Stimulated by Harwood et al 2022.
LBP – low back painkey to acronyms
US – United States of America
HCCI – Heath Care Cost Institute
ED – emergency department
EM – emergency medicine
This is very large retrospective observational cohort from the US examining opioid use, other healthcare utilisation, and costs in patients with LBP. I have highlighted other papers studying opioid use from the US on this blog in 2019 and 2021.[2,3]
This is the second paper to look at the initial healthcare provider in LBP. The first looked at the initial healthcare provider in new cases of low back pain and the risk of ending up on opioid medication: Initial healthcare provider and opioid use in LBP?
This paper used data from the Heath Care Cost Institute (HCCI), which includes health insurance claims data for approximately 50 million individuals, across 4 private health insurance companies active in the US.
The study included patients with ICD9/10 codes for non-specific LBP, but excluded patients with LBP or opioid prescription in the previous 6 months, and also excluded those patients who saw more than one provider on the index date.
The sample included 3 799 593 patients, of which 24.8% had seen a chiropractor and 1% had seen an acupuncturist as the initial healthcare provider.
Early and long opioid prescription were lowest for patients who saw an acupuncturist as the initial healthcare provider – 1.2% and 0.4% respectively. The figures for chiropractors were 1.7% and 0.6% These figures were nearly 10 times higher for doctors and advanced practice nurses.
Healthcare utilisation in terms of MRI/CT, hospitalisation and surgery were all lowest for the patients who saw acupuncturists, but surprisingly, total health care costs appeared to be second highest for this cohort. The total costs were lowest for those seeing a chiropractor, but the rates of ED visits for this cohort were over double those of all other groups apart from EM physicians of course.
This seems to be the largest study of this type to date from the US, and it included 37 522 patients who saw an acupuncturist as the initial healthcare provider out of the total sample of just under 4 million. The very similar paper from 2019 only included 1839 patients who saw an acupuncturist.
The other paper I mentioned was not restricted to LBP but compared a group who received acupuncture matched to a group receiving NSAIDs or PT. This paper included 52 346 patients who received acupuncture, so slightly more than the current highlighted paper. You can read more about the study here: Does acupuncture reduce opioid use?
I will finish this blog with a rather interesting quote from the discussion of Harwood et al:
While we have limited information on health outcomes, our findings support that some conservative providers deliver lower cost while providing care aligned with clinical practice guidelines. With scope of practice laws being relaxed across states temporarily due to the COVID crisis, the country is going through a natural experiment as individuals have greater access to varied providers. While these practice laws may change, our results suggest that policymakers should consider less restrictive laws so as to not limit access to effective providers.
1 Harwood KJ, Pines JM, Andrilla CHA, et al. Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US. BMC Health Serv Res 2022;22:694. doi:10.1186/s12913-022-08092-1
2 Kazis LE, Ameli O, Rothendler J, et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019;9:e028633. doi:10.1136/bmjopen-2018-028633
3 Pham T, Ma Q, Agiro A, et al. Do Acupuncture Services Reduce Subsequent Utilization of Opioids and Surgical Interventions Compared to Noninvasive Therapies among Patients with Pain Conditions? Pain Med Malden Mass 2021;22:2754–62. doi:10.1093/pm/pnab187
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