subsequent healthcare utilization associated with early physical therapy for new episodes of low...
TRANSCRIPT
SUBSEQUENT HEALTHCARE UTILIZATION ASSOCIATED WITH
EARLY PHYSICAL THERAPY FOR NEW EPISODES OF LOW BACK PAIN IN
OLDER ADULTS
Deven Karvelas, MD
University of Michigan
10/04/2015, AAPM&R Annual Assembly
Disclosures – None
Funding Source – Agency for Healthcare Research and Quality
•$10 million ARRA CHOICE award - 1R01HS019222-01
•Back Pain Outcomes Using Longitudinal Data (BOLD)
•PI: Jerry Jarvik, MD, MPH
•Details: www.backpainproject.org
This is a prospective cohort study (Level 1 Evidence)
DISCLOSURES AND FUNDING
Sean RundellJanna FriedlyAlfred Gellhorn Laura GoldBryan ComstockPatrick HeagertyBrian BresnahanDavid NerenzJeffrey Jarvik
ACKNOWLEDGEMENTS
• Lifetime incidence between 60% and 85%
• Accounts for a substantial portion of our annual healthcare expenditures
• Physical therapy is a commonly-prescribed treatment
• Optimal timing of physical therapy is not clear
• Two prior studies (Gellhorn et al and Fritz et al) found early PT was associated with a decrease or no change in subsequent healthcare utilization
LOW BACK PAIN BACKGROUND
To estimate the association between initiating early physical therapy following a new visit for an episode of low back pain and subsequent back-pain-specific health care utilization in older adults after adjusting for disease severity, symptom duration and sociodemographic factors.
STUDY OBJECTIVE
Design: Prospective cohort study in 3 major integrated healthcare systems (BOLD registry)
Patient sample: 4,723 adults, aged 65 and older, presenting to a primary care setting with a new episode of low back pain
Intervention: Patients who had early PT (within 28 days of index visit)
Comparator: Patients who didn’t have early PT
Sub-analysis: Patients with a self-reported symptom duration of less than one month
DESIGN
Primary outcome: Total back-pain-specific relative value units (RVUs), from days 29-365
Secondary outcomes: Overall RVUs for all healthcare use and use of specific health care services including: • Imaging (x-ray and MRI or CT)• Emergency Department visits• Physician visits• Physical therapy• Spinal injections• Spinal surgeries• Opioid use
OUTCOMES
Adjustment performed with generalized linear models
All models adjusted for age, sex, race, ethnicity, education, marital status, smoking status, duration of back pain, back-related disability, back pain NRS, leg pain NRS, expectations for recovery, anxiety symptoms, depression symptoms, EQ-5D, study site, and total RVUs for the 365 days prior to the index visit.
ANALYSIS
RESULTS
Unadjusted RVUs for days 29-365
Early PT (n=628) No Early PT (n=4095)
Mean SD MedianInterquartile
Range Mean SD MedianInterquartile
RangeRatio of means 95% CI p-value
Total RVUs 64.7 141.3 25.8 12.6 53.0 50.8 125.3 20.6 8.4 46.4 1.28 1.06 1.54 0.01
Total Spine RVUs 17.0 93.2 0 0 5.9 9.5 72.0 0 0 0.5 1.79 1.10 2.91 0.02
Total Physical Therapy RVUs
3.7 5.6 1.8 0.0 5.3 1.3 3.6 0 0 0 2.86 2.47 3.31 <0.001
Total Injections RVUs
1.0 4.7 0 0 0 0.6 3.8 0 0 0 1.79 1.20 2.68 0.01
Total Spine Image RVUs
2.9 7.0 0 0 1.1 1.8 5.4 0 0 0 1.64 1.33 2.03 <0.001
Total Surgical RVUs
10.1 81.1 0 0 0 5.1 59.0 0 0 0 1.99 0.97 4.11 0.06
RESULTS
Adjusted RVUs for days 29-365 Early PT No Early PT
Mean SD Mean SD Ratio of means 95% CI p-value
Total RVU 56.1 5.0 52.3 2.1 1.07 0.88 1.31 0.49
Total Spine RVU 12.2 2.6 10.2 1.2 1.19 0.72 1.96 0.49
Total Physical Therapy RVU 3.4 0.2 1.3 0.1 2.56 2.17 3.03 <0.001
Total Injections RVU 0.8 0.1 0.6 0.1 1.33 0.89 2.00 0.17
Total Spine Image RVU 2.5 0.3 1.8 0.1 1.37 1.09 1.71 0.01
Total Surgical RVU 5.9 1.9 5.7 1.0 1.03 0.50 2.12 0.94
RESULTS
Acute low back pain sub-analysis:• 246 participants with early PT and 1348 without• Performed for primary outcome only • No statistically significant difference noted• Ratio of means 2.01, 95% CI 0.98 to 4.15, P 0.06.
Exploratory analysis:• Total spine RVUs from day 1-365• Performed to include PT RVUs from first month• Similar results to primary analysis• Ratio of means 1.13, 95% CI 0.76 to 1.70, P 0.54
RESULTS
• Early PT was not associated with any meaningful change in subsequent healthcare utilization
• This was true even when the RVUs for the initial PT were included
• Early PT specifically for acute LBP also is not associated with any change in subsequent back-pain-specific healthcare utilization
DISCUSSION
• Rundell, et al.: Functional outcomes after early PT in BOLD
• Modest improvement in the primary outcome (RMDQ) in patients who had early PT (mean RMDQ 1.4 points less)
• Early PT may lead to modestly improved outcomes without an increase in overall healthcare utilization
DISCUSSION
In older adults presenting for a new episode of LBP, early PT is not associated with any difference in subsequent back-pain-specific healthcare utilization compared to patients not receiving early PT, even for patients with acute LBP.
CONCLUSION