Neck pain service utilization and costs: association with timing of non-pharmaceutical services for individuals initially contacting a primary care provider. A retrospective cohort study

Abstract

Background: Neck pain (NP) is prevalent and costly. NP clinical practice guidelines are similar to those for low back pain (LBP), emphasizing non-pharmaceutical and non-interventional first-line approaches. Primary care providers (PCP) are frequently consulted by individuals with NP. Objective: Examine the association between guideline concordant incorporation of non-pharmaceutical therapies, use of imaging, pharmaceutical, and interventional services, and total episode cost for individuals with NP initially contacting a PCP. Design: Retrospective cohort study using identical methods to a previous LBP study Setting/Patients: National sample of individuals with non-surgical NP occurring in 2017-2019. Measurements: Independent variables were initial contact with a PCP, and the timing of incorporation of 5 types of non-pharmaceutical therapies. Dependent measures included use of 13 types of health care services and total episode cost. Results: 70,252 PCPs were initially contacted by 124,780 individuals with 137,274 episodes of non-surgical NP. 30.9% of PCPs and 22.1% of episodes included at least one of five non-pharmaceutical services at any time during an episode. Active care (13.7% of episodes), manual therapy (10.8%), and chiropractic manipulative therapy (9.4%) were the most common non-pharmaceutical services. 7.4% of episodes included a non-pharmaceutical service during the first 7 days with these episodes associated with a modest reduction (risk ratio 0.28 to 0.78) in the use of prescription pharmaceuticals. Younger individuals from ZIP codes with higher adjusted gross income were more likely to receive a non-pharmaceutical service in the first 7 days of an episode. When included during an episode, non-pharmaceutical services were associated with an increase in total episode cost with the smallest increase associated with chiropractic and osteopathic manipulation. Limitations: As a retrospective observational analysis of associations there are numerous potential confounders and limitations. Conclusions: Non-pharmaceutical services are infrequently provided to individuals with non-surgical NP initially contacting a PCP. For these individuals, non-pharmaceutical services, if provided, are most commonly introduced later in an episode after receiving pharmaceutical, imaging, and interventional services. For individuals with NP initially contacting a PCP there is an opportunity to increase the guideline concordant incorporation of non-pharmaceutical services early in an episode.