2. Association between initial site of care and subsequent treatment patterns for back and neck pain

Abstract

<h3>BACKGROUND CONTEXT</h3> Nonspecific neck and back pain are highly variable conditions with hundreds of treatment options. Using standard analytical techniques, it is difficult to understand how patients seek and receive health care across service locations. <h3>PURPOSE</h3> To build and display a comprehensive understanding of common utilization patterns for nonspecific neck and back pain. Also, to understand how observable patient characteristics (including insurance type, age and comorbidities) and initial sites of care (patient self-triage decisions to one of 9 initial sites of care including primary care, chiropractor and the emergency room) are associated with subsequent treatment and utilization patterns. <h3>STUDY DESIGN/SETTING</h3> This retrospective, observational study leveraged a US multipayer medical and pharmaceutical administrative claims dataset. Although not nationally representative, the data are comprised of commercial and Medicaid insured patients from 47 states and the District of Columbia. Each patient was eligible for at least 24 months in the database, enabling researchers to study utilization patterns over time and across service locations. <h3>PATIENT SAMPLE</h3> We identified a sample of 113,654 episodes for patients aged 18-64 who received care for nonspecific neck or back pain. Patients had a neck and back pain "clean" period of at least 12 months prior to initial presentation and were observed 6 months after the index claim. Subjects were excluded if their medical history and pain causes indicated potential deviation from conservative diagnostic and treatment practices. <h3>OUTCOME MEASURES</h3> The patient's initial site of care, the patient's subsequent diagnostic and treatment pattern (one of 14 clusters representing the 6 months after the index neck or back pain event), and common utilization metrics (eg, procedures, emergency care, and opioid prescription rates) within 6 months of the initial encounter. <h3>METHODS</h3> We applied a sequence alignment and density-based clustering methodology to identify treatment pathways based on the types and ordering of each patient's neck and back pain-related events for 6 months after the index claim. Using a series of multinomial models, we examined how observable patient characteristics were associated with the initial site of care and how the initial site of care was associated with the patient's subsequent treatment pathway. Prediction accuracy was evaluated using an 80% training, 20% testing division of the sample. We calculated health care utilization during the first 6 months after the index event. <h3>RESULTS</h3> The clustering methodology discovered 14 distinct patterns of how patients are diagnosed and treated for nonspecific neck and back pain in the first 6 months after the index encounter. The patterns ranged significantly in terms of utilization rates of advanced diagnostic imaging, opioid prescribing, and use of conservative therapy. The algorithm also identified 3.1% of episodes in which patients underwent uncommon treatment plans that included invasive procedures, multiple advanced images, and emergency or inpatient admissions. While some patient characteristics (including insurance type and geography) were associated with the patient's initial site of care, patient characteristics alone could not accurately predict this self-triage decision for an individual patient (47.9% vs 45.2% naïve prediction). In contrast, the initial site of care is highly predictive of the subsequent treatment pathway (42.3% prediction accuracy using initial site of care alone vs 30.3% naïve prediction). <h3>CONCLUSIONS</h3> The patient journey clustering methodology created a granular, data-driven understanding into how patients are diagnosed and treated after an index neck or back pain claim. The analyses suggest that the patient's self-triage decision to an initial site of care is difficult to predict using observable patient characteristics. However, once this initial site of care is chosen, the patient's subsequent treatment pattern and utilization within the first 6 months becomes more predictable. Follow-up studies on more generalizable samples are needed to use the data to proactively route patients toward high-quality, appropriate treatment plans. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.