1. SUBSEQUENT HEALTHCARE UTILIZATION ASSOCIATED WITH EARLY PHYSICAL THERAPY FOR NEW EPISODES OF LOW BACK PAIN IN OLDER ADULTS Deven Karvelas, MD University of Michigan 10/04/2015, AAPM&R Annual Assembly

2. Disclosures – None Funding Source – Agency for Healthcare Research and Quality $10 million ARRA CHOICE award - 1R01HS019222-01 Back Pain Outcomes Using Longitudinal Data (BOLD) PI: Jerry Jarvik, MD, MPH Details: www.backpainproject.org This is a prospective cohort study (Level 1 Evidence) DISCLOSURES AND FUNDING

3. Sean Rundell Janna Friedly Alfred Gellhorn Laura Gold Bryan Comstock Patrick Heagerty Brian Bresnahan David Nerenz Jeffrey Jarvik ACKNOWLEDGEMENTS

4. Lifetime incidence between 60% and 85% Accounts for a substantial portion of our annual healthcare expenditures Physical therapy is a commonly-prescribed treatment Optimal timing of physical therapy is not clear Two prior studies (Gellhorn et al and Fritz et al) found early PT was associated with a decrease or no change in subsequent healthcare utilization LOW BACK PAIN BACKGROUND

5. To estimate the association between initiating early physical therapy following a new visit for an episode of low back pain and subsequent back-pain-specific health care utilization in older adults after adjusting for disease severity, symptom duration and sociodemographic factors. STUDY OBJECTIVE

6. Design: Prospective cohort study in 3 major integrated healthcare systems (BOLD registry) Patient sample: 4,723 adults, aged 65 and older, presenting to a primary care setting with a new episode of low back pain Intervention: Patients who had early PT (within 28 days of index visit) Comparator: Patients who didn’t have early PT Sub-analysis: Patients with a self-reported symptom duration of less than one month DESIGN

7. Primary outcome: Total back-pain-specific relative value units (RVUs), from days 29-365 Secondary outcomes: Overall RVUs for all healthcare use and use of specific health care services including: Imaging (x-ray and MRI or CT) Emergency Department visits Physician visits Physical therapy Spinal injections Spinal surgeries Opioid use OUTCOMES

8. Adjustment performed with generalized linear models All models adjusted for age, sex, race, ethnicity, education, marital status, smoking status, duration of back pain, back- related disability, back pain NRS, leg pain NRS, expectations for recovery, anxiety symptoms, depression symptoms, EQ-5D, study site, and total RVUs for the 365 days prior to the index visit. ANALYSIS

9. RESULTS

10. Unadjusted RVUs for days 29-365 Early PT (n=628) No Early PT (n=4095) MeanSDMedian Interquartile RangeMeanSDMedian Interquartile Range Ratio of means95% CIp-value Total RVUs 64.7 141. 3 25.812.653.050.8125.320.68.446.41.281.061.540.01 Total Spine RVUs 17.093.2005.99.572.0000.51.791.102.910.02 Total Physical Therapy RVUs 3.75.61.80.05.31.33.60002.862.473.31<0.001 Total Injections RVUs 1.04.70000.63.80001.791.202.680.01 Total Spine Image RVUs 2.97.0001.11.85.40001.641.332.03<0.001 Total Surgical RVUs 10.181.10005.159.00001.990.974.110.06 RESULTS

11. Adjusted RVUs for days 29-365 Early PTNo Early PT MeanSDMeanSD Ratio of means 95% CIp-value Total RVU 56.15.052.32.11.070.88 1.3 1 0.49 Total Spine RVU 12.22.610.21.21.190.72 1.9 6 0.49 Total Physical Therapy RVU 3.40.21.30.12.562.17 3.0 3 <0.001 Total Injections RVU 0.80.10.60.11.330.89 2.0 0 0.17 Total Spine Image RVU 2.50.31.80.11.371.09 1.7 1 0.01 Total Surgical RVU 5.91.95.71.01.030.50 2.1 2 0.94 RESULTS

12. Acute low back pain sub-analysis: 246 participants with early PT and 1348 without Performed for primary outcome only No statistically significant difference noted Ratio of means 2.01, 95% CI 0.98 to 4.15, P 0.06. Exploratory analysis: Total spine RVUs from day 1-365 Performed to include PT RVUs from first month Similar results to primary analysis Ratio of means 1.13, 95% CI 0.76 to 1.70, P 0.54 RESULTS

13. Early PT was not associated with any meaningful change in subsequent healthcare utilization This was true even when the RVUs for the initial PT were included Early PT specifically for acute LBP also is not associated with any change in subsequent back-pain-specific healthcare utilization DISCUSSION

14. Rundell, et al.: Functional outcomes after early PT in BOLD Modest improvement in the primary outcome (RMDQ) in patients who had early PT (mean RMDQ 1.4 points less) Early PT may lead to modestly improved outcomes without an increase in overall healthcare utilization DISCUSSION

15. In older adults presenting for a new episode of LBP, early PT is not associated with any difference in subsequent back- pain-specific healthcare utilization compared to patients not receiving early PT, even for patients with acute LBP. CONCLUSION