Musculoskeletal Imaging for Low Back Pain in Direct Access Physical Therapy Compared to Primary Care: An Observational Study

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Abstract

Background

Overutilization of diagnostic imaging is associated with poor outcomes and increased costs. Physical therapists demonstrate the ability to order diagnostic imaging safely and appropriately, and early access to physical therapy reduces unnecessary imaging, lowers healthcare costs, and improves outcomes.

Hypothesis/Purpose

The primary purpose of this study was to compare rates of compliance with the National Committee for Quality Assurance – Healthcare Effectiveness Data and Information Set (HEDIS) recommendations for diagnostic imaging in low back pain between physical therapists and primary care providers in young, athletic patients.

Study Design

Retrospective cohort study.

Methods

Military Health System Data Repository (MDR) data from January 2019 to May 2020 was reviewed for compliance with the low back pain HEDIS recommendation. The low back pain imaging HEDIS measure identifies the percentage of patients who did not have an imaging study (plain X-ray, MRI, CT Scan) ordered on the first encounter with a diagnosis of low back pain or in the 28 days following that first diagnosis. Chi-square tests compared HEDIS compliance rates, with α = 0.05 set a priori.

Results

From January 2019 to May 2020, in patients age 18-24, the MDR database identified 1,845 total visits for LBP identified in the Physical Therapy Clinic and 467 total visits for LBP in the Primary Care Clinic. In the Physical Therapy Clinic, 96.7% of encounters did not have imaging ordered within the first 28 days of onset of symptoms, compared with 82.0% in the Primary Care Clinic (p < .001).

Conclusions

Utilizing data from a national standardized healthcare performance measure, physical therapists practicing in a direct-access setting were significantly more likely than primary care providers to adhere to guidelines for low back pain imaging in young, athletic patients.

Level of Evidence

Level 3.

Related collections

Most cited references 20

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The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.

Christopher Murray (2013)

Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.

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Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?

Bruce E. Lehnert, Robert L. Bree (2010)

The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines. The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes. Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only thirteen percent [corrected] of inappropriate studies had positive results and affected management. A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.

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Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.

Julie M Fritz, John Childs, Robert S Wainner … (2012)

A retrospective cohort. To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs. Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed. Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined. Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care. Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

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Author and article information

Journal

Journal ID (nlm-ta): Int J Sports Phys Ther

Journal ID (iso-abbrev): Int J Sports Phys Ther

Journal ID (publisher-id): 2159

Title: International Journal of Sports Physical Therapy

Publisher: NASMI

ISSN (Electronic): 2159-2896

Publication date (Electronic, pub): 2 February 2022

Publication date (Electronic, collection): 2022

Volume: 17

Issue: 2

Pages: 237-246

Affiliations

[1 ] eduBaylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship

Author notes

Corresponding author: Michael S Crowell, PT, DSc Baylor University – Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship 900 Washington Road, West Point, NY, 10966, USA michael_crowell@baylor.edu; (845) 938-3067

Author information

Michael S Crowell http://orcid.org/0000-0003-1025-0380

Article

Publisher ID: 31720

DOI: 10.26603/001c.31720

PMC ID: 8805092

PubMed ID: 35136693

SO-VID: 1b77018e-9f74-4e15-a491-a41cdea52706

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (4.0) which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Musculoskeletal Imaging for Low Back Pain in Direct Access Physical Therapy Compared to Primary Care: An Observational Study

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Abstract

Background

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Study Design

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Conclusions

Level of Evidence

Related collections

Electron Channelling Contrast Imaging (ECCI)

Most cited references 20

The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.

Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?

Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.

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