Tuesday, October 13, 2015 Study: Seeing a PT First for LBP Decreases 1-Year Utilization Rates Among Privately Insured Researchers analyzing data from privately insured individuals have found that when it comes to low back pain (LBP), the provider a patient sees first can make a big difference in health care utilization over the course of a year: start with a physical therapist (PT), and you have a lower chance of receiving imaging or being treated through surgery or injections; go to physiatrist first, and those chances increase—along with overall costs. In a study appearing in the Journal of Evaluation in Clinical Practice in September (abstract only available for free), researchers looked at insurance claims data from 747 patients who initially sought treatment for LBP from 1 of several potential providers: a primary care provider (family medicine, internal medicine, or obstectrics/gynecology), physiatrist, chiropractor, PT, spine surgeon, an emergency department (ED), or other specialist such as a rheumatologist or neurologist. Authors linked the provider choice to utilization outcomes at 1 year after the initial visit, tracking the use of radiographs of the lumbar or pelvic region, advanced imaging, office visit with a spine surgeon after the initial visit, surgery, epidural injections, and LBP-related ED visits beyond initial visit. Julie Fritz, PT, PhD, FAPTA, served as lead author for the study. Results showed that compared with overall averages, patients who saw a PT first recorded fewer radiographs (32.7% of all patients compared with 16.7% of PT patients), advanced imaging (12.6% overall, 6.2% for PT patients), ED visits (4.2% overall, 2.1% of PT patients), spinal injections (9.2% overall, 2.1% of PT patients), and surgeries (2.4% overall, with no PT patients receiving surgery). The only area in which PT patients had higher utilization rates than the overall rates was for surgeon visits, where 6.2% of PT patients reported a visit, compared with an overall 4.8% rate. In terms of estimated costs associated with LBP treatment, patients who consulted a PT first averaged $904 after 1 year, similar to the $878 estimate associated with a first visit to a chiropractor, but much lower than the $2,283 in cost linked to physiatrists. An initial visit to a primary care provider resulted in estimated 1-year costs of $1,167. Overall average cost was estimated at $1,194. "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," authors write. In terms which providers were sought out by patients more often, the primary care providers led the way, with 54.8% of the patients beginning treatment in that setting. Chiropractors drew 27.7%, followed by physiatrists at 11.1%. PTs were sought out as initial treatment providers by 6.4% of the patients studied. Authors characterize the work done by PTs and chiropractors to treat LBP as "generally consistent with practice guidelines for new episodes of LBP," and speculate that this more evidence-based care may be linked to both practice restrictions and inherent qualities of manual therapy and exercise interventions. "Non-doctor providers are unable to order MRIs or prescribe opioids in contradiction to guidelines," authors write. "Non-doctor providers also tend to see patients more frequently and for longer durations, providing greater opportunity for patient education." Those last elements—more time spent with patients and greater opportunities for patient education—tend to be difficult for primary care doctors to achieve, they write. The findings of the private insurance studies are consistent with similar research conducted using data from Medicaid patients in the same Utah-based health system. In that study, authors found that Medicaid patients whose first visit for LBP was with a PT had lower 1-year utilization costs compared with Medicaid patients who saw a primary care provider first, or whose first LBP-related contact was through an ED. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.