Transforming low back pain care delivery in the United States.

Low back pain (LBP) is a nearly ubiquitous human experience second only to upper respiratory infection as a reason for a primary care office visit in the United States. Back pain is the leading causeof disabilityworldwide and in theUnitedStates, and rates of chronic LBP and resultant disability continue to increase. The societal impact of LBPcannot be attributed to undertreatment. Low back pain and neck pain were the costliest health condition in the United States for 2016, with an estimated $134.5 billion spending paid across private (57%), public (34%), and out-of-pocket payers. Surgical management of LBP is costly but incurred by a relatively small percentage of LBP cases, whereas the majority of costs are still incurred by those receiving care in the ambulatory setting. Current ambulatory care practices are characterized by overutilization of low-value services including advanced imaging, opioid medication, and spinal injections. Ineffective LBP management is a significant contributor to the opioid crisis as the most commondiagnosis for prescriptions, despite no evidence of sustained benefit. Furthermore, when opioids are prescribed for LBP, the risk of chronic opioid use is greater compared to other musculoskeletal pain conditions. Low-value care (ie, treatments or procedures with little or no evidence of effectiveness, have the potential to cause harm, and are costly) often occurs early in the course of care-seeking for LBP, frequently accelerating the escalation of care to more costly services. Perpetuating these care patterns comes at the expense of evidence-based, nonpharmacologic options focused on physical activity and promoting self-management. The paradox of rapidly increasing resource utilization for LBPwith no change in outcomes represents a failure of healthcare delivery on the part of relevant stakeholders, including patients, payers, health systems, andclinicians. Lowbackpain evidence-practice gapshave been recognized for many years but have proven difficult to overcome. Improvement efforts in the United States, such as the Choosing Wisely campaign, targeted towards both patients and clinicians, focuses on practices within a particular care setting (eg, primary care and emergency department) leading to varying impact. Given the multitude of practitioners and settings involved in LBP care, it can be argued that the need to transform delivery models spans across and between disciplines with the goal of creating pathways that better align with guideline recommended care. Individuals with a misperception of the need for identifying a definitive cause of LBP contribute to this paradox by increasing resource utilization for imaging. Therefore, existing pathways often facilitate unwarranted, premature escalation of care for LBP due to converging forces from provider, patient, and health system stakeholders. This occurs despite mounting evidence that opioid pain management, invasive procedures and advanced imaging should be limited to the small proportion of patients with very specific indications. In a “call to action” article published in Lancet, priority was given to improve clinical pathways that focus initial care towards nonpharmacologic approaches and facilitate uptake of selfmanagement strategies. Such alternative pathways have been advocated and implemented in various delivery settings worldwide. Although designedwith the common objective of improving the quality of care provided to individuals with LBP, differing healthcare policies, practices, and resourcesnecessitate adaptations of existing models to local context. The purpose of this Topical Review is to provide the framework for an evidence-based clinical pathway that can transform service delivery for LBP in the United States. This Review is intentionally focused on transformation in the context of one country’s health care, but there are general principles described in the proposed framework that are likely to be relevant for the delivery of health care in other countries.