Patient Characteristics and Healthcare Use for High-cost Patients with Musculoskeletal Disorders in Norway: A Cohort Study

Patient Characteristics and Healthcare Use for High-cost Patients with Musculoskeletal Disorders in Norway: A Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient Characteristics and Healthcare Use for High-cost Patients with Musculoskeletal Disorders in Norway: A Cohort Study Olav Amundsen, Tron Anders Moger, Jon Helgheim Holte, Silje Bjørnsen Haavaag, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4002700/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2024 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background: A high proportion of healthcare costs can be attributed to musculoskeletal disorders (MSDs). A small proportion of patients account for most of the costs, and there is increasing focus on addressing service overuse and high costs. We aimed to describe healthcare use contributing to high costs over a five-year period at the individual level and to examine differences between high-cost patients who use healthcare in accordance with guidelines and those who do not. These findings can contribute to the understanding of healthcare use for high-cost patients and help in planning future MSD-care. Methods: This study combines Norwegian registries on healthcare use, diagnoses, demographic, and socioeconomic factors. Patients (≥ 18 years) were included by their first MSD-contact in 2013–2015. We analysed healthcare use during the subsequent five years. Descriptive statistics are used to compare high-cost (≥95 th percentile) and non-high-cost patients, and to describe the most expensive specialist healthcare contact and healthcare care use prior to this contact. Logistic regression was used to assess factors associated with having seen healthcare personnel delivering conservative treatment prior to the most expensive specialist care contact. Results: High-cost patients were responsible for 60% of costs, with 90% related to hospital treatment. Seventy-seven percent of high-cost patients had one specialist healthcare contact responsible for more than half of their total costs, predominantly related to surgical treatment. Fractures/injuries were the most common diagnosis for these contacts, while osteoarthritis and spinal, shoulder and knee disorders accounted for 42%. Less than half had seen a healthcare service delivering conservative treatment, other than GPs, the year before this contact. Being male, from a small municipality, lower education and higher comorbidity were associated with lower odds of having been to healthcare services focused on conservative treatment prior to the most expensive specialist care contact. Conclusion: Most health care costs are concentrated among a small proportion of patients. In contrast to recommendations, less than half had been to a healthcare service focused on conservative management prior to specialist care treatment. This could indicate that there is room for improvement, and that ensuring sufficient capacity for conservative care can be beneficial for reducing overall costs. Health care utilisation musculoskeletal register-based research Figures Figure 1 Figure 2 Figure 3 Introduction Musculoskeletal disorders (MSDs) include a wide range of conditions. These conditions can range from short-lived and mildly bothersome to chronic conditions that result in life-long disability, activity-limitations and reduced work and social participation ( 1 , 2 ). MSDs are one of the leading causes of years lived with disability in most countries according to the Global Burden of Disease Study ( 3 ). Approximately one-third of all European workers are affected by MSDs, making it the most common work-related health problem in Europe ( 4 ). The prevalence of MSDs increases with age, and it is expected that the societal burden associated with MSDs will increase significantly in the future ( 5 , 6 ). MSDs exert a substantial strain on societal economic resources. They represent one of the diagnostic groups with the highest direct healthcare costs and account for a significant proportion of countries’ healthcare budgets ( 7 – 10 ). There are large variations in healthcare use for MSDs, where most people with musculoskeletal pain do not seek any care, and a small proportion are responsible for the majority of costs and number of healthcare contacts ( 11 – 15 ). Modern healthcare systems have an increased focus on reducing unwarranted costs and addressing overuse ( 16 – 19 ). An overarching principle for cost-reduction is that the patient is treated at the lowest effective level of care ( 20 , 21 ). Previous research has shown that the highest costs for MSDs are associated with hospitalisation and surgical treatment ( 10 , 22 ). Traumatic MSDs are routinely examined and treated in specialist care, where this management can be considered absolutely warranted ( 23 ). Many nontraumatic MSDs can be handled effectively in primary care with interventions such as self-management advice, exercise therapy, psychosocial interventions, and simple analgesics ( 24 , 25 ). Recommendations for conservative treatment for MSDs include using patient-centred care considering individual values, goals, and psychosocial factors, providing education and information, and include management that addresses physical activity and exercise ( 25 , 26 ). Guidelines recommend that patients with nontraumatic MSDs should predominantly be managed in primary care and be offered conservative treatment prior to surgical management ( 16 , 25 , 27 – 30 ). Stepwise care models in which high-quality conservative management and rehabilitation are attempted prior to specialist care referral have been suggested to increase the quality of care and reduce the costs of MSDs ( 31 – 35 ). However, prior research indicates that care for MSDs is often in discordance with guidelines and that patients commonly have low use of conservative treatment before they are treated surgically ( 36 – 42 ). There are numerous reasons why treatment may or may not adhere to clinical guidelines, such as unfamiliarity with guidelines, disagreement with recommendations, pressure from patients and fear of repercussions ( 43 – 45 ). Additionally, guidelines are meant only to support decision-making, and not intended as replacement for clinical judgement or to be followed meticulously ( 46 , 47 ). In each individual case, there could be important factors, e.g., specific clinical characteristics or unremitting high disability and pain intensity, that explain why treatment did or did not follow guidelines. The first aim of this study is to describe patterns of health care use that contribute to particularly high costs over a five-year period at the individual level. We expect large variation in health care use, but if patients’ health care use in general is in accordance with recommendations and guidelines, we would expect that certain health care use patterns emerge in the data for high-cost users: 1) Patients have high costs related to specialist care management of acute and traumatic conditions with low use of health care services prior to this, and 2) patients with high costs related to specialist care management of nontraumatic MSDs have frequent use of primary care services and conservative treatment before they are treated in specialist care. If these patterns are not typical in our data, it raises the question of whether better implementation of guidelines is required, or whether the guidelines themselves need to be revised. The second aim is to examine whether there are systematic differences in geographical location, demographic and socioeconomic factors between high-cost patients that have a health care use pattern in accordance with recommendations and those who do not. The findings from his study can provide information on how different service use contributes to high costs in the long-term, how primary and specialist care are used in combination and whether health care use patterns for high-cost patients in general follow current management recommendations and guidelines. These findings can contribute to the understanding of the characteristics and service use patterns of high-cost patients and aid in planning of future MSD-care. Methods Design and Setting This cohort study was conducted as part of the INnovations in use Of REGistry data (INOREG) project at the Institute of Health and Society, University of Oslo. The project combines several registries from 2008 to 2020 to create a cohort with healthcare use, costs, demographic and socioeconomic factors and outcomes for chronic diseases in Norway. The present study uses national registries with primary and specialist healthcare data, capturing all use of public healthcare in Norway. The reporting of this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for observational studies with the REporting of studies Conducted using Observational Routinely-collected Data (RECORD) extension (48, 49). We used data on healthcare utilisation for MSDs from the Norwegian public healthcare service. Norway has a national universal healthcare system with the overarching goal of ensuring equal access to services for all residents (50). The main providers for MSD-care in Norway include general practitioners (GPs), hospital services, physiotherapists and chiropractors. Additionally, contract specialists, municipal rehabilitation (mostly focused on elderly care with home-based rehabilitation and short-term rehabilitation stays in municipal institutions), municipal emergency care and specialist rehabilitation institutions are also involved. Other professionals such as naprapaths and osteopaths are also involved but work fully in the private market. Norway has had a Regular GP scheme in which all inhabitants are assigned their own GP since 2001 (50). Ninety-six percent of the population are registered with a GP (51). GPs function as gatekeepers in the Norwegian health care system and are responsible for coordinating care and referrals to specialist care (50). Additionally, since 2008, physiotherapists with a master’s degree in treatment of MSDs (manual therapists) and chiropractors have had the right to refer to specialist health care and radiological examinations and to prescribe sick leave for up to 12 weeks for MSDs. GPs and physiotherapists are part of municipal primary care and receive capitation from the municipal for running the services. The costs for consultations for GPs and physiotherapists are covered through a combination of fee-for-service reimbursement from The Norwegian Health Economics Administration (HELFO) and out-of-pocket payment from the patients. Chiropractors operate as private practitioners and can set their own price but also receive a modest fee-for-service reimbursement from HELFO covering approximately 10% of the total cost (52). Hospital care is provided by trusts owned by regional health authorities. Inpatient care is fully covered for patients, while outpatient care has an out-of-pocket cost similarly to that of GPs and physiotherapy services. A cost-sharing ceiling with a maximum limit for out-of-pocket costs exists to protect patients with high healthcare use from high costs. Sample Selection This study included patients who were registered as residents of Oslo or Trondheim at any point between 2008 and 2020. We included patients with an MSD-related healthcare contact in The Control and reimbursement of healthcare claims (KUHR) database, ICPC-2 Chapter L, or the Norwegian Patient Registry (NPR), ICD-10 Chapter M, during the years 2013-2015 and no MSD-related contacts during the preceding three years. Inclusion started in 2013 to ensure that the data from all healthcare services were complete. The time of the first MSD-related contact during 2013-2015 served as an index date, irrespective of which healthcare professional registered the first contact. Prior studies have defined a three-year wash-out period as optimal for excluding ongoing disorders and identifying new cases for common MSDs (53, 54). The data on GP-services are complete from 2008, enabling us to use three years prior to the first contact as a washout-period. Patients younger than 18 years, or who died within five years after the index contact were excluded. Additionally, patients with MSD-diagnoses related to infection, malignancy, or inflammatory rheumatic diseases (ICPC-2 codes: L70, L71, L88 or L97. ICD-10 codes (M00-M03, M05-M08, M10, M11, M13, M30-M36, M45, M46, M60, M65 and M71 and M86) were excluded as the present study focused on symptom-based diagnoses. We used a follow-up period of five years for each patient, starting from the individual index date. To account for the COVID-19 pandemic, where it is expected that the lockdown had major impact on healthcare delivery, we excluded patients for whom the five-year follow-up extended beyond 12 th March 2020. Data sources and variables The fee-for-service reimbursements from HELFO are registered in KUHR, which allows the identification of contacts and costs for healthcare use at an individual level. Hospitals operate with activity-based funding based on the Nordic Diagnosis-Related Group (DRG) system to classify patients. This is registered in the NPR with a cost-weight, making it possible to calculate costs for contacts and procedures for each healthcare contact in the hospital. We used data from the KUHR to capture primary healthcare utilisation. This allowed the calculation of use and costs for services provided by GPs, physiotherapists, chiropractors, contract specialists and municipal emergency care services. The NPR was used to capture specialist healthcare use and to calculate the corresponding costs. Statistics Norway and FD-Trygd were used for demographic and socioeconomic factors. The Norwegian Cause of Death Registry was used to exclude patients who died during the follow-up period. The selected registries provide a complete overview of public healthcare use, meaning that there was no loss to follow-up due to a lack of reporting. All costs represent the reimbursement costs for the services and do not include capitation from the municipality, the block grants to hospitals or the out-of-pocket costs for the patients. This means that the costs reflect what the public healthcare system reimburses for the actual services provided, but not the expenses of running the services or the patients’ out-of-pocket costs. The GP-service, physiotherapy and hospitals receive approximately half of their income from capitation from the municipality or block grants from the state, while the other half are based on activity-based funding. This means that it is likely that the total cost is greater than what we present in our findings. The total costs related to treatment by chiropractors are underestimated in our results, as this service is mainly financed by out-of-pocket costs. A detailed list of the data sources, variables and their definitions used in this study are presented in Table 1. Categorizations and definitions are based on definitions by Statistics Norway if available or defined by the authors. Table 1: Data sources, variables and variable definitions Source Variable Definition KUHR Index date First registered date with an MSD-related healthcare contact, if first date were registered in KUHR Diagnoses International Classification of Primary Care, 2nd edition (ICPC-2) codes within chapter “L; Musculoskeletal” was used to identify contacts and costs related to MSDs. Patients registered with the specific codes L70 (Infection of musculoskeletal system), L71 (Malignant neoplasm musculoskeletal), L88 (Rheumatoid/seropositive arthritis and L97 (Neoplasm musculoskeletal benign/unspecific) were excluded. Comorbidity A previously adapted comorbidity index from GP-diagnoses based on ICPC-2 diagnoses, which have been validated to be used as an adjustment variable in epidemiological research in primary care databases (55). This is a comorbidity index based on primary care data with eighteen selected diagnoses and the individual patient are assigned an index score based on number of diagnoses that can be identified. The comorbidity index was dichotomised into 0-1/2 or more. Healthcare contact Frequency of contacts for GP, physiotherapy, chiropractors, municipal emergency care and contract specialists with an MSD-diagnosis. Contact was defined as a healthcare contact with a fee indicating a face-to-face/video-consultation individually or group based and does not include fees that indicate simple communication, prescription writing or administrative work. This approach has shown high validity for the GP-service (56). Included fees: GP: 2ad, 2ak, 2ae, 2ed Physiotherapy: A2a-f, A3a-b, A8a, A9a, A1a, A1d, c34 Chiropractors: K1, K2 Healthcare cost All reimbursement fees for contacts with an MSD-diagnosis. Costs are calculated in Norwegian currency but written in text as Euro (1€=11.3 NOK, per 19.02.2024) Geographical location The municipality where the first GP-contact with an MSD-diagnosis were registered. The municipalities were classified as: “Large city, large municipality, small municipality” based on a national classification system from Statistics Norway (57) NPR Index date First registered date with an MSD-related healthcare contact, if first date were registered in NPR Diagnoses ICD-10 codes (58) within chapter “Diseases of the musculoskeletal system and connective tissue” were used to categorise contacts and costs related to MSDs. Patients registered with the specific codes related to infections (M00, M01, M02), malignant disease (M86) and inflammatory rheumatic disease (M05-M08, M10, M11, M13, M30-M36, M45, M46) were excluded. Musculoskeletal conditions include all ICD-10 codes chapter M, excluding those specified above, and the code G55. Injuries to the musculoskeletal system includes codes within chapter “Injury, poisoning and certain other consequences of external causes” related to MSD, codes S32-34, S40-S99 and T08-T13, excluding codes related to superficial injuries and wounds (Sx0 and Sx1) Healthcare contacts Frequency of contacts after index date registered as outpatient contact or inpatient stay with an MSD-diagnosis. This includes contact with all healthcare personnel in specialist care. Healthcare cost related to DRGs Cost weight of DRG (corrected version) per MSD-related contact multiplied with cost of 1 DRG for the specific year. Cost of 1 DRG increased from 39447 NOK in 2013 to 45808 NOK in 2020. Costs are calculated in Norwegian currency but written in text as Euro (1€=11.3 NOK, per 19.02.2024) Procedure codes Procedure codes using the Norwegian Clinical Procedure Codes for surgical and medical procedures (59). Used to identify procedures for the most expensive specialist care contact for high-cost patients. Episode's discipline Used to identify what proportion of the most expensive contact are related to treatment in surgical departments. Also used to assess use of Physical Medicine and Rehabilitation physicians prior to high-cost patients most expensive specialist care contact. Municipality electronic patient journal Municipal rehabilitation Proportion that received municipal rehabilitation services prior to the most expensive specialist care contact. Municipal rehabilitation services do not include diagnosis codes. Statistics Norway Age Age in years at index date Gender Male/female Education Highest registered education. Categorised: 13 years or less/more than 13 years Income Income registered the year before inclusion. Categorised as below/above median. Immigrant background Categorised: No immigration background or Any immigration background (Includes: first generation immigrant, Norwegian-born second-generation immigrant, one foreign parent, born outside Norway from Norwegian parents) FD-Trygd Disability pension If the patient is registered on disability pension prior to inclusion Norwegian Cause of Death Registry Date of death Date of death were used to exclude patients that died during the five-year follow-up period. Abbreviations: KUHR: The Control and Reimbursement of Healthcare Claims. NPR: Norwegian Patient Registry. MSD: Musculoskeletal disorder. GP: General practitioner. ICPC-2: International Classification of Primary Care, 2nd version. ICD-10: International Statistical Classification of Diseases and Related Health Problems 10th Revision. DRG: Nordic Diagnosis-Related group Statistical analysis High-cost users were defined as individuals whose cost during the five-year period was equal to or exceeded the 95 th percentile. There is no consensus on the definition of high-cost patients, and the definition varies among studies (14, 60-62). In our data, the 95 th percentile for total costs in the five year-period was 3 791 Euro (€), which was used as a cut-off when describing patient characteristics. healthcare use and costs for high-cost patients compared to non-high-cost patients. The relationships between the number of MSD-related costs and contacts were described using a scatterplot. For the high-cost users, we identified the most expensive specialist health care contact for each patient during the five-year period, and presented descriptive statistics on the diagnosis, proportion of contacts related to surgical treatment and costs. We examined healthcare use before the most expensive specialist care contact for high-cost patients to determine whether this adhered to current recommendations. Conservative treatment and rehabilitation are recommended as first-line treatments for conditions such as osteoarthritis (29, 63, 64), spinal disorders (16, 28, 38), shoulder pain (27, 41, 65, 66), and knee disorders (67-69). The main providers of conservative care in Norway are GPs, physiotherapists, chiropractors and Physical Medicine and Rehabilitation (PM & R) physicians in specialist care. We assessed whether the patients had registered a contact with any of these healthcare services prior to their most expensive specialist care contact. We defined that the contacts with GPs, physiotherapists, chiropractors and PM & R physicians needed to be less than one year prior to the specialist care contact to ensure that the contact was relatively close to the most expensive specialist care contact. Due to the uncertainty of the specific diagnosis codes used in primary care, we did not restrict the exact diagnosis but included all contacts with any MSDs. There is no standardized method for identifying what health care contacts are relevant to the condition the patient were treated in specialist care for, and what contacts are related to other musculoskeletal problems. It could be argued that our definition is too strict, as it is possible that conservative treatment more than one year prior to the specialist care contact may be relevant, or not strict enough, as it does not restrict on specific diagnosis codes relevant to the specialist care contact. To account for this, we included results with both a stricter and a less strict definition in the supplementary as a sensitivity analysis. The stricter definition included only contacts the year before which included a diagnosis code relevant for the most expensive specialist care contact. The less strict definition included all contacts for any MSDs (including contacts where fees indicated simple communication, prescription writing or administrative work) between the index date and the specialist care contact. For patients for whom the most expensive specialist care contact was related to osteoarthritis or spinal, shoulder or knee disorders, we used logistic regression analysis to assess what factors were associated with having been to a health care service that provides conservative care prior to their most expensive specialist care contact. We assessed the associations with demographic factors (age, gender, immigration background), socioeconomic factors (education, income, being on disability pension), comorbidities and geographical variation (large city, large municipality or small municipality) in univariate and multivariate analyses. In the logistic regression, we also included the number of GP-contacts prior to the most expensive specialist care contact as a covariate, as most patients (approximately 85%) had at least one contact with a GP, and the number of GP-contacts influences the opportunity to refer to conservative treatment. Results The initial database included 1 016 638 patients who were registered with an MSD-diagnosis between 2008 and 2020. We excluded patients based on index year, follow-up time after the COVID-19 lockdown, age less than 18 years, specific diagnosis and death during the five-year period. This led to a final sample consisting of 139 249 patients (Figure 1). Patients with healthcare costs above the 95 th percentile were older, had less education, had more comorbidities, and were more likely to recieve disability pensions prior to the index date than non-high-cost patients (Table 2). The high-cost patient group had fewer patients registered in a large city and fewer patients with an immigrant background. There were negligible differences in income and gender. Table 2: Patient characteristics for high-cost and non-high-cost patients. N=139 249. High-cost patients N=6 961 (5%) Non-high-cost patients N=132 288 (95%) Age, years (mean (SD)) 54 (19) 42 (17) Gender, female 51.8% 50.3% Geographical location Large city Large municipality Small municipality 63.9% 17.4% 18.8% 72.9% 14.7% 12.4% Education, more than 13 years 37.9% 49.3% Income in € (median (IQR)) 32 685 (26 100) 33 837 (29 122) Disability pension before index 13.4% 6.4% Immigrant background 21.0% 31.0% Comorbidity, 2 or more a 7.5% 3.1% a Comorbidity index based on the International Classification of Primary Care (ICPC-2) (55). High-cost patients had a median cost of €7 835 (IQR 6 454), while non-high-cost patients had a median cost of €115 (IQR 265). High-cost patients had a median of 34 (IQR 48) healthcare contacts in the five-year follow-up period, while non-high-cost patients had 5 (IQR 11) healthcare contacts. High-cost patients accounted for 59% of all costs during the follow-up period. The cost distributions per service for high-cost patients and non-high-cost patients are illustrated in Figure 2. Ninety-four percent of high-cost patients had higher costs in specialist care than in primary care, while 6% had higher costs in primary care (Figure 3). The patients with higher costs in specialist care had 93% of their costs related to specialist care, and 53% of their contacts related to physiotherapy. For patients with higher costs in primary care, 70% of the costs and 87% of the contacts were related to physiotherapy. For the high-cost patients, 77% had one specialist healthcare contact that accounted for more than half of their total costs over a five-year period. The most expensive specialist healthcare contact was registered in a surgical department or with a surgical procedure code for 94% of the patients, varying from 80 to 99% between diagnosis categories. Table 3 shows the diagnosis categories for these contacts, the associated costs and the proportion of contacts related to a surgical department or surgical treatment. A table including all specific diagnoses included in each diagnostic category (Supplementary 1) and the most common procedures for each diagnostic category (Supplementary 2) is included in the supplementary material. Table 3: Characteristics for the most expensive specialist healthcare contact per person for high-cost patients Diagnostic category N (%) Median (IQR) cost Surgical department Fractures/injuries 3 110 (45.3) 6 404 (4 3166) 98.8% Osteoarthritis 1 269 (18.5) 10 880 (3 342) 99.5% Spinal disorders 1 022 (14.9) 5 890 (5 590) 80.4% Shoulder 288 (4.2) 2 809 (1 114) 94.8% Knee 287 (4.2) 3 138 (2 189) 99.3% Other MSDs 894 (13.0) 2 671 (3 288) 82.0% Total 6 870 6 224 (6 337) 93.8% Costs presented in Euro. Surgical department is defined as contact registered in a surgical department and/or with a surgical procedure code. All diagnosis codes included in each category are presented in supplementary 2. Ninety-two patients (1.3%) in the high-cost group had no specialist care use and were not included in table. Approximately 85% of patients whose most expensive contact was related to osteoarthritis, spinal-, shoulder- and knee disorders had seen their GP the year before the year before the most expensive specialist care contact, while patients treated for fractures showed low use of GP-services prior to the specialist care contact (Table 4). Approximately 45-50% of patients with contacts related to osteoarthritis, and spinal, shoulder and knee disorders had seen any health care personnel delivering conservative treatment other than GPs the year prior to their most expensive specialist care contact. Depending on the definition, this varies from 28-40% between diagnoses with a stricter definition to 55-67% with a less strict definition (Supplementary 3). The proportions of patients having seen a physiotherapist, chiropractor or PM & R physician per diagnosis category are presented below (Table 4). Additionally, 1.5% of patients were registered with a municipal rehabilitation service at any time before the specialist care treatment. Table 4: Proportion with at least one MSD-contact per service the year before their most expensive specialist healthcare contact GP Physiotherapy Chiropractor PM & R Any other than GP Diagnostic category Proportion with one or more contacts Proportion with one or more contacts Proportion with one or more contacts Proportion with one or more contacts Proportion with one or more contacts Fractures/injuries 32.7% 6.8% 4.6% 0.5% 11.1% Osteoarthritis 83.7% 37.8% 6.1% 2.8% 43.2% Spinal disorders 83.1% 26.7% 19.7% 12.1% 45.7% Shoulder 88.9% 41.7% 4.9% 10.4% 51.4% Knee 79.1% 42.2% 7.0% 0.3% 46.0% Other MSDs 68.7% 24.2% 8.5% 4.5% 32.8% Total 58.6% 20.7% 7.8% 3.6% 28.2% Categorised by diagnosis registered for the most expensive specialist care contact. PM & R: Physical Medicine and Rehabilitation Univariate and logistic regression analyses were performed to analyse the association between having seen a physiotherapist, chiropractor or PM & R physician prior to the most expensive specialist care contact (Table 5). These analyses included patients who had their most expensive specialist care contact for diagnosis where conservative care is recommended as first-line treatment (osteoarthritis, spinal-, shoulder- and knee disorders). Table 5: Logistic regression analysis for having seen physiotherapy, chiropractor or Physical Medicine and Rehabilitation physician prior to the most expensive specialist care contact Univariate Multivariate * Age .99 (.98-.99) .99 (.99-1.00) Gender, female 1.32 (1.14-1.53) 1.35 (1.15-1.58) Geographical location Large city (reference) Large municipality Small municipality Reference .86 (.70-1.05) .72 (.59-.87) Reference .94 (.76-1.16) .78 (.63-.96) Education, more than 13 years 1.22 (1.05-1.42) 1.22 (1.03-1.46) Income, more than median 1.16 (1.01-1.35) 1.07 (.90-1.27) Disability pension before index .68 (.55-.85) .83 (.65-1.06) Immigration background 1.11 (.94-1.33) .84 (.69-1.03) Comorbidity, 2 or more a .52 (.36-.73) .62 (.43-.91) Only patients whose most expensive specialist care contact was related to osteoarthritis, or spinal, shoulder or knee disorders were included (N=2 801). * Adjusted for all variables in table and number of GP-contacts the year prior to the most expensive specialist care contact. a Comorbidity index based on the International Classification of Primary Care (ICPC-2) (55). Discussion Main findings Our study identified differences in patient characteristics between high-cost and non-high-cost patients. High-cost patients were older, had less education, had more comorbidity and a higher proportion were on disability pensions than non-high-cost patients. There was a lower proportion of immigrants and fewer registered in a large city in the high-cost group, and there was no gender difference. High-cost patients accounted for close to 60% of all costs in the 5-year period. Eighty-nine percent of their costs were related to specialist health care. Ninety-four percent of high-cost patients had most of their costs related to specialist care use, while 6% had health care use characterized by very many physiotherapy contacts. Over three quarters of the high-cost patients had one specialist care contact that accounted for more than half of their costs in the five-year period, and 95% of these contacts were related to surgical departments. The year prior to the most expensive specialist care contact most patients had seen their GP, except for patients with fractures and injuries, while fewer than half had seen either physiotherapists, chiropractors, or PM & R physicians. Being male, having lower education and being registered in a small municipality were associated with lower odds of having seen physiotherapists, chiropractors, or PM & R physicians. Comparison of high-cost and non-high-cost patients Age, education, comorbidity and being on disability pension are factors that have previously been found to be associated with a greater burden of MSDs and poorer outcomes (70, 71), and may explain the higher costs for these patients. There were a greater proportion of immigrants in the non-high-cost group, despite prior research indicating that immigrants in Norway report a greater prevalence of MSDs (72). This discrepancy may be attributed to lower specialist care utilisation by immigrants compared to native Norwegians (15). Health care use for high-cost patients – room for improvement? Previous research has shown that surgical procedures and hospitalisation account for the highest costs related to MSDs in the short-term (22), and our findings demonstrate that this is also the case from a five-year perspective. Our findings show that older patients are more likely to be high-cost users, indicating that costs will increase significantly in the future as the population ages. Current models of care may not be sustainable for handling this increased burden (73, 74), highlighting the importance of researching resource use and discussing models of care that can handle the increasing burden and costs of MSDs. Forty-five percent of the most expensive specialist care contacts were related to management of fractures and injuries. As expected, these patients had low use of all healthcare services before their most expensive specialist contact. For these conditions, management in specialist healthcare is essential, can be considered absolutely warranted and cannot be prevented by prior healthcare use or primary care management. Approximately 40% percent of the individuals’ most expensive specialist care contacts were related to specialist care management of osteoarthritis and spinal, shoulder and knee disorders. Conservative management and rehabilitation are generally recommended as first-line treatments for these conditions (16, 25, 27-29, 38, 63-69). Fewer than half of patients with high costs related to specialist care treatment for osteoarthritis and spinal, shoulder and knee disorders had seen a healthcare service delivering conservative treatment, other than GPs, the year prior to their most expensive specialist contact. This finding is supported by previous research showing that 30-40% of patients receive appropriate nonsurgical care for osteoarthritis, 35% of patients receive a conservative plan of care the year prior to elective lumbar spine surgery and 65% of patients with rotator cuff disorders receive a nonsurgical management program (39-42). The implementation of a structured model of care for hip and knee osteoarthritis has been shown to increase the quality of care and be cost-effective, primarily by leading to reduced surgery rates, and stepwise care approaches have been shown to be cost-effective for knee disorders (34, 35). Studies have also shown that exercise therapy and patient education can lead to reduced surgery rates (75-79). Our findings indicate that the commonly recommended stepwise care model in which patients use conservative management and rehabilitation prior to more expensive specialist care treatment is underutilised in current practice. Increased use of conservative treatment such as patient education, rehabilitation, and exercise therapy as first-line treatment, as recommended in guidelines, could offer cost-savings by reducing or postponing more expensive specialist care procedures. There is a low capacity for both primary and specialist care rehabilitation compared to the demand, resulting in long waiting times before patients can access rehabilitation in Norway (80). Early access to physiotherapy is associated with lower MSD-related costs and lower use of imaging, injections and surgical interventions compared to delayed access, indicating that the timing of care is important (81). Guidelines state that patients who have undergone surgical procedures are prioritized for primary care rehabilitation services, while patients with acute and chronic MSDs have lower priority in Norway (82). A lack of capacity and reduced access to rehabilitation services before surgical procedures are likely to be important barriers for why stepwise care approaches are not routinely used in current practice. Previous research has shown that women are more likely to use of GP-services and physiotherapy than men are (83-85), and that women are older and have more advanced disease states when undergoing orthopaedic surgery (86, 87). Men have greater expectations to the effect of surgical interventions, while women are more concerned about potential risks and less likely to prefer surgical management (85, 88, 89). Women also encounter more barriers in the healthcare system before receiving surgical care, including negative interactions with healthcare personnel, difficulties in self-advocating for their care and experience less involvement by healthcare personnel in the decision-making process (85). Clinicians have also been shown to treat patients with MSDs differently based on gender. Women are less likely to receive imaging, are prescribed lower doses of medications and clinicians are more likely to suggest mental health referrals, while men are more likely to be recommended surgical interventions (90-92). The gender difference in our findings may be attributed to differences in health care seeking between genders, such as women being more likely to prefer to try other treatments for MSDs before surgical care, while men have greater expectations of the effect of surgical interventions and are more likely to advocate for this. The gender difference could also be due to clinician behaviour, where healthcare personnel are more likely to suggest surgical care for men. Whether this indicates that men are less likely to receive appropriate guideline concordant care with conservative management prior to surgical management, or represents a gender bias where women have more barriers for appropriate referrals is unclear. There is geographic variation in orthopedic procedures in Norway, where some procedures are more common in rural areas, while others are more common in urban areas (93, 94). It has been suggested that lack of uniformity in conservative care in Norway may be a driver of variation in surgery rates (93). Our findings indicate that there is a geographical difference in the use of conservative care, where patients from smaller municipalities are less likely to receive conservative care prior to specialist care management. This may indicate differences in accessibility to conservative care management in rural areas, which could lead to higher proportions being directly referred to specialist care. In that case, this could indicate an unwanted geographical service variation. The lack of clinical data in our study makes it impossible to determine whether there are important clinical factors that explain why patients are referred directly to specialist care and are not treated in primary care. Patients with spinal pain referred to PM & R specialist care in Norway have been found to have more severe symptoms, poorer quality of life, less education and greater psychosocial distress than patients treated in primary care (95). In contrast, a study on hand osteoarthritis in Norway showed that patients who were directly referred for surgical care had less pain and fewer limitations than patients who underwent rehabilitative interventions before referral (96). Fewer than half of the patients in our study had seen healthcare personnel delivering conservative treatment other than GPs the year preceding their most expensive specialist care contact, even for conditions where guidelines recommend rehabilitation as a first line treatment. It is unlikely that specific clinical characteristics or symptom severity can explain why such a substantial proportion of patients have not undergone conservative management or rehabilitation. High-cost users in primary care Our data show that approximately 6% of the high-cost patients had high costs related to long-term follow-up in primary care, most commonly due to a large number of physiotherapy contacts. This finding is similar to previous findings (15, 97). Patients with high levels of physiotherapy use have been found to have high pain and disability and to have negative health and illness perceptions, lower levels of internal health locus of control, poor self-management and high emotional distress (98-100). Patients who frequently use physiotherapy report less improvement in clinical outcomes than patients with less use (100), and studies indicate that a greater number of physiotherapy contacts does not lead to improved clinical outcomes (101-103). This suggests that a greater number of physiotherapy contacts does not necessarily lead to improved outcomes for patients, making it important to discuss whether the high use of physiotherapy contacts in a small group of patients in our findings may indicate an overuse of physiotherapy. On the other hand, healthcare delivery for patients with persistent MSDs and chronic conditions is complex and the value of providing healthcare may not be captured sufficiently by traditional clinical outcome measures (104). The high use of primary care treatment could lead to reduced use of more expensive specialist care interventions, resulting in a net benefit. The complex interplay of overuse and underuse illustrates the difficulty of optimizing healthcare delivery for patients with MSDs, and the balance between resource savings and personalized patient care remains an important challenge for healthcare systems. Strengths and limitations This study provides novel contributions to the existing body of literature on high-cost users in musculoskeletal health care. Most prior studies have focused on costs related to services rather than individuals, used short timeframes, or focused on predictive models (14, 22, 52, 97, 105-108). This study utilises registry data at the population-level and allows us to use a longer timeframe for defining high-cost users compared to previous research. By using individualised data to assess health care use and costs, we provide detailed information on patterns of health care use for patients with high costs, and whether these patterns are in concordance with current recommendations and guidelines. Using registries that include a large population linked at the individual level provides a unique dataset with complete information on public primary and specialist healthcare use and demographic and socioeconomic factors. This makes it possible to create a comprehensive cohort without problems with selection bias that influence the validity of the findings (109). This ensures that the study provides a more accurate overview of real-life clinical practice than what is possible to achieve with other designs (110). Our study uses primary care diagnoses and defined contacts by only using fees that indicate face-to-face, group or video consultation, an approach that has been shown to have high validity for the GP-service (56). It is important to acknowledge that differing coding behaviour between clinicians and professions, and different software between clinics might challenge the validity of diagnosis codes used in registry data (111). To account for this, we included all MSDs as one broad category rather than categorizing on individual codes, except for the most expensive specialist care contact, as this would most likely reduce accuracy. The study only has access to data for patients who were registered as residents in Oslo or Trondheim at any point between 2008 and 2020. Patients could live in another municipality when they were treated for their MSD, making it possible to assess differences in geographical location. Nevertheless, this leads to an underrepresentation of patients from smaller municipalities and other parts of the country. Our results only capture the reimbursement costs for the public healthcare system. This means that our reported healthcare costs underestimate the true cost of healthcare use, as these services are partially financed from out-of-pocket expenses and receive additional funding for running the services. As our data are based on reimbursement costs, we most likely underestimate the cost of chiropractors, as patients with high use of chiropractors cannot reach the 95 th percentile for costs due to low reimbursement. Another limitation is that we can only include patients who use the public healthcare system. There is an ambition in Norway that all parts of the population should have equal access to public high-quality healthcare services (50) and public healthcare represents 86% of all healthcare use in 2022 (112). The use of private healthcare increased significantly during the recent years, and in 2021, approximately 13% of the population had private health insurance (113). This means that there is a substantial amount of healthcare use on which we have no information, as privatized healthcare is not included in registries. Direct comparisons between countries are difficult due to large differences in health care organisations, welfare systems and social structures. We believe that the findings of our study are generalizable to other countries with similar health care organisations and structures. Conclusion The five percent of patients with the highest health care costs were responsible for nearly 60% of all costs for MSD-related care over a five-year period. High-cost patients were older, had less education, had more comorbidities and were more likely to receive disability pensions than non-high-cost patients were. More than 75% of high-cost users had one specialist care contact that accounted for more than half of their costs during the five-year period, mainly related to surgical treatment. We found a relatively low use of healthcare services delivering conservative care and rehabilitation, other than GPs, the year before patients’ most expensive specialist healthcare contact. This was also found in conditions where guidelines recommend conservative management and rehabilitation before specialist referral. Previous studies have shown that stepwise care approaches and interventions such as patient education and exercise therapy can reduce surgery rates and costs. Overall, this may indicate that it is possible to reduce overall costs by offering patients with nontraumatic MSDs the opportunity to try conservative management and rehabilitation before being referred to specialist care management. It is important to acknowledge that this most likely requires significant investments as the demand is greater than the current capacity. Abbreviations MSDs Musculoskeletal disorders INOREG INnovations in use of REGistry data STROBE Strengthening the Reporting of Observational Studies in Epidemiology RECORD REporting of studies Conducted using Observational Routinely-collected Data GP General practitioner HELFO The Norwegian Health Economics Administration KUHR The Control and Reimbursement of Health Care Claims NPR Norwegian Patient Registry FD-Trygd Statistics Norway's Social Security Event History Database ICPC-2 International Classification of Primary Care, 2nd version ICD-10 International Classification of Diseases DRG Nordic Diagnosis-Related Group PM & R Physical Medicine and Rehabilitation Declarations Ethics approval and consent to participate This project has been granted access to registry data and exemption from requiring informed consent by the Regional Committees for Medical Research Ethics South East Norway (REC South East), with reference number 118725. All methods were performed in accordance with relevant guidelines and regulations. Consent for publication Not applicable Availability of data and materials The datasets used in the current study are based on national registries and are not publicly available. Access to pseudonymized data from the national registries is only granted through application to the Norwegian Centre for Research Data and Regional Committees for Medical and Health Research Ethics. Other data and materials can be obtained from the corresponding author upon reasonable request. Competing interests The authors declare that they have no conflicts of interest. Funding The project is funded through The Research Council of Norway, project code 302782/H40. Authors’ contributions OA, NKV, TAM, JHH and TT contributed to the study conception and design. OA was responsible for the data management and analysis, with important contributions from NKV, TAM, TT and JHH. All the authors contributed to the interpretation of the findings, per their expertise. OA and NKV were responsible for drafting the manuscript, and all the authors contributed to the revision of the manuscript. All authors approved the manuscript prior to submission. Corresponding author Correspondence to [email protected] . Acknowledgements All the authors are grateful for the contributions of the project reference group, which includes patient representatives, clinicians, stakeholders from primary and specialist health care and other Nordic research collaborators. The reference group provided important input throughout the research process and contributed to the interpretation of the findings. Disclaimer Data from the Control and Reimbursement of Health Care Claims, the Norwegian Patient Registry, Statistics Norway, and the Cause of Death Registry are used in the project. 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Holsen M, Hovind V, Bedane HK, Osvoll KI, Gjertsen JE, Furnes ON, et al. Geographical variation in orthopedic procedures in Norway: Cross-sectional population-based study. Scand J Surg. 2022;111(4):92–8. Bale M, Aksnes J, Holsen M, Osvoll K, Bedane H. Orthopaedic Healthcare Atlas for Norway: Use of orthopaedic health services 2012–2016. Førde: Helse Førde. 2019(1). Tyrdal MK, Veierød MB, Røe C, Natvig B, Wahl AK, Stendal Robinson H. Neck and back pain: Differences between patients treated in primary and specialist health care. J Rehabil Med. 2022;54:jrm00300. Gravås EMH, Tveter AT, Nossum R, Eide REM, Klokkeide Å, Matre KH, et al. Non-pharmacological treatment gap preceding surgical consultation in thumb carpometacarpal osteoarthritis - a cross-sectional study. BMC Musculoskelet Disord. 2019;20(1):180. Mose S, Kent P, Smith A, Andersen JH, Christiansen DH. Trajectories of Musculoskeletal Healthcare Utilization of People with Chronic Musculoskeletal Pain - A Population-Based Cohort Study. Clin Epidemiol. 2021;13:825–43. Opseth G, Wahl AK, Bjørke G, Mengshoel AM. Negative perceptions of illness and health are associated with frequent use of physiotherapy in primary healthcare. Musculoskelet Care. 2018;16(1):133–8. Wahl AK, Opseth G, Nolte S, Osborne RH, Bjørke G, Mengshoel AM. Is regular use of physiotherapy treatment associated with health locus of control and self-management competency? A study of patients with musculoskeletal disorders undergoing physiotherapy in primary health care. Musculoskelet Sci Pract. 2018;36:43–7. Budtz CR, Mose S, Christiansen DH. Socio-demographic, clinical and psychological predictors of healthcare utilization among patients with musculoskeletal disorders: a prospective cohort study. BMC Health Serv Res. 2020;20(1):239. Dubé M-O, Dillon S, Gallagher K, Ryan J, McCreesh K. One and Done? The effectiveness of a single session of physiotherapy compared to multiple sessions to reduce pain and improve function and quality of life in patients with a musculoskeletal disorder: a systematic review with meta-analyses. Arch Phys Med Rehabil. 2023. Hopewell S, Keene DJ, Heine P, Marian IR, Dritsaki M, Cureton L, et al. Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT. Health Technol Assess. 2021;25(48):1–158. Darnall BD, Roy A, Chen AL, Ziadni MS, Keane RT, You DS, et al. Comparison of a Single-Session Pain Management Skills Intervention With a Single-Session Health Education Intervention and 8 Sessions of Cognitive Behavioral Therapy in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Netw Open. 2021;4(8):e2113401. Mengshoel AM, Bjorbækmo WS, Sallinen M, Wahl AK. It takes time, but recovering makes it worthwhile'- A qualitative study of long-term users' experiences of physiotherapy in primary health care. Physiother Theory Pract. 2021;37(1):6–16. Mutubuki EN, Luitjens MA, Maas ET, Huygen F, Ostelo R, van Tulder MW, et al. Predictive factors of high societal costs among chronic low back pain patients. Eur J Pain. 2020;24(2):325–37. Becker A, Held H, Redaelli M, Strauch K, Chenot JF, Leonhardt C, et al. Low back pain in primary care: costs of care and prediction of future health care utilization. Spine (Phila Pa 1976). 2010;35(18):1714–20. Mose S, Kent P, Smith A, Andersen JH, Christiansen DH. Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs – a Danish population-based cohort study. BMC Health Serv Res. 2021;21(1):980. Emilson C, Åsenlöf P, Demmelmaier I, Bergman S. Association between health care utilization and musculoskeletal pain. A 21-year follow-up of a population cohort. Scandinavian J Pain. 2020;20(3):533–43. Nilsen RM, Vollset SE, Gjessing HK, Skjærven R, Melve KK, Schreuder P, et al. Self-selection and bias in a large prospective pregnancy cohort in Norway. Paediatr Perinat Epidemiol. 2009;23(6):597–608. Thygesen LC, Ersbøll AK. When the entire population is the sample: strengths and limitations in register-based epidemiology. Eur J Epidemiol. 2014;29(8):551–8. Riiser S, Haukenes I, Baste V, Smith-Sivertsen T, Hetlevik Ø, Ruths S. Variation in general practitioners’ depression care following certification of sickness absence: a registry-based cohort study. Fam Pract. 2020;38(3):238–45. OECD, Union E. Health at a Glance: Europe 20222022. Fåne JE. Ni av ti behandlingsforsikringer er via arbeidsgiver. Finans Norge; 2022. Additional Declarations No competing interests reported. Supplementary Files Art2Supplementary1.docx Art2Supplementary2.docx Art2Supplementary3.docx Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 17 Mar, 2024 Submission checks completed at journal 14 Mar, 2024 Editor assigned by journal 14 Mar, 2024 First submitted to journal 01 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4002700","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":279661284,"identity":"8d225d9d-7eba-49ec-a73b-1690b1912ce4","order_by":0,"name":"Olav Amundsen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYDACdjgrAYgrgPgwA8MBIMWDUwszipYzJGthbGOAqMcH+JmZn0kw1GxL3M6e/vBx4bxtcnzH2R8eLmA4LMPPwHvwARYtks1sZhIMx24n7ux5Y2w8c9ttY8nDPAaHZzAc5pFs4Es2wKLF4DCDsQED2+3EDTdy2KR5twEZh3kYwMjgAA/QNGxa2D8bMPwDaUl//pt3zu36DYfZHxDQwmP4gLENpCXBjJm34XYC0F4DvFokm3kKHyT23TbecOaNsTTPsduGM0F+4TFI5wFKGWPzCz97+4YDH77dlt1wPP3hZ56a2/J8548//sxTYW3Pz95jiC3EwCABi4MZkKNsFIyCUTAKRgGJAABbtGP6iIclfgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Oslo","correspondingAuthor":true,"prefix":"","firstName":"Olav","middleName":"","lastName":"Amundsen","suffix":""},{"id":279661285,"identity":"4323be71-a399-4650-8fc9-ac6eef587f5a","order_by":1,"name":"Tron Anders Moger","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Tron","middleName":"Anders","lastName":"Moger","suffix":""},{"id":279661286,"identity":"af43c0e8-3507-4fe1-9e1a-a34c10ee27ea","order_by":2,"name":"Jon Helgheim Holte","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Jon","middleName":"Helgheim","lastName":"Holte","suffix":""},{"id":279661290,"identity":"dbf579d6-6b55-40c9-ace6-4cea5c5ae720","order_by":3,"name":"Silje Bjørnsen Haavaag","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Silje","middleName":"Bjørnsen","lastName":"Haavaag","suffix":""},{"id":279661291,"identity":"310dbbcc-ea77-4c02-9897-3871158c7520","order_by":4,"name":"Line Kildal Bragstad","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Line","middleName":"Kildal","lastName":"Bragstad","suffix":""},{"id":279661292,"identity":"a5d17977-5ffe-464f-a3fb-5e258dde339f","order_by":5,"name":"Ragnhild Hellesø","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Ragnhild","middleName":"","lastName":"Hellesø","suffix":""},{"id":279661293,"identity":"d342096f-118d-4d0c-bed9-67842a1d12fd","order_by":6,"name":"Trond Tjerbo","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Trond","middleName":"","lastName":"Tjerbo","suffix":""},{"id":279661294,"identity":"79e6590d-9f57-4102-b86d-0c36ecf67c43","order_by":7,"name":"Nina Køpke Vøllestad","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Nina","middleName":"Køpke","lastName":"Vøllestad","suffix":""}],"badges":[],"createdAt":"2024-03-01 09:15:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4002700/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4002700/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-12051-3","type":"published","date":"2024-12-18T15:57:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53016201,"identity":"e59c3e44-d134-4dfb-88b0-ebab00b890ae","added_by":"auto","created_at":"2024-03-19 16:04:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":173800,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the sample selection process. MSD=Musculoskeletal disorder\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/db4615b6c7ad9291bdd16b3f.png"},{"id":53016203,"identity":"9ed1a5ec-9cc6-4679-a2a3-1072bd56f42f","added_by":"auto","created_at":"2024-03-19 16:04:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":156013,"visible":true,"origin":"","legend":"\u003cp\u003ePie diagram showing the relative proportion of healthcare costs for each service, for high-cost patients and non-high-cost patients. GP=general practitioner. EC=emergency care\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/425fd94aacdc97ce87527ec9.png"},{"id":53017748,"identity":"701237f1-0460-43ea-958d-ec1d9de98985","added_by":"auto","created_at":"2024-03-19 16:12:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1032490,"visible":true,"origin":"","legend":"\u003cp\u003eHealthcare contacts (X-axis) and costs in NOK (Y-axis) for MSDs in years 1 through 5. Blue marks patients with higher costs in specialist care than in primary care (94%), and red marks patients with higher costs in primary care than in specialist care (6%). Twelve patients with costs above €45 000 are not shown. SHC=Specialist health care. PHC=Primary health care\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/f72923f4cd7eddd4c5c2fdb2.png"},{"id":72201848,"identity":"39c5abd2-c614-42c3-b860-d24e0d230e6a","added_by":"auto","created_at":"2024-12-23 16:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1940855,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/fea58afa-1115-4aa8-b931-ce5f0ba17a27.pdf"},{"id":53016206,"identity":"1c10e820-8a84-44ec-8afc-05890d7d7c46","added_by":"auto","created_at":"2024-03-19 16:04:55","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":18449,"visible":true,"origin":"","legend":"","description":"","filename":"Art2Supplementary1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/54508353e0ad21c3eca775f3.docx"},{"id":53016205,"identity":"47c39c4c-6000-4994-9fd8-6678d9d14777","added_by":"auto","created_at":"2024-03-19 16:04:55","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":15689,"visible":true,"origin":"","legend":"","description":"","filename":"Art2Supplementary2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/5149c21ca821d59ccae5c7d5.docx"},{"id":53016202,"identity":"a6b9b4ef-e27e-4371-aed2-00d308659ae6","added_by":"auto","created_at":"2024-03-19 16:04:54","extension":"docx","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":16780,"visible":true,"origin":"","legend":"","description":"","filename":"Art2Supplementary3.docx","url":"https://assets-eu.researchsquare.com/files/rs-4002700/v1/b4c55fa763f5758aa534ca98.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient Characteristics and Healthcare Use for High-cost Patients with Musculoskeletal Disorders in Norway: A Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMusculoskeletal disorders (MSDs) include a wide range of conditions. These conditions can range from short-lived and mildly bothersome to chronic conditions that result in life-long disability, activity-limitations and reduced work and social participation (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). MSDs are one of the leading causes of years lived with disability in most countries according to the Global Burden of Disease Study (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Approximately one-third of all European workers are affected by MSDs, making it the most common work-related health problem in Europe (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The prevalence of MSDs increases with age, and it is expected that the societal burden associated with MSDs will increase significantly in the future (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMSDs exert a substantial strain on societal economic resources. They represent one of the diagnostic groups with the highest direct healthcare costs and account for a significant proportion of countries\u0026rsquo; healthcare budgets (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). There are large variations in healthcare use for MSDs, where most people with musculoskeletal pain do not seek any care, and a small proportion are responsible for the majority of costs and number of healthcare contacts (\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eModern healthcare systems have an increased focus on reducing unwarranted costs and addressing overuse (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). An overarching principle for cost-reduction is that the patient is treated at the lowest effective level of care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Previous research has shown that the highest costs for MSDs are associated with hospitalisation and surgical treatment (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Traumatic MSDs are routinely examined and treated in specialist care, where this management can be considered absolutely warranted (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Many nontraumatic MSDs can be handled effectively in primary care with interventions such as self-management advice, exercise therapy, psychosocial interventions, and simple analgesics (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Recommendations for conservative treatment for MSDs include using patient-centred care considering individual values, goals, and psychosocial factors, providing education and information, and include management that addresses physical activity and exercise (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Guidelines recommend that patients with nontraumatic MSDs should predominantly be managed in primary care and be offered conservative treatment prior to surgical management (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Stepwise care models in which high-quality conservative management and rehabilitation are attempted prior to specialist care referral have been suggested to increase the quality of care and reduce the costs of MSDs (\u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, prior research indicates that care for MSDs is often in discordance with guidelines and that patients commonly have low use of conservative treatment before they are treated surgically (\u003cspan additionalcitationids=\"CR37 CR38 CR39 CR40 CR41\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). There are numerous reasons why treatment may or may not adhere to clinical guidelines, such as unfamiliarity with guidelines, disagreement with recommendations, pressure from patients and fear of repercussions (\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Additionally, guidelines are meant only to support decision-making, and not intended as replacement for clinical judgement or to be followed meticulously (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In each individual case, there could be important factors, e.g., specific clinical characteristics or unremitting high disability and pain intensity, that explain why treatment did or did not follow guidelines.\u003c/p\u003e \u003cp\u003eThe first aim of this study is to describe patterns of health care use that contribute to particularly high costs over a five-year period at the individual level. We expect large variation in health care use, but if patients\u0026rsquo; health care use in general is in accordance with recommendations and guidelines, we would expect that certain health care use patterns emerge in the data for high-cost users: 1) Patients have high costs related to specialist care management of acute and traumatic conditions with low use of health care services prior to this, and 2) patients with high costs related to specialist care management of nontraumatic MSDs have frequent use of primary care services and conservative treatment before they are treated in specialist care. If these patterns are not typical in our data, it raises the question of whether better implementation of guidelines is required, or whether the guidelines themselves need to be revised. The second aim is to examine whether there are systematic differences in geographical location, demographic and socioeconomic factors between high-cost patients that have a health care use pattern in accordance with recommendations and those who do not.\u003c/p\u003e \u003cp\u003e The findings from his study can provide information on how different service use contributes to high costs in the long-term, how primary and specialist care are used in combination and whether health care use patterns for high-cost patients in general follow current management recommendations and guidelines. These findings can contribute to the understanding of the characteristics and service use patterns of high-cost patients and aid in planning of future MSD-care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eDesign and Setting\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis cohort study was conducted as part of the INnovations in use Of REGistry data (INOREG) project at the Institute of Health and Society, University of Oslo. The project combines several registries from 2008 to 2020 to create a cohort with healthcare use, costs, demographic and socioeconomic factors and outcomes for chronic diseases in Norway. The present study uses national registries with primary and specialist healthcare data, capturing all use of public healthcare in Norway. The reporting of this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for observational studies with the REporting of studies Conducted using Observational Routinely-collected Data (RECORD) extension\u0026nbsp;(48, 49).\u003c/p\u003e\n\u003cp\u003eWe used data on healthcare utilisation for MSDs from the Norwegian public healthcare service. Norway has a national universal healthcare system with the overarching goal of ensuring equal access to services for all residents\u0026nbsp;(50). The main providers for MSD-care in Norway include general practitioners (GPs), hospital services, physiotherapists and chiropractors. Additionally, contract specialists, municipal rehabilitation (mostly focused on elderly care with home-based rehabilitation and short-term rehabilitation stays in municipal institutions), municipal emergency care and specialist rehabilitation institutions are also involved. Other professionals such as naprapaths and osteopaths are also involved but work fully in the private market. Norway has had a Regular GP scheme in which all inhabitants are assigned their own GP since 2001\u0026nbsp;(50). Ninety-six percent of the population are registered with a GP\u0026nbsp;(51). GPs function as gatekeepers in the Norwegian health care system and are responsible for coordinating care and referrals to specialist care\u0026nbsp;(50). Additionally, since 2008, physiotherapists with a master\u0026rsquo;s degree in treatment of MSDs (manual therapists) and chiropractors have had the right to refer to specialist health care and radiological examinations and to prescribe sick leave for up to 12 weeks for MSDs. GPs and physiotherapists are part of municipal primary care and receive capitation from the municipal for running the services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe costs for consultations for GPs and physiotherapists are covered through a combination of fee-for-service reimbursement from The Norwegian Health Economics Administration (HELFO) and out-of-pocket payment from the patients. Chiropractors operate as private practitioners and can set their own price but also receive a modest fee-for-service reimbursement from HELFO covering approximately 10% of the total cost\u0026nbsp;(52). Hospital care is provided by trusts owned by regional health authorities. Inpatient care is fully covered for patients, while outpatient care has an out-of-pocket cost similarly to that of GPs and physiotherapy services. A cost-sharing ceiling with a maximum limit for out-of-pocket costs exists to protect patients with high healthcare use from high costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSample Selection\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study included patients who were registered as residents of Oslo or Trondheim at any point between 2008 and 2020. We included patients with an MSD-related healthcare contact in The Control and reimbursement of healthcare claims (KUHR) database, ICPC-2 Chapter L, or the Norwegian Patient Registry (NPR), ICD-10 Chapter M, during the years 2013-2015 and no MSD-related contacts during the preceding three years. Inclusion started in 2013 to ensure that the data from all healthcare services were complete. The time of the first MSD-related contact during 2013-2015 served as an index date, irrespective of which healthcare professional registered the first contact. Prior studies have defined a three-year wash-out period as optimal for excluding ongoing disorders and identifying new cases for common MSDs\u0026nbsp;(53, 54). The data on GP-services are complete from 2008, enabling us to use three years prior to the first contact as a washout-period. Patients younger than 18 years, or who died within five years after the index contact were excluded. Additionally, patients with MSD-diagnoses related to infection, malignancy, or inflammatory rheumatic diseases (ICPC-2 codes: L70, L71, L88 or L97. ICD-10 codes (M00-M03, M05-M08, M10, M11, M13, M30-M36, M45, M46, M60, M65 and M71 and M86) were excluded as the present study focused on symptom-based diagnoses. We used a follow-up period of five years for each patient, starting from the individual index date. To account for the COVID-19 pandemic, where it is expected that the lockdown had major impact on healthcare delivery, we excluded patients for whom the five-year follow-up extended beyond 12\u003csup\u003eth\u003c/sup\u003e March 2020.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData sources and variables\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe fee-for-service reimbursements from HELFO are registered in KUHR, which allows the identification of contacts and costs for healthcare use at an individual level. Hospitals operate with activity-based funding based on the Nordic Diagnosis-Related Group (DRG) system to classify patients. This is registered in the NPR with a cost-weight, making it possible to calculate costs for contacts and procedures for each healthcare contact in the hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe used data from the KUHR to capture primary healthcare utilisation. This allowed the calculation of use and costs for services provided by GPs, physiotherapists, chiropractors, contract specialists and municipal emergency care services. The NPR was used to capture specialist healthcare use and to calculate the corresponding costs. Statistics Norway and FD-Trygd were used for demographic and socioeconomic factors. The Norwegian Cause of Death Registry was used to exclude patients who died during the follow-up period.\u003c/p\u003e\n\u003cp\u003eThe selected registries provide a complete overview of public healthcare use, meaning that there was no loss to follow-up due to a lack of reporting. All costs represent the reimbursement costs for the services and do not include capitation from the municipality, the block grants to hospitals or the out-of-pocket costs for the patients. This means that the costs reflect what the public healthcare system reimburses for the actual services provided, but not the expenses of running the services or the patients\u0026rsquo; out-of-pocket costs. The GP-service, physiotherapy and hospitals receive approximately half of their income from capitation from the municipality or block grants from the state, while the other half are based on activity-based funding. This means that it is likely that the total cost is greater than what we present in our findings. The total costs related to treatment by chiropractors are underestimated in our results, as this service is mainly financed by out-of-pocket costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA detailed list of the data sources, variables and their definitions used in this study are presented in Table 1. Categorizations and definitions are based on definitions by Statistics Norway if available or defined by the authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Data sources, variables and variable definitions\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"664\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" valign=\"top\"\u003e\n \u003cp\u003eSource\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eDefinition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eKUHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eIndex date\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eFirst registered date with an MSD-related healthcare contact, if first date were registered in KUHR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnoses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eInternational Classification of Primary Care, 2nd edition (ICPC-2) codes within chapter \u0026ldquo;L; Musculoskeletal\u0026rdquo; was used to identify contacts and costs related to MSDs. Patients registered with the specific codes L70 (Infection of musculoskeletal system), L71 (Malignant neoplasm musculoskeletal), L88 (Rheumatoid/seropositive arthritis and L97 (Neoplasm musculoskeletal benign/unspecific) were excluded.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eA previously adapted comorbidity index from GP-diagnoses based on ICPC-2 diagnoses, which have been validated to be used as an adjustment variable in epidemiological research in primary care databases\u0026nbsp;(55). This is a comorbidity index based on primary care data with eighteen selected diagnoses and the individual patient are assigned an index score based on number of diagnoses that can be identified. The comorbidity index was dichotomised into 0-1/2 or more.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency of contacts for GP, physiotherapy, chiropractors, municipal emergency care and contract specialists with an MSD-diagnosis. Contact was defined as a healthcare contact with a fee indicating a face-to-face/video-consultation individually or group based and does not include fees that indicate simple communication, prescription writing or administrative work. This approach has shown high validity for the GP-service\u0026nbsp;(56). Included fees:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGP: 2ad, 2ak, 2ae, 2ed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePhysiotherapy: A2a-f, A3a-b, A8a, A9a, A1a, A1d, c34\u003cbr\u003e\u0026nbsp;Chiropractors: K1, K2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eAll reimbursement fees for contacts with an MSD-diagnosis. Costs are calculated in Norwegian currency but written in text as Euro (1\u0026euro;=11.3 NOK, per 19.02.2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eGeographical location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eThe municipality where the first GP-contact with an MSD-diagnosis were registered. The municipalities were classified as: \u0026ldquo;Large city, large municipality, small municipality\u0026rdquo; based on a national classification system from Statistics Norway\u0026nbsp;(57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eNPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eIndex date\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eFirst registered date with an MSD-related healthcare contact, if first date were registered in NPR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnoses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eICD-10 codes\u0026nbsp;(58)\u0026nbsp;within chapter \u0026ldquo;Diseases of the musculoskeletal system and connective tissue\u0026rdquo; \u0026nbsp;were used to categorise contacts and costs related to MSDs. Patients registered with the specific codes related to infections (M00, M01, M02), malignant disease (M86) and inflammatory rheumatic disease (M05-M08, M10, M11, M13, M30-M36, M45, M46) were excluded. Musculoskeletal conditions include all ICD-10 codes chapter M, excluding those specified above, and the code G55. Injuries to the musculoskeletal system includes codes within chapter \u0026ldquo;Injury, poisoning and certain other consequences of external causes\u0026rdquo; related to MSD, codes S32-34, S40-S99 and T08-T13, excluding codes related to superficial injuries and wounds (Sx0 and Sx1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare contacts\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency of contacts after index date registered as outpatient contact or inpatient stay with an MSD-diagnosis. This includes contact with all healthcare personnel in specialist care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare cost related to DRGs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eCost weight of DRG (corrected version) per MSD-related contact multiplied with cost of 1 DRG for the specific year. Cost of 1 DRG increased from 39447 NOK in 2013 to 45808 NOK in 2020. Costs are calculated in Norwegian currency but written in text as Euro (1\u0026euro;=11.3 NOK, per 19.02.2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eProcedure codes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eProcedure codes using the Norwegian Clinical Procedure Codes for surgical and medical procedures\u0026nbsp;(59). Used to identify procedures for the most expensive specialist care contact for high-cost patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eEpisode\u0026apos;s discipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eUsed to identify what proportion of the most expensive contact are related to treatment in surgical departments. Also used to assess use of Physical Medicine and Rehabilitation physicians prior to high-cost patients most expensive specialist care contact.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" valign=\"top\"\u003e\n \u003cp\u003eMunicipality electronic patient journal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eMunicipal rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eProportion that received municipal rehabilitation services prior to the most expensive specialist care contact. Municipal rehabilitation services do not include diagnosis codes.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eStatistics Norway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eAge in years at index date\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eMale/female\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eEducation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eHighest registered education. Categorised: 13 years or less/more than 13 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eIncome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eIncome registered the year before inclusion. Categorised as below/above median.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.34225621414914%\" valign=\"top\"\u003e\n \u003cp\u003eImmigrant background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.65774378585085%\" valign=\"top\"\u003e\n \u003cp\u003eCategorised: No immigration background or Any immigration background (Includes: first generation immigrant, Norwegian-born second-generation immigrant, one foreign parent, born outside Norway from Norwegian parents)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" valign=\"top\"\u003e\n \u003cp\u003eFD-Trygd\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eDisability pension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eIf the patient is registered on disability pension prior to inclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.234939759036145%\" valign=\"top\"\u003e\n \u003cp\u003eNorwegian Cause of Death Registry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53614457831325%\" valign=\"top\"\u003e\n \u003cp\u003eDate of death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.2289156626506%\" valign=\"top\"\u003e\n \u003cp\u003eDate of death were used to exclude patients that died during the five-year follow-up period.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: KUHR: The Control and Reimbursement of Healthcare Claims. NPR: Norwegian Patient Registry. MSD: Musculoskeletal disorder. GP:\u0026nbsp;General practitioner.\u0026nbsp;ICPC-2: International Classification of Primary Care, 2nd version. ICD-10: International Statistical Classification of Diseases and Related Health Problems 10th Revision.\u0026nbsp;DRG: Nordic Diagnosis-Related group\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eHigh-cost users were defined as individuals whose cost during the five-year period was equal to or exceeded the 95\u003csup\u003eth\u003c/sup\u003e percentile. There is no consensus on the definition of high-cost patients, and the definition varies among studies\u0026nbsp;(14, 60-62). In our data, the 95\u003csup\u003eth\u003c/sup\u003e percentile for total costs in the five year-period was 3 791 Euro (\u0026euro;), which was used as a cut-off when describing patient characteristics. healthcare use and costs for high-cost patients compared to non-high-cost patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe relationships between the number of MSD-related costs and contacts were described using a scatterplot. For the high-cost users, we identified the most expensive specialist health care contact for each patient during the five-year period, and presented descriptive statistics on the diagnosis, proportion of contacts related to surgical treatment and costs.\u003c/p\u003e\n\u003cp\u003eWe examined healthcare use before the most expensive specialist care contact for high-cost patients to determine whether this adhered to current recommendations. Conservative treatment and rehabilitation are recommended as first-line treatments for conditions such as osteoarthritis\u0026nbsp;(29, 63, 64), spinal disorders\u0026nbsp;(16, 28, 38), shoulder pain\u0026nbsp;(27, 41, 65, 66), and knee disorders\u0026nbsp;(67-69). The main providers of conservative care in Norway are GPs, physiotherapists, chiropractors and Physical Medicine and Rehabilitation (PM \u0026amp; R) physicians in specialist care. We assessed whether the patients had registered a contact with any of these healthcare services prior to their most expensive specialist care contact. We defined that the contacts with GPs, physiotherapists, chiropractors and PM \u0026amp; R physicians needed to be less than one year prior to the specialist care contact to ensure that the contact was relatively close to the most expensive specialist care contact. Due to the uncertainty of the specific diagnosis codes used in primary care, we did not restrict the exact diagnosis but included all contacts with any MSDs. There is no standardized method for identifying what health care contacts are relevant to the condition the patient were treated in specialist care for, and what contacts are related to other musculoskeletal problems. It could be argued that our definition is too strict, as it is possible that conservative treatment more than one year prior to the specialist care contact may be relevant, or not strict enough, as it does not restrict on specific diagnosis codes relevant to the specialist care contact. To account for this, we included results with both a stricter and a less strict definition in the supplementary as a sensitivity analysis. The stricter definition included only contacts the year before which included a diagnosis code relevant for the most expensive specialist care contact. The less strict definition included all contacts for any MSDs (including contacts where fees indicated simple communication, prescription writing or administrative work) between the index date and the specialist care contact.\u003c/p\u003e\n\u003cp\u003eFor patients for whom the most expensive specialist care contact was related to osteoarthritis or spinal, shoulder or knee disorders, we used logistic regression analysis to assess what factors were associated with having been to a health care service that provides conservative care prior to their most expensive specialist care contact. We assessed the associations with demographic factors (age, gender, immigration background), socioeconomic factors (education, income, being on disability pension), comorbidities and geographical variation (large city, large municipality or small municipality) in univariate and multivariate analyses. In the logistic regression, we also included the number of GP-contacts prior to the most expensive specialist care contact as a covariate, as most patients (approximately 85%) had at least one contact with a GP, and the number of GP-contacts influences the opportunity to refer to conservative treatment. \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe initial database included 1 016 638 patients who were registered with an MSD-diagnosis between 2008 and 2020. We excluded patients based on index year, follow-up time after the COVID-19 lockdown, age less than 18 years, specific diagnosis and death during the five-year period. This led to a final sample consisting of 139 249 patients (Figure 1).\u003c/p\u003e\n\u003cp\u003ePatients with healthcare costs above the 95\u003csup\u003eth\u003c/sup\u003e percentile were older, had less education, had more comorbidities, and were more likely to recieve disability pensions prior to the index date than non-high-cost patients (Table 2). The high-cost patient group had fewer patients registered in a large city and fewer patients with an immigrant background. There were negligible differences in income and gender.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Patient characteristics for high-cost and non-high-cost patients. N=139\u0026nbsp;249.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eHigh-cost patients\u003c/p\u003e\n \u003cp\u003eN=6 961 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eNon-high-cost patients\u003c/p\u003e\n \u003cp\u003eN=132 288 (95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eAge, years (mean (SD))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e54 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e42 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eGender, female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e51.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e50.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eGeographical location\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; Large city\u0026nbsp;\u003cbr\u003e\u0026nbsp; \u0026nbsp;Large municipality\u003cbr\u003e\u0026nbsp; \u0026nbsp;Small municipality\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.9%\u003c/p\u003e\n \u003cp\u003e17.4%\u003c/p\u003e\n \u003cp\u003e18.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.9%\u003c/p\u003e\n \u003cp\u003e14.7%\u003c/p\u003e\n \u003cp\u003e12.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eEducation, more than 13 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e37.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e49.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eIncome in \u0026euro; (median (IQR))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e32\u0026nbsp;685 (26\u0026nbsp;100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e33 837 (29 122)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eDisability pension before index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eImmigrant background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e21.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e31.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidity, 2 or more \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e7.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e3.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Comorbidity index based on the International Classification of Primary Care (ICPC-2) (55).\u003c/p\u003e\n\u003cp\u003eHigh-cost patients had a median cost of \u0026euro;7 835 (IQR 6 454), while non-high-cost patients had a median cost of \u0026euro;115 (IQR 265). High-cost patients had a median of 34 (IQR 48) healthcare contacts in the five-year follow-up period, while non-high-cost patients had 5 (IQR 11) healthcare contacts. High-cost patients accounted for 59% of all costs during the follow-up period. The cost distributions per service for high-cost patients and non-high-cost patients are illustrated in Figure 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNinety-four percent of high-cost patients had higher costs in specialist care than in primary care, while 6% had higher costs in primary care (Figure 3). The patients with higher costs in specialist care had 93% of their costs related to specialist care, and 53% of their contacts related to physiotherapy. For patients with higher costs in primary care, 70% of the costs and 87% of the contacts were related to physiotherapy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the high-cost patients, 77% had one specialist healthcare contact that accounted for more than half of their total costs over a five-year period. The most expensive specialist healthcare contact was registered in a surgical department or with a surgical procedure code for 94% of the patients, varying from 80 to 99% between diagnosis categories. Table 3 shows the diagnosis categories for these contacts, the associated costs and the proportion of contacts related to a surgical department or surgical treatment. A table including all specific diagnoses included in each diagnostic category (Supplementary 1) and the most common procedures for each diagnostic category (Supplementary 2) is included in the supplementary material.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Characteristics for the most expensive specialist healthcare contact per person for high-cost patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnostic category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003eMedian (IQR) cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003eSurgical department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eFractures/injuries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e3 110 (45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e6 404 (4 3166)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e98.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eOsteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e1 269 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e10 880 (3 342)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e99.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eSpinal disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e1 022 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e5 890 (5 590)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e80.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eShoulder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e288 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e2 809 (1 114)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e94.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eKnee\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e287 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e3\u0026nbsp;138 (2 189)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e99.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eOther MSDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e894 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e2 671 (3 288)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e82.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.140495867768596%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.669421487603305%\" valign=\"top\"\u003e\n \u003cp\u003e6 870\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.760330578512395%\" valign=\"top\"\u003e\n \u003cp\u003e6 224 (6 337)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.429752066115704%\" valign=\"top\"\u003e\n \u003cp\u003e93.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCosts presented in Euro. Surgical department is defined as contact registered in a surgical department and/or with a surgical procedure code. All diagnosis codes included in each category are presented in supplementary 2. Ninety-two patients (1.3%) in the high-cost group had no specialist care use and were not included in table.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproximately 85% of patients whose most expensive contact was related to osteoarthritis, spinal-, shoulder- and knee disorders had seen their GP the year before the year before the most expensive specialist care contact, while patients treated for fractures showed low use of GP-services prior to the specialist care contact (Table 4). Approximately 45-50% of patients with contacts related to osteoarthritis, and spinal, shoulder and knee disorders had seen any health care personnel delivering conservative treatment other than GPs the year prior to their most expensive specialist care contact. Depending on the definition, this varies from 28-40% between diagnoses with a stricter definition to 55-67% with a less strict definition (Supplementary 3). The proportions of patients having seen a physiotherapist, chiropractor or PM \u0026amp; R physician per diagnosis category are presented below (Table 4). Additionally, 1.5% of patients were registered with a municipal rehabilitation service at any time before the specialist care treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Proportion with at least one MSD-contact per service the year before their most expensive specialist healthcare contact\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003ePhysiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003eChiropractor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003ePM \u0026amp; R\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eAny other than GP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDiagnostic category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003eProportion with one or more contacts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003eProportion with one or more contacts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003eProportion with one or more contacts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003eProportion with one or more contacts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eProportion with one or more contacts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eFractures/injuries\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e32.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e6.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e4.6%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eOsteoarthritis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e83.7%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e37.8%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e6.1%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e43.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eSpinal disorders\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e83.1%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e26.7%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e19.7%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e12.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e45.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eShoulder\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e88.9%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e41.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e4.9%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e10.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e51.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eKnee\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e79.1%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e42.2%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e7.0%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e46.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eOther MSDs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e68.7%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e24.2%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e8.5%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e32.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e58.6%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e20.7%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.728476821192054%\" valign=\"top\"\u003e\n \u003cp\u003e7.8%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e3.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e28.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCategorised by diagnosis registered for the most expensive specialist care contact. PM \u0026amp; R: Physical Medicine and Rehabilitation\u003c/p\u003e\n\u003cp\u003eUnivariate and logistic regression analyses were performed to analyse the association between having seen a physiotherapist, chiropractor or PM \u0026amp; R physician prior to the most expensive specialist care contact (Table 5). These analyses included patients who had their most expensive specialist care contact for diagnosis where conservative care is recommended as first-line treatment (osteoarthritis, spinal-, shoulder- and knee disorders).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Logistic regression analysis for having seen physiotherapy, chiropractor or Physical Medicine and Rehabilitation physician prior to the most expensive specialist care contact\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate *\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e.99 (.98-.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e.99 (.99-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eGender, female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.32 (1.14-1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.35 (1.15-1.58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eGeographical location\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; Large city (reference)\u003cbr\u003e\u0026nbsp; \u0026nbsp;Large municipality\u003cbr\u003e\u0026nbsp; \u0026nbsp;Small municipality\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003cp\u003e.86 (.70-1.05)\u003c/p\u003e\n \u003cp\u003e.72 (.59-.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReference\u003cbr\u003e\u0026nbsp;.94 (.76-1.16)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e.78 (.63-.96)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eEducation, more than 13 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.22 (1.05-1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.22 (1.03-1.46)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eIncome, more than median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.16 (1.01-1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.07 (.90-1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eDisability pension before index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e.68 (.55-.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e.83 (.65-1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eImmigration background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.11 (.94-1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e.84 (.69-1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidity, 2 or more \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e.52 (.36-.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e.62 (.43-.91)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOnly patients whose most expensive specialist care contact was related to osteoarthritis, or spinal, shoulder or knee disorders were included (N=2 801). * Adjusted for all variables in table and number of GP-contacts the year prior to the most expensive specialist care contact. \u003csup\u003ea\u003c/sup\u003e Comorbidity index based on the International Classification of Primary Care (ICPC-2) (55).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cu\u003eMain findings\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOur study identified differences in patient characteristics between high-cost and non-high-cost patients. High-cost patients were older, had less education, had more comorbidity and a higher proportion were on disability pensions than non-high-cost patients. There was a lower proportion of immigrants and fewer registered in a large city in the high-cost group, and there was no gender difference. High-cost patients accounted for close to 60% of all costs in the 5-year period. Eighty-nine percent of their costs were related to specialist health care. Ninety-four percent of high-cost patients had most of their costs related to specialist care use, while 6% had health care use characterized by very many physiotherapy contacts. Over three quarters of the high-cost patients had one specialist care contact that accounted for more than half of their costs in the five-year period, and 95% of these contacts were related to surgical departments. The year prior to the most expensive specialist care contact most patients had seen their GP, except for patients with fractures and injuries, while fewer than half had seen either physiotherapists, chiropractors, or PM \u0026amp; R physicians. Being male, having lower education and being registered in a small municipality were associated with lower odds of having seen physiotherapists, chiropractors, or PM \u0026amp; R physicians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eComparison of high-cost and non-high-cost patients\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAge, education, comorbidity and being on disability pension are factors that\u0026nbsp;have previously been found to be associated with a greater burden of MSDs and poorer outcomes\u0026nbsp;(70, 71),\u0026nbsp;and\u0026nbsp;may explain the higher costs for these patients. There were a greater proportion of immigrants in the non-high-cost group, despite prior research indicating that immigrants in Norway report a greater prevalence of MSDs\u0026nbsp;(72). This discrepancy may be attributed to\u0026nbsp;lower specialist care utilisation by immigrants compared to native Norwegians\u0026nbsp;(15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eHealth care use for high-cost patients \u0026ndash; room for improvement?\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePrevious research has shown that surgical procedures and hospitalisation account for the highest costs related to MSDs in the short-term\u0026nbsp;(22), and our findings demonstrate that this is also the case from a five-year perspective. Our findings show that older patients are more likely to be high-cost users, indicating that costs will increase significantly in the future as the population ages. Current models of care may not be sustainable for handling this increased burden\u0026nbsp;(73, 74), highlighting the importance of researching resource use and discussing models of care that can handle the increasing burden and costs of MSDs.\u003c/p\u003e\n\u003cp\u003eForty-five percent of the most expensive specialist care\u0026nbsp;contacts\u0026nbsp;were related to management of fractures and injuries. As expected, these patients had low use of all healthcare services before their most expensive specialist contact.\u0026nbsp;For these conditions, management in specialist healthcare\u0026nbsp;is essential, can be considered absolutely warranted and cannot be prevented by prior healthcare use or primary care management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproximately 40% percent of the individuals\u0026rsquo; most expensive specialist care\u0026nbsp;contacts\u0026nbsp;were related to specialist care management of osteoarthritis and spinal, shoulder\u0026nbsp;and\u0026nbsp;knee disorders.\u0026nbsp;Conservative management and rehabilitation are\u0026nbsp;generally recommended as first-line treatments for these conditions\u0026nbsp;(16, 25, 27-29, 38, 63-69).\u0026nbsp;Fewer than half of patients with high costs related to specialist care treatment for osteoarthritis and spinal, shoulder and knee disorders had seen a healthcare service delivering conservative treatment, other than GPs, the year prior to their most expensive specialist contact. This finding is supported by previous research showing that 30-40% of patients receive appropriate nonsurgical care for osteoarthritis, 35% of patients receive a conservative plan of care the year prior to elective lumbar spine surgery and 65% of patients with rotator cuff disorders receive a nonsurgical management program\u0026nbsp;(39-42).\u003c/p\u003e\n\u003cp\u003eThe implementation of a structured model of care for hip and knee osteoarthritis has been shown to increase the quality of care and be cost-effective, primarily by leading to reduced surgery rates, and stepwise care approaches have been shown to be cost-effective for knee disorders\u0026nbsp;(34, 35). Studies have also\u0026nbsp;shown that exercise therapy and patient education can lead to reduced surgery rates\u0026nbsp;(75-79).\u0026nbsp;Our findings indicate that the commonly recommended stepwise care model in which patients use conservative management and rehabilitation prior to more expensive\u0026nbsp;specialist care\u0026nbsp;treatment\u0026nbsp;is underutilised in current practice. Increased use of conservative treatment such as patient education,\u0026nbsp;rehabilitation, and exercise therapy\u0026nbsp;as first-line treatment, as recommended in guidelines,\u0026nbsp;could offer cost-savings by reducing or postponing more expensive specialist care\u0026nbsp;procedures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is a low capacity for both primary and specialist care rehabilitation compared to the demand, resulting in long waiting times before patients can access rehabilitation in Norway\u0026nbsp;(80). Early access to physiotherapy is associated with lower MSD-related costs and lower use of imaging, injections and surgical interventions compared to delayed access, indicating that the timing of care is important\u0026nbsp;(81). Guidelines state that patients who have undergone surgical procedures are prioritized for primary care rehabilitation services, while patients with acute and chronic MSDs have lower priority in Norway\u0026nbsp;(82). A lack of capacity and reduced access to rehabilitation services before surgical procedures are likely to be important barriers for why stepwise care approaches are not routinely used in current practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious research has shown that women are more likely to use of GP-services and physiotherapy than men are\u0026nbsp;(83-85),\u0026nbsp;and that women are older and have more advanced disease states when undergoing orthopaedic surgery\u0026nbsp;(86, 87).\u0026nbsp;Men have greater expectations to the effect of surgical interventions,\u0026nbsp;while women are more concerned about potential risks and less likely to prefer surgical management\u0026nbsp;(85, 88, 89). Women also encounter more barriers in the healthcare system before receiving surgical care, including negative interactions with healthcare personnel, difficulties in self-advocating for their care and experience less involvement by healthcare personnel in the decision-making process\u0026nbsp;(85).\u0026nbsp;Clinicians have also been shown to treat patients with MSDs differently based on gender. Women are less likely to receive imaging, are prescribed lower doses of medications and clinicians are more likely to suggest mental health referrals, while men are more likely to be recommended surgical interventions\u0026nbsp;(90-92).\u0026nbsp;The gender difference in our findings may be attributed to differences in health care seeking between genders, such as women being more likely to prefer to try other treatments for MSDs before surgical care, while men have greater expectations of the effect of surgical interventions and are more likely to advocate for this. The gender difference could also be due to clinician behaviour, where healthcare personnel are more likely to suggest surgical care for men. Whether this indicates that men are less likely to receive appropriate guideline concordant care with conservative management prior to surgical management, or represents a gender bias where women have more barriers for appropriate referrals is unclear. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is geographic variation in orthopedic procedures in Norway, where some procedures are more common in rural areas, while others are more common in urban areas\u0026nbsp;(93, 94). It has been suggested that lack of uniformity in conservative care in Norway may be a driver of variation in surgery rates\u0026nbsp;(93). Our findings indicate that there is a geographical difference in the use of conservative care, where patients from smaller municipalities are less likely to receive conservative care prior to specialist care management.\u0026nbsp;This may indicate differences in accessibility to conservative care management in rural areas, which could lead to higher proportions being directly referred to specialist care. In that case, this could indicate an unwanted geographical service variation.\u003c/p\u003e\n\u003cp\u003eThe lack of clinical data in our study makes it impossible to determine whether there are important clinical factors\u0026nbsp;that explain why patients are referred directly to specialist care and are not treated in primary care. Patients with spinal pain referred to PM \u0026amp; R specialist care in Norway have been found to have more severe symptoms, poorer quality of life, less education and greater psychosocial distress than patients treated in primary care\u0026nbsp;(95). In contrast, a study on hand osteoarthritis in Norway showed that patients who were directly referred for surgical care had less pain and fewer limitations than patients who underwent rehabilitative interventions before referral\u0026nbsp;(96).\u0026nbsp;Fewer than half of the patients in our study had seen healthcare personnel delivering conservative treatment other than GPs the year preceding their most expensive specialist care contact, even for conditions where guidelines recommend rehabilitation as a first line treatment. It is unlikely that specific clinical characteristics or symptom severity can explain why such a substantial proportion of patients have not undergone conservative management or rehabilitation.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eHigh-cost users in primary care\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOur data show\u0026nbsp;that approximately 6% of the high-cost patients had\u0026nbsp;high costs\u0026nbsp;related to long-term follow-up in primary care, most commonly due to a large number of physiotherapy contacts.\u0026nbsp;This finding is similar to previous findings\u0026nbsp;(15, 97).\u0026nbsp;Patients with\u0026nbsp;high levels of physiotherapy use have been found to have\u0026nbsp;high pain and disability and to have negative health and illness perceptions, lower levels of internal health locus of control, poor self-management and high emotional distress\u0026nbsp;(98-100).\u0026nbsp;Patients who frequently use physiotherapy\u0026nbsp;report less improvement in clinical outcomes than patients with less use\u0026nbsp;(100), and studies indicate that a greater number\u0026nbsp;of physiotherapy contacts does not lead to improved clinical outcomes\u0026nbsp;(101-103).\u0026nbsp;This suggests that a greater number of physiotherapy contacts does not necessarily lead to improved outcomes for patients, making it important to discuss whether the high use of physiotherapy contacts in a small group of patients in our findings may\u0026nbsp;indicate\u0026nbsp;an overuse of physiotherapy. On the other hand, healthcare delivery for patients with persistent MSDs and chronic conditions is complex and the value of providing healthcare may not be captured sufficiently by traditional clinical outcome measures\u0026nbsp;(104). The high use of primary care treatment could lead to reduced use of more expensive specialist care interventions, resulting in a net benefit. The complex interplay of overuse and underuse illustrates the difficulty of optimizing healthcare delivery for patients with MSDs, and the balance between resource savings and personalized patient care remains an important challenge for healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStrengths and limitations\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides novel contributions to the existing body of literature on high-cost users in musculoskeletal health care. Most prior studies have focused on costs related to services rather than individuals, used short timeframes, or focused on predictive models\u0026nbsp;(14, 22, 52, 97, 105-108). This study utilises registry data at the population-level and allows us to use a longer timeframe for defining high-cost users compared to previous research. By using individualised data to assess health care use and costs, we provide detailed information on patterns of health care use for patients with high costs, and whether these patterns are in concordance with current recommendations and guidelines.\u003c/p\u003e\n\u003cp\u003eUsing registries that include a large population linked at the individual level provides a unique dataset with complete information on public primary and specialist healthcare use and demographic and socioeconomic factors. This makes it possible to create a comprehensive cohort without problems with selection bias that influence the validity of the findings\u0026nbsp;(109). This ensures that the study provides a more accurate overview of real-life clinical practice than what is possible to achieve with other designs\u0026nbsp;(110).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study uses primary care diagnoses and defined contacts by only using fees that indicate face-to-face, group or video consultation, an approach that has been shown to have high validity for the GP-service\u0026nbsp;(56). It is important to acknowledge that differing coding behaviour between clinicians and professions, and different software between clinics might challenge the validity of diagnosis codes used in registry data\u0026nbsp;(111). To account for this, we included all MSDs as one broad category rather than categorizing on individual codes, except for the most expensive specialist care contact, as this would most likely reduce accuracy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study only has access to data for patients who were registered as residents in Oslo or Trondheim at any point between 2008 and 2020. Patients could live in another municipality when they were treated for their MSD, making it possible to assess differences in geographical location. Nevertheless, this leads to an underrepresentation of patients from smaller municipalities and other parts of the country.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur results only capture the reimbursement costs for the public healthcare system. This means that our reported healthcare costs underestimate the true cost of healthcare use, as these services are partially financed from out-of-pocket expenses and receive additional funding for running the services. As our data are based on reimbursement costs, we most likely underestimate the cost of chiropractors, as patients with high use of chiropractors cannot reach the 95\u003csup\u003eth\u003c/sup\u003e percentile for costs due to low reimbursement. Another limitation is that we can only include patients who use the public healthcare system. There is an ambition in Norway that all parts of the population should have equal access to public high-quality healthcare services\u0026nbsp;(50)\u0026nbsp;and public healthcare represents 86% of all healthcare use in 2022\u0026nbsp;(112). The use of private healthcare increased significantly during the recent years, and in 2021, approximately 13% of the population had private health insurance\u0026nbsp;(113). This means that there is a substantial amount of healthcare use on which we have no information, as privatized healthcare is not included in registries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDirect comparisons between countries are difficult due to large differences in health care organisations, welfare systems and social structures. We believe that the findings of our study are generalizable to other countries with similar health care organisations and structures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe five percent of patients with the highest health care costs were responsible for nearly 60% of all costs for MSD-related care over a five-year period. High-cost patients were older, had less education, had more comorbidities and were more likely to receive disability pensions than non-high-cost patients were. More than 75% of high-cost users had one specialist care contact that accounted for more than half of their costs during the five-year period, mainly related to surgical treatment. We found a relatively low use of healthcare services delivering conservative care and rehabilitation, other than GPs, the year before patients\u0026rsquo; most expensive specialist healthcare contact. This was also found in conditions where guidelines recommend conservative management and rehabilitation before specialist referral. Previous studies have shown that stepwise care approaches and interventions such as patient education and exercise therapy can reduce surgery rates and costs. Overall, this may indicate that it is possible to reduce overall costs by offering patients with nontraumatic MSDs the opportunity to try conservative management and rehabilitation before being referred to specialist care management. It is important to acknowledge that this most likely requires significant investments as the demand is greater than the current capacity.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMusculoskeletal disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eINOREG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eINnovations in use of REGistry data\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTROBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRECORD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eREporting of studies Conducted using Observational Routinely-collected Data\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHELFO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Norwegian Health Economics Administration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKUHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Control and Reimbursement of Health Care Claims\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNorwegian Patient Registry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFD-Trygd\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistics Norway's Social Security Event History Database\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICPC-2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Classification of Primary Care, 2nd version\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICD-10\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Classification of Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDRG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNordic Diagnosis-Related Group\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePM \u0026amp; R\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysical Medicine and Rehabilitation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis project has been granted access to registry data and exemption from requiring informed consent by the Regional Committees for Medical Research Ethics South East Norway (REC South East), with reference number 118725. \u0026nbsp;All methods were performed in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used in the current study are based on national registries and are not publicly available. Access to pseudonymized data from the national registries is only granted through application to the Norwegian Centre for Research Data and Regional Committees for Medical and Health Research Ethics. Other data and materials can be obtained from the corresponding author upon reasonable request.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe project is funded through The Research Council of Norway, project code 302782/H40.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOA, NKV, TAM, JHH and TT contributed to the study conception and design. OA was responsible for the data management and analysis, with important contributions from NKV, TAM, TT and JHH. All the authors contributed to the interpretation of the findings, per their expertise. OA and NKV were responsible for drafting the manuscript, and all the authors contributed to the revision of the manuscript. All authors approved the manuscript prior to submission. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCorresponding author\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors are grateful for the contributions of the project reference group, which includes patient representatives, clinicians, stakeholders from primary and specialist health care and other Nordic research collaborators. The reference group provided important input throughout the research process and contributed to the interpretation of the findings. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDisclaimer\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eData from the Control and Reimbursement of Health Care Claims, the Norwegian Patient Registry, Statistics Norway, and the Cause of Death Registry are used in the project. The interpretation and reporting of these data are the sole responsibility of the authors, and no endorsement by the registry owners is intended, nor should it be inferred.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. 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JAMA Netw Open. 2021;4(8):e2113401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMengshoel AM, Bjorb\u0026aelig;kmo WS, Sallinen M, Wahl AK. It takes time, but recovering makes it worthwhile'- A qualitative study of long-term users' experiences of physiotherapy in primary health care. Physiother Theory Pract. 2021;37(1):6\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMutubuki EN, Luitjens MA, Maas ET, Huygen F, Ostelo R, van Tulder MW, et al. Predictive factors of high societal costs among chronic low back pain patients. Eur J Pain. 2020;24(2):325\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker A, Held H, Redaelli M, Strauch K, Chenot JF, Leonhardt C, et al. Low back pain in primary care: costs of care and prediction of future health care utilization. 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Paediatr Perinat Epidemiol. 2009;23(6):597\u0026ndash;608.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThygesen LC, Ersb\u0026oslash;ll AK. When the entire population is the sample: strengths and limitations in register-based epidemiology. Eur J Epidemiol. 2014;29(8):551\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiiser S, Haukenes I, Baste V, Smith-Sivertsen T, Hetlevik \u0026Oslash;, Ruths S. Variation in general practitioners\u0026rsquo; depression care following certification of sickness absence: a registry-based cohort study. Fam Pract. 2020;38(3):238\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOECD, Union E. Health at a Glance: Europe 20222022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eF\u0026aring;ne JE. Ni av ti behandlingsforsikringer er via arbeidsgiver. Finans Norge; 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health care utilisation, musculoskeletal, register-based research","lastPublishedDoi":"10.21203/rs.3.rs-4002700/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4002700/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA high proportion of healthcare costs can be attributed to musculoskeletal disorders (MSDs). A small proportion of patients account for most of the costs, and there is increasing focus on addressing service overuse and high costs. We aimed to describe healthcare use contributing to high costs over a five-year period at the individual level and to examine differences between high-cost patients who use healthcare in accordance with guidelines and those who do not. These findings can contribute to the understanding of healthcare use for high-cost patients and help in planning future MSD-care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study combines Norwegian registries on healthcare use, diagnoses, demographic, and socioeconomic factors. Patients (≥ 18 years) were included by their first MSD-contact in 2013–2015. We analysed healthcare use during the subsequent five years. Descriptive statistics are used to compare high-cost (≥95\u003csup\u003eth\u003c/sup\u003e percentile) and non-high-cost patients, and to describe the most expensive specialist healthcare contact and healthcare care use prior to this contact. Logistic regression was used to assess factors associated with having seen healthcare personnel delivering conservative treatment prior to the most expensive specialist care contact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigh-cost patients were responsible for 60% of costs, with 90% related to hospital treatment. Seventy-seven percent of high-cost patients had one specialist healthcare contact responsible for more than half of their total costs, predominantly related to surgical treatment. Fractures/injuries were the most common diagnosis for these contacts, while osteoarthritis and spinal, shoulder and knee disorders accounted for 42%. Less than half had seen a healthcare service delivering conservative treatment, other than GPs, the year before this contact. Being male, from a small municipality, lower education and higher comorbidity were associated with lower odds of having been to healthcare services focused on conservative treatment prior to the most expensive specialist care contact. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost health care costs are concentrated among a small proportion of patients. In contrast to recommendations, less than half had been to a healthcare service focused on conservative management prior to specialist care treatment. This could indicate that there is room for improvement, and that ensuring sufficient capacity for conservative care can be beneficial for reducing overall costs.\u003c/p\u003e","manuscriptTitle":"Patient Characteristics and Healthcare Use for High-cost Patients with Musculoskeletal Disorders in Norway: A Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-19 16:04:50","doi":"10.21203/rs.3.rs-4002700/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-18T01:59:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-14T14:54:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-14T14:54:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-03-01T08:16:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67795679-9c4b-44d2-80fd-9aa3d1f18a02","owner":[],"postedDate":"March 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:02:37+00:00","versionOfRecord":{"articleIdentity":"rs-4002700","link":"https://doi.org/10.1186/s12913-024-12051-3","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-12-18 15:57:41","publishedOnDateReadable":"December 18th, 2024"},"versionCreatedAt":"2024-03-19 16:04:50","video":"","vorDoi":"10.1186/s12913-024-12051-3","vorDoiUrl":"https://doi.org/10.1186/s12913-024-12051-3","workflowStages":[]},"version":"v1","identity":"rs-4002700","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4002700","identity":"rs-4002700","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}