Risk of Care Escalation after Non-Pharmacologic Treatment: Leveraging Real World Physical Therapy Data

减去 肌肉骨骼疼痛是一种非常普遍、昂贵和负担沉重的疾病，通常使用阿片类药物进行治疗。 阿片类药物通常不能充分解决疼痛，并有很高的误用和成瘾风险。因此，临床上 实践指南强烈建议对肌肉骨骼疼痛进行非药物治疗。物理 治疗师是美国最常见的非药物疼痛护理提供者之一。但最高可达 接受理疗师提供的非药物治疗的人中有43%继续寻求治疗 对于他们的疼痛状况，超过理疗插曲，信号非最佳反应 药物治疗。通常接受的其他治疗是风险更高、侵入性更强、 目前的实践指南(如阿片类药物、外科手术)所推荐的。这一项目的总体目标是 使用真实世界的数据来更好地了解对非药物治疗反应不佳的风险因素 理疗师。这一知识将增强个人的治疗决策(例如，何时考虑 协调多模式护理)，并就如何重新设计非药理学护理模式提供指导 更好地应对应对不力的风险。在目标1中，我们将确定与不利因素相关的基线因素 接受治疗的患者中疼痛相关残疾的变化(升级护理的常见先兆) 理疗师的治疗。使用ATI结果注册表数据集，最大的结果之一 特定于物理治疗的数据集，我们将推导出以下自我报告残疾的共同轨迹 启动护理(次级目标1a)并开发多变量模型，以确定不利的风险因素 残疾变化轨迹(次级目标1b)。AIM 2将使用一个单独的、基于索赔的大型数据集，该数据集包括 行业工会工人以确定与护理升级相关的基线因素(即随后使用 成像、阿片类药物、注射和手术)后由理疗师开始治疗 肌肉骨骼疼痛(次级目标2a)。子目标2b将使用基于索赔的数据集的子集，该数据集也是 包括在ATI结果注册表中，以确定护理升级概率的增量变化 与残疾分数每提高一分相关。这些信息可以帮助临床医生设置 残疾改善的目标是有意义地降低护理升级的风险。在探索性分析中，我们 将评估与新冠肺炎相关的医疗保健服务大规模中断对这些问题的影响。我们 将对每个目标进行分层分析，以1)确定残疾轨迹和因素 与这些轨迹相关的轨迹在新冠肺炎发作后发生了变化，以及2)确定 在新冠肺炎发作之前或之后接受物理治疗与贫困风险的差异有关 结果。总体而言，这项工作旨在改善非药物护理的提供，以努力减少 减少使用阿片类药物的风险，更好地解决肌肉骨骼疼痛对个人和社会的重大影响。

ABTRACT Musculoskeletal pain is a highly prevalent, costly, and burdensome condition commonly managed with opioids. Opioids do not often adequately address pain and have high risk for misuse and addiction. As a result, clinical practice guidelines strongly recommend non-pharmacologic treatments for musculoskeletal pain. Physical therapists are one of the most common providers of non-pharmacologic pain care in the US. However up to 43% of people receiving non-pharmacologic treatments delivered by physical therapists continue to seek care for their pain condition beyond the physical therapy episode, signaling a sub-optimal response to non- pharmacologic treatment. Additional treatments received often are higher risk, more invasive, and not recommended by current practice guidelines (e.g., opioids, surgery). The overarching aim of this project is to use real-world data to better understand risk factors for poor response to non-pharmacologic care delivered by physical therapists. This knowledge will enhance individual treatment decision making (e.g.., when to consider coordinated multimodal care) and provide direction on how to re-design non-pharmacologic care models to better address risk for poor response. In Aim 1, we will identify baseline factors associated with an unfavorable change in pain-related disability (a common precursor to escalation of care) among patients undergoing treatment by a physical therapist. Using the ATI Outcomes Registry Dataset, one of the largest outcomes datasets specific to physical therapy, we will derive common trajectories of self-reported disability following initiation of care (Sub-Aim 1a) and develop multivariable models to identify risk factors for an unfavorable disability change trajectory (Sub-Aim 1b). Aim 2 will use a separate, large claims-based dataset comprised of industrial union workers to identify baseline factors associated with escalation of care (i.e., subsequent use of imaging, opioids, injection, and surgery) following initiation of treatment by a physical therapist for musculoskeletal pain (Sub-Aim 2a). Sub-Aim 2b will use a subset of the claims-based dataset that is also included in the ATI Outcomes Registry to determine the incremental change in probability of care escalation associated with each one-point improvement in disability score. This information could help clinicians set disability improvement targets for a meaningful reduction in risk for escalating care. In exploratory analyses, we will assess how the mass disruption of healthcare delivery related to COVID-19 impacts these questions. We will perform stratified analyses for each Aim to 1) determine whether disability trajectories and factors associated with those trajectories have changed following the onset of COVID-19, and 2) establish whether receiving physical therapy prior to or after onset of COVID-19 is associated with differences in risk for poor outcomes. Collectively, this work aims to improve the delivery of non-pharmacologic care in an effort to reduce risk for opioid use and better address the substantial personal and societal impact of musculoskeletal pain.