Currently Viewing:
The American Journal of Managed Care October 2018
Putting the Pieces Together: EHR Communication and Diabetes Patient Outcomes
Marlon P. Mundt, PhD, and Larissa I. Zakletskaia, MA
Primary Care Physician Resource Use Changes Associated With Feedback Reports
Eva Chang, PhD, MPH; Diana S.M. Buist, PhD, MPH; Matt Handley, MD; Eric Johnson, MS; Sharon Fuller, BA; Roy Pardee, JD, MA; Gabrielle Gundersen, MPH; and Robert J. Reid, MD, PhD
From the Editorial Board: Bruce W. Sherman, MD
Bruce W. Sherman, MD
Recent Study on Site of Care Has Severe Limitations
Lucio N. Gordan, MD, and Debra Patt, MD
The Authors Respond and Stand Behind Their Findings
Yamini Kalidindi, MHA; Jeah Jung, PhD; and Roger Feldman, PhD
The Characteristics of Physician Practices Joining the Early ACOs: Looking Back to Look Forward
Stephen M. Shortell, PhD, MPH, MBA; Patricia P. Ramsay, MPH; Laurence C. Baker, PhD; Michael F. Pesko, PhD; and Lawrence P. Casalino, MD, PhD
Nudging Physicians and Patients With Autopend Clinical Decision Support to Improve Diabetes Management
Laura Panattoni, PhD; Albert Chan, MD, MS; Yan Yang, PhD; Cliff Olson, MBA; and Ming Tai-Seale, PhD, MPH
Medicare Underpayment for Diabetes Prevention Program: Implications for DPP Suppliers
Amanda S. Parsons, MD; Varna Raman, MBA; Bronwyn Starr, MPH; Mark Zezza, PhD; and Colin D. Rehm, PhD
Clinical Outcomes and Healthcare Use Associated With Optimal ESRD Starts
Peter W. Crooks, MD; Christopher O. Thomas, MD; Amy Compton-Phillips, MD; Wendy Leith, MS, MPH; Alvina Sundang, MBA; Yi Yvonne Zhou, PhD; and Linda Radler, MBA
Currently Reading
Medicare Savings From Conservative Management of Low Back Pain
Alan M. Garber, MD, PhD; Tej D. Azad, BA; Anjali Dixit, MD; Monica Farid, BS; Edward Sung, BS, BSE; Daniel Vail, BA; and Jay Bhattacharya, MD, PhD
An Early Warning Tool for Predicting at Admission the Discharge Disposition of a Hospitalized Patient
Nicholas Ballester, PhD; Pratik J. Parikh, PhD; Michael Donlin, MSN, ACNP-BC, FHM; Elizabeth K. May, MS; and Steven R. Simon, MD, MPH
Gatekeeping and Patterns of Outpatient Care Post Healthcare Reform
Michael L. Barnett, MD, MS; Zirui Song, MD, PhD; Asaf Bitton, MD, MPH; Sherri Rose, PhD; and Bruce E. Landon, MD, MBA, MSc

Medicare Savings From Conservative Management of Low Back Pain

Alan M. Garber, MD, PhD; Tej D. Azad, BA; Anjali Dixit, MD; Monica Farid, BS; Edward Sung, BS, BSE; Daniel Vail, BA; and Jay Bhattacharya, MD, PhD
This instrumental variables analysis estimates that Medicare would realize $362 million in annual savings if all patients with newly diagnosed low back pain were managed conservatively.
ABSTRACT

Objectives: Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP.

Study Design: We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis.

Methods: We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management.

Results: Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more.

Conclusions: Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.

Am J Manag Care. 2018;24(10):e332-e337
Takeaway Points

Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis.
  • Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more.
  • Medicare would save $362 million annually if all patients with newly diagnosed idiopathic LBP were managed in accordance with clinical guidelines.
Low back pain (LBP) is the most common type of pain reported by adults and represents the fifth most common reason for physician visits in the United States.1,2 One-fourth of adults in the United States report experiencing back pain lasting at least 1 day in the past 3 months,1 and more than 80% of adults will experience LBP at some point in their lives.3 The condition is costly: A 2008 study estimated that spine problems led to $85.9 billion in medical expenditures in 2005.4

Although serious medical conditions, including neurological compromise, infectious and inflammatory processes, and malignancy, can cause LBP, most episodes of back pain are considered mechanical in nature and do not require specific therapy. Observational studies and randomized controlled trials have demonstrated that routine lumbar spine imaging (plain radiographic film followed by magnetic resonance imaging [MRI] or computed tomography [CT]) does not improve clinical decisions5,6 or patient outcomes.7,8 Further, such routine imaging leads to increased costs, unnecessary patient exposure to radiation and subsequent invasive treatments, and emotional turmoil.9-12 Given the robust evidence against routine imaging for LBP, medical specialty societies13-15 and governmental organizations16,17 recommend against lumbar spine imaging for LBP within the first 6 weeks of diagnosis, unless patients present with “red flags” for underlying conditions such as malignancy, infection, or spinal fracture.13

Thus, the standard of care is to defer imaging, relying instead on a focused history and physical exam in initial evaluation of patients with no red flags.17 Despite these clinical recommendations, however, diagnostic imaging has been employed in a steadily increasing proportion of initial evaluations of back pain among both privately insured patients18 and Medicare beneficiaries since the 1990s.19-21 An estimated 20% to 50% of patients undergo imaging studies for LBP within the first 6 weeks of diagnosis, often on the date of their initial physician visit. Further, a significant proportion of patients with LBP do not receive a physical exam when they first present to a physician.22

Although a conservative approach to LBP has been shown to be cost-effective, it has not been adopted widely in clinical settings. According to the findings of one study, if guidelines for diagnosing LBP were fully implemented in practice, whether via cultural shifts in physician approaches to care or implementation of new incentive structures, annual cost savings in the United States could reach $300 million.11 However, that estimate is based on older prevalence and cost estimates collected through meta-analysis, rather than primary claims data; further, it did not account for regional and provider-specific variations in patterns of care, with resulting variability in costs.19

We sought to estimate the cost implications to Medicare of full adoption of an initial conservative approach to LBP. To do so, we first estimated 1-year costs and the clinical sequelae associated with initial diagnostic strategy options. Because treatment assignment is not random, we used instrumental variable (IV) methods to account for confounding by indication. In this approach, a doctor’s risk-adjusted propensity to use imaging technologies for patients without back pain is treated as a quasi-randomizing variable. Finally, we estimated potential Medicare savings from switching those who receive initial imaging to conservative management.

METHODS

We conducted an observational study evaluating clinical and cost outcomes at 1 year for Medicare patients with acute uncomplicated LBP who received either conservative management or imaging (MRI or CT) within 6 weeks of their initial diagnosis.

Data Sources and Description

We analyzed a 5% sample of Medicare administrative claims data from 2006 to 2010 to perform this analysis. These data included patient claims, associated diagnosis and procedure codes, socio­demographic information (eg, age, race, zip code of residence, and Medicaid eligibility status), and clinical characteristics (eg, diagnosis of LBP and the presence of comorbid medical conditions). Data were restricted to those of patients enrolled in fee-for-service Medicare and included data from Medicare Part A (inpatient) and Part B (outpatient).


 
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up