Abstract
Background/Objectives
Low back pain (LBP), a prevalent costly condition, has evidenced-based pharmacologic and non-pharmacologic treatments. Because the prevalence of LBP and opioids use differs between the U.S. Census Regions, we compared the treatments used for LBP and their related costs between regions.
Methods
De-identified patient health claims data from persons with LBP along with treatments received was extracted from a large commercially insured dataset (2007-2009; N=1,630,438). Descriptive statistics and ANOVA analyses were used during data analysis.
Results
An opioid was used by 49.8% (n=812,479) of this sample while nonpharmacologic therapies were rarely used (8%-psychological therapies; 19%-exercise therapies; 12%-PT). The median costs for pharmacologic and non-pharmacologic treatments are variable. We found significant differences in the medications and therapies used in the U.S. Census Regions (p<.0001).
Conclusion
Overuse of pharmacologic and underuse of non-pharmacologic treatments is common among persons with LBP. Differences exist in the receipt of various LBP treatments geographically.
Keywords: low back pain, standardized costs, recommended treatments
Introduction
Impact and Prevalence of Low Back Pain
An estimated 67% to 84% of persons residing in industrialized countries experience low back pain (LBP). This prevalence is variable in geographic locations throughout the U.S. (U.S. Census Regions; Figure 1a) (Centers for Disease Control and Prevention, 2013; Fourney et al., 2011). Low back pain (LBP) is a significant source of lost productivity, disability claims, and increased health care costs (Centers for Disease Control and Prevention, 2013; Chou et al., 2007; Dagenais, Caro, & Haldeman, 2008; Fourney et al., 2011; Luo, Pietrobon, Sun, Liu, & Hey, 2004). An estimated 2% of the U.S. workforce is compensated for work days lost to back injuries, and LBP is responsible for more lost workdays and disability claims than any other health condition (Chou et al., 2007; Fourney et al., 2011). The most current published data (1998) estimates the direct, treatment costs of LBP to be 90 billion U.S. dollars (Dagenais et al., 2008; Luo et al., 2004).
Figure 1.
a. Prevalence of LBP
b. Total mean milligrams of opioids dispensed per resident.
c. Comparisons of medication usage (in percentages) by regions among adult patients with low back pain (N = 1,630,438)
Frequency of Adults with Low Back Pain by US Census Bureau Regions
*Comparison significant at the p < .0001 level
d. Comparisons of therapy usage (in percentages) by regions among adult patients with low back pain (N = 1,630,438)
*Comparison significant at the p < .0001 level
e. Comparisons of therapy usage (in percentages) by regions among adult patients with low back pain (N = 1,630,438)
†Comparison significant at the p = .01 level
*Comparison significant at the p < .0001 level
Treatments for Low Back Pain
In efforts to prevent disability, in 2007 the American College of Physicians (ACP) and the American Pain Society (APS) developed clinical practice guidelines for the diagnosis and management of acute and chronic LBP (Chou et al., 2007). Three of the seven guidelines address treatment and include: 1) providing patient education about the course of the condition and self-care, 2) the use of medications with proven efficacy, and 3) the use of non-pharmacologic therapies with proven efficacy (Chou et al., 2007). There were only three treatments with “good” evidence (defined as: results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes) to support a moderate effect in the treatment of acute LBP (Defined as: 10 to 20 point improvement on a 100-point scale for pain and functional status). These three treatments include: 1) the use of non-steroidal anti-inflammatory drugs (NSAIDs), 2) the use of skeletal muscle relaxants, and 3) the application of superficial heat (Chou et al., 2007). For chronic LBP the six therapies that had “good” evidence to produce a “moderate” effect were: the use of NSAIDs, exercise therapy, cognitive behavioral therapy, interdisciplinary rehabilitation, spinal manipulation, and tricyclic anti-depressants (Chou et al., 2007). Interestingly, there was only “fair” evidence (Defined as: sufficient but the strength of the evidence is limited) to support the moderate effect of opioids, tramadol, and benzodiazepines (Chou et al., 2007). Although authors of the ACP and APS guidelines include the use of medications classified as opioids and benzodiazepines as a potential LBP treatment option, they also state that the potential harms of therapy (i.e., potential addiction and overdose) should be considered prior to initiating therapy.
All Cause Opioid Use Across the U.S
Because of the varying prevalence of LBP in U.S. Census Regions and the described use of opioids for LBP treatment, it is interesting that opioid use also varies in different regions and states within the U.S. (Centers for Disease Control and Prevention, 2013; McDonald, Carlson, & Izrael, 2012). For example, in 2008, the top five states (Nevada, Delaware, Florida, Kentucky and Tennessee) for milligrams of opioids dispensed per resident, had a 155% to 210% increase above the mean (McDonald et al., 2012). There is a significant difference in the total mean milligrams of opioids dispensed per resident in the states included in the various U.S. Census Regions (p = .0014; Northeast = 3,829, Midwest = 5,229, West = 7,092, South = 11,724; Figure 1b) (McDonald et al., 2012).
Adherence with Recommended LBP Guidelines and Related Clinical Importance
Despite LBP treatment recommendations and cautions, there is research suggesting that the use of evidenced-based LBP treatments is variable. Ivanova and colleagues extracted data from a large private insurance database from 2004 to 2006 and found that 42% of persons with LBP filled a prescription for an opioid pain medication and12% filled a prescription for a benzodiazepine; yet only 23% received exercise therapy and 8% received cognitive behavioral therapy (Ivanova et al., 2011) suggesting that pharmacologic therapies are often over utlized and nonpharmacologic therapies under utlized. Because there is evidence from the nursing literature suggesting that 40% of patients with acute LBP have functional limitations at 3 months, it is critically important that we identify areas where LBP can be improved (Howard & Shapiro, 2013). This data is important for orthopaedic nurses to improve patients' health outcomes. Important first steps are confirming prior research suggesting that evidence-based therapies are not being practiced and then determining the barriers to receipt of these evidenced-based therapies (Ivanova et al., 2011).
Purpose
Because prior research suggests that there is wide variation in the use of evidenced-based LBP treatments, and that opioid medication use and the prevalence of LBP differs between U.S. Census Regions, we aimed to provide further depth to the understanding about utilization of LBP treatment recommendations in the various U.S. geographic regions by describing and comparing the therapies used and their related costs (Centers for Disease Control and Prevention, 2013; Ivanova et al., 2011; McDonald et al., 2012).
Materials and Methods
Our research team licensed deidentified patient health claims information from a large commercially insured population for the period January 1, 2007 to December 31, 2009. The dataset is a nationally representative sample of 15 million patients annually across the U.S. Data are collected at the patient level and linked across administrative and health data including: administrative data (i.e., gender, age), pharmacy claims data (i.e., national drug code, pricing), physician and facility claims (i.e., procedure codes, diagnosis codes, pricing), and lab results (i.e., logical observation identifiers names and codes, lab test name).
Data from persons with the diagnosis of LBP or related terms (ICD-9 code: 724.2 [lumbago], 724.5 [backache], 724.9 [disorder of pain NOS], 847.2 [lumbar region sprain/strain], 846. 0 [lumbosacral sprain/strain], 724.79 [symptom back NEC], 724 [disorder back other unspecified]) was extracted along with linked treatments including: physical therapy services, occupational therapy, self-care training, exercise therapy, traction, biofeedback, psychological therapies, surgical procedures, and medications (Tables 1-3: CPT codes extracted). Each person is represented one time in data analyses. Because it appeared that some medications were erroneously linked to the diagnosis of LBP, only those medications that are used for the treatment of LBP are reported. For example, statins, oral contraceptives, and anti-hypertensive medications were not included in this analysis. Although the ACP/APS clinical practice guidelines for the diagnosis and management of acute and chronic LBP (Chou et al., 2007) do not describe the use of anticonvulsants or hypnotics, these medications could plausibly be used for the indication of LBP and therefore, are included in our analysis.. The demographic data (i.e, age, income, education, race/ethnicity) for these individuals were also extracted. The University of Kentucky Institutional Review Board approved this study.
Table 1. CPT Codes for spinal surgical procedures.
| CPT Code | Description |
|---|---|
| 20930-31 | Allograft for spine surgery only, morselized; structural |
| 20936-38 | Autograft for spine surgery only, local; morselized; structural |
| 225-48;58;85 | Arthrodesis- anterior transoral or extraoral technique; anterior interbody technique, including minimal discectomy, lumbar; anterior approach, lumbar, each additional interspace |
| 226-12,14,30,32 | Arthrodesis- posterior or posterolateral technique, lumbar; posterior or posterolateral technique, each additional vertebral segment; posterior interbody technique, lumbar; posterior interbody technique, each additional interspace |
| 22830 | Exploration of spinal fusion |
| 22840 | Posterior non-segmental instrumentation |
| 22841 | Internal spinal fixation by wiring of spinous processes |
| 22842-44 | Posterior segmental instrumentation- 3-6 vertebral segments; 7-12 vertebral segments; 13+ vertebral segments |
| 22845-47 | Anterior instrumentation, 2-3 vertebral segments; 4-7 vertebral segments; 8+ vertebral segments |
| 22849 | Reinsertion of spinal fixation device |
| 22850 | Removal of posterior nonsegmental instrumentation |
| 22851 | Application of intervertebral biomechanical device |
| 22852;55 | Removal of posterior segmental instrumentation; anterior instrumentation |
| 63005;011 | Laminectomy with exploration and/or decompression, 1-2 vertebral segments, lumbar; sacral |
| 63012 | Laminectomy with removal of abnormal facets with decompression, lumbar |
| 63017 | Laminectomy with exploration and/or decompression, >2 vetebral segments, lumbar |
| 63030;35 | Laminotomy (hemilaminectomy) with decompression, 1 interspace, lumbar; each additional interspace, cervial or lumbar |
| 63042;44 | Laminotomy (hemilaminectomy) with decompression, reexploration, 1 interspace, lumbar; each additional lumbar interspace |
| 63047,48 | Laminectomy, facetectomy, and foraminotomy with decompression, 1 vertebral segment, lumbar; each additional vertebral segment |
| 63056,57 | Transpedicular approach with decompression, 1 segment, lumbar; each additional segment, lumbar |
| 63170 | Laminectomy with myelotomy, cervical, thoracic, or thoracolumbar |
| 63185,90 | Laminectomy with rhizotomy, 1-2 segments; more than 2 segments |
| 63200 | Laminectomy, with release of tethered spinal cord, lumbar |
| 63267,68 | Laminectomy with excision or evacuation of intraspinal lesion other than neoplasm, lumbar; sacral |
| 63272,73 | Laminectomy for excision of intraspinallasion other than neoplasm, lumbar; sacral |
| 22224,26 | Osteotomy of spine, including didcectomy, lumbar;, each additional segment |
| 62287 | Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc (e.g., percutaneous discectomy, percutaneous laser discectomy) |
| 69990 | Microsurgical techniques, requiring use of operating microscope |
Table 3. CPT codes of other low back pain treatment.
| CPT Code | Description |
|---|---|
| 97003 | Occupation therapy evaluation |
| 97004 | Occupational therapy re-evaluation |
| 97124 | Massage |
| 97535 | Self-care training |
| 97110 | Exercise therapy |
| 90801, 90802, 90816, 90818, 90821,90853, 96150, 96151, 96152, 96153, 97770 | Psychological therapies |
| 90901, 90875, 90876 | Biofeedback |
Statistical analyses
We used descriptive statistics to describe the sample and the frequency of the treatments received for LBP. We used ANOVA to compare the different U.S. Census Regions. A level of significance of .05 was used during analyses. SAS version 9.3 (SAS Institute, Inc., Cary, NC) was used during statistical analyses.
Results
Demographics
The predominance of our sample (N = 1,630,438 persons with LBP [or a related term] claim) resided in the Midwest and South U.S. Census Regions. Similarly, 73% of persons were Caucasian and 58% were female. There was an equitable distribution of levels of income and education within this sample (Table 4).
Table 4.
Demographic characteristics (N = 1,630,438).
| Variable | Sample n (%) | 2013 General U.S. Population |
|---|---|---|
| Gender | ||
| Male | 692,253 (42.5%) | 49.2% |
| Female | 938,105 (57.5%) | 50.8% |
|
| ||
| Race/Ethnicity | ||
| Caucasian | 1,183,171 (72.6%) | 77.7% |
| African American | 105,156 (6.5%) | 13.2% |
| Hispanic | 151,209 (9.3%) | 17.1% (62.6% White alone, not Hispanic or Latio) |
| Other | 190,902 (11.7%) | 8.9% |
|
| ||
| Education | ||
| Less than 12th Grade | 31,224 (1.9%) | |
| High School Diploma | 601,395 (36.9%) | 88% (2012) |
| Some college | 606,102 (37.2%) | |
| Associate Degree | 112,380 (6.9%) | |
| Bachelor Degree | 221,964 (13.6%) | |
| Master/Professional/Doctoral Degree | 2,383 (0.14%) | |
| Uncoded | 35,366(2.2%) | |
|
| ||
| Income | Median household income 2009-2013: $53,046 | |
| < $30,000 | 99,479(6.1%) | 29.7% |
| $30,000-$49,999 | 350,377 (21.5%) | 18.9% |
| $50,000-$74,999 | 412,641 (25.3%) | 20.3% ($50,000-$79,999) |
| $75,000-$99,999 | 263,268 (16.2%) | 8.9% ($80,000-$99,999) |
| $100,000-$149,999 | 213,303(13.1%) | 12.4% ($100,000-$149,999) |
| $150,000-$250,000 | 38,581 (2.4%) | 9.4% (>$150,000) |
| Uncoded | 233,165(14.3%) | |
(National Information Center for Higher Education Policymaking and Analysis, 2013; U.S. Census Bureau, 2013)
Treatments Used
A prescription for an opioid or analgesic medication (specifically- tramadol) was filled by nearly half of the sample (analgesic: n = 166,958 [10.2%]; opioid: n = 812,479 [49%]) and 24% (n = 394,212) of this sample filled a prescription for a muscle relaxant. Similarly, 39% (n = 642,243) filled a prescriptions for a NSAID. The use of other medications to treat LBP (i.e., hypnotics, steroids, sedatives, and anticonvulsants) is described in Figure 2.
Figure 2. Frquency of drug use per class.
We evaluated the median standardized cost of medications used to treat LBP per drug class along with the interquartile range (IQR [25th-75th percentile]; Figure 3). Although the fewest number of persons obtained a prescription for anti-convulsants (n = 49,073), the standardized cost was the highest ($452; IQR = $185.15-1,536). In contrast, opioids were the most frequently used (n = 812,479) with the lowest standardized cost ($16; IQR = $7.72-42.66) (Figure 3).
Figure 3. Median cost per medication class.
Nonpharmacologic therapies such as exercise therapy and cognitive behavioral therapy were rarely used by persons in this sample (psychological therapies: n = 128,507 [8%]; exercise therapies n = 308,677 [19%]). Only 12% of persons in this sample received a physical therapy evaluation (Figure 4).
Figure 4. Frequency of use of non-pharmacologic treatments for LBP.
The median costs and associated interquartile ranges for non-pharmacologic treatments are variable with surgical procedures being exponentially more costly ($5,526; IQR = $1,312-15,670 - surgical procedures vs. $40; IQR $23-100 - hot and cold packs; Figure 5).
Figure 5. Median cost per non-pharmacologic treatment.
Differences between the U.S. Census Regions
There was a significant difference in the medications and therapies used in the four U.S. Census Regions. Interestingly, self-care training is a first-line treatment recommendation; yet, only 1.4% to 2.2% of persons received this treatment. Persons residing in the Northeast and Midwest were more likely to receive psychological therapies. Similarly, persons residing in the Midwest (18.2%), Northeast (24.3%), and West (25.5%) were more likely to receive exercise therapy than those in the South (16%) (Figure 5).Persons in the South were more likely to fill a prescription for opioids (South 53.2%, Midwest 48.6%, West 47%, Northeast 41.8%) and benzodiazepines (South 16.5%, Northeast 14.5%, West 13.7%, Midwest 12.7%) (Figure 1c -1e).
Discussion
Findings from this study support prior research reporting the frequency in which many LBP treatments are utilized (Ivanova et al., 2011). Prior research found that 42% of persons with LBP filled a prescription for an opioid pain medication and in our study we found that 49% filled a prescription for an opioid. Because the South U.S. Census Region has an increased prevalence of LBP and increased opioid use, the slight differences found between these studies may be due to the over-representation of the South in our sample (Centers for Disease Control and Prevention, 2013; McDonald et al., 2012). Approximately 15% of our sample filled a prescription for a benzodiazepine compared with prior studies reporting that 12% of their sample filled a prescription for this drug class; thus, a negligible difference (Ivanova et al., 2011). In our study only 19% of persons received exercise therapy compared with prior studies reporting 23% of their sample received this therapy. Prior research reports that same percentage of persons received psychological therapies for LBP (8%) suggesting that the use of this resource is persistently poor (Ivanova et al., 2011). Considering the prevalence of LBP and availability of cognitive therapies, it is possible this is a problem with access to care.
Opioids were the most commonly prescribed medication class for LBP in this study (n = 812,479), and they were the least costly (median cost per person = $16.23); in contrast, only 49,073 persons filled a prescription for an anticonvulsant and the cost was $451.93 (Figure 3). The range of the cost of medications per class was also variable. Similar variability was found in the non-pharmacologic treatments for LBP. Although only 2,685 persons received surgery for LBP the median cost per person was $5,526 and the interquartile range was $1,312 to $15,670. Approximately 308,677 persons received exercise therapy and the cost was $350 per person with a range of $120 to $880 (Figure 5). Although direct costs of treatment have been reported, we could not identify studies that have conducted similar analyses for comparison.
Prior research has suggested that LBP is more prevalent and opioid use is increased in the South U.S. Census Region (Centers for Disease Control and Prevention, 2013; McDonald et al., 2012). Findings from this study support that opioid use for the diagnosis of LBP is significantly increased the South region; yet many non-pharmacologic therapies such as psychological therapies are used less frequently. Future studies should aim to determine if non-pharmacologic treatments for LBP are not ordered by health care providers or if patients choose not to pursue therapies despite provider recommendations. Identifying and developing interventions aimed at decreasing barriers to patients receiving evidenced-based therapies for LBP should be addressed in future research. It seems plausible that providers do not recommend therapies because of lack of availability to their patient population or that provider orders are written but, because of lack of access or costs, patients do not receive the therapies. By clarifying barriers to evidenced-based LBP treatment such as these, problem-directed interventions can be developed.
Data from this study was obtained from a high-quality, large private insurance database; yet it is a retrospective study and therefore, we were limited by the data available. With this being said, it is possible that persons with the diagnosis of LBP were later found to have a more specific etiology for their LBP (i.e., spinal stenosis). There could also be inaccuracies in the linkages between diagnosis and treatment codes (i.e., medications were erroneously linked to LBP diagnosis). The possibility exists that persons represented in a private insurance dataset systematically receive different treatments than persons who use governmental health insurance or pay for healthcare out-of-pocket. It is also possible that additional treatments that did not incur an insurance cost were received by persons in our sample. For example, persons in the sample may have received educational counseling by their provider and this service was not billed with a CPT code. The medications cost may be a representation of those medications preferred by insurance plans. An additional limitation of this study is that each U.S. Census Region was not equally represented.
Clinical Nursing Implications
Our study findings suggest that many evidenced-based treatments for LBP are not received by patients and that significant differences exist in the receipt of therapies in geographic regions in the U.S. These findings identify an area for improvement in the care provided to patients with LBP and because an estimated 40% of acute LBP patients experience long-term disability, it is imperative that barriers to patient receipt of evidenced-based care are identified and interventions developed (Howard & Shapiro, 2013). Nurses play a critical role in facilitating access to treatments for persons with variable resources; thus, study findings are important first steps towards improvement in the patient care provided by nurses caring for patients with LBP.
Conclusion
From this study along with prior research, we can conclude that the utilization of treatments for LBP is widely variable (Ivanova et al., 2011). Opioid medications are used by nearly half of this large sample while only 19% of the sample received exercise therapy. We also found that there are significant differences in the receipt of various LBP treatments per U.S. Census Region. These findings along with future research can provide clarity the geographic barriers that exist to patients receiving evidence-based LBP treatments.
Table 2. CPT codes for physical therapy services.
| CPT Code | Description |
|---|---|
| 97001 | physical therapy evaluation |
| 97002 | physical therapy re-evaluation |
| 97140 | manual therapy |
| 97530 | therapeutic activities |
| 97112 | neuromuscular re-education |
| 97113 | aquatic therapy |
| 97116 | gait training |
| 97010 | hot/cold packs |
| 97035 | iontophoresis |
| 97012 | traction |
Acknowledgments
The project described was supported by the National Center for Advancing Translational Sciences, UL1TR000117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Footnotes
Financial Interests and Conflict of Interest: Authors do not have any financial interests or conflicts of interest to report.
References
- Centers for Disease Control and Prevention. Severe headache or migraine, low back pain, and neck pain among adults aged 18 and over, by selected characteristics: United States, selected years 1997-2012. CDC website: CDC; 2013. [Google Scholar]
- Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr, Shekelle P, Owens DK. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491. doi: 10.7326/0003-4819-147-7-200710020-00006. Practice Guideline Research Support, Non-U.S. Gov't. [DOI] [PubMed] [Google Scholar]
- Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008;8(1):8–20. doi: 10.1016/j.spinee.2007.10.005. Review. [DOI] [PubMed] [Google Scholar]
- Fourney DR, Andersson G, Arnold PM, Dettori J, Cahana A, Fehlings MG, et al. Chapman JR. Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach. Spine (Phila Pa 1976) 2011;36(21 Suppl):S1–9. doi: 10.1097/BRS.0b013e31822f0a0d. Introductory Research Support, Non-U.S. Gov't. [DOI] [PubMed] [Google Scholar]
- Howard PK, Shapiro SE. What is known about outcomes of patients with low back pain? Advanced Emergency Nursing Journal. 2013;35(1):3–7. doi: 10.1097/TME.0b013e31827c6d05. [DOI] [PubMed] [Google Scholar]
- Ivanova JI, Birnbaum HG, Schiller M, Kantor E, Johnstone BM, Swindle RW. Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care. Spine J. 2011;11(7):622–632. doi: 10.1016/j.spinee.2011.03.017. Research Support, Non-U.S. Gov't. [DOI] [PubMed] [Google Scholar]
- Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976) 2004;29(1):79–86. doi: 10.1097/01.BRS.0000105527.13866.0F. [DOI] [PubMed] [Google Scholar]
- McDonald DC, Carlson K, Izrael D. Geographic variation in opioid prescribing in the U.S. J Pain. 2012;13(10):988–996. doi: 10.1016/j.jpain.2012.07.007. Research Support, N.I.H., Extramural. [DOI] [PMC free article] [PubMed] [Google Scholar]
- National Information Center for Higher Education Policymaking and Analysis. ACS Educational Attainment by Degree-Level and Age-Group (American Community Survey) 2012 Retrieved February 3, 2015 from http://www.higheredinfo.org/dbrowser/index.php?submeasure=232&year=2012&level=nation&mode=graph&state=0.
- United States Census Bureau. State and County Quickfacts. 2013 Retrieved February 3, 2015 from http://quickfacts.census.gov/qfd/states/00000.html.
- U.S. Census Bureau. 2012 Annual Social and Economic Supplement to the Current Population Survey. 2013 Retrieved February 3, 2015 from https://www.census.gov/hhes/www/poverty/publications/pubs-cps.html.