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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.
RESULTS

Using a 5% sample of all Medicare beneficiaries from 2006 to 2010, we identified 744,262 patients with any diagnosis of LBP in the outpatient setting, of whom 250,771 (34%) qualified for the final study sample. A cohort diagram of the construction of the analytic sample, including all exclusion criteria, is available in the Figure. Characteristics of the patients in the sample are presented by initial diagnostic strategy (conservative management, MRI, or CT) in Table 1. MRI was the most common form of early imaging, accounting for 21% of the study cohort. Only 3% of the cohort received CT, and 76% of patients received neither form of early imaging.

In general, patients undergoing MRI and patients receiving conservative management had similar characteristics in terms of age, race, socioeconomic status (as determined by Medicaid eligibility), history of recent hospitalization, recent medical costs, and observed comorbidities (Table 1). Thus, the observable characteristics of patients receiving MRI in our sample were similar to those of patients receiving conservative management, even before adjustment for relevant comorbidities and quasi-randomization with our IV. This implies that observed differences in medical costs for patients receiving MRI and patients receiving no imaging in our sample can reasonably be attributed to differences in the management of their LBP, rather than differences in the etiology of that LBP. However, patients in our study cohort who received CT imaging were slightly older at initial diagnosis and were more likely to be male, to be eligible for Medicaid, and to have had a hospitalization or received SNF or hospice care in the year prior to diagnosis. Patients undergoing CT also accrued higher medical costs in the year prior to their diagnosis and were more likely to have certain comorbidities, including diabetes, heart failure, and chronic obstructive pulmonary disease (Table 1). Patients receiving CT may have had contraindications to MRI that were associated with higher medical costs beyond those captured in our models.

Our motivation for using an IV, physician propensity to refer for imaging, as a quasi-randomization tool in this analysis was that the health of patients who receive early imaging may differ from that of patients who do not receive imaging. This difference may be reflected in their observed health characteristics (Table 1) and addressed in part by including patient characteristics in a multivariable regression. However, such an approach does not account for unobserved health characteristics, which we address here by implementing IVs.

Another indication of unobserved differences in health between our patient groups would be differences in survival after their LBP diagnosis. We used Cox proportional hazard models to estimate the survival of patients who received MRI, CT, or no early imaging after their initial LBP diagnosis. We found no differences in survival across these groups, both in an unadjusted analysis (eAppendix Figure 1A) and in a survival analysis that adjusted for patients’ pre-existing conditions and for geographic variation in service use (eAppendix Figure 1B).

Although early use of imaging in LBP does not appear to be associated with improved clinical outcomes, our IV analyses of patient costs indicate that patients who receive early imaging have substantially higher average medical costs in their first year after diagnosis. Cumulative estimated Medicare expenditures in the 1 year post diagnosis are reported for each diagnostic strategy in Table 2 (see eAppendix for full regression output). The conservative management strategy was associated with the lowest annual Medicare expenditures, whereas those receiving an MRI accrued $2512 more and those receiving CT accrued $19,899 more in total Medicare expenditures in the year following diagnosis.

Table 2 also shows potential Medicare health expenditure savings from increased use of conservative diagnostic strategies for patients diagnosed with LBP. Shifting patients who receive CT to no imaging would save $203 million annually ($19,899 saved per patient per annual diagnosed cohort), and shifting those who receive MRI to no imaging would save $159 million annually ($2512 saved per patient per annual diagnosed cohort).


 
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