SPINE Volume 35, Number 7, pp 769 –777
©2010, Lippincott Williams & Wilkins
Increased Expenditures for Other Health Conditions
After an Incident of Low Back Pain
Ashok Nimgade, MD,* Eileen McNeely, PhD,* Donald Milton, MD, DrPH,*
and Joseph Celona, MD†
Study Design. We reviewed healthcare expenditures
in a random sample of 655 patients from a managed
health plan with new onset low back pain (LBP) in 1999.
Objective. To understand the affect of LBP on health
care utilization for other health conditions.
Summary of Background Data. Researchers often con-
sider individual diseases in isolation rather than seeking a
more comprehensive picture of comorbid conditions and
their collective influence. Although underlying health
conditions may exacerbate LBP, as has been discussed
extensively, minimal attention has been given to the po-
tential affect of LBP on other conditions.
Methods. We compared the healthcare expenses us-
ing 30-, 60-, and 90-day back care time windows before
and after the initial LBP visit. Diagnostic (International
Classification of Diseases, Ninth Revision) and treatment
codes (Current Procedural Terminology [CPT]) were used
to identify the expenditures for LBP and other conditions.
Results. Average monthly expenses per patient for
other health conditions increased after LBP initiation
when compared with the prior 1 to 3 months. This in-
crease persisted even after the following conservative
adjustments: (a) excluding all radiology expenses that
occurred coincident with LBP; (b) excluding billings for
non-LBP conditions that occurred on days of any LBP visit
because these charges may have reflected mere conve-
nience “shopping or servicing” behavior; (c) excluding
patients with a baseline of low healthcare utilization be-
fore LBP initiation because convenience may have been
especially important for this cohort. Patients with greater
non-LBP expenses were likelier to have been prescribed
psychiatric medications.
Conclusion. LBP episodes were associated with in-
creased expenditures for other health conditions. This
suggests that the traditional estimates of LBP based pri-
marily on LBP services underestimate the true cost of the
condition. Further research may help to delineate the role
of LBP, along with physical or mental comorbidities in
boosting non-LBP costs.
Key words: low back pain (LBP), health expenditure,
healthcare utilization, spillover, mental comorbidity, de-
pression, community health. Spine 2010;35:769 –777
From the *Environmental and Occupational Medicine, Harvard
School of Public Health, Boston, MA; and †Fallon Clinic Inc., Worces-
ter, MA.
Acknowledgment date: February 13, 2008. Revision date: October 29,
2008. Acceptance date: July 13, 2009.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Ashok Nimgade, MD,
Environmental and Occupational Medicine, Harvard School of Public
Health, Boston, MA 02446; E-mail: animgade@gmail.com
The high price of low back pain (LBP) contributes to
significant lost productivity, disability, and healthcare
resource consumption.1– 4 In addition, the high preva-
lence of LBP only magnifies this cost. In working popu-
lations, prevalence rate estimates range from 15% to
34% depending on the country and data source.5
But the burden of LBP may exceed what is typically
measured.6 Most researchers take a narrow biomedical
view considering one disease entity at a time7,8 versus a
more comprehensive picture of comorbid conditions and
their collective or propagating influence on health.9,4
Underlying psychosocial factors, in addition to physical
factors, may predispose individuals to LBP or to amplifica-
tion of its consequences.10,11 For instance, LBP may precip-
itate other coincident health conditions or exacerbate pre-
existing conditions.12 Understanding the proverbial straw
that breaks the back necessitates a broader view that incor-
porates other biopsychosocial factors.4,11,13
To understand the full brunt of LBP would entail con-
sidering an individual’s entire healthcare experience
throughout a LBP episode. Studies have shown debilitating
effects for years after a LBP event regarding pain, disability,
productivity, income, employment, and family effects.14,15
But in these studies, the long-time period considered or the
focus on group comparisons makes it difficult to untangle
factors attributable to LBP for individuals. One study
found that over a year, back-injured individuals spent more
than non-back pain patients on health care even after ad-
justing for direct back care costs.16 But this study cannot
explain whether back-injured subjects somehow differed
from controls in unaccounted ways.
The current study, in contrast, examines the same indi-
viduals before and after an incident of nonspecific LBP. A
temporally close range view here may also better allow for
assessing how LBP may increase non-LBP costs within a
few months of LBP onset. Because prior research found
more mental health conditions in LBP patients,13,17,18 we
also examine the relationship between LBP events and uti-
lization of psychiatric care. This study’s broader view of
LBP events may provide a more accurate account of true
costs of LBP and challenge the traditional view of LBP as
isolated from other health needs.
Materials and Methods
Overall Design
This study was based on analysis of health claims between
December 1, 1998 and March 2004 in a community-based
health maintenance organization in Massachusetts that serves
more than 200,000 clients. The data contained information on
demographics, International Classification of Diseases (ICD)
769
770 Spine • Volume 35 • Number 7 • 2010
Table 1. Study Sample Characteristics (N ⴝ 655)
Gender (%)
Female
Male
Age (yr)
LBP ICD code distribution (%)
724.5 (back ache)
724.2 (lumbago, low back syndrome)
847.2 (lumbar sprain/strain)
Other (724.8, 724.9, 846.0, 846.1, 846.9, 847.2, 847.9)
LBP covered by workman’s compensation (%)
LBP indicates low back pain; ICD, International Classification of Diseases.
codes, procedure codes (CPT), provider specialties, nature of
visit, prescriptions, and charges.
Subject Sample
Eligible patients were defined as being members in the managed
care plan beginning from January 1, 1998 to December 31,
2000 without gaps of more than 45 days in the 2-year period.
Furthermore, subjects had been diagnosed with uncomplicated
LBP during 1999 but without any LBP visits in the preceding
365 days. “Uncomplicated LBP” was defined by the ICD codes
corresponding to back ache, lumbago, low back syndrome,
lumbar sprain or strain, and other minor criteria (Table 1). The
conditions such as radiculopathy and lumbar surgery were ex-
cluded. Throughout this article, the term LBP refers to non-
complicated LBP. A total of 4521 patients met the eligibility
criteria. From this population, we drew a 15% random sample
(N ⫽ 655) for detailed data extraction.
Measurement of LBP Episode
For each patient, the initial LBP visit was “calibrated” to be “Day
Zero” (Figure 1). This permitted facile comparison of health ser-
vices utilization before versus after Day Zero across all patients.
For the pre-LBP baseline period, 30- and 90-day intervals were
used (Our initial preference was to work with just a 90-day pre-
LBP baseline. However, no data were available before December
1, 1998. As a result, analyses of the 90 days pre-LBP period had to
exclude patients with LBP onset in January and February 1999.
No statistical differences were seen between the excluded and non-
excluded patients in terms of age, gender, average charges, and
ever having been on workman’s compensation between 1999 and
2004 (P ⬍ 0.05 level). In this article, we have included the 30-day
pre-LBP baseline in our analyses to confirm that no spurious find-
ings resulted from having eliminated some data in analyses in the
90-day pre-LBP baseline studies); for the post-LBP period, 30-,
60-, and 90-day intervals were used.
Analytical Plan
The primary variables involved LBP or non-LBP expenditures
per patient summed over a given period. Most analyses in-
volved t tests to compare these expenses before versus after LBP
Figure 1. Cartoon depicting time-
line of study. The first day of a low
back pain (LBP) visit for any given
patient is termed Day Zero. In this
study, average non-LBP expenses
per patient before Day Zero are
compared with those in the 1, 2, or 3
months after. A statistically signifi-
cant increase may imply “spillover
effects” of LBP into non-LBP health
effects.
initiation. Because the patients in the “before” period were not
necessarily the same as those in the “after” period, unpaired t
tests were generally used. (paired t tests, however, were used
53.7
when looking at the same cohort of patients who had been
46.3
43.9 (0.9) using health services before and after LBP initiation). Because
of the non-normally distributed monetary data, effect sizes
70.0 were not appropriate and were not calculated (The t test, in
16.3
comparison, is less affected by such skew since it involves dif-
9.1
4.7 ferences between 2 populations). Data analysis were performed
6.5 using Stata (StataCorp LP, College Station, TX).
After finding evidence for the primary effect sought, various
conservative adjustments were made to demonstrate robust-
ness of the results. An important adjustment involved in elim-
inating expensive “outlier” cases, which have the potential to
skew results. The cutoff levels for eliminating outliers were
based on 90th and 95th percentile level of individual billed
charges (A charge was defined as any amount submitted for
billing. A patient could, thus, accumulate several charges on a
given day at the health center based on different procedures or
treatments received).
Three other adjustments were made individually and then in
combination. These were as follows: (a) expensive ancillary
charges: radiology expenses were eliminated to see whether
these potentially high charges biased outcomes. This maneuver
was undertaken to guard against the remote possibility that
expensive LBP-related procedures, identified by procedure
(CPT) and ICD codes, were misclassified as non-LBP expenses.
(Note that no lumbar surgeries were performed on any study
patients between 1999 and 2004, obviating the need to simi-
larly control for surgery expenses). (b) Analysis was restricted
to just the “old cohort” patients who were already actively
using the healthcare system during either 30 or 90 days before
their LBP started, to avoid the possibility of new patients to the
system being sufficiently different to bias outcomes. (c) Non-
LBP charges incurred on Day Zero and on any day on which a
patient presented with a primary diagnosis of LBP were dis-
carded to reduce potential “encounter effects,” whereby pa-
tients present ailments that they might otherwise have ignored
outside the clinic (Figure 2).
Measuring Psychiatric Comorbidities
Two measures of psychiatric stressors were used. The first was
based on a patient bearing one or more ICD codes pertaining to
depression, anxiety, or bipolar between 1998 and 2004. The
second was based on the patient’s utilization of psychiatric
medications at any point between 1998 and 2004. (These in-
clude antidepressants or antipsychotics but not benzodiaz-
epines, tricyclics, or sedatives). We used medication usage as a
proxy for mental health diagnoses because of prior studies that
have found these conditions to be underdiagnosed.19 Insuffi-
cient data were available for the period before the study year to
 Rise in Non-LBP After LBP Conditions • Nimgade et al 771

Figure 2. Reducing the potential

impact of “encounter effects.” In
this figure depicting treatment
course of a prototypical patient,
all geometric forms represent
health services charges. Bold
squares show days on which the
patient came in primarily for low
back pain (LBP) treatment. On
these days, all non-LBP charges
were eliminated from analysis
(as indicated by circles with
strikethroughs). On all other visit
days, the non-LBP charges were
counted regardless of whether
the patient may have come in
secondarily for LBP treatment
(indicated by unbolded squares).

identify which patients had preexisting mental health condi-
tions before the initial LBP incident.
Results
Subject Characteristics
Select characteristics of the sample of 655 participants are
summarized in Table 1. The patients were on average age of
44 years, with 54% being women. A total of 6.5% had
their LBP services covered by worker’s compensation, and
18% had received worker’s compensation health coverage
at some point during 1999 to 2004. The sample’s LBP di-
agnostic criteria breakdown is provided in Table 1. No
significant difference was seen between the population and
the study sample with respect to age, gender, worker’s com-
pensation status, or distribution of LBP diagnostic criteria
(P ⬍ 0.05 level). Of all visits involving LBP, 83% visits had
listed LBP as the primary diagnosis.
LBP was the primary diagnosis for 86% of all LBP
charges. During the first year after the initial LBP visit,
75% of all patients had no more LBP visits after 75 days.
Figure 3, which focuses on total non-LBP expenses per
patient in just the first month after LBP onset, demon-
strates potential impact of expensive outliers on results.
No evidence for seasonality was noted whether the data
were broken down into 3-month (␹2 test ⫽ 2.56, P ⫽
0.465) or 2-month blocks (␹2 test ⫽ 4.11, P ⫽ 0.537).
Evidence of LBP Effects on Other Health Conditions
Average monthly expenses per patient for non-LBP diag-
noses increased during 1 to 3 months after LBP initiation
compared with 1 to 3 months before LBP initiation (Table
2 and Figure 4). When no outlier charges were excluded,
monthly non-LBP expenses per patient increased signifi-
cantly from $163 in the 3 months before LBP initiation to
$482 in the first month after LBP initiation. Day Zero ac-
counted for 11% of all non-LBP expenses for the first 90
days of LBP. Median total expenses for non-LBP conditions
increased approximately 33% per patient in the 90-day
period after the initial LBP visit compared with the same
period before that LBP visit. Using either a 90- or a 30-day
pre-LBP baseline did not seem to affect the result trends
much. The choice of post-LBP window, conversely, made a
bigger difference. The largest boost in non-LBP expendi-
tures coincident with the LBP event, a phenomenon we
refer to as possible LBP “spillover effects,” appeared in the
first month after Day Zero. This spillover effect diminished
2 to 3 months post-LBP initiation.
When all radiology charges were eliminated from the
database, the significant results remained unchanged (Fig-
ure 5). Note that there was no need to repeat this maneuver
for lumbar surgeries because no such surgeries were under-
taken in the study group during the study period.
When the analysis was restricted to just the “old co-
hort” patients (who were already actively using the
healthcare system even before their LBP started), the
spillover effect remained (Figure 6). This spillover effect,
however, no longer persisted after the 2 months of LBP.
When encounter effects were reduced by discarding
non-LBP charges incurred on any day on which a patient
772 Spine • Volume 35 • Number 7 • 2010

Figure 3. Histogram of total non-

LBP expenses ($) per patient ac-
cumulated in just the first month
after Day Zero. Five percentage
of the study patients had accu-
mulated more than $2400 of ex-
penses in the first month of low
back pain (LBP). The long tail of
expenses implies a need to cutoff
extreme outliers when compar-
ing before and after Day Zero
non-LBP expenses.

presented with a primary diagnosis of LBP, the spillover
effect persisted (Figure 7). This spillover persisted even 3
months after LBP initiation.
When all the aforementioned potential confounders
were controlled in combination together, the spillover
effect persisted to a significant level for the first month of
LBP (Figure 8).
“Non-LBP” Expenses That Increased the Most After
Day Zero
During the course of the database (1998 –2004), patients
presented with some 2009 primary non-LBP diagnoses.
In the month preceding Day Zero, patients presented
with 204 primary diagnoses; in the month after, this
increased to 318 primary non-LBP diagnoses.

Table 2. Spillover Analysis: Comparing Non-LBP Monthly Expenses Before Versus After Initiation of LBP*
90 Days Pre-LBP
30 Days Pre-LBP
Period Expensive Outlier Expense Before Expense After
Postday 0 Cutoff % (SE) (SE) Increase P Expense Before Expense After Increase P

30 days after 100 163 (20) 482 (135) 319 0.0091 199 (38) 525 (123) 326 0.0047
95 141 (14) 328 (56) 187 0.0004 164 (23) 383 (62) 219 0.0002
90 128 (12) 293 (48) 165 0.0002 158 (21) 332 (49) 174 0.0002
60 days after 100 163 (21) 321 (72) 158 0.0149 199 (38) 394 (87) 195 0.0172
95 151 (17) 262 (42) 111 0.0043 172 (27) 311 (49) 139 0.0043
90 138 (14) 231 (31) 93 0.0013 158 (21) 264 (33) 106 0.0014
90 days after 100 163 (21) 287 (53) 124 0.0139 199 (38) 339 (61) 140 0.0215
95 153 (18) 249 (36) 96 0.0051 172 (27) 299 (44) 127 0.0042
90 141 (14) 217 (25) 76 0.0019 164 (23) 251 (30) 87 0.0054
The top left of the table shows how non-LBP monthly expenses per patient increased from the first 90 days before LBP initiation to the 30 days after. The first
line shows all expenses (i.e., “cutoff” at the 100th percentile); the second line eliminates the 5% most expensive charges (i.e., cutoff at 95 percentile); the third
line eliminates the 10% most expensive charges (i.e., cutoff at 90 percentile). Thus, the left side of the first line shows that, when no outlier charges are excluded,
monthly non-LBP expenses per patient increased significantly from $163 in the 3 months before LBP initiation to $482 in the first month after LBP initiation. The
2 lines below it show that as more expensive outlier charges are eliminated, the spillover effect diminishes but remains significant. Other segments of this table
can be interpreted similarly. Overall, the spillover effect diminishes 2 to 3 months post-LBP initiation but remains statistically significant. In the right half of the
table, the baseline comparison period has been increased to 90 days. With the 30 days pre-LBP comparison group (right side of table), the spillover effect remains
and seems slightly higher. (Note that Bonferroni correction for multiple comparisons is not appropriate here given that the outcome variables here are highly
correlated— essentially the same variable examined from different angles.)
*Figure 4 summarizes these results pictorially.
LBP indicates low back pain; SE, standard error.
 Rise in Non-LBP After LBP Conditions • Nimgade et al 773

Figure 4. An increase in average

monthly non-low back pain (LBP)
expenses (“spillover”) per patient
in 30, 60, or 90 days after initial LBP
visit versus the 90 days preceding.
This figure depicts the data from
Table 2. The first third of the graph
shows the increase in non-LBP ex-
penses without eliminating any
high outlier charges. The increase
in non-LBP expenses are larger in
the month after LBP initiation (Day
Zero) and seem to decrease with
time. The middle third of the graph
excludes highest fifth percentile of
charges. A similar pattern of de-
clining spillover effect with the
passage of time after Day Zero is
seen here as well. The right third
excludes highest 10th percentile of
charges and also shows a similar
pattern. *P ⬍ 0.05, t test.

The 50 non-LBP diagnoses that accounted for the great-
est increase in total average expenses per patient from the
month preceding Day Zero to the month after are listed in
Table 3. Only 6.5% of the increase in total expenses in-
volved with these 50 diagnoses was from back pain com-
plications such as “thoracolumbar neuritis” or thoracic
pain. (Recall that the term LBP throughout the text refers to
noncomplicated LBP). Removing these from back pain
complications did not, however, affect the thrust of the
main spillover findings: for instance, even after subtracting
expenses from these back pain complications, average
monthly non-LBP expenses per patient increased from
$192.5 in the 30 days before Day Zero to $495.0 in the 30
days after (P ⬍ 0.008) (Table 1).
Several musculoskeletal diagnoses, actually, had de-
creased costs from the 1 month before the 1 month after:
for instance, sprains or strains on nonlumbosacral back
(ICD 847), knee pain, and “limb pain.” In fact, the de-
crease in sprains or strains in nonlumbosacral back (ICD
847), more than offset the aforementioned expenses
from back pain complications. With dozens of diagnoses
involved, given a possible role for randomness, one must
not read too much into all such fluctuations.
Effect of Psychiatric Comorbidities
In the first month after Day Zero, increased non-LBP total
expenses seemed significantly associated with any psychiat-
ric medication use during 1998 to 2004 (increasing from
$139 [SE, 46] from a month before $788 [SE, 389] a month
after Day Zero, P ⫽ 0.0497). Other measures of psychiatric
health were not significantly associated with increasing
non-LBP expenses (For patients who had been diagnosed
with depression during the same time, non-LBP total ex-
penses averaged $363 [SE, 143] vs. $275 [SE, 262] for those

Figure 5. An increase in average

monthly non-low back pain (LBP)
expenses (“spillover”) per pa-
tient excluding all radiology ex-
penses after LBP initiation. This
should be interpreted in a similar
fashion to the prior figure. Even
after excluding all radiologic ex-
penses, the spillover effect per-
sists to a significant level (al-
though slightly attenuated)
through all 3 months after LBP
initiation.
774 Spine • Volume 35 • Number 7 • 2010
Figure 6. An increase in average
monthly non-low back pain (LBP)
expenses in old cohort only (i.e.,
in patients with non-LBP visits in
90 days preceding initial LBP
visit). This figure, which depicts
data from Table 3, should be in-
terpreted in a similar manner as
the preceding figure (it also
shows data from 30, 60, or 90
days after initial LBP visit vs. the
90 days preceding). The increase
in non-LBP expenses persists for
the first 2 months after Day Zero,
indicating that recruitment by
LBP of a new cohort of patients
into the system (“cohort effects”)
cannot explain away the spill-
over effect. *P ⬍ 0.05, t test.
never diagnosed with depression [P ⫽ 0.616]. Likewise, for
anxiety: non-LBP total expenses averaged $343 [SE, 131]
vs. $331 [SE, 356] for those never diagnosed with anxiety
[P ⫽ 0.513]. For patients who had been on benzodiazepines
at one point or the other, non-LBP total expenses averaged
$198 [SE, 197] vs. $404 [SE, 159] for those never on these
medications [P ⫽ 0.775]. Note that a very small number of
bipolar patients precluded analysis for this condition).
In the first 30 days after Day Zero, the patients in
either the top 5 or the top 10% for non-LBP total ex-
penses were likelier to have been on psychiatric medica-
tions at one point or the other during 1998 to 2004 (for
top 5%: ␹2 test ⫽ 5.6, P ⫽ 0.018; for top 10%: ␹2 test ⫽
6.1, P ⫽ 0.013). They were not, however, significantly
likelier to be diagnosed as ever being depressed during
this time period (For top 5%: ␹2 test ⫽ 1.9, P ⫽ 0.66; for
top 10%: ␹2 test ⫽ 1.3, P ⫽ 0.25).
The patients in the top 5% for increase in non-LBP
total expenses from the 30 days before Day Zero to the
30 days after were likelier to have been on psychiatric
medications at one point or the other during 1998 to
2004 (␹2 test ⫽ 3.9, P ⫽ 0.049). The corresponding
patients in the top 10% were not significantly likelier to
have been on psychiatric medications (␹2 test ⫽ 2.6, P ⫽
0.10). These patients with large increases in non-LBP
expenses over the corresponding time periods were not
Figure 7. An increase in average
monthly non-low back pain (LBP)
expenses after excluding all
charges on days of patient visits
primarily for LBP (to help to re-
move “encounter effects”). This
figure should be interpreted in a
similar manner as the preceding 2
figures (as mentioned in the pre-
ceding paragraph, it also shows
data from 30, 60, or 90 days after
initial LBP visit vs. the 90 days pre-
ceding). The increase in non-LBP
expenses persists and indicates
that encounter effects alone may
not explain away the spillover ef-
fect. *P ⬍ 0.05, t test.

Figure 8. An increase in aver-
age monthly non-low back pain
(LBP) expenses in old cohort
only after removing “encounter
effects” and excluding all radi-
ology expenses. This figure
should be interpreted in a sim-
ilar manner as the preceding 2
figures (as mentioned in the
preceding paragraph, it also
shows data from 30, 60, or 90
days after initial LBP visit vs.
the 90 days preceding). The in-
crease in non-LBP expenses
persists for the first 30 days af-
ter Day Zero. *P ⬍ 0.05, t test.
significantly likelier to be diagnosed as ever being de-
pressed (for top 5%: ␹2 test ⫽ 1.9, P ⫽ 0.66; for top
10%: ␹2 test ⫽ 0.003, P ⫽ 0.96).
Although there was a tendency for average total de-
pression billings per patient to increase from the month
before Day Zero to the month after ($4.40 –$43.91), this
was nonsignificant (P ⫽ 0.11).
Discussion
The spillover effect from LBP episodes persisted even
after various adjustments including: excluding radiology
expenses and excluding any billings on days, which the
patient presented for any LBP care and therapy. This
effect cannot be accounted for merely through the re-
cruitment of a new cohort of patients because of LBP:
even in the cohort of patients, using this healthcare sys-
tem in the month preceding LPB initiation, the booster
effect was seen.
It is possible that encounter effects—the bundling of
services as a matter of convenience—accounted for
some of the spillover effects. Some of this attenuation,
however, might simply be attributable simply to hav-
ing less data on hand because of eliminating charges
from analysis.
Only a small amount of the increase in total average
expenses per patient from the month preceding Day Zero
to the month after could be attributable to back pain
complications that were not filtered out by the original
patient inclusion criteria. Some of this reflects a Byzan-
tine diagnostic coding system, whereby healthcare pro-
viders may record the same condition with a variety of
codes. This may attenuate the spillover effect to a slight
extent (in the order of 6.5% of total expenses involved
with the 50 non-LBP diagnoses that increased the most in
expenses after Day Zero).
The wide range of the 50 non-LBP diagnoses that ac-
counted for the most cost escalation after Day Zero sug-
Rise in Non-LBP After LBP Conditions • Nimgade et al 775
gests that LBP may not directly account for all of the
non-LBP spillover effect. One can posit, for instance, a
common underlying biopsychosocial process or condi-
tion giving rise to both LBP and non-LBP morbidities.
Alternatively, non-LBP morbidities could actually give
rise to LBP morbidities. For instance, altered biomechan-
ics resulting from femur fractures could lead to LBP.
LBP, however, can be seen as a marker for a change on
the health status of an individual with often wide-
ranging consequences. Recent studies that have evi-
denced the negatively reinforcing consequences of co-
morbid conditions for healthcare costs lead to
appreciation of comprehensive management approaches
geared to work across chronic illnesses.8
The patients with greater non-LBP expenses did have
a significantly higher rate of psychiatric prescriptions but
did not have a higher rate of psychiatric diagnoses. This
discrepancy might be explained by the phenomenon of
psychiatric conditions still being stigmatized by society
to the point where patients would rather see their pri-
mary physicians for such conditions rather than special-
ists.16 Coding for these conditions may likewise be
downplayed.
We were limited by data available to adopt a rough
methodology to identify patients who may have had a
predisposition toward psychiatric conditions. Use of psy-
chiatric medication and benzodiazepines may not prove
an accurate proxy for mental health conditions; this is
particularly the case for just one-time psychiatric medi-
cation prescriptions (Our database did not provide the
number of refills per prescription). Also, we lacked suf-
ficient numbers of cases to study bipolar or anxiety con-
ditions alone (e.g., only 3 instances of lithium use were
found in the database; anxiety medications can be non-
specific). Nonetheless, the association of LBP with psy-
chiatric medications here supports prior studies that
776 Spine • Volume 35 • Number 7 • 2010

Table 3. The 50 Non-LBP Diagnoses That Accounted for and considers the full spectrum of biopsychosocial needs
the Greatest Increase in Total Average Expenses per of the person. Future research can help us to understand
Patient From the 30 Days Preceding Day 0 to the whether this model ultimately contains costs and im-
30 Days After proves outcomes.
Increased
ICD Diagnosis Expenses Methodologic Considerations
In general, using a window of 90 days before LBP initi-
1 821.01 Fracture femur shaft 35026.0
2 38.42 Septicemia 19298.6 ation provides more positive results regarding spillover
3 428 Heart failure 17347.0 effects than using the shorter window of 30 days. We
4 642.51 Pre-eclampsia 15120.2 favor using a 90-day pre-LBP window rather than a 30-
5 996.77 Complications joint prosthesis 13064.7
6 486 Pneumonia 10857.4 day pre-LBP window for 2 reasons: (a) a 90-day pre-LBP
7 789 Abdomen/pelvis symptoms 9773.5 window, being longer, provides a better baseline of pre-
8 592.1 Ureter stone 9617.5 LBP expenses; (b) for the old cohort only portion of this
9 218.1 Leiomyoma of uterus 8835.8
10 552.1 Umbilical hernia 7281.3 study patients seen for a routinely followed condition
11 296.89 Bipolar disorders 6886.4 within 1 month before their first LBP visit might not have
12 Unknown 5963.3 follow-up visits scheduled until several months into the
13 820.21 Fracture femur trochanter 5508.0
14 730.28 Osteomyelitis 5158.8 future. This phenomenon would tend to decrease the
15 592 Kidney/ureter stone 5044.8 non-LBP charges in the post-LBP follow-up periods for
16 553.1 Paraumbilical hernia 4526.0 the old cohort.
17 642.5 Severe pre-eclampsia 3951.0
18 780.6 Fever 3591.5 The approach we followed to help eliminate the po-
19 787.03 Vomiting 3022.9 tential bundling of services for convenience, or the “en-
20 786.52 Painful respiration 2871.6 counter effect,” was to eliminate all non-LBP charges
21 625.9 Female genital organs symptoms 2814.5
22 821 Fracture femur—unspecified 2459.0 incurred on days patients came primarily for LBP care.
23 724.4* Thoracolumbar neuritis/radiculitis 2387.0 This approach would not exclude all expenses for the
24 722.2* Intervertebral disc disorders 2309.0 aforementioned new non-LBP diagnoses, because pa-
25 724.3* Neuritis of sciatic nerve 2211.0
26 848.9* Sprains/strains nonlumbosacral back 2116.0 tients might schedule further visits primarily for the new
27 729.2 Neuralgia, neuritis 2012.0 diagnoses. Yet, this approach could be too conservative
28 780.79 Malaise and fatigue 1965.2 because it would eliminate all charges for non-LBP ex-
29 730.27 Osteomyelitis—unspecified 1932.0
30 823.2 Fracture tibia/fibula 1801.0 penses that the patient would have shown anyway to the
31 788 Urinary symptoms 1727.0 physician on another visit. Because patients may be
32 789.07 Abdominal pain 1641.5 prone to consolidate visits,20 it is likely that our ap-
33 722.93* Lumbar unspecified disc disorder 1602.0
34 722.52* Lumbosacral intervertebral disc 1556.0 proach may prove reasonable balance.
35 786.05 Shortness of breath 1512.5 Further studies may also help to delineate the role of
36 786.5 Chest pain 1490.5 LBP, along with physical comorbidities or mental stres-
37 723.3 Cervicobrachial syndrome (diffuse) 1460.0
38 218.9 Leiomyoma of uterus, unspecified 1459.0 sors, in boosting non-LBP costs. Ideal study designs
39 569.3 Hemorrhage of rectum 1435.0 would allow for questionnaire-based information from
40 739.3* Lumbar region—nonallopathic lesions 1428.0 patients about the impact of their LBP visits on other new
41 564 Digestive disorders 1427.5
42 608.9 Male genital organs—unspecified 1364.0 conditions. Better information about preexisting psychi-
43 552.21 Ventral hernia 1335.0 atric comorbidities would also allow for analyzing the
44 726.9 Enthesopathy—unspecified 1265.0 impact of these conditions on the spillover effect. Having
45 839.2* Thoracic and lumbar vertebra 1107.0
46 721 Spondylosis 1035.0 sufficient lead-time data would also allow for more study
47 786.2 Cough 1032.8 of the encounter effect by allowing for identification of
48 518.81 Acute respiratory failure 1032.0 new ancillary diagnoses in the course of treatment for
49 721.3* Lumbosacral spondylosis—no myelopathy 1017.0
50 839 Dislocations—other 1015.0 LBP. Some of the ancillary diagnoses, however, might be
The “increased expenses” column shows the total increase in these ex-
part of a cascade of health effects involving the patient’s
penses summed across all patients. LBP. It would also be interesting to compare the spillover
*Represent potential low back pain complications but combined account for effects from LBP with spillover effects from other health
only 6.5% of increased “non-LBP” expenses.
LBP indicates low back pain; ICD, International Classification of Diseases. conditions.

have found an association between mental health and
LBP.9,13
Our results supports a costing model for LBP that
includes the “incremental costs” associated with the LBP
incidents, for example, costs that go beyond services spe-
cifically targeting the LBP.6 This broad picture of spill-
over effects from LBP reinforces a holistic approach to
LBP treatment that goes beyond an acute injury model
Conclusion
Evidence was found here for existence of spillover effects;
that is, non-LBP expenses increasing after LBP initiation.
The spillover effect seems particularly stronger in the first
month after LBP initiation and diminished within 2
months. LBP can serve as a marker for increased non-
LBP health services yet to come over the next couple of
months. Also, considering the relationship between LBP

events and non-LBP expenditures, the true cost of LBP
may be underestimated
The possibility of encounter effects contributing to the
spillover effect—particularly the diagnoses of new con-
ditions in the course of LBP evaluation— cannot be ruled
out. Further studies on the spillover effect in workman’s
compensation groups are recommended to help to eval-
uate whether this system provides ample coverage for
addressing spillover effects. Further research may help to
delineate the role of LBP, potentially along with physical
comorbidities or mental stressors, in boosting non-LBP
costs.
Our research specifically highlights how treatment for
LBP must be aligned with other primary care services to
somehow prevent a “ballooning” of health needs around
the time of the LBP episode. This is especially important
given the shortages in primary care providers and the
increasing fragmentation and specialization in the
healthcare system. In addition, our nuanced focus on
outpatient services in particular suggests where this sep-
aration of purpose may begin.
Key Points
● In a database study of a community-based man-
aged care organization, average monthly ex-
penses per patient for non-LBP diagnoses in-
creased after LBP initiation.
● This spillover effect persisted even after adjusting
for possible confounders.
● Mental stressors may be involved, since patients
with higher spillover non-LBP expenses were
likelier to have been on psychiatric medications.
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