Back pain is a common source of disability, both from work-related injuries and from injuries that occur outside of the workplace. Annually in the United States, over $15 billion is spent for the treatment of low back pain and disorders, and approximately 15 percent of the costs in workers’ compensation medical care are for low back pain cases. 

This study focuses on care provided or directed by physicians and addresses the following questions:

• What are the patterns of medical care for workers with common low back conditions in the 16 states studied?
• How do these patterns vary across states?
• How do the patterns of medical practice in the study states compare with evidence-based treatment guideline recommendations?

Overall, we found workers with similar low back conditions received very different care, depending on the state. These interstate differences were most noticeable for cases with nonspecific low back pain in the areas of diagnostic services and pain management injections. For disc cases, the interstate differences were most notable in the utilization of nerve testing, pain management injections, back surgery, and physical medicine. Large interstate differences in the timing of care were also seen for both types of low back conditions.  

We also identified several areas of service and a number of states where the patterns of care were inconsistent with evidence-based treatment guidelines. The inconsistency is seen in the frequency of use and early use of X rays and MRIs especially for nonspecific low back pain and in the early timing of back surgery and injections for disc cases.

Among our findings:

·         X rays and MRIs were used more often and earlier than recommended by evidence-based treatment guidelines, especially for cases with nonspecific low back pain. For example, the percent of cases with X rays ranged from 42 percent in Massachusetts to 77 percent in Louisiana. When provided, 78–91 percent of first X rays were performed early within four weeks postinjury. 

·         Nerve testing was used typically in 20–26 percent of disc cases among the 16 states, higher in pre-reform California, Pennsylvania, Michigan, and pre-reform Texas (28-32 percent) and lower in Arkansas, Connecticut, Indiana, Massachusetts, North Carolina, and pre-reform Tennessee (10–17 percent).

·         Workers with disc conditions in Georgia and Indiana were twice as likely to receive injections as workers in Massachusetts and Connecticut. While 40–50 percent of disc cases had injections in most states studied, the figure was higher in Georgia and Indiana (59–62 percent), double that in Massachusetts and Connecticut (31 percent).

·         The percentage of disc cases with surgery was the highest in Arkansas and pre-reform Tennessee (40–45 percent), double that in pre-reform California, pre-reform Florida, and pre-reform Texas (17–22 percent). The surgery rate was also higher than typical of the 16 states in Georgia, Indiana, Louisiana, and North Carolina (33–37 percent).

·         In Arkansas, North Carolina and pre-reform Tennessee, workers with disc conditions were not only more likely to receive surgery, but also had surgery performed early—within six weeks postinjury. More frequent early surgery in those states was inconsistent with evidence-based treatment guidelines that recommend surgical options being considered only for patients with severe and persistent radicular symptoms after 4–6 weeks of conservative care.

·         Utilization of medical services (X rays, MRIs, nerve testing, injections, and surgery) was consistently higher in Louisiana than in the other study states for both types of low back cases. Conversely, utilization of the same services was consistently lower to typical in Connecticut, Illinois, Maryland, Massachusetts, and Wisconsin.

The 16 states in the study (Arkansas, California, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Maryland, Massachusetts, Michigan, North Carolina, Pennsylvania, Tennessee, Texas, and Wisconsin) are geographically diverse and represent differences in fee schedules, choice of provider and other key aspects of workers’ compensation systems. For California, Florida, Tennessee, and Texas, the results are largely or entirely pre-reform, providing a baseline for monitoring relevant reforms in these states.