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Associations of the timing of physical therapy utilization and subsequent health care costs and utilization in care pathway

for patients with low back pain

Julie M. Fritz, PT, PhDProfessor, Department of Physical Therapy

University of Utah

Why Low Back Pain?

• About 26% of adults in U.S. experience LBP at least 1 day in past 3 months.

• 2nd most common reason for physician visits

– Estimated 44.4 million physician visits for back pain in 2006 (US Bone Jt Decade)

• Estimated $193 billion total direct medical costs in 2004

– Increase of 49% since 1996

Source: Deyo et al. Overtreating low back pain Am Board Fam Phys. 2009

Chronic LBP Prevalence in North Carolina Residents

From Freburger et al, Archives Int Med, 2009

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• Clinicians often apply acute care model to chronic LBP and expect a “cure”.

• Motivates more imaging, operations, injections and opioids for LBP

– unlikely to improve outcomes

• A “chronic care model” would acknowledge LBP as a chronic condition to be managed.

– Focus on prevention (secondary vs. primary)

– Emphasis on self-management strategies

Improvement in Health Outcomes

Should be the preeminent goal in health care because it is what ultimately matters to its customers (patients) and unites the interests of all system actors. Porter & Teisburg, Harvard Business Review, 2006

Money SpentValue =

Created by a full cycle of care, not any single provider or intervention

Based on delivering the right care to the right patient at the right time

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ProcessEntry Point

Value is created by a full cycle of care, not any single provider or intervention.

Womack & Jones

Patient with LBP decides to seek care

Process

Process ProcessHealth Outcome

Cycle Complete

• Many decisions are preference sensitive –

– Multiple management strategies exist

– Often no clearly “correct” decision for an individual patient

– Chronic condition for which self-management should be the focus on initial care strategies

Why is Value Difficult to Achieve for Back Pain?

Poor decision-making in areas of preference-sensitive care

Enthusiasm for unproven methods ...

Over-use, mis-use, under-use based on provider preferences...

Quality = spare no expense ...

More care is always better…

• Examined Medicare enrollees (2003-2004) receiving treatment for LBP with no treatment in prior year. (n=431,195)

• Treatment received within 1-year of physician visit

– Physical Therapy: 16.1%

– Lumbosacral Injections: 11.9%

– Lumbar Surgery: 3.1%

• Timing of Physical Therapy Utilization:

– 52.0% within 4 weeks (acute)

– 18.1% 4 weeks - 3 months (subacute)

– 29.9% >90 days (chronic)

“Early PT use was strongly associated with decreased use of lumbosacral injections, physician office visits for LBP and lumbar surgery, when compared with PT that occurred at later times.”

SETTING Data extracted from Mercer HealthOnline® a database of members of employee-sponsored health plans.

PATIENTS32,070 patients with a new primary care consultation for LBP from November 1, 2007 - January 31, 2009.

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STUDY SAMPLE

• Age 18-60 at the index visit date

• No claims related to LBP for 6 months preceding index date.

• Continuously eligible in database 6 months prior and 18 months after the index visit date.

• Excluded patients with likely non-musculoskeletal cause for LBP based on ICD-9 codes. (e.g. kidney stones, UTI, caudaequina syndrome, osteomyelitis, cancer, prior spinal surgery)

PHYSICAL THERAPY UTILIZATION

Evaluated in the 90-period after the index visit:

– Recorded if a physical therapy visit occurred.

– Categorized the timing of physical therapy based on days from index visit to first PT visit:

EARLY (0-14 days)

DELAYED (15-90 days)

31,474

Age <18 or >60

76,967Continuously-eligible patients with

primary care visit for LBP

10,266

Prior care in past 6 months

2,077

Non-musculoskeletal cause

222

Prior spine surgery

32,070

2,234 (7.0%)Utilized PT within 90 days

1,102 (53.1%)EARLY PT

975 (46.9%)DELAYED PT

Likelihood of Utilization for Delayed vs. Early Physical Therapy

Odds Ratio (95% confidence interval)

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

Advanced Imaging

Lumbar Surgery

Spinal Injection

Narcotic Use

Physician Visits

Implications of Timing and Quality of Physical Therapy on Low Back Pain Utilization and

Costs in the Military Health SystemJohn D. Childs, PT, PhD, MBA

Samuel S. Wu, PhD

Eric Robertson, PT, DPT

Forest S. Kim PhD, MHA, MBA

Robert S. Wainner, PT, PhD

Timothy W. Flynn, PT, PhD

Steven Z. George, PT, PhD

Julie M. Fritz, PT, PhD

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Methods

• Extract LBP ICD-9 codes from: Jan 1, 2007 - Dec 31, 2009

• Extract full history of these cases from Jan 1, 2006 - Dec 31, 2011

– Determine previous medical history for 1-year preceding the index visit

– Conduct 2-year follow-up from index visit

• Newly consulting LBP defined as no claims with a LBP-related ICD-9 code for 6 months preceding the index date

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24-month utilization outcomes

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24-month cost outcomes PURPOSE

• Evaluate the utilization and timing of physical therapy in the care of newly consulting patients with LBP enrolled with University Health Plan.

– Enrollees in either Medicaid or Commercial insurance plan

• Examine relationships between physical therapy timing and subsequent LBP-related costs and utilization

METHODS

• Retrospective review of claims data

• Newly consulting patients with LBP-related ICD 9 code.– 90-day wash out period

– 180-day follow-up window

– Excluded patients with fracture diagnosis or systemic disease

• Health care costs associated with LBP computed during follow-up window

• Utilization of specific services (MRI, injections, surgeon visits, surgery) were recorded.

RESULTSMEDICAID (n=817) COMMERCIAL (n=607)

Mean age = 43.7 years Mean age = 40.1%

70% female 62% female

PT utilizers = 16.2% PT utilizers = 21.9%

Predictors of Early PT: Initial Provider: PMR 38%, PCP 12%, ED 8%

Predictors of Early PT: Initial Provider: PMR 41%, PCP 16%

Early PT associated with ↓ risk of: MRI, surgeon visit, injection

Early PT associated with ↓ risk of: surgeon visit, injection, surgery

Cost difference: $441 (95% CI: $182, $700) Cost difference: $2,015 (95% CI: $1039, $2990)

63.2%EARLY PT

36.8%DELAYED PT

67.9%EARLY PT

32.1%DELAYED PT

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Summary

Similar to other settings, early use of physical therapy was associated with decreased future health care utilization and costs.

Overall utilization of PT was higher, and the percentage of early PT utilizers was greater for Health Plan enrollees.

Physical therapy utilization predicted by initial provider type.

Thank you