Cost-effectiveness of a Multidisciplinary Back Pain Care System in a Managed Care Setting

June 30, 2015

Background Context

There has been an exponential increase in costs for spine care. Prior work has shown that isolated lumbar strengthening and integrated team approach can significantly reduce pain and reduce physical and psychological dysfunction. We studied a comprehensive treatment protocol that was intermediate between secondary and tertiary care and compared the cost effectiveness to standard treatment for back and neck pain.

Purpose

We compared the cost-effectiveness of two-types of treatments to treat chronic neck and low back pain and radiculopathy in a managed care setting.

Study Design

Two-year retrospective case-control study comparing total cost of spine care between two different protocols of care.

Patient Sample

SpineZone patients and non-SpineZone patients were selected from a managed-care group in San Diego County. The control patients were matched with the ICD-9 codes. The average age of the non-SpineZone patients (NSZ) were 59.1 years (+/- 17.8 years) with 63% female and 37% male. The average age of the SpineZone (SZ) patients were 54.9 years (+/- 14.8 years) with 62% female and 38% male.

Outcome Measures

Claims data was provided for both groups of patients and included procedures-related to diagnoses relevant to the study. Cost analysis was then performed by examining the category associated costs. Pain levels were measured before and after the program in the SpineZone group on the Visual Analog Scale.

Measurements

Claims data were provided for SpineZone patients and a group of control subjects over a two-year period. Both groups suffered from greater than 6 weeks of pain that was not controlled by standard treatment by the primary care physician. The SpineZone group underwent up to three months of measurement driven, targeted strengthening, postural measurement and treatment, behavioral management, and spine-specific education (including mobility and flexibility exercises). Patients were seen for initial and monthly visits with either orthopedic spine surgeon or physician assistant. The control group underwent “standard care” which consisted of physical therapy, chiropractic, pain management injections, and or spine specialist evaluation as per the discretion of the primary care physician. Comparison of the groups was performed using two-sample T-tests.

Results

A 31% reduction of total cost per patient was noted in the SpineZone population as compared to the Non-SpineZone population with significant savings in inpatient (which includes surgery) and emergency room costs. There were higher costs in physical therapy and primary care evaluation and management in the SpineZone population. There was a savings of $953 per patient over the two-year study period. Pain levels decreased 46% from 5.4 to 2.9 in the SZ group.

Conclusion

A treatment protocol incorporating targeted strengthening within a multidisciplinary system with routine evaluation and follow-up by orthopedic spine surgeon or physician assistant can significantly decrease the overall cost of spinal care in a managed care population.

Keywords
Medical expenditure; spine expenditures; back pain; neck pain; utilization; health services; outcomes.

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Excerpt from a clinical study currently in peer review.

TITLE: Healthcare utilization and cost of care for a multidisciplinary integrated practice unit model of spine rehabilitation compared to standard or no physical therapy

Authors: Bahar Shahidi PT, DPT, PhD 1 , Connor Richards MASt 2 , Lara Havandjian BS 1,2 , Lissa Taitano PT, DPT 2 , Caitlin Gibson MAT, ATC 2 , Seyed Reza Haghayeh Zavareh 1 , Kamshad Raiszadeh MD 2

Affiliations: (1) UC San Diego Department of Orthopaedic Surgery, La Jolla CA USA (2) SpineZone Medical Fitness, San Diego CA USA

Disclosures and statements: This study was funded in part by the Foundation for Physical Therapy Research Magistro Family Foundation Grant, and NIH R01HD100446 awarded to BS.
KR discloses that he is the Chief Medical Officer of SpineZone Medical Fitness. Due to the de- identified nature of the data utilized in this study, it was determined to be exempt from IRB approval.

Corresponding Author:
Bahar Shahidi PT, DPT, PhD
9500 Gilman Dr. MC0863
La Jolla CA 92093
Bshahidi@health.ucsd.edu

TITLE: Healthcare utilization and cost of care for a multidisciplinary integrated practice unit model of spine rehabilitation compared to standard or no physical therapy

Disclosures and statements: This study was funded in part by the Foundation for Physical Therapy Research Magistro Family Foundation Grant and NIH R01HD100446. One author discloses a role as Chief Medical Officer of a medical fitness clinic. Due to the de-identified nature of the data utilized in this study, it was determined to be exempt from IRB approval.

ABSTRACT:

Objective: To compare healthcare utilization and cost in individuals with spine pain who undergo no physical therapy, standard physical therapy, or physical therapy in an integrated practice unit model.

Design: A retrospective observational study

Methods: De-identified claims data from a single insurance provider was reviewed for individuals under Medicare Advantage with a spine-pain related diagnosis from January 2019- December 2021. Patients were categorized into three cohorts: No physical therapy (NoPT), standard physical therapy (SPT), and physical therapy within an integrated practice unit model (IPUPT) based on their physical therapy history during the data collection period. Number and
percentage of patients reporting claims, number of claims/patient per year, paid amount, and number of RVUs were compared across groups using chi-square or one-way ANOVA with multiple comparisons corrections.

Results: Data from 13,569 patients was included in this study. The number of patients with spine-related inpatient claims was highest in the SPT group (2.8%) compared to the IPUPT (1.5%) and NoPT (1.3%) groups (p=0.004). Outpatient care utilization was driven by radiology
(54.7%) and laboratory (22.1%) claims and was lowest in the IPUPT group (N=1,096; 56.8%) compared to the SPT group (N=1,654; 68.3%) and NoPT group (N=9,150; 99.3%, p<0.001). The SPT group was most costly per person ($2,243.66(11,048.94)) followed by the NoPT ($1,352.01(6,419.2), p<0.001) and the IPUPT ($1,259.88(9,061.23), p<0.001) groups. The greatest contributor to cost was outpatient procedures, averaging $142.39(1,046.26) per person.

Conclusion: An integrated multidisciplinary rehabilitation model may be a cost-effective method of multimodal care in individuals with spine pain.

Key Words: cost effectiveness, spine pain, low back pain, neck pain, physical therapy, economic evaluation

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METHODS: Individuals undergoing a 6-9 week of supervised exercise-based rehabilitation were offered enrollment in a 4-week video-based daily mindfulness meditation program. Low back- and neck-related disability assessed with the Oswestry Disability Index (ODI) and Neck Disability Index (NDI) were compared across no (0), low (1-9), medium (10-19), and high (20-28) video engagement, using Analysis of Covariance. A receiver operating characteristic (ROC) curve was generated to identify a threshold for video engagement resulting in clinically significant reductions in disability (>10 points).

RESULTS: A total of 342 individuals participated, with 23.3% (80) not engaging, 44.4% (152) with low engagement, 21% (72) with medium engagement, and 11.1% (38) with high engagement in mindfulness videos. Mean (SD) age was higher in the high engagement group compared to the no-engagement group (58 (15) vs 50 (18) years, p = 0.031), as was duration of pain (118 (143) vs 63 (99) months, p = 0.044). Body mass index (BMI) was greater in the low engagement group compared to the medium engagement group (27.9 (6) vs 25.6 (5) kg/m², p = 0.035). There was a greater reduction in ODI in participants with high versus low engagement (11(15) vs 4(10) pts, p = 0.012) in the adjusted model, while no significant group differences were observed for NDI (p = 0.728). A threshold of 10 videos was identified to predict a clinically important reduction in ODI, with a sensitivity of 46% and a specificity of 72%; AUC = 0.59 (95%CI = .512-.665), p < 0.05).

CONCLUSION: Greater engagement in mindfulness videos is associated with larger reductions in low back-, but not neck-related disability in individuals undergoing exercise-based physical therapy for spine pain. A minimum of 10 videos is recommended to achieve clinically important improvement.

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SpineZone is a wholly owned subsidiary of Livara Health, operating 9 musculoskeletal clinics in Southern California.

Background: The recent onset of the COVID-19 pandemic has highlighted the need to reduce barriers to access physical therapy and associated care through the use of web-based programs and telehealth for those seeking treatment for low back pain (LBP). Despite this need, few studies have compared the effectiveness of clinic-based versus web-based or telehealth services.

Objective: This study aims to compare the clinical outcomes of clinic-based multidisciplinary therapy in an integrated practice unit (C-IPU) model with online integrated multidisciplinary therapy (O-IPU) in individuals undergoing conservative care for LBP.

Methods: A total of 1090 participants were prospectively recruited to participate in a clinical trial registry (NCT04081896) through the SpineZone rehabilitation IPU program. All participants provided informed consent. Participants were allocated to the C-IPU (N=988) or O-IPU (N=102) groups based on their personal preferences. The C-IPU program consisted of a high-intensity machine-based core muscle resistance training program, whereas the O-IPU program consisted of therapist-directed home core strengthening exercises through a web-based platform. Changes in LBP symptom severity (Numeric Pain Rating Scale), disability (Oswestry Disability Index), goal achievement (Patient-Specific Functional Scale), and frequency of opioid use were compared between the C-IPU and O-IPU groups using multivariate linear regression modeling adjusted for age, gender, treatment number, program duration, and baseline pain and disability.

Results: Approximately 93.03% (1014/1090) of the participants completed their recommended programs, with no group differences in dropout rates (P=.78). The C-IPU group showed greater pain relief (P<.001) and reductions in disability (P=.002) than the O-IPU group, whereas the O-IPU group reported greater improvements in goal achievement (P<.001). Both programs resulted in reduced opioid use frequency, with 19.0% (188/988) and 21.5% (22/102) of participants reporting cessation of opioid use for C-IPU and O-IPU programs, respectively, leaving only 5.59% (61/1090) of participants reporting opioid use at the end of their treatment.

Conclusions: Both in-clinic and web-based multidisciplinary programs are beneficial in reducing pain, disability, and opioid use and in improving goal achievement. The differences between these self-selected groups shed light on patient characteristics, which require further investigation and could help clinicians optimize these programs.

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