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Study: Only 10% of Physician Visits for LBP Resulted in Physical Therapy Referrals 1997–2010 While O

In brief:

  • Study analyzed data from 170 million visits to a primary care physician 1997–2010

  • Referrals for physical therapy occurred in 10% of the visits, a rate that was fairly constant during the study period

  • Prescriptions for opioids rose from about 15% to 45% by 2010; patients who didn't receive a physical therapy referral were more likely to receive an opioid prescription

  • Disparities in referral rates were found, with Medicare and Medicaid beneficiaries less likely to be referred to a PT

  • Authors call for more education on physical therapy as a first-line treatment for LBP

If there is consensus among physicians that physical therapy is a preferred first-line treatment for low back pain (LBP), you wouldn't be able to tell it from the referral rates cited in a recent study. Researchers found that between 1997 and 2010 only about 10% of LBP visits resulted in a referral to a physical therapist (PT), while opioid prescription rates climbed to 45% by the study's end—and those numbers get worse for patients whose care is paid for by Medicare, Medicaid, and even HMOs.

The study, published in Spine (abstract only available for free), analyzed an estimated 170 million visits to a primary care physician (PCP) for LBP during a the period 1997–2010. Using statistics supplied from the National Hospital and Ambulatory Medical Center Survey as well as survey data from emergency departments, researchers were able to not only look at overall percentage of referrals for physical therapy but also to analyze those patterns in terms of demographics and payer source.

While that time period was prior to recommendations by the US

Centers for Disease Control and Prevention (CDC) and other groups for physical therapy as a first-line treatment for LBP and other types of pain, researchers believe that the efficacy of physical therapy was already well-established by the late 90s. They describe the data they uncovered as "concerning." Among the findings:

  • Over the 15 years of the study, the percentage of referrals for physical therapy changed a little, but not much, and not in ways that indicated any discernable trend—10.1% overall, with yearly fluctuations between 4.8% (2001) and 15.1% (2004).

  • Opioid prescriptions were a different story, for the most part steadily moving from about 15% of all LBP visits in 1997 to nearly 45% by 2010.

  • Referral for physical therapy also correlated to a patient's type of insurance. Patients with preferred provider organization plans were 53% more likely to receive treatment from a PT, with patients in HMOs being 44.7% more likely to be referred for physical therapy. Medicare and Medicaid beneficiaries were 53% and 47% less likely to be referred to a PT, respectively.

  • The patient population in the study had an average age of 50.4 years, and about half were female. About 22.3 million had Medicare, and 2 million had Medicaid. Whites made up 19.8 million of the patient population, with 12.4 Black patients and 2.3 million Hispanic patients (the study used only 3 ethnic categories).

Researchers believe their findings reveal some "concerning" and "disconcerting" patterns—among them an increased likelihood that patients who aren't referred for physical therapy will wind up with an opioid prescription, and a connection between the kind of insurance patients have and the likelihood that they will receive a referral to a PT.

Authors assert that while an opioid prescription may seem like the more cost-effective option in terms of upfront costs, the long-term toll—both in terms of money spent and harm to patients—far outweighs the spending associated with physical therapy. "With more evidence that [physical therapy] is an effective method of treating back pain, there needs to be a push for more insurance coverage of [physical therapy] referrals to avoid overutilization of cheaper but less effective, and potentially harmful, forms of treatments," authors write.

Additionally, say the authors, disparities in insurance coverage need to be addressed. Given the indications that patients who don't receive a referral for physical therapy are more likely to receive an opioid prescription, the connection between referral rates and the type of insurance a patient has reveal "disconcerting economic disparities [that] need to be quantified, elucidated, and addressed," they write.

According to the researchers, while "the ideal physical therapy referral rate [for LBP] has yet to be defined," the fact that the rate remained so steady while opioid prescription rates climbed—even as evidence of physical therapy's effectiveness continued to mount—"suggests that initiatives are needed to educate both providers and patients about the utility of physical therapy."

APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign , an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at , the #ChoosePT campaign includes national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach.

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