1. Economics of spine-related disability: Societal costs Simon Dagenais, DC, PhD, MSc 1

2. Spine-related 2 Low back pain  Nonspecific  Neurological / radiculopathy  Serious spinal pathology (e.g. tumor, fracture, infection, arthritides) Neck pain  Nonspecific  Neurological / radiculopathy  Serious spinal pathology (e.g. tumor, fracture, infection, arthritides) Other  Pediatric / congenital  Scoliosis / deformity  Spinal cord injury  Other

3. Epidemiology 3 Low back pain  Point prevalence (now)28.4%  Lifetime prevalence (ever)84.1%  6 month prevalence71.9%  Low intensity / low disability48.9%  High intensity / low disability12.3%  High intensity / high disability10.7% Cassidy, 1998 (PMID 9762743)

4. Health services utilization – Primary care 4 Low back pain #1 reason for visiting a chiropractor #1 reason for visiting a physical therapist #2 reason for visiting a primary care physician Hurwitz, 1998 (PMID 9585743) Bekkering, 2003 (PMID 12952520) Bigos, 1996 (PMID 8892135)

5. Health services utilization – Specialist care 5 Low back pain #1 reason for visiting an orthopedic surgeon #1 reason for visiting a neurologic surgeon #3 reason for obtaining elective surgery Hurwitz, 1998 (PMID 9585743) Bekkering, 2003 (PMID 12952520) Bigos, 1996 (PMID 8892135)

6. Health services utilization – ED Low back pain  ~2% of all ED visits (2.6 million each year in US) Diagnostic testing  31% had x-rays  10% had CT or MRI  19% had urinalysis  10% had blood work Prescription medication  61% received opioids  50% received NSAIDs  43% received muscle relaxants Friedman, 2010 (PMID 21030902) 6

7. Health services utilization – Opioids Low back pain  #1 indication (~50% of users) Opioid overdose One of the leading causes of accidental death (16,651 in 2010) 7 Edlund, 2010 (PMID 20634006) Okie, 2010 (PMID 21083382) 2015 ?

8. Economic impact 8  Also known as cost of illness, burden of illness  Attempt to measure the economic consequences of a specific health condition  Think of anything that may change with a health condition  Try to put a price tag on it  Add it all up  Goal is to inform decision making for stakeholders  Allocate resources to address health condition

9. Systematic review 9 Main goal was to look at how others had already tackled this issue

10. Systematic review 10  Identified 27 studies from 8 different countries  Australia, Belgium, Japan, Korea, Netherlands, Sweden, UK, US  All defined back pain differently  e.g. self-reported vs. ICD-9 codes, >3/6/12 months  Differed in the scope of costs considered  14 examined direct / health care costs  18 examined indirect / productivity costs  8 examined both direct and indirect costs

11. Direct / health care costs 11 Studies did not all consider different types of health care When studies looked for specific costs, they found them

12. Indirect / productivity costs 12 Absenteeism  Formal (e.g. temporary paid leave)  Informal (e.g. personal time off) Presenteeism  Self-reported  Estimated by supervisor Early retirement  Government  Private Inactivity  Forfeited leisure time Household productivity  Paid  Unpaid

13. Indirect / productivity costs 13 Human capital approach  Productivity losses based on remaining lifespan e.g. 35 year-old with back pain is losing out on 30 years of productivity 30 years x $50,000/year = $1.5 million Friction approach  Assumes injured workers are eventually replaced e.g. 35 year-old IT engineer replaced in 6 months 6 months x $100,000/year = $50,000

14. Total costs 14

15. Total costs 15 Indirect (85%) Direct (15%) Inpatient 2.6% Physical therapy 2.6% Pharmacy 2.0% Primary care 2.0% Outpatient 1.2% Imaging 1.1% Specialists 1.1% Chiropractic 0.8% Other 0.8% Surgery 0.8% CAM 0.3% Emergency 0.2% Mental health 0.2% Sick leave61.2% Early retirement11.9% Presenteeism6.8% Household3.4% Inactivity0.9%

16. Findings for US 16  No study measured both direct and indirect costs  Direct costs $12.2 - $90.6 billion  Indirect costs $7.4 - $28.2 billion  In other countries that examined both:  Direct costs were 3 - 66% of total (median 15%)  Indirect costs were 34 - 97% of total (median 85%)  Based on proportions observed in other countries  Total costs in US could be $84.1 - $624.8 billion

17. Findings for US 17 2015 $162 billion Self-reported disability increased by 25% (From 20% with spine problems to 25%) Martin, 2008 (PMID 18270354)

18. Other considerations 18  Costs higher if we include all spine-related conditions  ~5-10% of total health care costs depending on scope  Costs don’t fully reflect cases associated with workers’ compensation or personal injury  Legal, administrative, health care  No estimate of costs for back problems related to Social Security Disability or Department of Defense  One of the leading causes