Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain among Older Medicare Beneficiaries

James M Whedon; Anupama Kizhakkeveettil; Andrew WJ Toler; Serena Bezdjian; Daniel Rossi; Sarah Uptmor; Todd A. MacKenzie; Jon D Lurie; Eric L. Hurwitz; Ian Coulter; Scott Haldeman

doi:10.1097/BRS.0000000000004118

Table 2.
Proportion of Clinical Encounters Indicative of Escalation of Care
Primary Cohorts Crossover Cohorts Combined Cohorts Total

Cohort SMT OAT SMTX OATX SMTC OATC
N 4,998 20,947 1,431 784 6,429 21,731 28,160
Encounters [n (%)]

Secondary Care Encounter for Primary Diagnosis of LBP

Any Secondary Care Encounter 2,563 (51.3) 19,488 (93.0) 1,189 (83.1) 542 (69.1) 3,752 (58.4) 20,030 (92.2) 23,782
Hospitalization 38 (0.8) 1,026 (4.9) 50 (3.5) 18 (2.3) 88 (1.4) 1,044 (4.8) 1,132
Injections and other interventional procedures 509 (10.2) 10,348 (49.4) 575 (40.2) 179 (22.8) 1,084 (16.9) 10,527 (48.4) 11,611
Advanced Diagnostic Imaging 740 (14.8) 9,426 (45.0 594 (41.5) 217 (27.7) 1,334 (20.7) 9,643 (44.4) 10,977
Specialist Visit 967 (19.3) 16,493 (78.7) 802 (56.0) 307 (39.2) 1,769 (27.5) 16,800 (77.3) 18,569
Emergency Department Visit 229 (4.6) 4,787 (22.9) 201 (14.0) 59 (7.5) 430 (6.7 4,846 (22.3) 5,276

Potential Complications of LBP

Encounter for Same -level Fall with Trauma 1,192 (23.8) 12,676 (60.5) 702 (49.1) 282 (36.0) 1,894 (29.5) 12,958 (59.6) 14,852
Encounter for Spinal Injury 920 (18.4) 2,514 (12.0) 279 (19.5) 144 (18.4) 1,199 (18.6) 2,658 (12.2) 3,857
Notes: SMT = subjects who initiated SMT in 2013 for long-term management of cLBP, with no concurrent OAT; OAT = subjects who initiated OAT in 2013 for long-term management of cLBP, with no concurrent SMT; SMTX = subjects with any occurrence of SMT in 2013, followed by initiation in 2013 of OAT for long-term management of cLBP; OATX = subjects with any occurrence of OAT in 2013, followed by initiation in 2013 of SMT for long-term management of cLBP; SMTC = combination of primary and crossover cohorts, in which all patients chose SMT as the initial treatment; OATC = combination of primary and crossover cohorts, in which all patients chose OAT as the initial treatment; n = number of subjects; Secondary care encounters = patient visits for primary diagnosis of LBP, identified by Current Procedural Terminology (CPT) code; Trauma = Head injury or Hip Fracture; Spinal Injury = sprain, dislocation, or fracture of the lumbosacral spine

	Primary Cohorts		Crossover Cohorts		Combined Cohorts		Total

Cohort	SMT	OAT	SMTX	OATX	SMTC	OATC
N	4,998	20,947	1,431	784	6,429	21,731	28,160
Encounters [n (%)]
Secondary Care Encounter for Primary Diagnosis of LBP

Any Secondary Care Encounter	2,563 (51.3)	19,488 (93.0)	1,189 (83.1)	542 (69.1)	3,752 (58.4)	20,030 (92.2)	23,782
Hospitalization	38 (0.8)	1,026 (4.9)	50 (3.5)	18 (2.3)	88 (1.4)	1,044 (4.8)	1,132
Injections and other interventional procedures	509 (10.2)	10,348 (49.4)	575 (40.2)	179 (22.8)	1,084 (16.9)	10,527 (48.4)	11,611
Advanced Diagnostic Imaging	740 (14.8)	9,426 (45.0	594 (41.5)	217 (27.7)	1,334 (20.7)	9,643 (44.4)	10,977
Specialist Visit	967 (19.3)	16,493 (78.7)	802 (56.0)	307 (39.2)	1,769 (27.5)	16,800 (77.3)	18,569
Emergency Department Visit	229 (4.6)	4,787 (22.9)	201 (14.0)	59 (7.5)	430 (6.7	4,846 (22.3)	5,276

Potential Complications of LBP

Encounter for Same -level Fall with Trauma	1,192 (23.8)	12,676 (60.5)	702 (49.1)	282 (36.0)	1,894 (29.5)	12,958 (59.6)	14,852
Encounter for Spinal Injury	920 (18.4)	2,514 (12.0)	279 (19.5)	144 (18.4)	1,199 (18.6)	2,658 (12.2)	3,857