Research Review By Dr. Michael Haneline©


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Date Posted:

February 2022

Study Title:

Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims


Anderson B, McClellan WS & Long C

Author's Affiliations:

Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa; Integrated Musculoskeletal Care, Tallahassee, Florida, USA

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2021; 44(5): 372-377. doi: 10.1016/j.jmpt.2021.03.001.

Background Information:

Neck pain is one of the leading causes of disability worldwide (1), with a global age-standardized point prevalence of approximately 3.5% (2).

Clinical practice guidelines typically recommend education, self-management, exercise, manipulation/mobilization, and nonopioid analgesics for the management of neck pain, although the duration of neck pain is not usually taken into consideration.

The routine use of imaging, opioid medications, injections, and surgery has increased over the past couple of decades, even though this sort of practice contradicts treatment guidelines. In fact, the use of these procedures has been shown to significantly contribute to costs associated with the treatment of spinal pain (3).

Treatment escalation refers to increasing the complexity of care in the management of a disease, or any care beyond the typical treatment a person uses to manage their condition (4). Treatment escalation has been well-described in the literature for several conditions, including asthma, eczema, cancer, end-of-life care, and the use of certain medications, but has only been briefly described for musculoskeletal disorders (5).

The aim of this project was to evaluate the relationship between treatment escalation and type of care in episodes associated with diagnosed cervical spine disorders by analyzing health insurance claims from a large Fortune 500 company. The authors hypothesized that episodes in nonrecipients of spinal manipulation (i.e. ‘other care’) would have a higher risk of treatment escalation than episodes in recipients of spinal manipulation.

Pertinent Results:

There were 771797 claims to start with, but after removing those not related to the cervical spine, those anatomically unrelated to the cervical spine, and patients younger than 18 years, 58147 claims remained, representing 7951 unique episodes.

Treatment escalation was present in 42% of claims overall, with 2448 claims (46%) associated with other care and 876 (26%) associated with spinal manipulation. Treatment escalation for spinal manipulation claims was mainly related to imaging: 783 out of 876 claims (89%).

The adjusted relative risk for every escalation procedure was higher in those who received other care compared to those who received spinal manipulation. Overall, the risk of treatment escalation was 2.13 times higher in those who received other care than in those who received spinal manipulation.

Clinical Application & Conclusions:

This study showed that patients who did not receive spinal manipulation had a statistically significant increased risk of treatment escalation compared to those who received spinal manipulation. These findings parallel another study which showed that people with neck pain who initiated care with primary care versus a chiropractic physician had higher odds of using advanced imaging, injections, and opioid medications (6).

The results of this study can be used to support initial chiropractic care/spinal manipulation in patients with neck pain when discussing the matter with patients, insurance companies, referrers, and other parties.

Study Methods:

This was a retrospective study of health insurance claims from a single, self-insured Fortune 500 company for individuals with cervical spine disorders. The insurance records were searched using the keywords “cervic-” or “neck” with anatomically unrelated terms, such as “femoral neck” and “swan-neck deformity”, being excluded. Inflammatory spondylopathies, claims with missing or unrelated procedure codes and claims for patients younger than 18 years were also excluded.

Claims were classified as spinal manipulation using a Current Procedural Terminology (CPT) code for spinal manipulative therapy (98940-98943). Claims that did not include one of these codes were classified as ‘other care’.

Claims data that included CPT codes representing imaging, injection, emergency-department visits, or surgery were considered to indicate treatment escalation during an episode.

Risk scores were used in the data analysis. Risk scores are calculated based on characteristics such as demographic information and medical and pharmacy claims which can be used to predict expected health care costs and use of health care services. The relative risk of each escalation procedure and escalation for other care compared to spinal manipulation was estimated, adjusted for sex, age, episode duration, and risk scores.

Study Strengths / Weaknesses

Given that this was a retrospective review of health insurance claims, the study design that was used is low in the hierarchy of evidence, with numerous possible limitations (ex. no control group, no randomization, etc.). Nonetheless, the study was well done and will add to the literature concerning the care of patients with neck pain.

The authors listed several study limitations, including:
  • pharmaceutical claims were not included;
  • a proprietary risk score index was used;
  • data were derived from claims filed with a single Fortune 500 company, which may not be generalizable;
  • certain variables, such as education, level of disability, and self-reported measures of health were not available; and
  • only the primary diagnosis was available, not secondary conditions, which could have influenced the likelihood of treatment escalation.
In addition, there were several possible confounding variables that could have affected the findings of this study, including:
  • potential barriers to treatment escalation that exist within chiropractic, but not in medical practice, due to limitations in scope of practice; and
  • medical providers are affiliated with health organizations that allow for easy access to escalation procedures, which is atypical for providers that utilize spinal manipulation.
Because of these limitations, the authors suggested that interpreting the results of this study is complex and further research is necessary to determine the specific characteristics associated with treatment escalation.

Additional References:

  1. James S et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990−2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392: 1789-1858.
  2. Safiri S, Kolahi A-A, Hoy D, et al. Global, regional, and national burden of neck pain in the general population, 1990-2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ 2020;368.
  3. Allen H, Wright M, Craig T, et al. Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. J Occup Environ Med 2014; 56: 604-20.
  4. Donelson R, Spratt K, McClellan WS, et al. The cost impact of a quality-assured mechanical assessment in primary low back pain care. J Man Manip Ther 2019; 27: 277-86.
  5. Dahill M, Powter L, Garland L, Mallett M, Nolan J. Improving documentation of treatment escalation decisions in acute care. BMJ Qual Improv Rep 2013; 2.u200617.w1077.
  6. Horn ME, George SZ, Fritz JM. Influence of initial provider on health care utilization in patients seeking care for neck pain. Mayo Clin Proc Innov Qual Outcomes 2017; 1: 226¬23.

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