A retrospective cohort study1 of people who experience nonsurgical low back pain (LBP) was conducted from 2017-2019 by David Elton, DC, OptumLabs vice president of musculoskeletal R&D (and our 2022 Person of the Year), 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.
What Happens When LBP Patients See a Doctor of Chiropractic First
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 provider and provider type 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 HCP, 5.2% from a fourth and 2.5% from a fifth.
Compared to primary care providers, 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 health care provider when they were the second, third and fourth HCP seen. Not surprisingly, neurosurgeons were among the least likely to be the last HCP seen.
Chiropractic Manipulation: The Most Effective, Least Costly First-Line Service
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 to second- and third-line services.
The First, Not Last, Option for LBP
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 [read "Insurers Are Finally Figuring It Out: Which Provider Is the Best Choice for LBP?" (September 2022 issue) and "Chiropractic Best for Neck Pain" (October 2022 issue)], these latest two studies are preprints and have not been certified by peer review as of our press time. They report new medical research that has yet to be evaluated and thus should not be used yet to guide clinical practice. For background on the ongoing research efforts by Optum / Dr. Elton, et al., read "Putting Spine Care in the Right Hands" in our March 2019 issue.
References
- Elton D, Zhang M. Low back pain care pathways - is the last provider seen more important than the first: a retrospective cohort study. medRxiv 2022.10.27.22281624. www.medrxiv.org/content/10.1101/2022.10.27.22281624v1
- Elton D, Zhang M. Low back pain service utilization and costs: association with number of visits of chiropractic manipulation, active care, or manual therapy. A retrospective cohort study. medRxiv, 2022.10.28.22281664. www.medrxiv.org/content/10.1101/2022.10.28.22281664v2.full
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