Initial Encounter Guideline-Concordance and Downstream Costs for Low Back Pain:

Study Design: Retrospective cohort study using electronic health records and claims data (January 2021–June 2023). Cost data were log-transformed and analyzed using ordinary least squares regression. Objective: To evaluate the impact of concordance with imaging, opioids, and physical therapy (PT) guidelines at an initial encounter on downstream costs and payments for patients with LBP without red flags. Summary of Background Data: Despite clinical guidelines recommending conservative management for low back pain (LBP), guideline-discordant care, including early imaging and opioid prescribing, remains common. Methods: Initial encounter care for adults with a new LBP diagnosis (n=56,407) at 162 primary care, urgent care, and emergency departments within a community US health system was categorized by concordance with clinical guidelines: PT-only (concordant), no intervention, or combinations involving imaging and/or opioids (discordant). Primary outcomes were total cost to the health system and total payment (patient + payor) for downstream LBP-related care over two years. Patients with red flag conditions were excluded. Results: PT was ordered at 11.5%, opioids at 15.2%, and imaging at 24.5% of initial encounters. Compared with PT-only (referent), patients receiving no interventions had a 5.73% lower total cost ( p =0.004), whereas combinations involving imaging and opioids had significantly higher costs, with PT+opioids+imaging showing a 19.96% increase in total cost ( p =0.04) and a 23.74% increase in total payment ( p =0.07). Conclusions: Guideline-concordant care was associated with more favorable cost outcomes. Combinations involving imaging and opioids increased costs. These findings support rethinking financial models to incentivize care aligned with clinical guidelines.