Tracking Low Back Problems in a Major Self-Insured Workforce: Toward Improvement in the Patient’s Journey

Allen, Harris PhD; Wright, Marcia PharmD; Craig, Terri PharmD; Mardekian, Jack PhD; Cheung, Raymond PhD; Sanchez, Robert PhD; Bunn, William B. III MD, JD, MPH; Rogers, William PhD

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From the Harris Allen Group, LLC (Dr Allen), Brookline, Mass; US Medical Affairs (Dr Wright), Pfizer Integrated Health, Overland Park, Kans; Pfizer Primary Care Medical Affairs (Dr Craig), Lincoln, Nebr; Pfizer Inc (Dr Mardekian), New York; Pfizer Integrated Health (Drs Cheung and Sanchez), New York; Health, Safety, Security & Productivity, Navistar, Inc (Dr Bunn), Lisle, Ill; and Tufts Medical Center (Dr Rogers), Boston, Mass.

Address correspondence to: Harris Allen, PhD, Harris Allen Group, LLC, 150 Walnut St Rd #2, Brookline, MA 02445 (

This study was sponsored by Pfizer Inc. Harris Allen and William Rogers are principal and a paid associate, respectively, of the Harris Allen Group, LLC, which served as a paid consultant organization to Pfizer in connection with this study and the development of this manuscript. William Bunn served as an unpaid adviser to the Harris Allen Group. Marcia Wright, Terri Craig, Jack Mardekian, and Raymond Cheung are employees of Pfizer Inc. Robert Sanchez was a full-time employee of Pfizer Inc at the time this manuscript was drafted.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (

The authors declare no conflicts of interest.


Objective: To assess the cost outcomes of treatment approaches to care for back problemsin a major self-insured workforce, using published guidelines to focus on low back pain.

Methods: Longitudinally tracked episodes of three types of International Classification of Diseases, Ninth Revision diagnosis code–identified back problems (n = 14,787) during 2001 to 2009. Identified five patterns of care on the basis of the first 6 weeks of claims and compared their total costs per episode with tests that included splits by episode type and duration, use of guidelines, and propensity-derived adjustments.

Results: Care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns, complex medical management and chiropractic reported the highest and lowest rates, respectively, of guideline-incongruent use of imaging, surgeries, and medications, and the highest and lowest total costs.

Conclusions: Approaches marked by higher resource utilization and lower guideline congruence are linked to greater low back pain total costs. Total cost is a needed input for guideline development.