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  • Study: LBP Patients With Comorbidities at Higher Risk for 'Guideline Discordant' Care

    In brief:

    • Researchers analyzed commercial insurance claims for 513,980 adults with an initial report of back pain; matched claims history with presence of 0, 1, or 2 or more comorbidities
    • Compared with those reporting no comorbidities, patients with 1 comorbidity were 14% more likely to become a long-term user of back care (3-year period); patients with 2 or more comorbidities were 29% more likely to engage in long-term use
    • Patients with comorbidities also more likely to receive imaging, visit the ED
    • Individuals with comorbidities more likely to be prescribed opioids as an initial treatment and more likely to fill those prescriptions
    • Authors describe results as a "concerning" indication that more vulnerable patients may be at a greater risk of receiving lower-quality care

    Authors of a new study have found that for patients with low back pain (LBP), the presence of comorbidities such as diabetes, mental health issues, and hypertension raises the risk that they'll receive LBP care that uses more resources and veers off-course from LBP guidelines—including more prescriptions for opioids.

    The study, published in the Journal of Evaluation in Clinical Practice (abstract only available for free), analyzes commercial insurance claims data from 2007 to 2011 involving 513,980 adults with new visits for back pain. Researchers tracked LBP care-related claims for 3 years after the initial visit as well as procedure use and treatment patterns for the first 42 days after the visit, and matched these data with patients identified as having 0, 1, or 2 or more comorbidities based on ICD-9 codes. APTA member Sean Rundell, PT, DPT, PhD, was lead author of the study.

    The patient population studied had an average age of 45.2 years. Females made up 54% of the study group, and 44% of the population came from the southern United States. Most (80%) reported no comorbidities, with 16% (83,242) reporting 1, and 4% (21,304) reporting 2 or more. The most common comorbidities reported were endocrine, nutritional, and metabolic diseases and immunity disorders (36%), followed by diseases of the musculoskeletal system (29%), and diseases of the circulatory system (27%).

    Among the findings:

    • Compared with patients having no comorbidities, those with 1 comorbidity were 14% more likely to become a "long-term user" of back pain-related care. Patients with 2 or more comorbidities had a 29% greater likelihood of long-term use. The resource use pattern tended to include at least 1 episode of care every quarter for the 3-year study period.
    • Among the individual comorbidities studied, patients with comorbid musculoskeletal conditions were 53% more likely than those without to be high users of long-term back care resources. Individuals with mental health disorders, nervous system, and respiratory comorbidities each had more than a 30% increase in odds of long-term resource use.
    • Patients with comorbidities also were more likely than those with no comorbidities to use advanced imaging, visit the emergency department, and fill at least 1 prescription for opioids.
    • Overall, 22% of the study population filled at least 1 opioid prescription, but that average was higher among patients with comorbidities: among patients with mental health comorbidities, 27% of patients with anxiety disorders and 45% of patients with substance use diagnoses filled at least 1 opioid prescription. The same pattern was observed for patients with chronic pulmonary disease (35% prescription fill rate) and asthma (26% rate).
    • When it came to opioid prescriptions as an initial treatment, patients with depressive disorders, substance abuse disorders, and anxiety disorders were more likely to receive a prescription, as were patients with chronic respiratory conditions and asthma.

    Authors note that "guidelines discordant" care is sometimes acceptable for LBP patients with comorbidities. Still, they assert, the opioid prescription and fill numbers are "disconcerting," particularly given that some the highest fill rates were associated with patients whose use of opioids could pose a danger: individuals with substance abuse diagnoses, patients with mental health disorders that may require psychotropic medications, and patients with respiratory conditions.

    "Despite long-standing guidelines, current management of back pain continues to lack concordance with recommended practices," authors write. "[The current study's] findings are concerning because it indicates that more vulnerable patients, ie, those with a higher comorbidity burden, may be receiving lower-quality care that has a higher risk for adverse events."

    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.

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