Characteristics of ambulatory spine care visits in the United States,2009

Abstract

BACKGROUND:

Back pain is a leading reason for seeking care in the United States (US), and is a major cause of morbidity.

OBJECTIVE:

To analyze demographic, patient, and visit characteristics of adult ambulatory spine clinic visits in the United States from 2009–2016.

METHODS:

Data from the National Ambulatory Medical Care Survey from 2009–2016 were used and were sample weighted.

RESULTS:

Most patients presenting for ambulatory spine care were 45–64 years (45%), were most commonly female (56.8%), and private insurance (45%) and Medicare (26%) were most common payors. The percentage of visits for spine care done at a primary care setting was 50.1% in 2009–2010 and 48.3% in 2014–2015. Approximately 15.5% were seen in orthopedic surgery clinics in 2009–2010 and 7.3% in 2015–2016. MRI was utilized in 11.7% in 2009–2010 and 11.0% in 2015–2016. Physical therapy was prescribed in 13.2% and narcotic analgesic medications were prescribed in 36.2% of patients in 2015–2016.

CONCLUSIONS:

MRI was used more frequently than guidelines recommended, and physical therapy was less frequently utilized despite evidence. A relatively high use of opiates in treatment of back pain was reported and is concerning. Although back pain represents a substantial public health burden in the United States, the delivery of care is not evidence-based.

Keywords

Low back pain epidemiology primary care

1. Introduction

A global burden of disease study in 2010 found low back pain to be ranked the highest in terms of years lived with disability and sixth in terms of disability-adjusted life years (DALYs) [1]. A similar study concluded that low back and neck pain were the fourth leading cause of DALYs globally, just after ischemic heart disease, cerebrovascular disease, and lower respiratory infection [2]. Point prevalence of low back pain may range between 9.4% and 28.4%, with lifetime prevalence reported to be 80% or higher [3, 4]. A 2008 study reported that the total costs of treating low back pain in the United States was $85.9 billion [5]. Indirect costs have been estimated to be double that of direct costs [6].

Despite these staggering numbers, very little is known on how health care is distributed to patients presenting to their physician with a complaint of spine pain in the United States. Information on characteristics of patients that present with spine pain, the specialty of physicians they seek treatment from, and utilization rates of diagnostic tests and treatments is valuable information in better understanding the state of spine care treatment in the United States. This information is needed for policy makers, researchers, clinicians, and patients. The aim of this study was to describe patient and visit characteristics of adult ambulatory spine clinic visits in the United States from 2009–2016. We also describe treatment practice patterns during ambulatory spine care visits.

2. Methods

2.1 Database description

Data were analyzed from the National Ambulatory Medical Care Survey (NAMCS). The NAMCS was conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) from 2009 to 2016. Non-federally employed office-based physicians reported data for this survey, with the purpose of assessing the provision and use of ambulatory medical care services in the United States. Each physician included in the survey was randomly assigned a one-week reporting period in which a patient record form used to capture data on select patient and visit characteristics was completed. Details on the NAMCS surveys and sampling techniques are available from their website [7]. Most pertinent to this study, is that sample size increased in 2012, and sampling was done both via two-way sampling (2009–11, 2015–16) and multivariate sampling (2012–14).

2.2 Patient populations and characteristics

Our report included visit data from 2009 to 2016. Patients $<$ 18 years old were excluded. The NAMCS classified visit data using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD–9–CM) codes through 2015 and International Classification of Diseases, 10th Edition, Clinical Modification (ICD–10–CM) codes for 2016. ICD billing code-based data for “symptoms referable to the musculoskeletal system” in the “reason for visit” variable in the datasets were defined as a musculoskeletal visit. A subset of these, comprising of “neck”, “back”, and “low back” were collectively analyzed in this study as representative of “spine.”

Patient demographics included age, sex, and race/ ethnicity. Patient characteristics assessed were tobacco use and obesity, which was defined as “body weight 20% over the standard optimum weight.” Visit characteristics included primary expected source of payment, specialty of the physician, if it was a new versus chronic problem, and whether there was an inciting injury for the reported complaint. Education or referrals for exercise, injury prevention, stress management, tobacco cessation and weight reduction were assessed. Diagnostic imaging including MRI and X-ray was quantified. Treatment via physical therapy or in-clinic injections (steroid injections, arthrocenteses, joint aspirations, and other injections into a joint, bursa, ligament, tendon or soft tissue) were also described. Treatment with medication was also assessed and categorized as narcotics, narcotic analgesic combinations, other analgesic combinations, NSAIDs, salicylates, COX-2 inhibitors, and miscellaneous analgesics.

2.3 Statistical analysis

Data from 2009 to 2016 were combined into blocks of two years each to stabilize estimates. Annual means were then calculated from these to provide single year estimates. We used a patient weighted scale sampling variable (PATWT) included in the NAMCS datasets. Two-year visit totals were rounded to the nearest hundred visits, and data from the U.S. Census Bureau were used for rate calculation [8, 9]. Between-year differences were identified using the Kruskal-Wallis Rank Sum test. Alpha was set at 0.05. All statistical analyses were performed using the R statistical package (Vienna, Austria: www.r-project.org).

Figure 1.

Average estimated number (in 100,000s) of adult ambulatory care musculoskeletal visits for spine symptoms, in two-year periods: U.S. National Ambulatory Medical Care Survey, 2009–2016. $p<$ 0.001 for differences between all two-year periods.

Figure 2.

Average estimated rate of ambulatory care musculoskeletal visits for spine symptoms per 100 U.S. adults in two-year periods, by body part of reason for visit ${}^{1}$ : U.S. National Ambulatory Medical Care Survey, 2009–2016. ${}^{1}$ Rate determined by data from U.S. Census Bureau Report. ${}^{2}$ $p<$ 0.001 for differences between all two-year periods.

3. Results

In 2009–2010, the number of estimated adult visits per year associated with complaints related to the neck, low back, and generalized back totaled 7.3 million, 9.3 million, and 12.8 million respectively (Fig. 1). In 2015–2016, there were 6.1 million, 6.1 million, and 11.4 million, respectively, associated with complaints related to the neck, low back, and generalized back. Rates of ambulatory visits for back pain were 12.6 visits per 100 U.S. adults in 2009–2010 and 9.4 visits in 2015–2016 (Fig. 2).

Table 1
Selected patient demographics of spine ambulatory care visits: U.S. National Ambulatory Medical Care Survey 2009–2016

	Total number ${}^{1}$ ( $\pm$ SE) (%)
Age
18–24 years	39.84 ( $\pm$ 0.16) (3.6%)
25–44 years	296.76 ( $\pm$ 0.16) (26.7%)
45–64 years	495.81 ( $\pm$ 0.17) (44.6%)
65–74 years	160.84 ( $\pm$ 0.21) (14.5%)
75 years and over	117.95 ( $\pm$ 0.23) (10.6%)
Sex
Female	631.51 ( $\pm$ 0.19) (56.8%)
Male	479.68 ( $\pm$ 0.17) (43.2%)
Race
White	798.67 ( $\pm$ 0.16) (71.9%)
Black	116.62 ( $\pm$ 0.19) (10.5%)
Hispanic	140.07 ( $\pm$ 0.21) (12.6%)
Other	55.83 ( $\pm$ 0.34) (5.0%)
Selected comorbidities
Tobacco use	196.41 ( $\pm$ 0.15) (17.7%)
Obesity ${}^{2}$	92.07 ( $\pm$ 0.17) (8.3%)
Expected payor source
Private insurance	499.03 ( $\pm$ 0.16) (44.9%)
Medicare	292.98 ( $\pm$ 0.21) (26.4%)
Medicaid, CHIP ${}^{2}$ or other state-	90.69 ( $\pm$ 0.18) (8.2%)
based program
Worker’s compensation	78.83 ( $\pm$ 0.15) (7.1%)
Other ${}^{3}$	96.23 ( $\pm$ 0.16) (8.7%)

${}^{1}$ In one-hundred thousands, ${}^{2}$ Children’s Health Insurance Program, ${}^{3}$ Includes no charge.

Demographics of all visits from 2009–2016 are shown in Table 1. Nearly half of all visits (45%) consisted of patients aged 45–64 years old. Patients 25–44 years old made up 27% of visits, and patients 65 and older represented 25% of visits. Fifty-seven percent of visits were female. Tobacco use and obesity were reported in 17.7% and 8.3% of visits, respectively. Expected payor source was private insurance 45% of the time, and consistent with the age demographics Medicare was expected payor source for 26% of visits. Notably during this time period, this represented a total of over 29 million visits in the Medicare population (source).

The most common reason for an ambulatory spine clinic visit was routine follow up for a chronic problem (38.6%), while visits for new problems comprised 36% of all ambulatory spine clinic visits (Table 2). Flare up of a chronic problem (19.3%), pre-surgery (1.5%), post-surgery (1.4%) and preventative care (1.4%) made up the remainder of visits.

Table 2

Visit types in spine ambulatory care visits

	Total number ${}^{1}$ ( $\pm$ SE) (%)
Major reason for visit
New problem (less than 3 mos.	401.42 ( $\pm$ 0.17) (36.1%)
onset)
Chronic problem, routine	429.19 ( $\pm$ 0.18) (38.6%)
Chronic problem, flare-up	214.99 ( $\pm$ 0.18) (19.3%)
Pre-surgery	16.62 ( $\pm$ 0.13) (1.5%)
Post-surgery	15.34 ( $\pm$ 0.16) (1.4%)
Preventive care	15.31 ( $\pm$ 0.42) (1.4%)

${}^{1}$ In one-hundred thousands.

Table 3

Visit by specialty in spine ambulatory care visits ${}^{1}$

Specialty	2009–2010	2011–2012	2013–2014	2015–2016
Orthopedic surgery	45.57 ( $\pm$ 0.09) (15.5%)	27.38 ( $\pm$ 0.06) (9.3%)	40 ( $\pm$ 0.06) (14.0%)	17.25 ( $\pm$ 0.14) (7.3%)
General/family practice	86 ( $\pm$ 0.11) (29.2%)	85.9 ( $\pm$ 0.09) (29.1%)	76.22 ( $\pm$ 0.10) (26.7%)	85.24 ( $\pm$ 0.53) (36.1%)
Internal medicine	61.38 ( $\pm$ 0.19) (20.9%)	54.71 ( $\pm$ 0.20) (18.5%)	38.84 ( $\pm$ 0.11) (13.6%)	29.65 ( $\pm$ 0.33) (12.6%)
Other specialties	99.63 ( $\pm$ 0.17) (33.9%)	125.93 ( $\pm$ 0.07) (42.7%)	130.89 ( $\pm$ 0.10) (45.8%)	103.77 ( $\pm$ 0.41) (44.0%)

${}^{1}$ In one-hundred thousands.

The percentage of visits for spine care seen in a primary care setting was overall stable from 38.8% in 2009–2010 to 47.0% in 2015–2016, though there was a shift away from internal medicine clinics to family medicine clinics over this time period (Table 3). The percentage of visits seen in orthopedic surgery clinic varied greatly from year to year, 15.5% in 2009–2010, 9.3% in 2011–2012, 14.0% in 2013–2014, and 7.3% in 2015–2016 (Table 3). Other specialties, which could not further be specified based on the survey design, comprised the remainder of visits.

The utilization rate of diagnostic MRI and X-ray over time appeared relatively stable over time, though the absolute totals decreased in proportion to decreased number of visits over time. In 2009–2010, 11.7% of ambulatory spine care visits resulted in an MRI being ordered, compared to 11.0% in 2015–2016 (Table 4). Interestingly, there was a decrease in MRI orders per visit in 2011–2012 (8.8%) and 2013–2014 (7.9%) but this was not sustained. X-ray utilization decreased slightly from 17.7% to 15.1% in that same overall time period.

Table 4

Diagnostic tests and Procedures ordered or provided in spine ambulatory care visits (Measured outcome is, patient weighed. Average of total 2 years visits percentage by each average total visits of 2 years and Standard Errors are provided)

Procedure	2009–2010	2011–2012	2013–2014	2015–2016
MRI	34.42 ( $\pm$ 0.16) (11.7%)	26.08 ( $\pm$ 0.09) (8.8%)	22.5 ( $\pm$ 0.09) (7.9%)	25.92 ( $\pm$ 0.28) (11.0%)
X-Ray	52.07 ( $\pm$ 0.17) (17.7%)	42.55 ( $\pm$ 0.12) (14.4%)	36.5 ( $\pm$ 0.07) (12.8%)	35.56 ( $\pm$ 0.33) (15.1%)
Physical therapy	82.96 ( $\pm$ 0.18) (28.2%)	44.66 ( $\pm$ 0.11) (15.1%)	30.07 ( $\pm$ 0.07) (10.5%)	31.19 ( $\pm$ 0.28) (13.2%)
Injection ${}^{2}$	6.45 ( $\pm$ 0.15) (2.2%)	8.02 ( $\pm$ 0.07) (2.7%)	8.32 ( $\pm$ 0.07) (2.9%)	2.63 ( $\pm$ 0.27) (1.1%)

Physical therapy was prescribed less than half as often in 2015–2016 (13.2%) compared to 2009–2010 (28.2%), with a nadir in 2013–2014 of 10.5%. Injection data is also presented in Table 4, though is only representative of in-clinic injections which may not account for the majority of injections related to spine care given that most interventional spine procedures (injections) require fluoroscopic guidance.

The use of narcotic and narcotic combination analgesic medications slightly increased from 31.6% of visits in 2009–2010 to 36.2% in 2015–2016 (Table 5). There was an overall similar trend seen in the use of NSAIDs (23.8% to 29.6%) and salicylates (4.8% to 7.7%) over this time period.

Table 5

Therapeutic drug categories ordered in spine ambulatory care visits: U.S. National Ambulatory Medical Care Survey, 2009–2016

Medication	2009–2010	2011–2012	2013–2014	2015–2016
CNS; Analgesics; Miscellaneous analgesics	17.18 ( $\pm$ 0.18) (5.8%)	13.19 ( $\pm$ 0.13) (4.5%)	8.36 ( $\pm$ 0.09) (2.9%)	6.29 ( $\pm$ 0.43) (2.7%)
CNS; Analgesics; Narcotic	21.11 ( $\pm$ 0.13) (7.2%)	40.32 ( $\pm$ 0.09) (13.7%)	63.61 ( $\pm$ 0.11) (22.2%)	31.85 ( $\pm$ 0.28) (13.5%)
CNS; Analgesics; NSAID	64.76 ( $\pm$ 0.15) (22.0%)	65.98 ( $\pm$ 0.11) (22.3%)	65.67 ( $\pm$ 0.10) (23.0%)	66.39 ( $\pm$ 0.36) (28.1%)
CNS; Analgesics; Salicylates	14.06 ( $\pm$ 0.14) (4.8%)	12.07 ( $\pm$ 0.09) (4.1%)	14.99 ( $\pm$ 0.08) (5.2%)	18.07 ( $\pm$ 0.44) (7.7%)
CNS; Analgesics; Analgesic combinations	3.02 ( $\pm$ 0.13) (1.0%)	5.42 ( $\pm$ 0.15) (1.8%)	3.8 ( $\pm$ 0.09) (1.3%)	1.29 ( $\pm$ 0.11) (0.5%)
CNS; Analgesics; Narcotic analgesic combinations	71.79 ( $\pm$ 0.15) (24.4%)	64.61 ( $\pm$ 0.10) (21.9%)	77.7 ( $\pm$ 0.10) (27.2%)	53.65 ( $\pm$ 0.54) (22.7%)
CNS; Analgesics; Cox-2 inhibitors	5.27 ( $\pm$ 0.13) (1.8%)	7.02 ( $\pm$ 0.09) (2.4%)	5.8 ( $\pm$ 0.09) (2.0%)	3.64 ( $\pm$ 0.39) (1.5%)

${}^{1}$ In one-hundred thousands.

Table 6

Health education/referrals provided in spine ambulatory care visits: U.S. National Ambulatory Medical Care Survey 2009–2016

	Total number ${}^{1}$ ( $\pm$ SE) (%)
Health education/referral
Tobacco cessation	31.6 ( $\pm$ 0.17) (2.8%)
Exercise	164.84 ( $\pm$ 0.24) (14.8%)
Weight reduction	38.24 ( $\pm$ 0.19) (3.4%)
Injury prevention	51.33 ( $\pm$ 0.22) (4.6%)
Stress management	15.52 ( $\pm$ 0.15) (1.4%)

${}^{1}$ In one-hundred thousands, ${}^{2}$ Defined as “body weight 20% over the standard optimum weight”.

Education or referrals for tobacco cessation (2.8%), exercise (14.8%), weight reduction (3.4%), injury prevention (4.6%), and stress management (1.4%) were uniformly low (Table 6).

4. Discussion

Overall, the total number of ambulatory spine care visits as captured in this survey is a major reason for patients to seek care. This must be put in context with available epidemiologic data [10], which consistently has shown spine pain to have a high global burden of disease, ranking highest in terms of years lived with disability and sixth in terms of disability-adjusted life years (DALYs) [1]. Similarly, a study from 2015 found low back and neck pain were ranked the fourth leading contributor to reduced DALYs globally just after ischemic heart disease, cerebrovascular disease, and lower respiratory infection [2]. Also noted was that low back and neck pain prevalence and disability have increased markedly over the past 25 years globally [2]. The reasons for the decreased number of physician visits for spine pain over time in this survey are unknown, and likely represent reduced response rate, reduced number of registered providers, and sample size issues within the survey. We caution against the use of our data to make interpretations about trends over time since sampling strategies of NAMCS changed during the study period.

Another interesting result was the varying percentage of ambulatory spine visits that were seen in orthopedic surgery clinics, which varied greatly from year to year but overall declined from 15.5% in 2009–2010 to 7.3% in 2015–2016 (Table 3). Some of this could certainly reflect a shift towards neurosurgery clinics, which is, unfortunately, information unavailable in this data set. Few of the visits seen in orthopedic surgery clinics were pre-surgery or post-surgery visits (Table 2). This is consistent with a recent report that of patients presenting with low back pain, only 1.2% of patients received surgery [11]. Notably, however, that same study found that those patients who get surgery accounted for 29.3% of total 12-month costs [11]. Allowing surgeons to clinically focus on this small subset of patients may be a means to optimize spine care in the United States. In fact, this concept is potentially reflected within our study, as the increased number of visits seen by “other” specialties is likely representative of non-operative specialties, such as Physical Medicine and Rehabilitation, and their roles in multi-specialty comprehensive spine centers.

The percentage of visits seen by primary care is also worth noting, which was relatively stable near 50% (Table 3). This is markedly higher than for other musculoskeletal related conditions such as shoulder, hip, and knee pain visits for which primary care sees 26–32% of encounters (unpublished data). This is possibly representative of the dated but still common assumption that in 90% of subjects with the symptom of low back pain, the diagnosis of “non-specific low back pain” is adequate [3, 4, 12]. A potential implication of this may be that specialty care is not needed. However, more appropriate means of diagnosis, including anesthetic injections, may be indicated in upwards of 90% of cases and can unmask treatable diagnoses such as facet pain, intervertebral disc pain, sacroiliac joint pain and may be appropriate for refractory pain of other etiologies [4]. It has been suggested elsewhere that a better term for “non-specific” low back pain is “undiagnosed” low back pain [13]; such a shift in approach may facilitate greater access to specialty care when appropriate. The wide age range of patients seen in this study (Table 1) supports the observation that spine pain is similar to many other musculoskeletal conditions, consisting most often of acute soft tissue injuries in younger people and transitioning to degenerative bone and joint pathology in aging people.

A 1998 publication with one year follow up that concluded that “the clinical course of low back pain presented in general practice, for most patients, clearly is less favorable than expected” [14]. Similar results have been found in studies with 5 year follow up [15]and meta-analysis [16]. A frequently cited review by Dunn and Croft concluded that while a majority of people who experience an episode of low back pain will improve over time, a sizeable proportion of patients also experience repeated episodes, recurrences, or continuous symptoms for many years [17]. Our study supports the observation that spine pain is a relapsing and remitting disease, with follow up visits for a chronic condition representing 57.9% of all ambulatory spine care visits to a physician in this sample. This data may be useful for primary care physicians as they assess appropriate referrals for patients with back pain. The increased participation of non-operative spine providers such as those from Physical Medicine and Rehabilitation specialty may be a suitable clinical referral pathway for many patients with back pain for optimal and cost-effective care.

Perhaps the most concerning finding in this study is the significant increase in proportion of visits during which an opioid was prescribed. Over the eight-year period from 2009 to 2016, the proportion of back pain-related outpatient visits during which an opioid analgesic was prescribed nearly doubled from 7.2% to 13.5% annually (Table 3). This trend is concerning because several studies have found opioids to be ineffective for chronic back pain as compared with non-opioid alternatives, and studies published as early as 2006 identified evidence of opioid-induced hyperalgesia [18, 19, 20, 21, 22, 23]. The adverse-effects of opioid analgesics are severe and common, ranging from nausea and constipation (incidence estimated at 23–50% and 15–71%, respectively) to addiction (incidence estimated at 8–12%) and death [24, 25, 26, 27, 28]. While guidelines from the US Centers for Disease Control and Prevention (CDC), Department of Defense (DOD), and Department of Veterans’ Affairs (VA) were published in 2016 and 2017 (after this study period), much of the literature for these guidelines was published during our study period.

MRI utilization remained relatively unchanged from 11.7% of back-pain related ambulatory visits in 2009–2010 to 11.0% in 2015–2016. Evidence has shown that routine imaging among individuals with acute or sub-acute back pain is not associated with improved pain, function, patient-reported quality of life, patient-reported improvement, or psychological benefits [29, 30]. Despite physician perception that MRI reduces patient anxiety regarding etiologic factors in low back pain, diagnostic yield of serious concern is extremely low. In a primary care setting, approximately 0.7% of patients presenting with low back pain have metastatic cancer, 0.04% have cauda equina syndrome, and 0.01% have an infection of the spine; the majority of these particularly concerning cases have discernable risk factors [32, 33, 34]. Further, there is evidence that receiving MRI results can contribute to lower incremental patient-reported symptom improvement, perhaps due to misattribution of symptoms to perceptions of underlying pseudopathology [35]. Our findings suggest that advanced diagnostic imaging is ordered much more often in practice than supported by evidence.

Unfortunately, these trends of high utilization of MRI did not extend to more evidence-based approaches to treat low back pain. Exercise therapy has been shown to be effective at preventing low back pain and associated disability, and at reducing pain in those suffering from chronic low back pain [38, 39]. Guidelines for the treatment of low back pain published in 2017 list physical therapy as a first-line option, specifically citing its low risk profile and evidence of effectiveness [40]. While these guidelines were published after the study period, the guidelines were based on assessment of previously published data. Patient-specific factors should be considered when deciding whether to refer patients to physical therapy, and evidence suggests that a more stratified, patient-specific approach to therapy referral results in superior outcomes [41, 42, 43, 44]. Our data found that only 13.2% to 28.2% of patients were referred for physical therapy.

Education or referrals for tobacco cessation (2.8%), exercise (14.8%), weight reduction (3.4%), injury prevention (4.6%), and stress management (1.4%) were uniformly low (Table 6). While certain comorbidities such as obesity and smoking are associated with the presence of pain, it is less known whether weight loss and smoking cessation are effective treatments for spine pain [45, 46, 47]. Alternatively, other interventions such as exercise have known benefits both in isolation, as detailed above, or as a mitigator to certain comorbidities such as obesity [45].

A primary limitation of this analysis is inherent to secondary data analysis using administrative datasets such as the NAMCS. It is possible that data on variables such as tobacco use and obesity were underreported. We caution against the use of our data to make interpretations about trends over time since sampling strategies of NAMCS changed during the study period. The strengths of this study include data that is less subject to potential confounders, such as payor mix, relative utilization of certain treatments which would be seen as “orders” such as MRI, and relative utilization of primary care versus specialty clinics.

5. Conclusion

Ambulatory spine clinic visits in the United States are characterized by a wide age range and as acute and chronic problems. Despite evidence to the contrary, advanced imaging such as MRI was used more frequently than recommended. Conversely, evidence-based treatments such as physical therapy and management of comorbidities such as obesity were less frequently utilized. A relatively high use of opiates in treatment of back pain was reported and is concerning. Thus, although back pain represents a substantial public health burden in the United States, the delivery of care is not evidence-based. Further research into paradigms of care such as referrals of patients with back pain to specialized non-operative providers such as those in Physical Medicine and Rehabilitation and its impact on provision of evidence-based care is needed.

Footnotes

Conflict of interest

None to report.

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Characteristics of ambulatory spine care visits in the United States,2009–2016

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

2.1 Database description

2.2 Patient populations and characteristics

2.3 Statistical analysis

Table 1 Selected patient demographics of spine ambulatory care visits: U.S. National Ambulatory Medical Care Survey 2009–2016

5. Conclusion

Footnotes

Conflict of interest

References

Table 1
Selected patient demographics of spine ambulatory care visits: U.S. National Ambulatory Medical Care Survey 2009–2016