Despite almost no mortality, back pain is one of the most burdensome conditions society faces. Direct costs for diagnosing and managing back pain are nearing $100 billion/year in the USA alone. Indirect costs, those associated with impairment and disability, can be X1 to X2 that amount. Efforts to improve back pain care from a population health perspective have included national guidelines, diagnostic and management prompts added to electronic health records, and provider-delivered web-based apps to guide activities of daily living and exercise. Isolated examples of success have occurred; however, spending trends and disability continue to increase.
To reduce or prevent further issues related to back pain such as increased medical costs, disability, wide variation in care, inappropriate imaging, and opioid abuse, it’s important to address the problem at the front end of the pain episode. A web-based app designed for patients can assist in determining if the individual needs to seek medical attention for their back pain or can self-manage the episode i.e. “Does the person need to become a patient?” Ample evidence now exists to demonstrate the benefit of engaging early contact providers for back pain, which include primary care physicians (and their physician extenders, nurse practitioners, and physician assistants), as well as doctors of chiropractic and physical therapy. Current data suggests the one-year prevalence of an episode of back pain is approximately 30% of the population (in higher-income countries), with individuals seeing a healthcare provider in about ½ of those episodes. For those that do seek provider care, some 45 – 50% will see a primary care physician, and 30 – 35% will see a doctor of chiropractic as their first providers. Providing individuals with the tools to self-triage and/or self-manage an episode of back pain can add even greater efficiency, reducing the likelihood of ‘downstream’ wasteful care.
There are more than 10 internationally published guidelines for the evaluation and management of back pain, and the message is quite consistent: avoid early imaging, avoid the use of opioids, start with non-pharmacological approaches, remain as active as possible, avoid the use of catastrophizing language with those experiencing an episode of back pain, and use pharmacy to promote a return to activity. The challenge has been the implementation of these guidelines into clinical practice. Two studies (Mafi 2013 and 2021) demonstrate guideline discordant practice among all physicians, especially among primary care physicians, who see up to 50% of back pain patients as the first provider. While there are programs that have succeeded in engaging primary care physicians in guideline-concordant back care (Weeks 2020), directly engaging individuals when they first experience an episode of back pain may hold even more promise in reducing the burden of back pain.
A person-facing, web-based app for back pain must first help the individual decide if they need to see a provider, and if they do, which provider should they see. This part of the algorithm will generally parse the individual into emergent care (seek immediate medical attention at an emergency department), necessary provider-based care (seek care with a primary care physician, doctor of chiropractic, or physical therapist, ideally those engaged with an evidence-based continuum of care pathway for back pain), or self-management. The addition of A.I. holds promise for improving both the sensitivity (are all those patients who need to see a provider captured?) and specificity (are individuals parsed to a provider seeing the most appropriate provider?) of the decision-making algorithm of an app. A.I. may also help with improving those self-management strategies that individuals are most compliant with and which give the best results. Tools like PROMIS (patient-reported outcome measurement information system) standardize outcome tracking with reliability and validity.
While improving provider compliance with patient-centered, evidence-based clinical guidelines is an important aspect of health care quality, addressing the very front end of care, “Does the person need to become a patient?”, can add greater effectiveness and efficiency to solving the challenges of back pain.
