Neck pain service utilization and costs: association with timing of non-pharmaceutical services for individuals initially contacting a primary care provider. A retrospective cohort study

Background Neck pain (NP) is prevalent and costly. NP clinical practice guidelines are similar to those for low back pain (LBP), emphasizing non-pharmaceutical and non-interventional first-line approaches. Primary care providers (PCP) are frequently consulted by individuals with NP. Objective Examine the association between guideline concordant incorporation of non-pharmaceutical therapies, use of imaging, pharmaceutical, and interventional services, and total episode cost for individuals with NP initially contacting a PCP. Design Retrospective cohort study using identical methods to a previous LBP study Setting/Patients National sample of individuals with non-surgical NP occurring in 2017-2019. Measurements Independent variables were initial contact with a PCP, and the timing of incorporation of 5 types of non-pharmaceutical therapies. Dependent measures included use of 13 types of health care services and total episode cost. Results 70,252 PCPs were initially contacted by 124,780 individuals with 137,274 episodes of non-surgical NP. 30.9% of PCPs and 22.1% of episodes included at least one of five non-pharmaceutical services at any time during an episode. Active care (13.7% of episodes), manual therapy (10.8%), and chiropractic manipulative therapy (9.4%) were the most common non-pharmaceutical services. 7.4% of episodes included a non-pharmaceutical service during the first 7 days with these episodes associated with a modest reduction (risk ratio 0.28 to 0.78) in the use of prescription pharmaceuticals. Younger individuals from ZIP codes with higher adjusted gross income were more likely to receive a non-pharmaceutical service in the first 7 days of an episode. When included during an episode, non-pharmaceutical services were associated with an increase in total episode cost with the smallest increase associated with chiropractic and osteopathic manipulation. Limitations As a retrospective observational analysis of associations there are numerous potential confounders and limitations. Conclusions Non-pharmaceutical services are infrequently provided to individuals with non-surgical NP initially contacting a PCP. For these individuals, non-pharmaceutical services, if provided, are most commonly introduced later in an episode after receiving pharmaceutical, imaging, and interventional services. For individuals with NP initially contacting a PCP there is an opportunity to increase the guideline concordant incorporation of non-pharmaceutical services early in an episode.