Assessing Practice Pattern Differences in the Treatment of Acute Low Back Pain in the United States Military Health System

Background: Acute low back pain is one of the most common reasons for individuals to seek medical care in the United States. The US Military Health System provides medical care to approximately 9.4 million beneficiaries annually. These patients also routinely suffer from acute low back pain. Within this health system, patients can receive care and treatment from physicians, or physician extenders including physician assistants and nurse practitioners. Given the diversity of provider types and their respective training programs, it would be informative to evaluate variation in care delivery, adherence to clinical guidelines, and differences within the MHS among a complex mix of provider types.

Methods: This study was a retrospective, cross-sectional quantitative analysis that examined variations in treatment between provider types within the Military Health System in 2015 for treatment of acute low back pain using administrative data. In addition to descriptive and summary statistics, binomial logistic regression models were used to assess variation in practice patterns among physicians and mid-level practitioners for prescribing of non-steroidal anti-inflammatory, opioids, plain radiography, computed tomography, and magnetic resonance imaging.

Results: With regard to prescribing practices, results indicated that the odds of receiving non-steroidal anti-inflammatory prescriptions increased significantly for both physician assistants and nurse practitioners when compared to physicians. For basic radiological referrals, odds increased significantly for ordering plain radiography for physician assistants and nurse practitioners when compared to physicians. For more advanced imaging, odds significantly decreased for ordering computed tomography (CT) and slightly decreased for magnetic resonance for physician assistants, nurse practitioners and physician residents compared to the physician group. Additionally this study discovered differences in the prescribing patterns between provider categories. Both contractors and civilians had higher odds of prescribing opioids compared to active duty providers.

Conclusions: As physician assistants and nurse practitioners continue to gain popularity as physician extenders in the US and in addressing provider shortages for the Military Health System, further research should be conducted to determine what impact, if any, the differences found in this study have on patient outcomes. In addition, provider type warrants further investigation to determine if labor mix and outsourcing decisions within a single payer system impacts health delivery and value based care.