Patterns of health care utilization for low back pain

Figures & data

Table 1 Factor loading for LBP-related care among an incident LBP patient cohort* from Geisinger Clinic, 2012

Number of each type of care	Variable	Specialty without primary care	Surgical care	Laboratory dominant care	Opioid prescription	3+ inpatient encounters	One surgery
Only one	PCP encounter	−0.85
	Specialty encounter	0.85
	ED encounter						−0.81
	Inpatient encounter		−0.44	−0.72
	Surgery		0.65				0.52
	Non-MR image						0.41
	MR image
	Laboratory order			0.76
	Opioid order				0.93
	Injection for pain		0.88
Only two	PCP encounter	−0.95
	Specialty encounter	0.95
	ED encounter	0.54				−0.7
	Inpatient encounter	0.48	−0.41
	Surgery		0.77
	Non-MR image		0.42			0.57
	MR image
	Laboratory order			0.83		0.41
	Opioid order				0.97
	Injection for pain		0.89
Three or more	PCP encounter	−0.8
	Specialty encounter	0.95
	ED encounter			−0.41		−0.5
	Inpatient encounter	0.46	−0.42			0.66
	Surgery		0.82
	Non-MR image		0.56
	MR image					−0.43
	Laboratory order			0.79
	Opioid order				0.97
Eigenvalues		7.07	5.79	2.47	2.35	2	1.68

Note:

* Excluding patients who only had 1–2 LBP encounters without MR imaging, inpatient care, or surgery.

Abbreviations: ED, emergency department; MR, magnetic resonance; PCP, primary care physician; LBP, low back pain.

Table 2 Comparison of LBP-related care utilization by subgroup, Geisinger Clinic, 2012

Type of care	Utilization of care subgroup
	1–2 LBP visits n=22,645	Specialty and no PCP n=1,095	3+ opioid prescriptions n=1,656	Laboratory dominant care n= 1,238	One surgery n=788	2+ surgeries n=1,060	Other n=5,095	Total for each type of care (100%)
Ambulatory care visits (%)a	42.8	6.7	8.9	5.1	4.4	7.2	24.9	100%(n=27,42lb)
MR imaging (%)	0	10.8	17.5	9.4	10.4	17.1	35	100%(n=5,803b)
Laboratory (%)	45.9	5.7	7.5	26.1	7.4	7.4	0	100%(n=7,042b)
Opioids (%)	15	7.5	53.4	3	5.4	2.2	13.5	100%(n=20,879b)
Injectable (%)	7.3	1.1	3.1	2	13.7	65.1	7.8	100%(n=4,304b)
ED use (%)	0	10.6	25.8	5.7	6.1	15.2	36.7	100%(n=652b)
Inpatient without surgery (% total)	0	22.6	16.7	9.8	13	12	25.9	100% (n=1,127b)
Surgery (% total)					19.9	80.1	0	100%(n=396b)

Notes:

a Includes face to face visits with a primary care physician, specialist, and chiropractor but excludes medication orders only without a visit;

b refers to the number of encounters or orders for the specific type of care.

Abbreviations: ED, emergency department; LBP, low back pain; MR, magnetic resonance; PCP, primary care physician.

Table 3 Comparison of LBP-related care utilization concentration within each subgroup, Geisinger Clinic, 2012

Type of care	Number	Utilization of care subgroup
		1–2 LBP visits n=22,645 (67.4%)	Specialty and no PCP n=1,095 (3.3%)	3+ opioid prescriptions n=1,656 (4.9%)	Laboratory dominant care n=1,238 (3.7%)	One surgery n=788 (2.4%)	2+ surgeries n=1,060 (3.2%)	Other n=5,095 (15.2%)	Total n=33,577 (100%)
MR imaging	1	0	27.6	25.4	21.6	39.5	36.8	21.4	8.3
	2+	0	9.5	11.4	6.9	13.2	17.9	6.2	2.9
	Ratio*	–	2.9	2.2	3.1	3.0	2.1	3.5	2.9
Laboratory	1	12.2	19.1	14.4	63.5	26.2	16.4	0	13.1
	2+	1.0	7.6	6.8	36.5	16.4	12.8	0	3.4
	Ratio*	12.1	2.5	2.1	1.7	1.6	1.6	–	3.9
Injectable	1–2	1.4	3.1	5.3	4.2	57.2	41.8	4.2	4.7
	3+	0	0.3	0.5	0.6	2.4	49.7	0.4	1.7
	Ratio*	–	10.3	10.6	7.0	23.8	0.8	10.5	2.8
ED use	1	0	4.3	3.7	2.8	4.2	4.7	3.1	1.2
	2+	0	0.4	2.3	0.1	0.4	1.3	0.7	0.3
	Ratio*	–	10.8	1.6	28.0	10.5	3.6	4.4	4.0
Inpatient but not surgery	1	0	14.6	7.1	5.8	12.9	8.8	3.1	2.1
	2+	0	4.0	1.9	1.2	2.3	1.7	0.8	0.5
	Ratio*	–	3.7	3.7	4.8	5.6	5.2	3.9	4.2

Notes:

* Obtained by dividing the top row (1) by the second row (2+) in each care type category. Values in the table are presented as %, except for the rows already stated as being measured as a ratio.

Abbreviations: ED, emergency department; LBP, low back pain; MR, magnetic resonance; PCP, primary care physician.

Table 4 Demographic and health profile of the incident LBP patient cohort, Geisinger Clinic, 2012

Variable	Category/statistics	1–2 LBP visits n=22,645 (67.4%)	Specialty and no PCP n=1,095 (3.3%)	3+ opioid prescriptions n=1,656 (4.9%)	Laboratory dominant care n= 1,238 (3.7%)	One surgery n=788 (2.4%)	2+ surgeries n=1,060 (3.2%)	Other n=5,095 (15.2%)
Percent by female sex status Percent by age range (years)		62.9b	59.8	58.9	64.5a	53.6b	59.7	60.4
	<30	11.5a	8.3a	I3.Ia	8.2	6.0	6.2	8.7
	30–39	I5.Ia	I3.3a	I7.0a	12.9	13.5	10.7	12.9
	40–49	2I.2a	25.2a	22.2a	17.6	20.6	20.3	20.0
	50–59	2I.5a	2I.9a	I8.2a	22.6	22.6	23.2	21.8
	60+	30.7a	3I.2a	29.6a	38.6	37.4	39.6	36.6
Percent by smoking status	Current smoking	I8.8a	21.0	34.2a	20.0	23.6	20.2	20.9
	Quit	21.1a	21.4	2I.6a	24.6	23.6	23.6	23.7
	Never	38.4a	30.8	25.1a	33.4	29.8	30.9	33.9
	Missing	2I.7a	26.9	I9.Ia	22.0	23.0	25.3	21.6
Percent with BMI of 30+ (kg/m^2)	Yes	45.6	46.8	53.0	50.4	48.0	50.4	50.9
	Missing	3.3	1.8	1.6	1.3	1.0	0.9	1.9
Percent with a specific chronic progressive diagnosis	Type 2 diabetes	I6.6b	16.9	24.0b	20.6	19.3	20.0	22.0
	Hypertension	42.9b	40.6a	52.4	52.0	53.4	48.9	53.6
	Stroke-hemorrhage	0.3	0.6	0.4	0.7	0.5	0.4	0.5
	CAD	6.6a	8.7	9.9	8.6	10.3	10.3	10.2
	Heart failure	3.3	3.7	6.6	5.8	5.5	4.0	5.4
Percent with chronic episodic diagnosis	Migraine	24.4	22.9b	30.4	31.0	27.8	24.3	28.1
	Arthritis	32.5a	38.1a	42.2	46.0	45.9	44.1	42.3
	IBS	5.9	4.8	6.6	7.4	5.6	4.2	7.6
	GERD	32.9	27.1a	38.5	43.1	35.3	34.3	39.5b
	Asthma	14.3	I0.4b	I9.9b	18.1	12.6	14.6	16.3
	Allergic rhinitis	23.9b	16.9	25.8a	33.0a	21.2	19.2	28.6a
Percent by diagnosed depression severity	None	68.8a	67.5	47.7a	58.6	62.8	62.2	59.1
	Mild-moderate	20.6a	21.8	28.9a	24.8	23.0	25.2	25.1
	Severe	I0.6a	10.7	23.4a	16.6	14.2	12.6	15.8
Percent with anxiety disorder diagnosis		10.1	9.3	I9.4a	13.8	11.4	7.9	13.1
Percent with sleep disorder diagnosis		I8.9b	20.9b	33.0^Citation1	27.5	27.0	21.9	26.8
Percent with fibromyalgia diagnosis		I5.Ia	25.3	22.3	24.6^Citation1	32.4a	39.6	21.Ib
Mean Charleston Comorbidity Index before first encounter		0.6	0.6	0.9	0.8	0.6	0.7	0.7

Notes:

a Pairwise comparison differences between corresponding group and all other groups (P<0.05);

b pairwise comparison differences between corresponding group with at least five other groups (P<0.05).

Abbreviations: BMI, body mass index; CAD, coronary artery disease; GERD, gastroesophageal reflux disease; IBS, irritable bowel syndrome; PCP, primary care physician; LBP, low back pain.

Table 5 Care utilization profile of the incident LBP patient cohort, Geisinger Clinic, 2012

Variable	Category/statistics	Utilization of care subgroup
		1–2 LBP visits n=22,645 (67.4%)	Specialty and no PCP n=1,095 (3.3%)	3+ opioid prescriptions n=1,656 (4.9%)	Laboratory dominant care n= 1,238 (3.7%)	One surgery n=788 (2.4%)	2+ surgeries n=1,060 (3.2%)	Other n=5,095 (15.2%)
First LBP encounter with PCP		77.4	24.9a	75.9	79.3b	63.6	52.3	77.8
Percent by total number of encounters in year before first LBP encounter, count	0–2	I4.4b	22.0b	16.7	I2.lb	17.9	17.2	I2.lb
	3–6	28.3b	26.6b	22.9	20.Ib	19.7	24.7	24.8b
	7–10	20.4b	I7.0b	16.8	20.3b	19.5	14.4	I9.2b
	11–15	I6.3b	13.Ib	14.6	I8.2b	15.4	19.5	I7.0b
	>I5	20.7b	21.3b	29.1	29.3b	27.5	24.2	26.9b
Total opioid prescriptions in the year before the first LBP encounter, count	Non-user	93.5a	91.0	79.2b	90.7	86.9	87.9	90.5
		2.2a	2.5	4.6b	2.5	4.8	3.6	2.8
	2–4	2.4a	3.4	7.4b	3.6	5.1	4.6	3.5
	5+	I.9a	3.2	8.8	3.2	3.2	3.9	3.2
LBP diagnosis groupc	I	74.3	49.8	63.4	73.5	52.3	44.2	60.5
	II	10.8	14.6	13.5	9.6	19.3	19.9	15.2
	III	12.1	31.1	19.6	14.6	24.0	29.1	21.4
	IV	0.8	2.5	0.6	0.7	1.1	1.9	0.9
	Other	2.0	2.1	2.9	1.5	3.3	5.0	2.0
PEI	Mean	1.2	1.9	1.4	1.4	3.1	4.7	1.4
	Median	0.8	0.9	0.9	0.9	1.6	1.8	0.9
	IQR	0.6–1.3	0.6–2.5	0.6–1.4	0.6–1.5	0.8–3.6	0.8–3.7	0.6–1.4

Notes:

a Pairwise comparison differences between corresponding groups and all other groups (P<0.05);

b pairwise comparison differences between corresponding group with at least five other groups (P<0.05);

c pairwise comparison differences between all groups (P<0.05).

Abbreviations: IQR, interquartile range; LBP, low back pain; PCP, primary care physician; PEI, physician efficiency index

Table S1 Low back pain categories and diagnostic codes

Category	ICD-9 diagnosis code	Diagnosis name
Group 1: back pain with no neurologic findings	724.2	Lumbago
	724.5	Backache, unspecified
	846.0–846.9	Sprains and strains of sacroiliac region
	847.2,3,9	Sprains and strains of back (lumbar, sacrum, unspecified)
Group 2 back pain with neurologic findings	721.42	Spondylogenic compression of lumbar spinal cord
	721.91	Spondylosis of unspecified site, with myelopathy
	722.73	Lumbar disc disorder with myelopathy
	722.80	Post-laminectomy syndrome of unspecified region
	724.3	Sciatica
	724.4	Thoracic or lumbosacral neuritis or radiculitis, unspecified
Group 3a: congenital lumbar spine structural disorders	737.1	Kyphosis (acquired)
	737.20	Lordosis (acquired) (postural)
	737.3	Kyphoscoliosis and scoliosis
	739.3	Nonallopathic lesions, lumbar region
	739.4	Nonallopathic lesions, sacral region
	756.13–756.19	Anomalies of spine
Group 3b: acquired lumbar spine structural disorders	721.5–721.90	Kissing spine; ankylosing vertebral hyperostosis; traumatic spondylopathy; other allied disorders of spine; spondylosis of unspecified site without mention of myelopathy
	722.10	Lumbar intervertebral disc without myelopathy
	722.2	Displacement of intervertebral disc, site unspecified, without myelopathy
	722.30	Schmorl’s nodes, unspecified region
	722.32	Lumbar schmorl’s nodes
	722.52	Degeneration of lumbar or lumbosacral intervertebral disc
	722.6	Degeneration of intervertebral disc, site unspecified
	722.90	Other and unspecified disc disorder of unspecified region
	722.93	Other and unspecified lumbar disc disorder
	724.00	Spinal stenosis, unspecified region
	724.02	Lumbar stenosis
	724.09	Other
	738.4	Acquired spondylolisthesis
	756.12	Congenital spondylolisthesis
Group 4: other	307.89	Pain disorders related to psychological factors, other
	722.83	Post-laminectomy syndrome, lumbar
	724.6	Disorders of sacrum, including lumbosacral joint instability
	724.8	Other symptoms referable to back
	724.9	Other unspecified back disorders
	756.10	Anomaly of spine, unspecified
	805.4	Closed fracture of lumbar vertebrae without mention of spinal cord injury
	805.6	Closed fracture of sacrum or coccyx without mention of spinal cord injury
	805.8	Fracture of vertebral column without mention of spinal cord injury
	996.4	Mechanical complication of internal orthopedic device, implant, and graft

Note: Vogt et al¹.

Abbreviation: ICD-9, International Classification of Diseases, Ninth Revision.

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