Because most patients with an acute episode of low back pain (LBP) enter the health care system through primary care, it is important primary care providers consider the effects of their decisions on patient outcomes and costs. Although guidelines for primary care management of acute LBP do not place emphasis on physical therapy, they have not been updated since 2007, and more recent evidence supports the use of timely physical therapy in acute LBP patients without “red flags.” Additionally, many studies indicate specialist or surgical consultation is over-utilized, inflating costs and delaying physical therapy. The aim of this project was to determine if the type of provider referring acute LBP patients to physical therapy effects outcomes and costs, comparing referrals of three groups: primary care physicians, primary care nurse practitioners and physician’s assistants, and specialists. To do so, the project leader obtained data collected over twelve months by a large physical therapy organization through an outcomes-tracking program [Focus on Therapeutic Outcomes (FOTO)]. FOTO provided demographic information, referring physician, and outcomes data. Outcomes were determined by the change in functional score, which was a score computed by the FOTO survey. Cost data was estimated using the new Centers for Medicare & Medicaid Services (CMS) standardized payment information from the physician fee schedule search. A total of 342 patients fit the inclusion criteria of the project of the 2,070 patients seen with acute low back pain between October 1, 2015 and September 30, 2016. After outlier analysis, data from 329 patients was included in statistical analysis. One-way ANOVAs were used to compare mean change in functional score and mean cost between the three groups. All groups showed improvement at completion of physical therapy. There was no statistically significant difference in change in functional score between the three groups; however, there was a statistically significant difference in mean cost between the three groups. More specifically, the mean cost for patients referred by specialists was higher than both primary care physicians and primary care nurse practitioners and physician’s assistants. There was no statistically significant difference in mean cost between primary care physicians and primary care nurse practitioners and physician’s assistants. After further analysis through incremental cost-effectiveness ratios, the project leader determined the most cost-effective pathway for patients with acute LBP is direct referral from primary care nurse practitioners and physician’s assistants to physical therapy. The findings support the need for updated guidelines for primary care management of acute LBP to include referral to physical therapy and support the role of nurse practitioners and physician’s assistants in primary care.
Dr. Linda Wofford
Scholarly Project Team Member
Dr. Craig O’Neil
Scholarly Project Team Member
Dr. Leslie Higgins
Nursing, School of
Health Sciences & Nursing, Gordon E. Inman College of
Doctorate of Nursing Practice (DNP)
acute low back pain; primary care management; physiotherapy; guidelines; cost-effectiveness
Griggs, Corinne, "Provider Referral of Patients with Acute Low Back Pain to Physical Therapy: Implications for Outcomes and Costs" (2017). DNP Scholarly Projects. 35.