In Brazil, the public health system (SUS) provides universal and free health at all levels of care.1 The demographic and epidemiological transition in Brazil has resulted in greater longevity for the population.1 Consequently, there is an increasing prevalence of non-communicable chronic diseases such as spinal disorders, which have a considerable impact on healthcare demands.1,2 These demands resulted in new policies, particularly the implementation of Health Care Networks in 2010, aiming to provide more integrated healthcare assistance between the primary, secondary, and tertiary levels.3

Non-specific spinal disorders (i.e., an umbrella term to refer to a variety of spinal disorders, including back pain, neck pain, thoracic pain, scoliosis, sacroiliac joint pain) are considered a major public health problem and are one of the main chronic diseases resulting in years lived with disability worldwide.4 For instance, neck pain and low back pain accounted for approximately 22 and 63 million years lived with disability in 2019, respectively,5 and is one of the main causes of disability worldwide.4,5 Moreover, spinal disorders represent an economic burden for healthcare systems, as they are a frequent reason for using health services, including in Brazil.4,6-14

A previous study has shown considerable costs arising from the management of spinal disorders in Brazil.13 The study found more than 250,000 inpatient days related to approximately 36,000 hospital admissions due to spinal disorders in Brazil, in 2016, mainly dorsalgia and intervertebral disk disorders. Moreover, 18% of the total expenses were related to diagnostic imaging, and physical therapy interventions were widely adopted in outpatient units.13 Currently, there are recommendations for individuals with non-serious spinal disorders to be followed up in the primary healthcare.7,15 Such recommendations aim to reduce the costs of low value interventions (low evidence, e.g., routine use of imaging tests and medication),7,8,16-20 including frequent access by individuals with non-specific spinal disorders to emergency services.10-12 This is relevant because a recent study21 showed that the vast majority of management strategies in individuals with non-specific back pain in Emergency Departments of four public hospitals in Brazil were drug prescriptions, which are considered of low value to this condition.7,20

Due to the high disability and socioeconomic impact of spinal disorders, health professionals, managers and society should be concerned about the implementation of more effective strategies to manage these conditions.6,9,13,15,16 However, in Brazil, little attention has been given to spinal problems by health systems11,16,17 despite estimates of an increase in their prevalence in the upcoming years.2,8

Therefore, the understanding of the care pathway is essential to identify aspects for improvement and, consequently, how to effectively treat conditions affecting the spine.11,16 However, there are no specific data related to the care pathway of individuals with these conditions in the Public Health Care Networks in Brazil. Accordingly, we aimed to investigate and characterize the pathway for individuals with non-specific spinal disorders accessing the Health Care Network of the Distrito Federal, Brazil. The secondary aims were to verify the number of procedures and interventions adopted in the networks; and investigate if sociodemographic and clinical variables might predict the total number of imaging tests, the total number of prescribed medications, and the place of first access in the Health Care Network.

The records of 398 individuals were evaluated for eligibility. Fifty-eight (58) records were excluded because the access to the network was not related to spinal disorders. Another 13 individuals were excluded (i.e., well-defined spinal condition). After applying the inclusion and exclusion criteria, 327 patients were included in the cohort of seven years (from 2012 to 2018). The participant selection flowchart is presented in Supplementary Material - S2.

Table 1 presents the data on participant characteristics. The median age was 57 years. The majority were female, married, sedentary, and with comorbidities. Most participants were service workers and retail salespeople. Most participants did not have recorded data related to level of education and smoking. The listed comorbidities included high blood pressure (50.8%), depression (19.3%), diabetes mellitus (19%), fibromyalgia (16.5%), and obesity (15.9%).

In total, we found 1390 visits to the Heath Care Network for non-specific spinal disorders. The condition responsible for the highest number of visits was low back pain (84.5%), followed by neck pain (12.2%), and scoliosis (1.7%). The other spinal conditions (e.g., spondylosis) totalled 1.5%.

Details pertaining to the number of visits by healthcare setting are presented in Fig. 1 and Supplementary Material - S3. The Emergency Department was the most accessed setting (43.2% of the visits). Approximately 33.4% of the visits were in the Outpatient Clinic, 23% in the Primary Health Care, and 0.4% were Hospital Admissions. These findings illustrated in Fig. 1 demonstrate the higher frequency of access at the Emergency Department.

Fig. 1.

Graphic representation of the pathways of patients in the Health Care Network, for non-specific spinal disorders, between 2012 and 2018. The central circles represent the settings of the health system investigated (ED: Emergency Department; PHC: Primary Health Care; OC: Outpatient Care; and HA: Hospital Admission) and the larger their size, the greater the frequency of access by users in this instance. In the edges, each circle represents an individual. The stems represent the usage of the service in the settings for each individual. The more frequently the user visits the Health Care Networks, the larger the size of the circle. In cases where the stems are connected in more than one setting, the position of the individuals' circles is closer to the central circles (OC, PHC, HA, or ED), greater access is inferred in this setting.

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More than 60% of the participants received a prescription for at least one imaging test. X-ray was the most prescribed (48%), followed by Magnetic Resonance Imaging (22.6%) and Computerized Tomography (4.3%). Details on diagnostic imaging use are presented in Supplementary Material - S4.

Eighty-six percent of the individuals were prescribed medication, with analgesics and anti-inflammatory drugs being the most often used (69% and 64%, respectively). Those drugs were mostly prescribed for low back pain, neck pain, and spondylosis (Supplementary Material - S5).

Furthermore, physical exercise was prescribed to approximately 13% of the individuals and 55% were referred to physical therapists. The majority of exercise prescriptions were performed in the Outpatient and Primary Care (i.e., 2.9% and 0.9% of the total number of visits, respectively). Exercise prescriptions rarely occurred in the Emergency Department (0.3% of the total number of visits). Prior to 2013, there were no occurrences of exercise prescription, which was more frequently adopted starting in 2016.

The number of imaging tests prescribed was not associated with the variables included in the regression model. In contrast, the number of medications prescribed to individuals with first access to the Primary Care or Outpatient Clinic was significantly lower compared to those with first access via Emergency Departments (Tables 2 and 3).

Logistic regression analysis showed that females had a greater chance of first accessing the Emergency Department compared to Primary Care. The model also showed that for each extra year in age, there was an increase in the chance of a greater use of Outpatient compared with Primary Care (Table 4).

We observed that non-specific low back pain was the most prevalent condition and the Emergency Department was the most accessed setting. We found that most patients underwent imaging tests and were prescribed drugs. In contrast, exercises were prescribed for only a small portion of individuals and referrals to physical therapy were recorded for approximately half of the participants. Women were more likely to first access the Emergency Department, and when this setting was the choice for the first access, more drugs were prescribed. There was an association between increasing age and greater chance of first access via Outpatient Care.

We found that the Emergency Department was the most accessed setting by individuals with non-specific spinal disorders. Currently, it is recommended that individuals with this condition, especially low back pain, be treated and monitored within Primary Care,7,8,17-19 because only a small minority of cases present red flags or indications of severe spinal involvement.10,17,19,20,28-30 Furthermore, the care of individuals with low-severity spinal disorders in the Emergency Department was associated with frequent use of resources and interventions considered of low value (i.e., low or no evidence), such as routine imaging tests, which do not provide additional clinical benefits30 and increase costs to the health system.12,13,28 These findings are worrying and are supported by previous studies reporting increased use of emergency services by patients with non-serious spinal disorders.11,28

Although there is an effort, through the Family Health Strategy, to strengthen Primary Care as the first level of care for the management of non-specific chronic pain,25 there are some organizational inconsistencies in the health care process, such as the scarcity of human resources and the lack of engagement in implementing evidence-based interventions.11,16,25 However, one of the main recommendations, particularly in cases of non-specific spinal disorders,15 involves treatment by a multidisciplinary team in Primary Health Care, with the objective of rational use of resources and avoiding the fragmentation traditionally observed in the biomedical model.7,16,31

Our findings showed that most individuals underwent imaging tests. In addition, drugs were prescribed to the vast majority, corroborating the findings from a previous study in Brazil.21 The use of medications and routine diagnostic imaging was determined to have limited evidence of clinical benefits, especially in cases of non-specific low back pain and uncomplicated spinal disorders.8,18,30,32 An interesting finding was the low prescription of muscle relaxants for back pain, which is in accordance with current recommendations and was also observed by a previous study in Brazil.33 Previous studies have shown that the unjustified use of imaging tests and medication increases direct healthcare costs9,13,34 and can be harmful due to exposure to radiation and greater likelihood of performing unnecessary surgeries, in addition to gastrointestinal toxicity and other side effects.17,35 International clinical guidelines7,19,20 and previous studies15,17,30 recommend, preferably, non-pharmacological treatment (e.g., exercise therapy) and recommend imaging tests only in cases with indications of serious spinal pathology. Thus, our findings demonstrate that there is a gap between scientific evidence and its implementation in clinical practice in Brazil.

We found that interventions such as exercise were prescribed, but without referral to a physical therapist. In addition to guidelines and studies recommending intervention strategies such as supervised exercise for non-specific spinal disorders,8,15,30 a recent Cochrane systematic review36 showed that exercise was effective in managing non-specific low back pain compared to no treatment, usual care or placebo. However, referral to a physical therapist was performed for approximately half of the individuals. Oliveira et al.21 corroborate our findings, as they also identified a low referral rate of patients with non-specific low back pain to other health professionals such as physical therapists. The physical therapist is a vital professional in the management of spinal disorders17 and contributes with the prescription of specific exercises, strategies for self-management and health education, in addition to functional diagnosis and other actions.37,38 Moreover, early referral to the physical therapist provided several benefits, such as reduced disability and pain intensity,37 further reducing the use of unnecessary clinical resources and lowering subsequent direct costs.37,38 This aspect is relevant because, although physical therapy has been part of the Family Health Support Centres since 2008, its operation is limited, e.g., the low population coverage due to the deficit in the number of professionals and the great demand imposed for conditions such as low back pain.16,39,40 It is possible to assume that these aspects explain the low frequency of referrals to this professional.

We observed an association between increasing age and greater use of Outpatient Care, as well as a greater chance of women first accessing the Emergency Department. Even though Primary Health Care is recommended as a gateway to health services and has a characteristic of longitudinal care for patients with chronic pain,1-3,25 there is the possibility of direct access to specialists in the Public Health System (SUS).41 Such access may represent competition between Primary Care and other settings and represents a challenge for the strengthening of Primary Health Care as the initial access point for health care.42 Moreover, organizational barriers in accessing Primary Care, such as shorter operating hours and long waiting lines can encourage access through other settings, such as the outpatient clinic and Emergency Department.40 With regard to women having first access via Emergency units, although previous studies33,43 reported similar findings, this was unexpected. Traditionally, men tend to neglect their health compared to women and, consequently, seek care in Emergency units only when the condition gets worse.44,45 In contrast, women have a profile of regular use of the health care system, seeking prevention and monitoring.44 It is possible to assume that these results were influenced by the smaller number of men in our sample.

We found that the Emergency Department was the most accessed setting by individuals with non-specific spinal disorders using the HCN of the Federal District, Brazil. Most individuals underwent a large number of imaging tests and received a high number of drug prescriptions, and individuals who used Outpatient and Primary Health Care received a lower number of drug prescriptions. Few patients were prescribed physical exercise, and only half were referred to a physical therapist. We also found that women were more likely to access the HCN for the first time via the Emergency Department, and increasing age was associated with a greater chance of accessing Outpatient Clinics as the first contact with the Network.