A Regional Analysis of Low Back Pain Treatments in the Military Health System

Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care. 7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS. The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%. 1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0. 97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0. 051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis. Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.Study Design.Claims-based analysis of cohorts of TRICARE Prime beneficiaries.To compare rates of utilization of 5 low back pain (LBP) treatments (physical therapy (PT), manual therapy, behavioral therapies, opioid, and benzodiazepine prescription) across catchment areas and assess their association with the resolution of LBP.Guidelines support focusing on nonpharmacologic management for LBP and reducing opioid use. Little is known about patterns of care for LBP across the Military Health System.Incident LBP diagnoses were identified data using the International Classification of Diseases ninth revision before October 2015 and 10th revision after October 2015; beneficiaries with "red flag" diagnoses and those stationed overseas, eligible for Medicare, or having other health insurance were excluded. After exclusions, there were 159,027 patients remained in the final analytic cohort across 73 catchment areas. Treatment was defined by catchment-level rates of treatment to avoid confounding by indication at the individual level; the primary outcome was the resolution of LBP defined as an absence of administrative claims for LBP during a 6 to 12-month period after the index diagnosis.Adjusted rates of opioid prescribing across catchment areas ranged from 15% to 28%, physical therapy from 17% to 39%, and manual therapy from 5% to 26%. Multivariate logistic regression models showed a negative and marginally significant association between opioid prescriptions and LBP resolution (odds ratio: 0.97, 95% CI: 0.93-1.00; P = 0.051) but no significant association with physical therapy, manual therapy, benzodiazepine prescription, or behavioral therapies. When the analysis was restricted to the subset of only active-duty beneficiaries, there was a stronger negative association between opioid prescription and LBP resolution (odds ratio: 0.93, 95% CI: 0.89-0.97).We found substantial variability across catchment areas within TRICARE for the treatment of LBP. Higher rates of opioid prescription were associated with worse outcomes.Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.The MHS provides health care to active-duty and retired military personnel and their civilian dependents, either through a direct care system staffed and operated by military employees (either uniformed or civil service) or through a purchased care system of civilian health care providers.5 Studies have documented substantial geographic variation in care within the MHS with important cost implications.5,6 Large geographic variations in treatment rates are often associated with uncertainty regarding the best treatment, as is the case with LBP care.7 Numerous clinical practice guidelines for the treatment of LBP, including one specifically from the Department of Veterans Affairs and Department of Defense, support focusing on nonpharmacologic management, promoting self-care, and reducing reliance on medication, particularly opioids.8,9Little is known about the variability in patterns of care for LBP across the MHS. In this study, we use the MHS data repository (MDR) to characterize variations in care for LBP. Using these data, we evaluate variations in utilization and outcomes among adult TRICARE beneficiaries with LBP. We hypothesize that patients are treated differently across TRICARE catchment areas and that these treatment differences are associated with different rates of resolution of LBP across areas.