Article Figures & Data
Tables
- Table 1.
Primary Care Physician Orders for 9574 Patients with Acute Low Back Pain Within the First 21 Days of Initial Encounter
Total (n = 9547) PCP Orders No order 1,401 (15%) One order 2,780 (29%) Two orders 2,743 (29%) Three orders 1,702 (18%) Non-pharmacologic only 729 (8%) Pharmacologic only 3,124 (33%) Multiple pharmacologic 3,400 (36%) Concordant with Guidelines * Non-pharmacologic 3,390 (36%) Physical therapy 3,321 (34%) Physical therapy + NSAID 1,057 (11%) Physical therapy + Muscle relaxant 1,247 (13%) Partially Concordant with Guidelines* Non-pharmacologic + 2nd Line Pharm 1,267 (13%) Physical therapy + Steroid 790 (8%) Physical therapy + Opioid 502 (5%) Physical therapy + Radiograph 721 (8%) Non-concordant with Guidelines* Opioid 1,706 (18%) Opioid + Muscle relaxant 742 (8%) Opioid + NSAID 397 (4%) Steroid 2,356 (25%) Steroid + Muscle relaxant 1,181 (12%) Steroid + NSAID 473 (5%) MRI or Radiograph 2,238 (23%) Solely 2nd Line Pharmacologic, Imaging, or Specialty 1,306 (14%) Notes. All values are n (%) where n is the number of patients who received the order.
*Rows are not mutually exclusive (i.e., patients who received physical therapy + NSAID are also included in the physical therapy row) unless otherwise stated.
Abbreviations: NSAID, non-steroidal anti-inflammatory drugs; PCP, primary care physicians.
- Table 2.
Cluster Analysis of Primary Care Physician Orders Within the First 21 Days from Initial Visit in 4073 Patients with Acute Low Back Pain
Non-Pharm & 1st Line Pharm
N = 18102nd Line Pharm
N = 1470Imaging
N = 525Specialty
N = 268Non-Pharmacologic 962 (53) 494 (34) 209 (40) 42 (16) 1st Line Pharmacologic 1,430 (79) 889 (60) 0 116 (43) 2nd Line Pharmacologic 0 1,470 (100) 206 (39) 154 (57) Specialty 39 (2) 0 14 (3) 268 (100) Imaging 264 (15) 255 (17) 525 (100) 88 (33) Notes. All values are n (%) where n is the number of patients within the cluster who received that order.
- Table 3.
Common Combinations of Primary Care Physician Orders Within the First 21 Days from Initial Visit in 4073 Patients with Acute Low Back Pain
Order Combinations Non Pharm & 1st Line Pharm 2nd Line Pharm Imaging Specialty 1st Line Pharm Only 697 (39) 1st Line Pharm with Non-Pharm 453 (25) Non-Pharm Only 361 (20) 2nd Line Pharm with 1st Line Pharm 419 (29) 2nd Line Pharm Only 401 (27) 2nd Line Pharm with 1st Line Pharm and Non-Pharm 215 (15) 2nd Line Pharm with Non-Pharm 180 (12) 2nd Line Pharm with 1st Line Pharm and Imaging 156 (11) Imaging Only 198 (38) Imaging with 2nd Line Pharm 118 (22) Imaging with Non-Pharm 107 (20) Imaging with 2nd Line Pharm and Non-Pharm 88 (17) Specialty Only 55 (21) Specialty with 1st Line Pharm and 2nd Line Pharm 40 (15) Specialty with 2nd Line Pharm 35 (13) Specialty with 1st Line Pharm 28 (10) Notes. All values are n (%) where n is the number of patients within the cluster who received that type of order or order combination.
Orders or combinations of orders less frequent than 10% are excluded.
- Table 4.
Specific Primary Care Physician Orders Within the First 21 Days from Initial Visit in 4073 Patients with Acute Low Back Pain
Orders Clusters Non-Pharm & 1st Line Pharm 2nd Line Pharm Imaging Specialty Non-Pharmacologic Physical Therapy 934 (52) 464 (32) 200 (38) 42 (16) Other* 24 (1) 16 (1) 5 (1) 1 (0) 1st Line Pharmacologic Acetaminophen 55 (3) 11 (1) 0 4 (1) Muscle relaxant 940 (52) 747 (51) 0 75 (28) NSAID 933 (52) 360 (24) 0 69 (26) 2nd Line Pharmacologic Benzodiazepine 0 96 (7) 17 (3) 11 (4) Opioid 0 655 (45) 93 (18) 94 (35) Steroid 0 913 (62) 12 (2) 91 (34) Antidepressant 0 144 (10) 11 (2) 15 (6) Imaging MRI or CT Scan 22 (1) 55 (4) 98 (19) 43 (16) Radiography 248 (14) 210 (14) 434 (83) 51 (19) Specialty Neurology or PM&R 14 (1) 0 3 (1) 118 (44) Spine surgery 25 (1) 0 12 (2) 161 (60) Notes. All values are n (%) where n is the number of patients who received the order within that cluster.
↵*Includes chiropractic, behavioral health, coaching, mind-body therapies, pain management, social work.
Abbreviations: NSAID, non-steroidal anti-inflammatory drugs; MRI, magnetic resonance imaging; CT, computed tomography; PM&R, physical medicine and rehabilitation.
- Table 5.
Characteristics of 1401 Patients with Acute Low Back Pain Who Did Not Receive a Physician Order and 4073 Patients Clustered by Predominant Physician Orders Within 21 Days of Initial Visit
No Order
N = 1401Non-Pharm & 1st-Line Pharm
N = 18102nd-Line Pharm
N = 1470Imaging
N = 525Specialty
N = 268Total
N = 4073Age, mean (SD) 52 (18) 48 (17) 50 (16) 56 (18) 53 (16) 50 (17) Women 826 (59) 1063 (59) 818 (56) 323 (62) 137 (51) 2341 (57) Race White 1113 (80) 1250 (69) 1289 (88) 454 (86) 210 (79) 3203 (79) Black 190 (14) 389 (22) 113 (8) 45 (9) 37 (14) 584 (14) Missing/Other 96 (6) 171 (9) 68 (4) 26 (5) 19 (7) 284 (7) Ethnicity Hispanic 64 (5) 102 (6) 43 (3) 15 (3) 15 (6) 175 (4) Non-Hispanic 1291 (92) 1658 (92) 1397 (95) 499 (95) 242 (91) 3796 (93) Missing 44 (3) 50 (2) 30 (2) 11 (2) 9 (3) 157 (4) Location Baltimore, MD 243 (17) 395 (22) 161 (11) 62 (12) 56 (21) 675 (17) Boston, MA 165 (12) 332 (18) 50 (3) 12 (2) 35 (13) 429 (11) Pittsburgh, PA 713 (51) 736 (41) 852 (58) 370 (70) 124 (47) 2082 (51) Salt Lake City, UT 278 (20) 347 (19) 406 (28) 81 (15) 53 (20) 887 (22) Insurance Medicare 355 (25) 295 (16) 291 (20) 170 (32) 58 (22) 814 (20) Medicaid 122 (9) 188 (10) 132 (9) 37 (7) 24 (9) 381 (9) Private 698 (50) 885 (49) 784 (53) 228 (43) 123 (46) 2020 (50) Missing/Other 224 (16) 442 (25) 263 (18) 90 (18) 61 (23) 856 (21) Current Smoker No 915 (68) 1140 (63) 956 (65) 391 (74) 156 (59) 2643 (65) Yes 115 (8) 179 (10) 227 (15) 51 (10) 45 (17) 502 (12) Missing 333 (24) 491 (27) 287 (20) 83 (16) 65 (24) 926 (23) Body Mass Index mean (SD) 29 (6) 32 (9) 32 (8) 30 (8) 32 (8) 32 (8) STarT Back Low 834 (60) 686 (38) 359 (24) 188 (36) 59 (22) 1292 (32) Medium 382 (27) 683 (38) 687 (47) 196 (37) 105 (39) 1671 (41) High 183 (13) 441 (24) 424 (29) 141 (27) 102 (39) 1108 (27) Baseline ODI, mean (SD)± 23 (17) 31 (18) 40 (19) 31 (20) 40 (21) 35 (19) Axial back pain 1210 (86) 1472 (81) 999 (68) 356 (68) 156 (59) 2983 (73) Back and leg pain 189 (14) 338 (19) 471 (32) 169 (32) 110 (41) 1088 (27) Back pain >3 months 219 (16) 239 (13) 192 (13) 88 (17) 60 (23) 579 (14) Notes. *All values are n (%) of patients within that cluster unless otherwise noted.
±ODI: Oswestry Disability Index; 0–100 with lower scores indicating less disability.
Abbreviations: SD, standard deviation.
Category Data for Each Category Acetaminophen Acetaminophen Acetaminophen Tylenol Antidepressants Amitriptyline Antidepressants Buproprion HCL Antidepressants Celexa Antidepressants Citalopram Antidepressants Clomipramine Antidepressants Doxepin Antidepressants Duloxetine Antidepressants Escitalopram Antidepressants Fluoxetin Antidepressants Fluvoxamine Antidepressants Mirtazapine Antidepressants Nortriptyline Antidepressants Olanzapine Antidepressants Paroxetine Antidepressants Perphenazine-amitriptyline Antidepressants Prozac Antidepressants Quetiapine Antidepressants Remeron Antidepressants Trazodone Antidepressants Venlafaxine Antidepressants Zoloft Behavioral Health Consult/Referral to Behavioral Health Program Behavioral Health Consult/Referral to Neuropsychology Behavioral Health Consult/Referral to Psychiatry Behavioral Health Consult/Referral to Psychology Behavioral Health Consult/Referral to Psychology Evaluation BENZOS Alprazolam BENZOS Clonazepam BENZOS Diazepam BENZOS Klonopin BENZOS lorazepam BENZOS Oxazepam BENZOS Temazepam BENZOS Triazolam BENZOS Valium Chiropractic/Osteopathic Manipulation Consult/Referral to Chiropractic Therapy Chiropractic/Osteopathic Manipulation Consult/Referral to Osteopathic Manipulative Therapy Chiropractic/Osteopathic Manipulation Osteopathic Manipulative Tx 1 to 2 Body Regions Chiropractic/Osteopathic Manipulation Osteopathic Manipulative Tx 3 to 4 Body Regions Chiropractic/Osteopathic Manipulation Osteopathic Manipulative Tx 5 to 6 Body Regions Chiropractic/Osteopathic Manipulation Osteopathic Manipulative Tx 7 to 8 Body Regions Coaching/Wellness/Lifestyle Consult/Referral for Wellness Education Coaching/Wellness/Lifestyle Consult/Referral to Prescription for Wellness Health Coach Diagnostic Imaging - MR/CT CT Lumbar spine Diagnostic Imaging - MR/CT CT Lumbar spine Diagnostic Imaging - MR/CT MR Lumbar and Thoracic spine Diagnostic Imaging - MR/CT MR Lumbar spine Diagnostic Imaging - MR/CT MR Lumbo-sacral spine Diagnostic Imaging - XRAY Xray Lumbar Spine 2 or 3 views Diagnostic Imaging - XRAY Xray Lumbar Spine Minimum 4 views Diagnostic Imaging - XRAY XRay Lumbar Spine Minimum 4 views with Oblique Diagnostic Imaging - XRAY Xray Lumbar Spine with Flex and Ext. Diagnostic Imaging - XRAY XRay pelvic complete minimum 3 views Diagnostic Imaging - XRAY XRay Sacroiliac Joints (G) Diagnostic Imaging - XRAY XRay Sacroiliac Joints 1 or 2 Views Diagnostic Imaging - XRAY XRay Sacroiliac Joints 3+ Views Diagnostic Imaging - XRAY XRay Sacroiliac Joints less than 3 Views Diagnostic Imaging - XRAY XRay Sacroiliac Joints Minimum 3 Views Diagnostic Imaging - XRAY XRay Sacrum/Coccyx 2 Views Diagnostic Imaging - XRAY XRay Sacrum/Coccyx 2+ Views Diagnostic Imaging - XRAY XRay Sacrum/Coccyx Minimum 2 Views Diagnostic Imaging - XRAY XRay Spine Lumbar (G) Diagnostic Imaging - XRAY XRay Spine Lumbar 1 View Diagnostic Imaging - XRAY XRay Spine Lumbosacral 2 or 3 Views Diagnostic Imaging - XRAY XRay Spine Lumbosacral 4+ Views Diagnostic Imaging - XRAY XRay Spine Lumbosacral w/ Bending 6+ Views Diagnostic Imaging - XRAY XRay Spine Scoliosis Study (G) Diagnostic Imaging - XRAY XRay Spine Thoracolumbar 2 Views Diagnostic Imaging - XRAY XRay Spine Thoracolumbar 2+ Views Mind and Body Therapies Consult/Referral for Acupuncture Mind and Body Therapies Consult/Referral for Musculoskeletal Health Mind and Body Therapies Consult/Referral Massage Therapy Mind and Body Therapies Massage Therapy MUSCLE RELAXANT Baclofen MUSCLE RELAXANT Carisoprodol MUSCLE RELAXANT Chlorzoxazone MUSCLE RELAXANT Cyclobenzaprine MUSCLE RELAXANT Flexeril MUSCLE RELAXANT Metaxalone MUSCLE RELAXANT Methocarbamol MUSCLE RELAXANT Orphenadrine MUSCLE RELAXANT Tizanidine Neurology Consult/Referral to Neurology NSAIDS Celecoxib NSAIDS Diclofenac NSAIDS Diclofenac-epolamine NSAIDS Diflunisal NSAIDS Etodolac NSAIDS Flurbiprofen NSAIDS Ibuprofen NSAIDS Ibuprofen-famotidine NSAIDS Indomethacin NSAIDS Ketorolac NSAIDS Meloxicam NSAIDS Motrin NSAIDS Nabumetone NSAIDS Naprosyn NSAIDS Naproxen NSAIDS Oxaprozin NSAIDS Piroxicam NSAIDS Sulindac NSAIDS Toradol NSAIDS-topical Diclofenac cream NSAIDS-topical Voltaren cream Opioids Acetaminophen-codeine Opioids Butabital-acetaminophen-caffeine-codeine Opioids Fentanyl Opioids Hydrocodone Opioids Hydrocodone-acetaminophen Opioids Hydromorphone Opioids Methadone Opioids Morphine Opioids Morphone Opioids Oxycodone Opioids Oxycodone-acetaminophen Opioids Oxymorphone Opioids Tramadol Opioids Tramadol HCL Opioids Tramadol-acetaminophen Opioids Vicodine Pain Management Consult/Referral for Peti-Chronic Pain Treatment Pain Management Consult/Referral to Pain Clinic Pain Management Consult/Referral to Pain Management Pain Management Consult/Referral to Physical Medicine and Rehabilitation Pain Management Consult/Referral to Sports Medicine Physical Therapy/Rehabilitation Consult/Referral to Aqua Therapy Physical Therapy/Rehabilitation Consult/Referral to Flexibility Exercise Physical Therapy/Rehabilitation Consult/Referral to Physical Therapy Physical Therapy/Rehabilitation Physical Therapy (PT) Evaluation and Treatment Physical Therapy/Rehabilitation Physical Therapy (PT) Outpatient Evaluation and Treatment Psychologically Informed Physical Therapy Consult/Referral to Psychologically Informed Physical Therapy (Stratified approach for LBP) Social Work Consult/Referral to Social Work Social Work Consult/Referral to Social Work/Case Management Spine Surgery Consult/Referral to Neurosurgery Spine Surgery Consult/Referral to Neurosurgery spine Spine Surgery Consult/Referral to Orthopedics Spine Surgery Consult/Referral to Orthopedics-spine Steroids Dexamethasone Steroids Dexamethasone - injection Steroids Hydrocortisone Steroids Medrol Steroids Methylprednisolone Steroids Methylprednisolone acetate - injection Steroids Methylprednisolone sodium succinate - injection Steroids Prednisone Abbreviations: NSAID, non-steroidal anti-inflammatory drugs; MRI, magnetic resonance imaging; CT, computed tomography.
- Appendix Table B.
Comparison of Training Data and Validation Data Clusters in the 4-Cluster Model
Validation Training Validation Training Validation Training Validation Training 2nd Line Pharm 2nd Line Pharm Non-Pharm and 1st Line Pharm Non-Pharm and 1st Line Pharm Imaging Imaging Specialty Specialty n = 1470 n = 1747 n = 1810 n = 1789 n = 525 n = 305 n = 268 n = 232 Female n, % 818 56% 985 56% 1063 59% 1032 58% 323 62% 196 64% 137 51% 125 54% Age mean, std 50 16 51 16 48 17 49 17 56 18 55 20 53 16 54 16 Body Mass Index, mean 32 32 32 32 30 30 32 32 Site BMC 50 3% 56 3% 332 18% 293 16% 12 2% 15 5% 36 113% 23 109% IMH 406 28% 472 27% 347 19% 335 19% 81 15% 50 16% 53 20% 46 20% JHU 162 11% 171 10% 395 22% 411 23% 62 12% 38 12% 56 21% 52 22% UPMC 852 58% 1048 60% 736 41% 750 42% 370 70% 202 66% 124 47% 112 48% Anxiety or depression n, % 141 10% 143 8% 72 4% 67 4% 30 6% 12 4% 19 7% 20 9% Obese n, % 775 53% 908 52% 948 52% 967 54% 222 42% 118 39% 139 52% 133 57% Insurance SelfPay/Other/Missing 263 18% 289 17% 442 24% 408 23% 90 17% 37 12% 61 23% 48 21% Medicaid 132 9% 141 8% 188 10% 186 10% 37 7% 21 7% 24 9% 18 8% Medicare 291 20% 326 19% 295 16% 274 15% 170 32% 93 31% 58 22% 61 26% private 784 53% 991 57% 885 49% 921 51% 228 43% 153 50% 123 46% 105 45% Smoking status n,% Not current smoker 956 65% 1122 64% 1140 63% 1098 61% 391 74% 234 77% 156 59% 140 60% Current smoker 227 15% 275 16% 179 10% 184 10% 51 10% 22 7% 45 17% 27 12% Missing/unknown 287 20% 350 20% 491 27% 507 28% 83 16% 48 16% 65 24% 65 28% Race n,% White 1289 88% 1556 89% 1250 69% 1264 71% 454 86% 257 85% 210 79% 194 84% Black 113 8% 116 7% 389 21% 374 21% 45 9% 32 11% 37 14% 25 11% Missing 32 2% 37 2% 75 4% 81 5% 12 2% 6 2% 8 3% 4 2% Other 36 2% 38 2% 96 5% 70 4% 14 3% 9 3% 11 4% 9 4% Hispanic n,% Non-Hispanic 1397 95% 1652 95% 1658 92% 1612 90% 499 95% 284 93% 242 91% 214 92% Hispanic 43 3% 44 3% 102 6% 102 6% 15 3% 9 3% 15 6% 10 4% Missing 30 2% 51 3% 50 3% 75 4% 11 2% 11 4% 9 3% 8 3% Back pain diagnosis n,% Axial back pain 999 68% 1118 64% 1472 81% 1452 81% 356 68% 225 74% 156 59% 123 53% Back and leg 471 32% 629 36% 338 19% 337 19% 169 32% 79 26% 110 41% 109 47% Duration of LBP n,% Less than 1 month 996 68% 1188 68% 1147 63% 1115 62% 280 53% 143 47% 117 44% 113 49% 1 to 3 months 282 19% 365 21% 424 23% 441 25% 157 30% 101 33% 89 33% 77 33% More than 3 months 192 13% 194 11% 239 13% 233 13% 88 17% 60 20% 60 23% 42 18% STarT Back Category High 424 29% 482 28% 441 24% 388 22% 141 27% 44 14% 102 38% 94 41% Low 359 24% 441 25% 686 38% 702 39% 188 36% 141 46% 59 22% 50 22% Medium 687 47% 824 47% 683 38% 699 39% 196 37% 119 39% 105 39% 88 38% Chronic at 6 months n,% 328/888 37% 343/1034 33% 267/966 28% 240/893 27% 110/295 37% 42/170 25% 87/151 58% 53/120 44% ODI Baseline n, mean 1426 40 1698 38 1749 31 1737 31 515 31 298 25 260 40 229 39 ODI 6 Months n, mean 891 22 1034 22 973 19 899 18 298 22 172 17 151 29 121 25 CLUSTER Validation Training Validation Training Validation Training Validation Training 2nd Line Pharm 2nd Line Pharm Non-Pharm and 1st Line Pharm Non-Pharm and 1st Line Pharm Imaging Imaging Specialty Specialty n = 1470 n = 1747 n = 1810 n = 1789 n = 525 n = 305 n = 268 n = 232 Non-Pharm 494 34% 591 34% 962 53% 901 50% 209 40% 117 38% 42 16% 40 17% Pharm1 889 60% 948 54% 1430 79% 1438 80% 0 0% 0 0% 116 43% 85 37% Pharm2 1470 100% 1747 100% 0 0% 12 1% 206 39% 0 0% 154 57% 141 61% Specialty 0 0% 0 0% 39 2% 69 4% 14 3% 7 2% 268 100% 232 100% Imaging 255 17% 460 26% 264 15% 266 15% 525 100% 305 100% 88 33% 75 32% Abbreviations: BMC, Boston medical center; IMH, Institute of mental health; UPMC, University of Pittsburgh medical center; JHU, Johns Hopkins university.
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