, entry in physiatry increased risk for
radiographs (OR = 3.46, P = 0.001),
advanced imaging (OR = 3.38, P < 0.001),
injections (OR = 4.91, P < 0.001),
surgery (OR = 4.76, P = 0.012)
and LBP-related costs (standardized B = 0.67, P < 0.001).
Entry in chiropractic was associated with decreased risk for
advanced imaging (OR = 0.21, P = 0.001)
or a surgeon visit (OR = 0.13, P = 0.005)
and increased episode of care duration (standardized B = 0.51, P < 0.001).
Entry in physical therapy decreased risk of
radiographs (OR = 0.39, P = 0.017)
and no patient entering in physical therapy had surgery.
CONCLUSIONS: Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs.
KEYWORDS: care pathways; economic analysis; health care utilization; health services research; low back pain
From the FULL TEXT Article:
Low back pain (LBP) impacts 60–80% of individuals at some in
their lives. [1, 2] Management imposes a large socio-economic
burden on health care systems. Total direct costs in the United
States were estimated at over 86 billion dollars in 2005  and
costs related to LBP have been increasing at a rate faster than
overall health care spending. [3, 4]
Given the prevalence of LBP it is not surprising that it ranks as
the second or third most common symptomatic conditions for
which an individual seeks health care. [5–7] An estimated one of
every 17 doctor visits are attributable to LBP  across several
specialties, and LBP is the most common condition encountered in
physical therapy and chiropractic practices. [8–10] Considering
the number of providers involved and the myriad management
options, it is not surprising that care patterns for LBP are highly
variable. [11–15] Fragmented and variable care for LBP contributes
to high levels of guideline discordant management, overuse of
expensive and invasive procedures, and continual cost escalations
without accompanying evidence of improved outcomes [16–18].
Research increasingly points to the importance of early care
decisions and guideline adherence in the prognosis of patients with
LBP who seek care. For example, ordering a magnetic resonance
imaging (MRI) or prescribing opioids within the first weeks is
associated with increased risk for persistent symptoms, work disability
and high costs. [19–23] Less attention has focused on the
earliest care decision made by a patient, the type of provider
selected to begin care. This decision likely has important implications
for the prognosis and costs associated with an episode of
LBP care.  Numerous provider types including several doctor
specialties, physical therapists and chiropractors may serve as the
point of entry for an individual with LBP. More research is needed
to explore the implications of beginning care with different
The purposes of this study were
(1) describe the entry providers
chosen by individuals with private health insurance for a new LBP
(2) examine differences in patient characteristics
based on entry setting and
(3) examine associations between entry
setting and duration of episode of care, subsequent health care
costs and risk for utilization of specific procedures including
radiographs, advanced imaging, injections, emergency department
or spine surgeon visits, or surgery for LBP.
Data and study sample
We conducted a retrospective study of new LBP consultations
between 1 January 2012 and 31 January 2013 using claims data
from the University of Utah Health Plans (UUHP). The UUHP is
a non-profit insurer and integrated subsidiary of University of Utah
Health Care. We included enrollees with private, employer-based,
coverage between the ages of 18 and 60. A new LBP consultation
was defined as a provider visit occurring during the inclusion dates
associated with a LBP-related ICD-9 code (720.2, 721.3, 722.1,
722.52, 722.73, 722.93, 724.×, 739.3, 739.4, 756.11, 756.12,
846.×, 847.2, 847.3, 847.9) as a primary or secondary diagnosis
for whom no charges associated with LBP were received in the
prior 90 days. Date of the new consultation was defined as the
entry visit. We excluded those not continuously enrolled with
UUHPfor at least 90 days preceding and 1 year following the entry
visit. We excluded patients presenting at the entry visit with an
ICD-9 code indicative of a possible non-musculoskeletal cause for
back pain including kidney (592.×) or gall bladder stone (574.×),
urinary tract infection (599.0), or patients with a red flag condition
that may require urgent management including spinal/pelvis fracture
(805.×–809.×, 820.×–821.×, 733.13–733.15 or 733.96–
733.98), osteomyelitis (733.×), ankylosing spondylitis (720.0),
cauda equina syndrome (344.6×) or any malignant neoplasm
(140.×–209.×) diagnosis at the entry visit. Each patient was
included only once in the analysis based on the first eligible entry
visit using the above criteria.
Based on the procedure code and provider associated with the
entry visit, we categorized the entry setting as (1) primary care
(family medicine, internal medicine, obstetrics/gynaecology), (2)
physiatry, (3) chiropractic, (4) physical therapy, (5) spine surgeon
(orthopedic or neurosurgeon), (6) emergency department or (7)
other doctor specialty (e.g. rheumatologist, neurologist, etc.). The
UUHP and state of Utah allow access to these providers without
prior authorization requirement.
Patient characteristics and covariates
We identified patient characteristics and co-morbid conditions
from UUHP enrolment information, the University of Utah Health
Care electronic medical record (EMR) and ICD-9 codes for all
claims recorded in the year following the entry visit. Patient
characteristics included sex, age, zip code of residence and LBP
as primary or secondary diagnosis at entry visit. Specific
co-morbidities recorded were mental health conditions (296.×,
297.×, 298.×, 300.×, 301.×, 308.×, 309.×, 311.×), smoking status
(305.1, V15.82, 649.0×), substance use disorders (291.×, 303.×–
304.×, 305.0, 305.2×–305.9×), chronic pain (338.×) prior lumbar
surgery (V45.4, 722.83) and obesity (278.×). We computed
the Charlson Co-Morbidity Index (CCI) , which was
dichotomized as low (?1) or high (?2).
We evaluated a 1–year period following the entry visit. We recorded
if any LBP-related charges occurred beyond the entry visit
and the duration of the LBP episode of care as the number of days
from entry to the last LBP-related charge in the 1–year follow-up.
We recorded the occurrence of the following utilization outcomes;
(1) radiographs of lumbo-pelvic region, (2) advanced imaging
(MRI or computed tomography scan of lumbo-pelvic region, (3)
office visit with a spine surgeon (orthopedic or neurosurgeon)
beyond the entry visit, (4) surgical procedure (discectomy,
laminectomy, fusion or rhizotomy of the lumbosacral region), (5)
fluoroscopically guided epidural injection of the lumbar spine or
sacroiliac joint) and (6) LBP-related emergency department visit
beyond the entry visit. Costs were recorded from allowed costs for
all claims associated with a LBP-related ICD-9 code during the
year following the entry visit and summed to compute total LBPrelated
health care costs. If health care utilization for LBP was
identified in the EMR but not in claims data, we imputed the cost
as the mean of available claims for the procedure.
Analyses were performed with settings comprising at least 5% of
the sample (primary care, physiatry, chiropractic and physical
therapy). We compared patient characteristics and co-morbidities
between entry settings using chi square and Kruskal–Wallis tests.
Episode of care duration and total LBP-related costs were
described as medians or means with 95% confidence interval (CI),
respectively. Because we did not randomly assign patients to entry
settings, we employed inverse probability weighting using propensity
score to control selection bias.  Propensity scores were
estimated using a multinomial logit regression because the
dependent variable was entry provider category with four groups:
physical therapy, primary care, physical medicine and chiropractic.
In this regression, covariates at baseline (age, gender, LBP
primary diagnosis, CCI, smoking status, obesity, chronic pain
co-morbidity, substance use disorder, mental health co-morbidity,
prior spine surgery, medications and patients’ zip codes were controlled.
The inverse probability weighting of each patient was used
in the logistic regressions and generalized linear regressions.
Utilization outcomes were compared using adjusted odds ratios
with 95% CI from multivariate logistic regression. Generalized
linear regressions with gamma distribution and log link function
were used to examine duration of care and costs because of the
positively skewed distributions.  A significance level of
P < 0.05 was used.
A total of 862 individuals had a new LBP consultation during the
study dates, and 747 met all inclusion criteria (Figure 1). Entry
visit setting was most commonly primary care (n = 409, 54.8%)
followed by chiropractic (n = 207, 27.7%), physiatry (n = 83,
11.1%) and physical therapy (n = 48, 6.4%). Patient characteristics
and co-morbidities by entry setting are outlined in Table 1. Likelihood
that LBP was the primary diagnosis was lower in primary
care or chiropractic compared with physical therapy or physiatry
(P < 0.001). Patients entering in primary care were more likely to
have co-morbid substance use disorders (P = 0.047), and those
entering in primary care or physiatry were more likely to have
chronic pain co-morbidity (P < 0.001).
Outcomes by entry visit setting are described in Table 2. Entry
setting was predictive of outcomes in the weighted multivariate
models (Table 3 & Table 4). Relative to entry in primary care,
entry in physiatry was associated with increased risk for radiograph
(OR = 3.46, P = 0.001), advanced imaging (OR = 3.38,
P < 0.001), injections (OR = 4.91, P < 0.001), surgery (OR =
4.76, P = 0.012) and total LBP-related health care costs (standardized
? = 0.67, P < 0.001). Entry in chiropractic was associated
with decreased risk for advanced imaging (OR = 0.21, P = 0.001)
or a surgeon visit (OR = 0.13, P = 0.005), and with increased
episode of care duration (standardized ? = 0.51, P < 0.001). Entry
in physical therapy was associated with decreased risk of radiographs
(OR = 0.39, P = 0.017) and no patient entering in physical
therapy had surgery.
The purpose of this study was to describe the choices made by
privately insured patients with LBP about where to begin seeking
health care. As expected, we found a wide variety of settings were
used for entry, but most common were primary care and chiropractic,
with smaller percentages entering with a physiatrist or
physical therapist. The percentages in our sample generally
conform to national averages.  We found the entry setting to
predict future health care utilization, costs and the LBP episode of
care duration after controlling for patient demographic and
co-morbidity variables. Relative to beginning in primary care,
entry with a chiropractor or physical therapist was associated with
reduced risk for imaging, injections, surgical consultation and
surgery, while entry with a physiatrist increased risk for many of
these outcomes and overall LBP-related health care costs.
Few studies have focused specifically on the choice of entry
visit provider as a determinant of the future course of LBP care,
but our findings support work that has been done suggesting the
future course of care is dependent on the provider with whom a
patient begins care. [24, 28] More specifically, existing studies
suggest there may be reduced exposure to expensive and invasive
procedures and lower costs when a non-doctor provider such as a
physical therapist or chiropractor is the initial provider compared
with patients beginning with a medical doctor. [29–31] In our
sample, episodes beginning in chiropractic or physical therapy
were less likely to involve imaging, surgeon visits or injections
over the subsequent year relative to episodes beginning with a
doctor, particularly physiatrists. Total LBP-related health care
costs were predictably highest for the entry setting with greatest
utilization of imaging and invasive procedures (physiatry) and
trended lower for chiropractic and physical therapy, although only
differences with physiatry reached statistical significance.
Several factors may explain these findings. Those seeking care
from non-doctor providers for LBP tend to be younger and
healthier.  In our sample, rates of co-morbidities and smoking
were lower for patients beginning care in chiropractic or physical
therapy. Although these factors were controlled in analyses, the
potential impact of selection bias cannot be eliminated.
Differences in the training and scope of practice of the provider
are likely another factor. Chiropractic and physical therapy
provide manual therapy and exercise interventions consistent with
their training, and these strategies are generally consistent with
practice guidelines for new episodes of LBP.  A recent review
found chiropractors and physical therapists are more likely to
provide guideline-adherent care for LBP than primary care doctors.  Non-doctor providers are unable to order MRIs or prescribe
opioids in contradiction to guidelines. Physical therapists in the
United States are unable to order radiographs. Non-doctor providers
also tend to see patients more frequently and for longer durations,
providing greater opportunity for patient education. Time
constraints and difficulty providing adequate education about
activity are cited by primary care doctors as challenges for providing
evidence-based care to patients with LBP. [35, 36] Greater
alignment of the practice of non-doctor providers with evidence-based
recommendations for LBP has led to suggestions that policy
changes that encourage shifting initial care seeking for LBP
towards greater use of non-doctor providers may be an effective in
reducing costs and improve outcomes for LBP care [37, 38], as
well as calls for greater efforts to provide consistent evidence-based
information to health care professionals who manage
patients with LBP regardless of discipline. 
The results of this study should be considered in light of important
limitations. Potential confounding variables were not represented
in our data including pain severity or duration of symptoms.
The lack of these and other variables along with the unbalanced
and small size of some of our groups limit the ability to control
selection bias. Our sample was small and involved a single insurer
in one geographic region. Patients in this study had insurance
coverage to access doctor or non-doctor specialists for LBP
without prior approval requirements. Although the generalizability
of these findings may be limited, they should encourage more
research on the influence of entry setting on the course of care for
LBP and exploration of policies to facilitate more efficient and
effective care for persons with LBP beginning with the first provider
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