Referral Patterns in Low Back Pain Patients

This study examined how 98 cases of new onset, uncomplicated low back pain was generally handled in patients with workers' compensation claims.

Over half of the cases were initially seen in emergency rooms or urgent-care facilities. The authors hypothesize that this is due to patient preference, or an employer's desire for employee to receive prompt care, or limited availability of low-cost, easy-access centers for work-related injuries. 24% of these patients then had their follow-up care in the same urgent care centers. This is an extremely inefficient and expensive way to treat the onset and course of low back pain.

The authors seemed surprised that just a few patients were seen on intake by a "occupational medicine" (OM) specialist. "The main provider of care was again most likely to be a primary care physician (47%), followed by non-OM specialists (23%) and OM specialists in 13% of the cases. Of the original 98 patients, 52% were referred to a specialist. Of the 35 referrals to surgeons only 2 did have surgical intervention. The authors estimated the median number of visits to all providers was five.

The authors conclude that the handling of uncomplicated low back pain cases was ultimately not cost effective:

"As noted, many of the utilization and referral practices described herein can reasonably be expected to increase the costs of managing such LBP claims, and in multiple published reports, they have not been shown to demonstrably increase efficacy of treatment."

The entire study was focused not on the effectiveness of a particular type of treatment and did not study outcome. The focus was on costs and "system efficiency." This is not surprising, as the study was funded in part by the Liberty Mutual Insurance Company and a center that that have as part of Harvard University.

Tacci J, Webster B, Hashemi L, Christiani D. Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims. Journal of Occupational and Environmental Medicine 1998;40(11):958-963.