Economics of spine-related disability: Societal costs

Simon Dagenais, DC, PhD, MSc

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Spine-related

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Low back pain Nonspecific Neurological / radiculopathy Serious spinal pathology (e.g. tumor, fracture, infection, arthritides)

Neck pain Nonspecific Neurological / radiculopathy Serious spinal pathology (e.g. tumor, fracture, infection, arthritides)

Other Pediatric / congenital Scoliosis / deformity Spinal cord injury Other

Epidemiology

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Low back pain

Point prevalence (now) 28.4%

Lifetime prevalence (ever) 84.1%

6 month prevalence 71.9%

Low intensity / low disability 48.9%

High intensity / low disability 12.3%

High intensity / high disability 10.7%

Cassidy, 1998 (PMID 9762743)

Health services utilization – Primary care

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Low back pain

#1 reason for visiting a chiropractor

#1 reason for visiting a physical therapist

#2 reason for visiting a primary care physician

Hurwitz, 1998 (PMID 9585743)Bekkering, 2003 (PMID 12952520)Bigos, 1996 (PMID 8892135)

Health services utilization – Specialist care

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Low back pain

#1 reason for visiting an orthopedic surgeon

#1 reason for visiting a neurologic surgeon

#3 reason for obtaining elective surgery

Hurwitz, 1998 (PMID 9585743)Bekkering, 2003 (PMID 12952520)Bigos, 1996 (PMID 8892135)

Health services utilization – EDLow back pain ~2% of all ED visits (2.6 million each year in US)

Diagnostic testing 31% had x-rays 10% had CT or MRI 19% had urinalysis 10% had blood work

Prescription medication 61% received opioids 50% received NSAIDs 43% received muscle relaxants

Friedman, 2010 (PMID 21030902)6

Health services utilization – OpioidsLow back pain #1 indication (~50% of users)

Opioid overdose

One of the leading causes of accidental death (16,651 in 2010)

7 Edlund, 2010 (PMID 20634006)Okie, 2010 (PMID 21083382)

2015 ?

Economic impact

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Also known as cost of illness, burden of illness

Attempt to measure the economic consequences of a specific health condition Think of anything that may change with a health

condition Try to put a price tag on it Add it all up

Goal is to inform decision making for stakeholders Allocate resources to address health condition

Systematic review

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Main goal was to look at how others had already tackled this issue

Systematic review

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Identified 27 studies from 8 different countries Australia, Belgium, Japan, Korea, Netherlands,

Sweden, UK, US

All defined back pain differently e.g. self-reported vs. ICD-9 codes, >3/6/12 months

Differed in the scope of costs considered 14 examined direct / health care costs 18 examined indirect / productivity costs 8 examined both direct and indirect costs

Direct / health care costs

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Studies did not all consider different types of health careWhen studies looked for specific costs, they found them

Indirect / productivity costs

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Absenteeism Formal (e.g. temporary paid leave) Informal (e.g. personal time off)

Presenteeism Self-reported Estimated by supervisor

Early retirement Government Private

Inactivity Forfeited leisure time

Household productivity Paid Unpaid

Indirect / productivity costs

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Human capital approach Productivity losses based on remaining

lifespane.g. 35 year-old with back pain is losing out on 30 years of productivity

30 years x $50,000/year = $1.5 million

Friction approach Assumes injured workers are eventually

replacede.g. 35 year-old IT engineer replaced in 6 months

6 months x $100,000/year = $50,000

Total costs

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Total costs

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Indirect (85%)

Direct (15%)

Inpatient 2.6% Physical therapy 2.6% Pharmacy 2.0% Primary care 2.0% Outpatient 1.2% Imaging 1.1% Specialists 1.1% Chiropractic 0.8% Other 0.8% Surgery 0.8%CAM 0.3% Emergency 0.2% Mental health 0.2%

Sick leave 61.2%Early retirement 11.9%Presenteeism 6.8%Household 3.4%Inactivity 0.9%

Findings for US

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No study measured both direct and indirect costs Direct costs $12.2 - $90.6 billion Indirect costs $7.4 - $28.2 billion

In other countries that examined both: Direct costs were 3 - 66% of total (median 15%) Indirect costs were 34 - 97% of total (median 85%)

Based on proportions observed in other countries Total costs in US could be $84.1 - $624.8 billion

1997 1998 1999 2000 2001 2002 2003 2004 200540

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Findings for US

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2015$162 billion

Self-reported disability increased by 25%(From 20% with spine problems to 25%)

Martin, 2008 (PMID 18270354)

Other considerations

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Costs higher if we include all spine-related conditions ~5-10% of total health care costs depending on

scope

Costs don’t fully reflect cases associated with workers’ compensation or personal injury Legal, administrative, health care

No estimate of costs for back problems related to Social Security Disability or Department of Defense One of the leading causes