Study: Costs reduced when low back pain treatment begins with
Physical therapy:
A study in the Scientific Journal Health Services
Research showed that initial referrals for physical therapy for patients
with new episodes of low back pain (LBP) resulted in less than half the cost of
imaging and generated lower costs associated with use of health care resources
over time.
Physical therapist researchers Julie M. Fritz, PT, PhD,
FAPTA, Gerard P. Brennan, PT, PhD, and Stephen J. Hunter, PT, PhD, OCS,
analyzed utilization records and other health information for patients who
consulted with a primary care provider about uncomplicated LBP and were
referred for management outside primary care within 6 weeks. They found that physical
therapy was the less costly approach—initial referral for physical therapy
cost $504 on average (for an average 3.8 visits), compared with an average of
$1,306 for magnetic resonance imaging (MRI). Also, average subsequent
costs over the next year were nearly 72% lower for patients who began with a
physical therapy referral—$1,871, compared with $6,664 for the imaging group
over the same time period.
Authors discovered that patients who receive imaging as a
first referral increased the likelihood of surgery and injections as well as
specialist and emergency department visits within a year. They noted that
advanced imaging often 'labels' a patient's LBP that might otherwise be viewed
as nonspecific and uncomplicated, causing heightened concern in some patients
and providers, motivating them to seek additional care. Authors said that
physical therapy may provide patients with an active approach to LBP, enhancing
patients' perceived ability to self-manage their condition. Authors acknowledge
that their study was limited to newly reported and uncomplicated LBP, and that
patient-centered function or satisfaction outcomes were not recorded.
"This is one of many studies demonstrating that
physical therapy is a cost-effective alternative to medication and
surgery," said American Physical Therapy Association President Paul Rockar
Jr, PT, DPT, MS. "Patients benefit from an active approach to their care and,
in turn, society is transformed through the benefits from reduced financial
burdens on our health care system."
Oh, my aching wallet: MRI instead of Physical Therapy for low
back pain leads to $4,793 higher price
Your back hurts (join the club) and you go to see your
primary care physician. Most of the time, your doctor will tell you to rest, maybe
take some ibuprofen or ice the affected area.
But when researchers looked at 841 people who needed
additional care, they found that the
ones sent first for MRIs were more likely to have surgery or injections, see a
specialist or visit an emergency room than those who were first sent to
physical therapists. And they (or their insurance companies) paid an average of
$4,793 more.
The reasons, said the study's lead author, are more likely
found in the heads of patients and doctors than in anyone's back. MRIs tend to
turn up all kinds of benign changes in spines and backs that occur as we move
through life. But those prompt patients to look for fixes and to pressure
doctors to refer them for those.
"The patient may feel and exert some pressure to
wanting to work it up more," said Julie Fritz, a professor of physical
therapy at the University of Utah. "It just changes the mind set of
everyone involved. It tends to accelerate the course of intervention."
Take degenerative disc disease, for example. Most people older than 40 or 50
have it to some degree, Fritz said, but often not to the extent that it causes
pain or other symptoms. But when an MRI turns up that ominous-sounding bit of
news, patients often ask for therapy and primary care doctors can succumb, she
said.
"It motivates patients to want to do more to look for
fixes for that problem, when it probably should be [considered] more like
wrinkles and gray hair," she said.
Another possibility is that some physicians have financial
interests in imaging services, the study notes.
Low back pain is incredibly common and debilitating. According
to one study, it causes more time disabled around the world than HIV, road
injuries, tuberculosis, lung cancer, chronic obstructive pulmonary disease and
pre-term birth complications. In the United States, Fritz's team noted in its
paper, the direct cost of treating low back pain was $86 billion in 2005.
An MRI exam can cost $1,000 or $1,500 and while many are
covered by insurance, patients often have to put up co-payments and meet
deductibles. Several studies have shown no evidence of benefits to low back
patients unless there are specific symptoms, according to Fritz's paper, which
was published March 16 in the journal Health Services Research. [Fritz is a
professor of physical therapy herself, but the paper is a peer-reviewed study,
not her opinion.]
Fritz and her colleagues set out to compare what happens to
patients sent first for MRIs versus those sent directly to physical therapists.
"Patients have expectations around receiving something perceived as
beneficial," they wrote. "Breaking an expectation by denying imaging
may be unacceptable to patients or providers. Consumer research suggests
offering an alternative to replace the broken expectation is important to patients."
In addition to seeking less invasive follow-up care, the
people who went directly to physical therapists spent an average of $1,871,
while those whose first move was an MRI spent an average of $6,664 in the year
following their initial complaint to their doctors. With only a few hundred
people in each sample, Fritz acknowledged, the cost figure was somewhat skewed
by a small number of very expensive surgeries among those who had MRIs first.
But overall, the cost difference is very clear.
Physical therapy focuses on educating patients about what
might be causing their back pain, assuring them that most problems subside in
time, and engaging them in their therapy, even if the therapist is providing
hands-on aid, Fritz said. Perhaps people who choose that option are more
motivated to be part of clearing up their problem, or they may just profit from
the approach; the research doesn't make that clear.
Either way, "we think this is an area where our
profession has something to offer, especially when it's timed correctly,"
Fritz said. "There's a place for advanced imaging. It's just not early in
the course of care for most patients."
References & Sources:
3. Health Services Research Journal
4. American Physical Therapy Association (APTA)
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