Low back pain: Two insights on treatment patterns from a patient journey analysis
Low back pain is a common problem for millions of Americans and a top contributor to US healthcare spending.1 The affliction costs the country more than $100 billion annually when medical spending, lost wages, and reduced productivity are considered, given that the majority of sufferers are in their prime working years.2 Low back pain thus has a significant impact on employers as well as patients.
A range of interventions of varying intensity can be used to treat low back pain, including self-care (e.g., yoga and stretching), physical therapy, over-the-counter and prescription drugs, spinal injections, and surgery. Pairing the right patient with the right treatment is critical; in theory, payers could assist providers with this process through the use of data-driven care management. However, it has been challenging from an analytics perspective to measure the appropriateness of a given low-back-pain treatment choice because that determination requires knowing when the pain started, what other treatments may have already been tried, and whether the current choice complies with evidence-based treatment guidelines.
The patient journey lens makes it possible to develop a finer-grained understanding of treatment patterns and patient experience. For each patient, the journey begins with the first claim that includes the back-pain diagnosis.3 Following the initial diagnosis, the approach tracks which treatments were given and in what sequence (e.g., were spinal injections administered before surgery was performed?), and whether that sequence complies with guidelines. The data for individual patients can then be aggregated to the population or provider level, which can reveal potential opportunities for improvement.
We derived two important insights from analyzing treatment patterns for low back pain among commercially insured patients:
1. Among patients in our sample who received surgery within one year of an initial diagnosis of low back pain (1.5% of all low-back-pain patients in our sample), about half (0.7% of all low-back-pain patients in our sample) underwent that surgery within three months of diagnosis (Exhibit 1).
In a few cases, rapid progression to surgery is appropriate. For example, pain with neurologic impairment is generally classified as a medical emergency, and guidelines suggest immediate surgery if noninvasive treatment “is not expected to become effective in time to save a patient from severely disabling neurologic deficits.”4 In the vast majority of patients, however, a more conservative approach is warranted. Outcomes and cost-effectiveness studies suggest that patients be given “conservative therapy with a wait-and-see attitude” and “switch[ed] to surgery if conservative therapy proves ineffective after 3–6 months.”5 These recommendations suggest that many low-back-pain patients who receive surgery within three months may be going under the knife either too late (because neurological impairment is present) or too soon (because it is not)—an issue both payers and providers should review.
2. Many patients undergo surgery without receiving first- or second-line therapies.6 For example, among patients who were operated on within six months of initial diagnosis, fewer than half had received spinal injections first.
Among all low-back-pain patients, only 1.5% underwent surgery within one year of initial diagnosis. Within this cohort, however, 26% were operated on within one month of diagnosis, 56% within three months, and 84% within six months (Exhibit 2). These results do not align with what we would expect given clinical guidelines. Indeed, they suggest that many patients could have avoided surgery had more conservative approaches been tried.
Clinical guidelines recommend that spinal injections be administered before surgery is performed unless the patient requires emergency surgery (based on the guidelines described above). Yet among the patients we studied, spinal injections had been given to only 26% of those operated on within three months, and less than 40% of those operated on within six months (Exhibit 2).
Taken together, our findings highlight that a data-driven patient journey approach can offer both payers and providers significant opportunities to improve patient care and, potentially, reduce unnecessary spending. Time-series analyses such as the ones described above can allow them to better understand how patients are treated over time and identify patterns of care that are discordant with clinical guidelines.
Payers can use the insights to develop utilization management approaches, risk-sharing arrangements, or other approaches that encourage providers to comply with generally accepted guidelines. For example, payers could create a care management program for low-back-pain patients that tracks whether appropriate conservative therapies are being tried and restricts authorization for surgery if the conservative therapies had not been used in accordance with guidelines.
Health systems that have entered risk-sharing arrangements can use the insights to evaluate their current low-back-pain treatment pathways and identify those providers whose treatment patterns may not align with guidelines. Systems can then educate physicians about how they can better adhere to current protocols and standards of care for low back pain.
Insights from patient journey analytics can also help patients understand their treatment options (including the possibilities offered by nonsurgical approaches) and guide them to providers who reliably follow evidence-based protocols.
- Dieleman JL et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316(24):2627-2646.
- Crow WT, Willis DR. Estimating cost of care for patients with acute low back pain: a retrospective review of patient records. Journal of the American Osteopathic Association. 2009;109(4):229-233.
- Note: All data used is anonymized to preserve patient privacy.
- Arce D, Sass P, Abul-Khoudoud H. Recognizing spinal cord emergencies. American Family Physician. 2001;64(4):631-640.
- Federico B, Jean D. An overview of conservative treatment for lower back pain. International Journal of Clinical Rheumatology. 2011;6(3):281-290.
- Last AR, Hulbert K. Chronic low back pain: evaluation and management. American Family Physician. 2009;79(12):1067-1074.