ORIGINAL RESEARCH

Implementation of the Primary Spine Care

Model in a Multi-Clinician Primary Care
Setting: An Observational Cohort Study
James M. Whedon, DC, MS, a Andrew W.J. Toler, MS, a Serena Bezdjian, PhD, a
Justin M. Goehl, DC, MS, b Robb Russell, DC, a Louis A. Kazal, MD, b and Melissa Nagare, DC, LAc a
ABSTRACT

Objective: The objective of this investigation was to compare the value of primary spine care (PSC) with usual care
for management of patients with spine-related disorders (SRDs) within a primary care setting.
Methods: We retrospectively examined existing patient encounter data at 3 primary care sites within a multi-clinic
health system. Designated clinicians serve in the role as PSC as the initial point of contact for spine patients,
coordinate, and follow up for the duration of the episode of care. A PSC may be a chiropractor, physical therapist, or
medical or osteopathic physician who has been trained to provide primary care for patients with SRDs. The PSC model
of care had been introduced at site I (Lebanon, New Hampshire); sites II (Bedford, New Hampshire) and III (Nashua,
New Hampshire) served as control sites where patients received usual care. To evaluate cost outcomes, we employed a
controlled quasi-experimental design for analysis of health claims data. For analysis of clinical outcomes, we
compared clinical records for PSC at site I and usual care at sites II and III, all with reference to usual care at site I.
We examined clinical encounters occurring over a 24-month period, from February 1, 2016 through January 31, 2018.
Results: Primary spine care was associated with reduced total expenditures compared with usual care for SRDs. At
site I, average per-patient expenditure was $162 in year 1 and $186 in year 2, compared with site II ($332 in year 1;
$306 in year 2) and site III ($467 in year 1; $323 in year 2).
Conclusion: Among patients with SRDs included in this study, implementation of the PSC model within a
conventional primary care setting was associated with a trend toward reduced total expenditures for spine care
compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may
be no more effective than usual care regarding clinical outcomes. (J Manipulative Physiol Ther 2020;43;667-674)
Key Indexing Terms: Primary Health Care; Back Pain; Neck Pain; Low Back Pain; Chiropractic

TAGEDH1INTRODUCTIONTAGEDEN line management, case coordination and follow-up of

There is a pressing need to identify and implement
guideline-concordant clinical pathways that improve out-
comes, reduce unnecessary escalation of care, and control
costs for management of patients with spine related disor-
ders (SRDs).1 Primary spine Care (PSC) is an innovative
approach to the care of SRDs.2,3,4,5 PSC is defined as first-
a
Health Services Research, Southern California University
Health System, Southern California University of Health Scien-
ces, Whittier, California.
b
Department of Community and Family Medicine, Geisel
School of Medicine at Dartmouth, Hanover, New Hampshire.
Corresponding author: James M. Whedon, DC, 16200 Amber
Valley Drive, Whittier, CA 90604.
(e-mail: jameswhedon@scuhs.edu).
Paper submitted July 22, 2019; in revised form April 9, 2020;
accepted May 1, 2020.
0161-4754
© 2020 by National University of Health Sciences.
https://doi.org/10.1016/j.jmpt.2020.05.002
patients with any spine related disorder (SRD), under the
direction of a certified Primary Spine Practitioner (PSP).
As an alternative to the usual primary care pathway, the
PSP serves as the initial point of contact for patients with
SRDs. A PSC clinician is competent in the diagnosis of
SRDs, and in a range of conservative nonpharmacological
therapies that constitute first-line, guideline-concordant
treatment options for spinal pain. The PSC clinician uses
evidence-based interventions6 and spine care pathways
for clinical decision support that include stratification and
management according to patient symptoms, working diag-
nosis, and biopsychosocial factors.7,8 Assessment of biop-
sychosocial factors provides prognostic information for
stratification of care that may enhance the management of
SRDs while reducing the cost of spine care.9,10,11 The
Global Spine Care Initiative has described primary level
care as a key element in a comprehensive model of care
intended to address the global burden of SRDs.12 Primary
spine care is essentially evidence-based practice in the care
668 Whedon et al
Primary Spine Care Model
of SRDs, and can be practiced by any qualified health pro-
fessional. A PSP may be a chiropractor, physical therapist,
or medical or osteopathic physician who has been specially
trained to provide primary care for patients with SRDs.
Formal programs of training in the PSC model have been
offered by the University of Pittsburgh, the Primary Spine
Provider Network, and Southern California University of
Health Sciences.
A PSP serves as the initial point of contact for patients
with SRDs and coordinates and follows up for the duration
of the episode of care, making the necessary referrals for
patients who require additional testing, more intensive
rehabilitation, or invasive procedures. Most cases are man-
aged by the PSC clinician, with the remainder comanaged
with providers from other specialties. Patients with SRDs
are subcategorized and matched with the most beneficial
conservative treatment, including but not limited to spinal
manipulation or mobilization, repeated end-range loading,
neural mobilization techniques, patient-specific exercises,
and evidence-based education materials. The PSC model
has been reported to decrease variability in care, decrease
costs, and improve outcomes for patients with SRDs.4,13
Most recently, in a controlled before-and-after study,
implementation of a conservative spine care pathway
within a primary care practice was found to be associated
with reduced health care expenditures over a 4-year
period.14
By contrast, the usual approach to spine care in a pri-
mary care setting may be less interventional. Patients may
be provided with self-care advice or a prescription for med-
ication or referred to physical therapy. In some cases, the
physician may order imaging or counsel the patient about
referral to a specialist.
The objective of this investigation was to retrospectively
evaluate outcomes associated with implementation of the
PSC model within a primary care setting compared with
usual care provided by medical and osteopathic physicians
in a primary care setting. We designed a study to answer
the research question: Among patients with SRDs, is imple-
mentation of the PSC pathway associated with lower costs
and improved outcomes compared with usual spine care?
TAGEDH1METHODSTAGEDEN
Overview
In early 2017, a clinician was hired to implement the
PSC model within a multi-provider primary care practice;
he was considered well-prepared by his peers to offer PSC.
The clinician was a doctor of chiropractic with a master of
science degree in sport science and rehabilitation and
5 years of experience in clinical practice. He completed a
residency in chiropractic at the Los Angeles Veterans
Health Administration hospital, followed by a clinical fel-
lowship in PSC at Southern California University of Health
Journal of Manipulative and Physiological Therapeutics
September 2020
Sciences, and was subsequently certified in PSC by the
University of Pittsburgh.
We retrospectively examined existing datasets. To study
cost outcomes, we examined health insurance claims data
extracted from a state-administered All Payer Claims Data-
base. For analysis of clinical outcomes, we analyzed health
system data derived from electronic health records and bill-
ing records of clinical encounters. The health system data-
sets and the state-administered claims datasets were not
merged, but managed and analyzed separately. In accor-
dance with standard rules for analysis of health claims, cells
with n < 11 were suppressed to prevent against disclosure
of protected health information. This study was approved
by Dartmouth College’s Committee for Protection of
Human Subjects and by the institutional review board of
Southern California University of Health Sciences.
Study participants included all patients who presented
from February 2016 through December 2017 for care at any
of the study sites for a primary diagnosis of SRD. Spine-
related disorder was defined as any condition that originates
in the spine or causes symptoms localized to the spine, includ-
ing back and neck pain disorders. The specific diagnosis
codes used to identify SRDs may be viewed in the Appendix.
We examined data on encounters with patients seen at 3
different primary care sites within a multi-clinic health sys-
tem: site I (Lebanon, New Hampshire) site II (Bedford,
New Hampshire), and site III (Nashua, New Hampshire).
At site I, the PSC model of care had been implemented
with 1 certified PSP (doctor of chiropractic), halfway
through the study period on February 1, 2017 (the index
date), and has continued to date. Thus, clinical data from
site I included care for SRDs provided via the PSC model
in addition to usual care. Sites II and III served as control
sites where all patients with SRDs received usual care
throughout the study period. Sites II and III were selected
based upon preliminary analysis of electronic health
records. Within the same health system, we examined sta-
tistics on 13 clinical sites regarding patient age, sex, race,
and Charlson Comorbidity Index score, in addition to aver-
age unique patients and average encounters per month per
site. Site demographic factors were analyzed for differences
as compared with site 1 using t tests or x2 analyses at the P
< .05 level. Among all sites examined, sites II and III were
found to be most comparable to site I regarding patient and
provider demographics.
We operationalized the definition of PSC as all evalua-
tion or treatment procedures tied to encounters with the
PSC clinician for primary diagnosis of SRD. Usual care
was operationalized as all evaluation or treatment proce-
dures tied to encounters for primary diagnosis of SRD with
a primary care medical physician (specialty of family medi-
cine, internal medicine, or general medical practice) at site
I, II, or III. In a pragmatic approach to ensure that usual
care represented actual current practice patterns, we imposed
no further limits or restrictions on the included procedures.
Journal of Manipulative and Physiological Therapeutics
Volume 43, Number 7
The PSC model included a clinician trained in the PSP
certification program, within a multidisciplinary ambula-
tory care setting. The clinical flow was a mixture of direct-
access patients and referrals from within the health system,
with most coming from primary care providers within the
same clinic. The primary pathway used for diagnosis, tri-
age, and management of patients comes from the Clinical
Reasoning in Spine Pain protocol, which provides frame-
work for a clinician to make evidence-informed decisions.
Treatment approaches focused on a “less is more” concept
ranging from reassurance and education to home exercises
and self-treatment options to clinician-based care including
joint manipulation or mobilization, neural mobilizations,
and various soft tissue treatment options.7,8 The manage-
ment of cases from onset to resolution was frequently per-
formed by the single practitioner but could include
comanagement with other departments including but not
limited to physical therapy, primary care, behavioral health,
and spine/pain clinics. Referrals to these departments were
on a case-by-case basis and often represented a need to
escalate care. Imaging was reserved for those cases with
indications that are included in the American College of
Radiology practice parameters for spinal radiography
including but not limited to traumas, the presence of neuro-
logic symptoms, possible infection or neoplasm, and for
those patients who failed to respond to conservative care.15
Decisions to order imaging were made in conjunction with
the American College of Radiology guidelines and the clin-
ical experience of the provider.
Analysis of Cost Outcomes
To compare costs between, before, and after the institu-
tion of the PSC, we designed a controlled quasi-experimen-
tal study to retrospectively examine cost outcomes before
and after the index date of February 1, 2017. The intent of
this approach was to evaluate the effect of a change in prac-
tice, that is, abrupt introduction of PSC into a conventional
primary care setting. To compare patient characteristics
and health status in the before-and-after groups, we ana-
lyzed for differences in age and sex by x2 analysis and for
differences in Charlson Comorbidity Index score by t test.
To calculate Charlson scores, we analyzed all comorbid
diagnoses documented within the 12-month period prior to
the first claim for SRD. To measure average costs by period
and clinical site, we analyzed claims associated with a pri-
mary diagnosis of SRD. We measured payments for pri-
mary care of SRDs. To develop a clinically meaningful
(Site I pre-index payments – Site I post-index payments) – (Site II pre-index payments – Site II post-index payments)
(Site I pre-index payments – Site I post-index payments) – (Site III pre-index payments – Site III post-index payments)
Fig 1. Definition of difference-in-difference methodology. (Color version of figure is available online.)
Whedon et al 669
Primary Spine Care Model
stratification of total payments for SRDs, we defined utili-
zation categories of patients whose care pathway was esca-
lated beyond conservative primary care. We examined total
payments for care of SRDs among patients who used (in
addition to primary care services) the emergency depart-
ment (ED), spinal imaging, spinal injection, spinal surgery,
hospitalization, and opioid prescription fill. We analyzed
for percentage change in payments by clinical site. We also
analyzed for difference-in-difference in payments between
the intervention site and the control sites (Fig 1)
Analysis of Clinical Outcomes
For analysis of clinical outcomes, we analyzed health
encounter and billing records. We compared outcomes for
patients who received PSC at site I, and those who received
usual care at sites II and III during the same period, all with
reference to usual care at site I.
We evaluated for the odds of selected utilization events,
as measures of escalation of the course of care beyond con-
servative primary care. Because unnecessary spinal imag-
ing has been identified as a key quality measure for spine
care, we compared the odds of patients diagnosed with
SRD receiving diagnostic imaging of the spine. We also
evaluated the odds of ED visits, hospitalizations, and
adverse drug events. All statistical analyses were performed
using SAS Enterprise Guide version 7.1 (Cary, North
Carolina).
TAGEDH1RESULTSTAGEDEN
Cost Outcomes
Of approximately 910 000 potentially eligible partici-
pants, 10 348 participants were included in the analysis.
Expenditures for primary care of SRDs at clinical site I
increased from year 1 to year 2, but remained lower than
expenditures at sites II and III. Regarding the primary care
of SRDs, for patients seen at site I, average per-person
expenditures were $162 (n = 693) in year 1, rising to $186
(n = 980) in year 2 (a 14% increase). For patients seen at
site II, comparable expenditures were $332 (n = 4050) in
year 1, dropping to $306 (n = 3615) in year 2 (an 8%
decrease). For patients seen at site III, comparable expendi-
tures were $467 (n = 449) per person in year 1, dropping to
$323 (n = 669) in year 2 (a 31% decrease).
Site and patient characteristics of the patient sample may
be viewed in Table 1. The before and after groups were
670 Whedon et al Journal of Manipulative and Physiological Therapeutics
Primary Spine Care Model September 2020

Table 1. Participant Characteristics by Site

Before After Before After
Site Characteristic n % n % P value Score (SD) 95% CI Score (SD) 95% CI
I Age category

18-34 94 13.7 135 13.9

35-44 112 16.3 157 16.2

45-54 177 25.8 259 26.7

55-64 212 30.9 288 29.7

65-74 62 9.0 81 8.4

75-84 27 3.9 46 4.7

85+ 4 0.6 4 0.4

Age .97

Sex category

Missing 3 0.4 7 0.7

Female 394 57.4 555 57.2

Male 291 42.4 408 42.1

Unknown − − − −

Sex .76

Charlson 0.5 (1.0) 0.5-0.6 0.3 (0.9) 0.3-0.4

Total N 688 970

II Age category

18-34 513 12.8 455 12.8

35-44 636 15.8 545 15.3

45-54 1009 25.1 818 22.9

55-64 1087 27.0 914 25.6

65-74 511 12.7 544 15.3

75-84 226 5.6 244 6.8

85+ 45 1.1 50 1.4

Age <.01

Sex category

Missing 39 1.0 65 1.8

Female 2317 57.6 2020 56.6

Male 1669 41.5 1483 41.6

Unknown 2 0.0 2 0.1

(continued)
Journal of Manipulative and Physiological Therapeutics Whedon et al 671
Volume 43, Number 7 Primary Spine Care Model

Table 1. (Continued)
Before After Before After
Site Characteristic n % n % P value Score (SD) 95% CI Score (SD) 95% CI
Sex .02

Charlson 0.79 (1.26) 0.75-0.82 0.57 (1.1) 0.5-0.6

Total N 4027 3570

III Age category

18-34 83 19.1 99 15.1

35-44 75 17.2 117 17.9

45-54 120 27.6 151 23.1

55-64 105 24.1 175 26.7

65-74 35 8.0 78 11.9

75-84 14 3.2 34 5.2

85+ 4 0.9 3 0.5

Age .06

Sex category

Missing 31 7.1 31 4.7

Female 241 55.4 368 56.2

Male 163 37.5 258 39.4

Unknown 1 0.2 − −

Sex .22

Charlson 0.8 (1.3) 0.7-0.9 0.6 (1.3) 0.5-0.7

Total N 436 657

Before/after relative to index date February 1, 2017; x analyses were conducted to examine differences in age and sex, and t tests were used to examine
2

differences in the Charlson Comorbidity Index score.

Charlson, average Charlson Comorbidity Index score; SD, standard deviation.

comparable regarding age and sex for sites I and III, but as Regarding total expenditures for care of SRDs, Tables 2
measured by Charlson score, the health status of the after and 3 show before and after changes for patients seen at
group was lower compared with the before group for each sites I, II, and III, displayed by utilization category.
site. Table 2 displays percentage change in expenditure by

Table 2. Percentage Change in Expenditures Between Sites

Utilization Category
Site ED Visit Spinal Imaging Spinal Injection Spinal Surgery
Site I: % change +7 −20 −41 −52

Site II: % change −4 −12 −29 −17

Site III: % change −42 0 +8 n/a

ED, emergency department.
672 Whedon et al
Primary Spine Care Model
Table 3. Difference-in-Difference in Expenditures
Comparison ED Visit
Site I vs site II +$154
Site I vs site III +$248
Average per-person amounts are presented for spine-related disorders.
ED, emergency department; N/A, not applicable.
site. For the utilization categories “opioid prescription
fill” and “hospitalization,” and at site III for the category
“spinal surgery,” cells with n < 11 were suppressed; the
data in these categories were insufficient to permit mean-
ingful statistical analysis. The percentage change in
expenditures trended downward in 3 of 4 utilization cate-
gories at site I, all 4 categories at site II, and 1 category
at site III.
Table 3 displays results in dollars for the difference-
in-difference analysis of total expenditures for patients
with SRDs. At all 3 clinical sites there was a downward
trend in average per-person expenditures for care of
SRDs from year 1 to year 2, except in the category “ED
visit,” for which total expenditures increased. However,
compared with patients seen at sites II and III, greater
decreases in total expenditures were observed for site I
in all categories, except “ED visit,” for which compara-
tive expenditures also increased. We found insufficient
data to compare site I vs site III for the utilization cate-
gory “spinal surgery.”
Clinical Outcomes
Patients whose spine care was managed according to the
PSC model were less likely to receive diagnostic imaging
compared with those in the control groups. Compared with
patients who received usual care at site I, patients who
received PSC had 72% lower odds of receiving spinal diag-
nostic imaging. Patients seen at sites II and III were more
likely to receive imaging compared with patients who
received usual care at site I (Table 4). No differences in
odds were detected for ED visits, hospitalizations, or
adverse drug events.
Table 4. Odds of Diagnostic Imaging of the Spine
Effect vs Usual Care at Site I Odds Ratio
PSC 0.280
Site II 1.586
Site III 1.625
Patients who received usual care at site 1 served as the reference group
(OR = 1.0) against which the other groups were compared.
OR, odds ratio; PSC, primary spine care.
Journal of Manipulative and Physiological Therapeutics
September 2020
Utilization Category
Spinal Imaging Spinal Injection Spinal Surgery
−$532 −$646 −$6914
−$653 −$973 N/A
TAGEDH1DISCUSSIONTAGEDEN
We report initial clinical and cost outcomes associated
with implementation of a PSC model for management of
patients with SRDs within a conventional primary care
environment. A general trend downward in expenditures
from 2016 through 2017 was observed for primary care
services at sites II and III and also for all clinical services at
all sites, except in the utilization categories “ED visit” at
site I and “spinal injection” at site III. In their study of the
implementation of conservative PSC, Weeks et al. also
reported a trend of reduced spine care costs in both inter-
vention and the control groups from 2014 to 2018.14 Also
similar to the findings of the Weeks study, regarding both
percentage change and difference-in-difference, in 3 of 4
utilization categories, greater decreases in total spine care
expenditures were observed for the intervention site.
The before and after study populations were comparable
regarding age and sex. Lower comorbidity scores in the
after group may have confounded the results of the percent-
age change analysis but would not be expected to confound
results of the difference-in-difference analysis. Both the
percentage change and the difference-in-difference cost
analyses demonstrated greater cost savings in the utilization
categories of spinal injection and spinal surgery. Because
these categories represent patients whose management has
escalated beyond a simple course of conservative spine
care, these findings suggest that the PSC model may offer
value for a wide range of patients with SRDs.
Regarding the odds of receiving diagnostic imaging of
the spine, the results for PSC are of questionable statistical
significance. However, the wide CI is likely owing to the
low number of patients who received imaging. We suspect
that in this case, the remarkable difference in odds ratios
between PSC and usual care reflects a real difference
that would bear further investigation. The American
Chiropractic Association recommends against the use of
95% CI
routine spinal imaging for patients with acute low back
0.064-1.227 pain during the 6 weeks after onset, in the absence of
1.035-2.432
fracture, suspected fracture, progressive neurologic symp-
toms, infection, tumor, osteopenia, osteoporosis, or axial
0.982-2.686 spondyloarthritis.16
Our findings lead us to hypothesize that implementation
of PSC may result in a lower risk of unneccesary escalation
of care, with reduced resource utilization and lower costs.
Journal of Manipulative and Physiological Therapeutics Whedon et al 673
Volume 43, Number 7 Primary Spine Care Model

However, the outcomes described here cannot be attributed TAGEDH1CONCLUSIONTAGEDEN

to a fully actualized and disseminated PSC model. As envi-
Among patients with SRDs included in this study,
sioned by its developers, the pure model calls for the PSC
implementation of the PSC model within a conventional
clinician to serve as the initial point of contact for all spine
primary care setting was associated with a trend toward
patients who present for care in a primary care setting.2,3,5
reduced total expenditures for spine care compared with
Furthermore, among colleagues of the clinician who pro- usual primary care. Implementation of PSC may lead to
vided PSC in this study, there appeared to be variable lev-
reduced costs and resource utilization, but may be no more
els of utilization of the PSC model. Therefore, not all
effective than usual care regarding clinical outcomes.
patients seen at site I for care of an SRD actually received
When considered in combination with the evidence of pre-
PSC. The results of this study suggest that the PSC model
vious studies of the PSC model, these findings justify fur-
may offer superior value compared to usual care. Patients
ther investigation and, if warranted, a rigorous
continue to receive care via the PSC pathway, and we plan
interventional study intended to assess the value of PSC for
further evaluation in a larger sample. We would expect a
care of patients with SRDs.
fully actualized and disseminated model to demonstrate
even higher value. For example, although our data were
insufficient to analyze for risk of opioid use, several recent
studies have found that utilization of nonpharmacologic
TAGEDH1FUNDING SOURCES AND CONFLICTS OF INTERESTTAGEDEN
pain therapies leads to decreased opioid use.17-21 Future This project was funded by the National Chiropractic
research could explore the benefit of the PSC model in Mutual Insurance Company Foundation. Health claims
reducing overprescription of opioids. data used for this research were supplied by the New
Additionally, we cannot be certain that variation in Hampshire Insurance Department and New Hampshire
access to care was identical across the 3 sites; however, the Department of Health and Human Services. All the conclu-
3 sites are part of the same health care system that strives sions and recommendations of this publication are solely
for standardization, including monitoring a metric from those of the authors. The authors have no conflicts of inter-
time of patient call to time seen in clinic. Additionally, the est to declare.
primary care clinicians are often exposed to similar contin-
ued medical education regarding care of spine-related pain
that is provided by the health care system and local and TAGEDH1CONTRIBUTORSHIP INFORMATIONTAGEDEN
regional educational courses to help ensure both standardi-
Concept development (provided idea for the research):
zation of care and access to care.
J.M.W., J.M.G., R.R., L.A.K., M.N.
Design (planned the methods to generate the results):
J.M.W., A.W.J.T., J.M.G., M.N.
Limitations
Supervision (provided oversight, responsible for organiza-
The observational design precludes inferences regard-
tion and implementation, writing of the manuscript):
ing causality. The same may be said of the evaluation of
J.M.W., S.B.
cost outcomes, although the quasi-experimental design of
Data collection/processing (responsible for experiments,
the difference-in-difference analysis does suggest that
patient management, organization, or reporting data):
adoption of the PSC pathway may lead to reduced spine
J.M.W., A.W.J.T., J.M.G., R.R., L.A.K.
care costs. To examine the potential for a cost offset effect
Analysis/interpretation (responsible for statistical analysis,
of PSC, we measured differences in total costs for all
evaluation, and presentation of the results): J.M.W.,
types of encounters for spine care, but the differences may
A.W.J.T., S.B., R.R., L.A.K.
have been confounded by unknown factors. The clinical
Literature search (performed the literature search): J.M.W.,
outcomes analysis may also have been confounded by
J.M.G., R.R., M.N.
unmeasured differences in the approach to usual care
Writing (responsible for writing a substantive part of the
across sites. The available data contained few variables
manuscript): J.M.W., S.B.
descriptive of patient characteristics and exposures. For
Critical review (revised manuscript for intellectual content,
example, smoking, exposure to stationary postures, repeti-
this does not relate to spelling and grammar checking):
tive motion, and stress can affect clinical and cost out-
J.M.W., A.W.J.T., S.B., J.M.G., R.R., L.A.K., M.N.
comes, but these factors are not included in claims
datasets. Access to health system data was also limited by
administrative delays, and for several analyses, the paucity
of data in certain groups precluded use of regression
TAGEDH1SUPPLEMENTARY MATERIALSTAGEDEN
modeling. This study should be regarded as a preliminary Supplementary material associated with this article can
evaluation of the effect of implementing the PSC model be found in the online version at doi:10.1016/j.
in a conventional primary care setting. jmpt.2020.05.002.
674 Whedon et al
Primary Spine Care Model
Practical Applications
 This study describes the successful introduc-
tion of PSC to a primary care health center
within a multisite health system.
 Primary spine care can be integrated into a
conventional primary care environment to
provide superior clinical outcomes at lower
cost than usual care.
 Primary spine care should be more widely
introduced in primary care settings to allow
further investigation of the model’s value.
 Successful implementation of PSC may
depend upon acceptance and dissemination of
integrative care within the conventional
healthcare environment.
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