Geisel School of Medicine, Lebanon, NH.
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
Spine (Phila Pa 1976). 2024 Feb 15;49(4):278-284. doi: 10.1097/BRS.0000000000004639. Epub 2023 Mar 24.
Claims-based analysis of cohorts of TRICARE Prime beneficiaries.
To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.
Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.
Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.
Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).
We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.
基于 TRICARE Prime 受益人群队列的理赔数据分析。
比较五个下腰痛 (LBP) 治疗方法（物理治疗 (PT)、手法治疗、行为疗法、阿片类药物和苯二氮䓬类药物处方）在不同医疗服务区的使用率，并评估它们与 LBP 缓解的关系。
指南支持将重点放在 LBP 的非药物管理上，并减少阿片类药物的使用。对于整个军事卫生系统的 LBP 护理模式，我们知之甚少。
使用国际疾病分类第 9 版和第 10 版在 2015 年 10 月前和之后分别识别 LBP 的诊断数据；排除有“红旗”诊断、海外驻军、有资格参加医疗保险或有其他健康保险的患者。排除后，在 73 个医疗服务区内，最终分析队列中有 159027 名患者。治疗方法是通过医疗服务区的治疗率来定义的，以避免个体水平上的指示性混杂；主要结局是 LBP 缓解，定义为在索引诊断后 6 至 12 个月期间没有行政 LBP 理赔。
各医疗服务区阿片类药物处方率从 15%到 28%不等，物理治疗率从 17%到 39%不等，手法治疗率从 5%到 26%不等。多变量逻辑回归模型显示，阿片类药物处方与 LBP 缓解呈负相关且具有边际显著性（比值比：0.97，95%置信区间：0.93-1.00；P = 0.051），但与物理治疗、手法治疗、苯二氮䓬类药物处方或行为疗法无显著相关性。当分析仅限于现役受益人群的子集时，阿片类药物处方与 LBP 缓解之间的负相关性更强（比值比：0.93，95%置信区间：0.89-0.97）。
我们发现 TRICARE 内治疗 LBP 的医疗服务区之间存在很大的差异。阿片类药物处方率较高与结果较差相关。
