Impact of the COVID-19 pandemic on low back pain management in commercially insured and Medicare Advantage cohorts. A retrospective cohort study

Background: The COVID-19 (COVID) pandemic has been associated with care seeking and delivery system changes. Before COVID the management of low back pain (LBP) was variable and a common source of low-value care. The purpose of this retrospective cohort study was to examine how the management of LBP changed during the COVID pandemic in commercially insured (CI) and Medicare Advantage (MA) cohorts. Methods: A US national sample of LBP episodes with a duration of less than 91 days experienced during 2019-2021 was analyzed. Independent variables included whether an individual had CI or MA coverage, and the timing of LBP onset. Secondary independent variables included individuals home address State. Dependent measures included the percent of individuals initially contacting eighteen types of health care provider (HCP) and receiving twenty-two types of health care services, and total episode cost. Early and late COVID measures were compared with a pre-COVID baseline to examine COVID related change. The impact of the stringency of State level COVID public policy response was evaluated. Results: The study included 222,043 CI and 466,125 MA complete episodes of LBP. During the pre-COVID period the MA cohort was older (MA median 72 vs. CI 45), with higher percent female (61% vs. 52%), and from zip codes with a higher Area Deprivation Index (median 52 vs. CI 38). MA and CI cohort attributes remained nearly identical in the early and late COVID periods. Initial contact with licensed acupuncturists (LAc risk ratio (RR) 0.66) and physical therapists (PT RR 0.82) in the CI cohort, and with PTs (RR 0.78), urgent care (RR 0.86), and emergency medicine (RR 0.87) in the MA cohort experienced the largest decreases during the early COVID period. The largest increase in the CI cohort was to PCPs (RR 1.08), and in the MA cohort to PCPs (RR 1.11) and nurse practitioners (RR 1.09). During the late COVID period the largest decreases in the CI cohort were to neurologists (RR 0.84), PTs (RR 0.86), and physical medicine and rehabilitation physicians (RR PMR 0.87) and in the MA cohort to rheumatologists (RR 0.81), PMR (RR 0.89) and pain management physicians (RR 0.89). The largest increases during the late COVID period in the CI cohort were to radiologists (RR 1.22), hospitals (RR 1.07) and orthopedic surgeons (OS RR 1.04) and in the MA cohort to LAcs (RR 1.32), radiologists (RR 1.11) and hospitals (RR 1.10). Compared to the pre-COVID period during the early COVID period the percent of episodes including most health care services was unchanged or reduced. In the late COVID period in both the CI and MA cohorts the percent of episodes with imaging studies increased, MRI (RR CI 1.15, MA 1.21), CT (RR 1.16, 1.16), and plain film radiology (RR 1.06, 1.06). The stringency of State COVID public policy responses was not associated with significant variability in either the type of HCP initially contacted, or services received for LBP. Conclusions: In both CI and MA LBP cohorts COVID was associated with changes in the types of HCP initially contacted and subsequent services provided. Guideline concordant first-line service use declined during COVID, and the rate of diagnostic imaging was higher in the late COVID period than the pre-COVID period. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: With data being de-identified or a Limited Data Set in compliance with the Health Insurance Portability and Accountability Act and customer requirements, the UnitedHealth Group Office of Human Research Affairs Institutional Review Board determined that this study was exempt from ongoing Institutional Review Boards oversight. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript