Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio - Fort Sam, Houston, Texas.
Doctoral Programs in Physical Therapy, Baylor University, San Antonio, Texas.
Pain Med. 2019 Mar 1;20(3):476-485. doi: 10.1093/pm/pny212.
Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories.
To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.
Retrospective observational cohort.
Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data.
From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001).
MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.
肌肉骨骼疼痛指南强调了阶梯式护理方法，建议在使用更具侵袭性或风险的循证干预措施（如手动治疗[MT]）之前，先使用风险较低的干预措施，如阿片类药物处方。护理的顺序和时间会改变康复轨迹。
比较脊柱或肩部疾病患者仅接受 MT 治疗与 MT 联合阿片类药物治疗一年后的下游医疗保健利用情况。次要目的是根据阿片类药物和 MT 的顺序和时间来比较差异。
回顾性观察队列。
纳入至少接受一次 MT 治疗的脊柱或肩部疾病初始就诊患者。Madigan 陆军医疗中心的一名高级医疗保健分析师汇总了来自军事健康系统管理和报告工具（M2）数据库的人员水平数据。根据干预措施的提供顺序和时间创建组。结果包括初始咨询后一年的医疗保健利用情况（医疗费用和就诊次数）。控制措施包括代谢、心理健康、慢性疼痛、睡眠和物质滥用合并症，以及先前的阿片类药物处方。由于成本数据严重偏态，因此使用伽马对数链接的广义线性模型进行分析。
在 1876 名接受 MT 治疗的脊柱或肩部疾病的独特患者中，有 1162 名（61.9%）患者还接受了处方阿片类药物。仅接受 MT 治疗的患者的一年平均费用（5410 美元，95%置信区间[CI] = 5109 美元至 5730 美元）明显低于 MT+阿片类药物治疗组（10498 美元，95%CI = 10043 美元至 10973 美元）。当患者同时接受两种治疗时，MT 首先治疗组（10782 美元，95%CI = 10050 美元至 11567 美元）的一年平均费用明显更低（P = 0.030），阿片类药物首先治疗组（11938 美元，95%CI = 11272 美元至 12643 美元），MT 首先治疗组的阿片类药物平均每日供应量（34.2 天 vs 70.9 天，P < 0.001）和阿片类药物平均独特处方数量（3.1 次 vs 6.5 次，P < 0.001）也明显更低。
仅接受 MT 治疗的患者的下游成本低于阿片类药物处方。治疗顺序（MT 先于阿片类药物处方）和治疗时间（MT < 30 天）都导致初始咨询后一年的资源（成本、就诊次数和阿片类药物使用）显著减少。临床医生应考虑首诊决策的影响和治疗选择的护理时机，以治疗脊柱和肩部疾病患者。
