Risk of Treatment Escalation in Recipients vs Nonrecipients of
Spinal Manipulation for Musculoskeletal Cervical Spine Disorders:
An Analysis of Insurance ClaimsThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther 2021 (Jun); 44 (5): 372–377
Brian R Anderson • W Steve McClellan • Cynthia R Long
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
Davenport, Iowa.
Objective: The purpose of this study was to evaluate the relationship between treatment escalation and spinal manipulation in a retrospective cohort of people diagnosed with musculoskeletal disorders of the cervical spine.
Methods: We used retrospective analysis of insurance claims data (2012-2018) from a single Fortune 500 company. After isolating the first episode of care, we categorized 58 147 claims into 7951 unique patient episodes. Treatment escalation included claims where imaging, injection, emergency room, or surgery was present. Modified Poisson regression was used to determine the relative risk of treatment escalation comparing recipients vs nonrecipients of spinal manipulation, adjusted for age, sex, episode duration, and risk scores.
Results: The sample was 55% women, with a mean age of 44 years (range, 18-103). Treatment escalation was present in 42% of episodes overall: 2448 (46%) associated with other care and 876 (26%) associated with spinal manipulation. The estimated risk of any treatment escalation was 2.38 times higher in those who received other care than in those who received spinal manipulation (95% confidence interval, 2.22-2.55, P = .001).
Conclusion: Among episodes of care associated with neck pain diagnoses, those associated with other care had twice the risk of any treatment escalation compared with those associated with spinal manipulation. In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic; therefore, these findings are relevant and should be considered in addressing solutions for neck pain. Additional research investigating the factors influencing treatment escalation is necessary to moderate the use of high-cost and guideline-incongruent procedures in people with neck pain.
Keywords: Chiropractic; Insurance; Manipulation, Spinal; Neck Pain; Patients; Risk.
From the FULL TEXT Article:
INTRODUCTION
Neck pain has been among the top 10 leading causes of global disability every decade since 1990, [1] and combined with low back pain, it is the leading cause of health care expenditures in the United States, at $135 billion. [2] The global age-standardized point prevalence of neck pain is approximately 3.5%. [3] Clinical practice guidelines for the management of neck pain recommend education, self-management, exercise, manipulation and mobilization, and nonopioid analgesics; the majority of these guidelines do not differentiate based on the duration of neck pain. [4] Despite recommendations against the routine use of imaging, opioid medications, injection procedures, and surgery, the use of these procedures has increased exponentially since 2000. [5-8] The use of high-cost and guideline-incongruent procedures significantly contributes to the costs associated with treatment of spinal pain disorders. [9]
Treatment escalation is defined as increasing the complexity of care in the management of a disease, as well as any care necessary beyond the “usual” treatment a person uses to manage their condition. [10] Treatment escalation is known to occur with a variety of conditions, including asthma, [11] eczema, [12] cancer, [13] end-of-life care,14 and use of medications such as antibiotics. [15] However, the concept has only briefly been described in the literature on musculoskeletal disorders. [16]
Individuals with neck pain commonly seek care from primary care physicians, but they also routinely visit chiropractors, physical therapists, and medical specialists. [17] A 2018 Gallup poll [18] indicated that 32% of US adults had seen a health care professional for neck or low back pain in the past 12 months, and that 53% of that population visited a doctor of chiropractic. The provider’s scope of practice and training play an important role in the care delivered. Doctors of chiropractic do not prescribe medication or perform invasive treatment such as injections or surgery. Instead, they typically provide manual therapies, therapeutic exercise, lifestyle advice, and other conservative therapies. [19] In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic. [20]
The primary aim of this project was to evaluate the relationship between treatment escalation and type of care in episodes associated with diagnosed musculoskeletal disorders of the cervical spine by analyzing health insurance claims from a large Fortune 500 company. We hypothesized that episodes in nonrecipients of spinal manipulation (other care) would have a higher risk of treatment escalation than those in recipients of spinal manipulation.
DISCUSSION
In our study, those not receiving spinal manipulation (ie, receiving other care) had a statistically significant increased risk of treatment escalation compared to recipients of spinal manipulation. Several studies in the physical-therapy literature explore health care utilization among provider types but do not characterize it as treatment escalation. [16, 25-27] Specific to neck pain and chiropractic care, Horn et al [27] found that people with neck pain initiating care with primary care vs chiropractic physicians had higher odds of using advanced imaging, injections, and opioid medications. Although they did not investigate the use of chiropractic services per se, Nelson et al [28] evaluated the effects of insurance plans with and without chiropractic coverage on use of advanced imaging, surgery, inpatient care, and plain-film radiographs in the management of neck and low back pain. The group with chiropractic benefits had a statistically significant decrease in use of surgery (23%), advanced imaging (23%), inpatient costs (28%), and plainfilm radiography (8%).
It has been well documented in the literature that people seeking chiropractic compared to medical care have higher educational attainment, fewer comorbid conditions, more moderate disability, and better overall self-rated physical and mental health. [29-33] However, participants in our study had similar retrospective and prospective risk scores across both treatment groups. Individuals seeking chiropractic care also have a high degree of confidence in the ability of chiropractors to improve their symptoms, compared to other treatment approaches. [9] Confidence in a provider may decrease the likelihood of seeking more escalated treatment.
The scope of available therapies varies among providers managing neck pain. Potential barriers to treatment escalation exist within chiropractic — and not in medical care — due to limitations in scope of practice, as already described. Additionally, medical providers are affiliated with health organizations which allow for easy access to escalation procedures; this is typically not the case for providers using spinal manipulation. Therefore, interpreting study results is complex, and further research is necessary to determine the specific characteristics associated with treatment escalation.
Limitations
Our data set did not include pharmaceutical claims and used a proprietary risk score index, both of which could be considered limitations. Our data set comprised privately insured members of a single Fortune 500 company, which may not be generalizable to the population at large. Although we adjusted for comorbidity via retrospective and prospective risk scores, variables such as education, level of disability, and self-reported measures of health were not available. As only the primary diagnosis was available, it is important to consider that secondary conditions could have influenced the likelihood of treatment escalation. Provider identification codes would have helped identify provider type more accurately; however, these were not available in our data set. While we cannot definitively determine the provider type administering spinal manipulation, there is a very high likelihood that these providers were chiropractors, since the majority of spinal manipulation is performed by chiropractors. [20]
There are inherent disadvantages to using existing data to answer new research questions, including unknown accuracy of billing codes, lack of outcome data, risk of unmeasured variables that may confound results, potentially flawed strategies for including or excluding specific cases, and altered use of specific services based on their coverage by the insurance plan. [34]
Treatment escalation is necessary and appropriate with some conditions, such as trauma, cervical artery dysfunction, and cancer, which require rapid escalation due to their life-threatening nature. Although these conditions are relatively rare, [35-38] it is likely that these patients will not seek spinal manipulation
CONCLUSIONS
Among episodes of care for a cohort of individuals diagnosed with neck pain, nonrecipients of spinal manipulation had more than twice the risk of any treatment escalation compared to recipients of spinal manipulation. In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic; therefore, these findings are relevant and should be considered in addressing solutions for neck pain. Additional research investigating the factors influencing treatment escalation is necessary to guide decreasing the use of high-cost and guideline-incongruent procedures in people with neck pain.
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