Tracking low back problems in a major self-insured workforce: toward improvement in the patient's journey.

Objective: To assess the cost outcomes of treatment approaches to care for back problems in 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.