A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan Spine Pathway

A Clinical Care Pathway for Patients With Chronic Mechanical Low Back Pain Having Restorative Neurostimulation for Multifidus Muscle: Description, Patient Compliance, Clinical Outcomes, and Satisfaction in the First Two Years

OBJECTIVES

Restorative neurostimulation for multifidus muscle is a novel therapy for chronic low back pain (CLBP). Optimal outcomes require interdisciplinary follow-up. We describe a clinical care pathway (CPW) for this therapy and report patient compliance, clinical outcomes, and patient satisfaction with the CPW.

MATERIALS AND METHODS

This study aimed to develop, at a single center, a CPW with derivation, practical basis, description, and evolution. Included in the study were audits of 1) patient compliance with attendance over 24 months, 2) medical and paramedical attendance at the clinic, 3) clinical outcomes in terms of reductions in both patient and cohort disability (Oswestry Disability Index, ODI) and CLBP numeric rating score (NRS), and 4) adverse events; and a prospective cross-sectional survey of patient satisfaction with the CPW.

RESULTS

A CPW that involved both preoperative and postoperative education and integrated interdisciplinary care was developed and incorporated into the clinical service with a dedicated clinic. In the two years under study, 172 patients attended the education session, and 92 proceeded to restorative neurostimulation for multifidus muscle therapy; 15 patients who had this therapy before the CPW also were incorporated into the CPW. Patient compliance with the pathway was 88% (95% CI 79%-94%) at 12 months. Attendance at the dedicated CPW clinic by the various subspeciality clinicians ranged between 74% and 100%. There were serial reductions in both ODI (38.9 [95% CI 35.9-41.9] to 24.7 (95% CI 21.1-28.3) and CLBP NRS (6.3 [95% CI 6.0-6.7] to 3.3 (95% 2.7-3.9) after 12 months; 76 of the 99 patients assessable (77%: 95% CI 67%-85%) had a minimally important clinical difference reduction in either ODI or pain NRS, whereas eight were unassessable. Patient satisfaction with the CPW was very high (mean 26.9; median 27, maximum 28).

CONCLUSIONS

The CPW facilitated clinical management and optimized outcomes in patients having restorative neurostimulation. Its design and delivery were very well accepted by patients.

The Alberta Back Care Pathway: The feasibility of implementing a novel care pathway to improve low back pain management for family physicians in primary care

BACKGROUND

Family physicians in Canada's universal healthcare system often manage low back pain patients using interventions not recommended in clinical guidelines, such as pharmaceuticals, imaging and spinal injections, while guideline-based treatments like education and exercise remain unfunded. The Alberta Back Care pathway was developed to address this gap, offering funded, evidence-based care for low back pain patients in 5 streams (acute, sub-acute, chronic, chronic non-responsive and stable radiculopathy).

OBJECTIVE

To evaluate the feasibility of implementing the pathway in two urban Primary Care Networks in Alberta, Canada.

MATERIALS AND METHODS

Each of the 5 pathway streams provided physicians with information scripts, no-cost interventions (pharmaceuticals and otherwise) and interventions to avoid. From April 2021 to November 2023, the RE-AIM framework was used to assess implementation feasibility of the pathway.

RESULTS

For the RE-AIM dimension of reach, 25% (n = 41/162) of eligible family physicians in Primary Care Network "A" and 12% (n = 26/221) in Primary Care Network "B" enrolled in the study. Over half of enrolled physicians (n = 21/41 and 21/26) referred at least one patient with most referrals to the GLA:D Back program for chronic low back pain stream (93% in network "A" and 88% in network "B"). Implementation, evaluated as the proportion of referrals by physician compared to their total low back pain caseload, was low (> 0-10% referred) for 52% (n = 11/21) of physicians in network "A", and medium-low (10-25% referred) for 52% (n = 11/21) of physicians in network "B". The number of pathway-appropriate patients in each physician's caseload was unknown. Maintenance at 12 months was 56% (n = 10/18) in network "A" and 39% (n = 7/18) in network "B".

CONCLUSION

The Alberta Back Care pathway was feasible to implement during the pandemic and primarily serving patients with chronic low back pain by providing access to a guideline-based education and exercise group program (GLA:D Back).

A consensus-based agreement on a definition of a process variable: findings from a New Zealand nominal group technique study

BACKGROUND

Musculoskeletal pain and disability are leading causes of reduced health and significant economic costs worldwide. Individualised, and evidence-based treatment approaches for specific musculoskeletal conditions aimed at improving patient outcomes and costs have not been successful. Recently authors have suggested that the 'process' of how care is implemented within a health system needs to be considered as an influencer on patient outcomes. With the rising prevalence of musculoskeletal conditions and the burgeoning costs associated with their treatment, it seems timely that new research focusing on process variables and their influence on patients with musculoskeletal conditions is explored. Before such studies can take place, a modern definition of a process variable within a musculoskeletal care pathway is needed to anchor future research endeavours. Therefore, the aim of this study was to establish a consensus-based definition of a process variable within a musculoskeletal care pathway, based on a New Zealand setting.

METHODS

This study used a virtual nominal group technique and took place in July 2023 using a Microsoft Teams platform. A nominal group technique employs a structured approach to generate information and solutions to problems that can then be prioritised through group discussion and consensus. It is unique because it allows expert participants to explore using in-depth inquiry, areas previously unidentified or not yet investigated. There was an inclusion criterion and the participants completed pre-work before the two-hour five stage virtual meeting. The Auckland University of Technology Ethics Committee (AUTEC) approved this study (AUTEC 23/94).

RESULTS

The study included eight participants (five male, three female) who had extensive experience with the New Zealand ACC insurance scheme and the design, implementation, and administration of musculoskeletal care pathways. The consensus definition was 'A health process variable is any modifiable factor in a health process or pathway that can be quantified and measured and that if varied may achieve a different operational or patient outcome'.

CONCLUSIONS

This study of New Zealand-based experts has formed a consensus-based agreement for a definition of a process variable in a musculoskeletal care pathway. This is an important first step in developing our understanding of process variables, and further research is needed to establish the link between process variables and their influence on the outcomes of patients with musculoskeletal conditions.

The Effectiveness and Optimal Dose of Resistance Training in Patients With Subacute and Persistent Low Back-Related Leg Pain: A Systematic Review

A subgroup of patients with low back pain (LBP) suffers from low back-related leg pain (LBLP), which can be classified as radicular pain, or somatic referred pain without nerve root involvement. LBLP is considered an obstacle to recovery and a strong negative prognostic factor for medium- and long-term disability. In this review, we aimed to investigate the effectiveness and optimal dose of resistance training (RT) in patients with subacute or persistent LBLP to provide clinical recommendations for practice. This systematic review was conducted by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the recommendations of the Cochrane Collaboration. We conducted a literature search on PubMed, PEDro, Cochrane Library, Scopus, and Web of Science databases. Only randomized controlled trials (RCTs) involving patients ≥18 years of age were included. The risk of bias in the included studies was assessed using "the Cochrane Collaboration's tool for assessing risk of bias" (RoB) and the inter-rater agreement for full-text selection was evaluated using Cohen's Kappa (K). The search elicited a total of 4.537 records, and two RCTs involving a total of 196 participants were identified through a selection process based on title, abstract, and full-text assessment. Both studies had a low to moderate risk of bias. The inter-examiner concordance index for the selection of full text was excellent (K=1). RT seems to be an effective and safe intervention for patients with LBLP, but its long-term effectiveness, superiority over other types of exercise-based therapies, and optimal dosage still constitute a gray area in the literature.

Global, Regional, and National Change Patterns in the Incidence of Low Back Pain From 1990 to 2019 and Its Predicted Level in the Next Decade

Objectives: To analyze and describe the spatiotemporal trends of Low back pain (LBP) burdens from 1990 to 2019 and anticipate the following decade's incidence. Methods: Using data from the Global Burden of Disease (GBD) 2019 Study, we described net drifts, local drifts, age effects, and period cohort effects in incidence and forecasted incidence rates and cases by sex from 2020 to 2029 using the Nordpred R package. Results: LBP remained the leading cause of the musculoskeletal disease burden globally and across all socio-demographic index (SDI) regions. China is the top country. For recent periods, high-SDI countries faced unfavorable or worsening risks. The relative risk of incidence showed improving trends over time and in successively younger birth cohorts amongst low-middle-, middle- and high-middle-SDI countries. Additionally, the age-standardized incidence rates (ASIR) of LBP in both sexes globally showed a decreasing trend, but the incident cases would increase from 223 to 253 million overall in the next decade. Conclusion: As the population ages, incident cases will rise but ASIR will fall. To minimise LBP, public awareness and disease prevention and control are needed.

Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain

Objective

To determine associations between post-emergency department (ED) management pathways and downstream opioid prescriptions in patients seeking care for incident neck and/or back pain.

Patients and Methods

We identified patients seeking first-time ED care for neck and/or back pain from January 1, 2013, through November 6, 2017. We reported demographic characteristics and opioid prescriptions across management pathways using descriptive statistics and assessed the relative risk of any opioid prescription 12 months post-ED visit among 5 different post-ED management pathways using Poisson regression adjusted for patient demographic characteristics.

Results

Within 12 months after the index ED visit, 58.0% (n=10,949) were prescribed an opioid, with most patients prescribed an opioid within the first week (average daily morphine milligram equivalents of 6.8 mg (SD 9.6 mg). The morphine milligram equivalents decreased to 0.7 mg (SD 8.2 mg) by week 4 and remained consistently less than 1 mg between week 4 and 12 months. Compared with the ED to primary care provider pathway, the relative risk of opioid prescription between 7 days and 12 months after the index ED visit was similar for the ED to physical therapy pathway, higher for both the ED to hospital admission or repeat ED visit pathway (30% increase; relative risk (RR), 1.3; 95% CI, 1.17-1.44) and the ED to specialist pathway (19% increase; RR, 1.19; 95% CI, 1.07-1.33), and lower in the ED with no follow-up visits pathway (41% decrease; RR, 0.59; 95% CI, 0.54-0.65).

Conclusion

In general, more conservative care was associated with lower opioid prescription rates, and escalated care was associated with higher opioid prescription rates.

Cost-utility analysis of endoscopic lumbar discectomy following a uniform clinical pathway in the Korean national health insurance system

INTRODUCTION

Full-endoscopic lumbar discectomy (FELD) is a type of minimally invasive spinal surgery for lumbar disc herniation (LDH). Sufficient evidence exists to recommend FELD as an alternative to standard open microdiscectomy, and some patients prefer FELD due to its minimally invasive nature. However, in the Republic of Korea, the National Health Insurance System (NHIS) controls the reimbursement and use of supplies for FELD, but FELD is not currently reimbursed by the NHIS. Nonetheless, FELD has been performed upon patients' request, but providing FELD for patients' sake is inherently an unstable arrangement in the absence of a practical reimbursement system. The purpose of this study was to conduct a cost-utility analysis of FELD to suggest appropriate reimbursements.

METHOD

This study was a subgroup analysis of prospectively collected data including 28 patients who underwent FELD. All patients were NHIS beneficiaries and followed a uniform clinical pathway. Quality-adjusted life years (QALYs) were assessed with a utility score using the EuroQol 5-Dimension (EQ-5D) instrument. The costs included direct medical costs incurred at the hospital for 2 years and the price of the electrode ($700), although it was not reimbursed. The costs and QALYs gained were used to calculate the cost per QALY gained.

RESULT

Patients' mean age was 43 years and one-third (32%) were women. L4-5 was the most common surgical level (20/28, 71%) and extrusion was the most common type of LDH (14, 50%). Half of the patients (15, 54%) had jobs with an intermediate level of activity. The preoperative EQ-5D utility score was 0.48±0.19. Pain, disability, and the utility score significantly improved starting 1 month postoperatively. The average EQ-5D utility score during 2 years after FELD was estimated as 0.81 (95% CI: 0.78-0.85). For 2 years, the mean direct costs were $3,459 and the cost per QALY gained was $5,241.

CONCLUSION

The cost-utility analysis showed a quite reasonable cost per QALY gained for FELD. A comprehensive range of surgical options should be provided to patients, for which a practical reimbursement system is a prerequisite.

Feasibility and Acceptability of a Telemedicine Triage Model Among Medicaid Patients with Low Back Pain Referred to a Spine Center

Background

The data for primary triage via telemedicine for spine related conditions are sparse but has potential to improve access, quality of care, and offer significant cost savings for Medicaid insured patients who have very limited access to care. The purpose of this study was to evaluate the feasibility and acceptability of implementing a telehealth triage framework using synchronous video conferencing appointments.

Methods

This is a prospective cohort feasibility study conducted within an academic spine center in the United States. Participants include Medicaid insured patients referred to an academic spine center for low back pain. We collected demographic information, a spine red flag survey, a patient satisfaction survey and demand and implementation feasibility metrics. Participants completed a demographic and red-flag survey followed by a telehealth spine appointment with a physiatrist. Immediately after the appointment, the participant completed a satisfaction survey.

Results

Nineteen patients met inclusion criteria but declined telehealth either due to preference for in-person appointment or lack of comfort with technology. Thirty-three participants enrolled and attended their initial telehealth appointment. Few participants reporting 1 or more red flag symptom also screened positive during their subsequent telehealth evaluation with the physician (n=7/28). Participant satisfaction was high across all domains including ease of scheduling, efficiency of virtual check in, ability to report their symptoms fully and accurately to the provider, imaging review, explanation of diagnosis and treatment plan. Most participants (n=19/20, 95%) would recommend an initial telehealth appointment.

Conclusions

The telehealth framework used was feasible and provided an acceptable form of care for Medicaid patients who were interested and able to participate in this form of care. Our acceptability results are promising but should be interpreted with caution given the proportion of patients who declined to participate.

Using general practitioners with an extended role in spinal practice for the initial assessment of patients referred to spinal surgeons: preliminary experience and challenges

AIM

To describe experience using general practitioners (GPs), with an extended role (GPwER) in spinal medicine, to expedite assessment, triage, and management of patients referred from primary care for specialist spinal surgical opinion.

BACKGROUND

Low back and neck pain are common conditions in primary care. Indiscriminate or inappropriate referral to a spinal surgeon contributes to long waiting times. Previous attempts at triaging patients who really require a surgical opinion have used practice nurses, physiotherapists, clinical algorithms, and interdisciplinary screening clinics.

METHODS

Within the setting of an independent spinal care centre, we have used GPs specially trained in spinal practice to expedite the assessment and triage of new referrals between 2015 and 2021. We reviewed feedback from a Patient Satisfaction Questionnaire and the postgraduate backgrounds, training, practice with regard to triage of new referrals, and experiences of the GPs who were recruited.

FINDINGS

Six GPwER had a mean of 26 years of postgraduate experience before appointment (range 10-44 years). The first four GPwER, appointed between 2015 and 2018, underwent an ad hoc in-house, interdisciplinary training programme and saw 2994 new patients between 2016 and 2020. After GPwER, assessment in only 18.9% (range 12.6 to 22.7%) of these patients was a spinal surgical opinion deemed necessary. Waiting times to see the spinal surgeon remained at 6-8 weeks despite a three-fold annual increase (from 340 to 1058) in new referrals. A Patient Satisfaction Questionnaire revealed high levels of satisfaction with the performances of the GPwER across seven dimensions. A dedicated training programme was designed in 2020, and the last two appointees underwent 20 h of clinical teaching prior to practice. Initial experience using GPwER, here termed 'Spinal Clinicians', suggests they are efficient at screening for patients needing spinal surgical referral. Establishing a recognised training programme, assessment, and certification for these practitioners are the next challenges.

The Effect of a Multidisciplinary Spine Clinic on Time to Care in Patients with Chronic Back and/or Leg Pain: A Propensity Score-Matched Analysis

Chronic back and leg pain are leading causes of disability worldwide. The purpose of this study was to compare the care in a unidisciplinary (USC) versus multidisciplinary (MSC) spine clinic, where patients are evaluated by different specialists during the same office visit. Adult patients presenting with a chief complaint of back and/or leg pain between June 2018 and July 2019 were assessed for eligibility. The main outcome measures included the first treatment recommendations, the time to treatment order, and the time to treatment occurrence. A 1:1 propensity score-matched analysis was performed on 874 patients (437 in each group). For all patients, the most common recommendation was physical therapy (41.4%), followed by injection (14.6%), and surgery (9.7%). Patients seen in the MSC were more likely to be recommended injection (p < 0.001) and less likely to be recommended surgery as first treatment (p = 0.001). They also had significantly shorter times to the injection order (log-rank test, p = 0.004) and the injection occurrence (log-rank test, p < 0.001). In this study, more efficient care for patients with back and/or leg pain was delivered in the MSC setting, which was evidenced by the shorter times to the injection order and occurrence. The impact of the MSC approach on patient satisfaction and health-related quality-of-life outcome measures warrants further investigation.

Clinical pathways for the management of low back pain from primary to specialised care: a systematic review

PURPOSE

Clinical pathways for low back pain (LBP) have potential to improve clinical outcomes and health service efficiency. This systematic review aimed to synthesise the evidence for clinical pathways for LBP and/or radicular leg pain from primary to specialised care and to describe key pathway components.

METHODS

Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) from 2006 onwards were conducted with further manual and citation searching. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. A narrative synthesis of findings is presented.

RESULTS

From 18,443 identified studies, 28 papers met inclusion criteria. Pathways were developed primarily to address over-burdened secondary care services in high-income countries and almost universally used interface services with a triage remit at the primary-secondary care boundary. Accordingly, evaluation of healthcare resource use and patient flow predominated, with interface services associated with enhanced service efficiency through decreased wait times and appropriate use of consultant appointments. Low quality study designs, heterogeneous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical- and cost-effectiveness. Pathways demonstrated basic levels of care integration across the primary-secondary care boundary.

CONCLUSIONS

The limited volume of research evaluating clinical pathways for LBP/radicular leg pain and spanning primary and specialised care predominantly used interface services to ensure appropriate specialised care referrals with associated increased efficiency of care delivery. Pathways demonstrated basic levels of care integration across healthcare boundaries. Well-designed randomised controlled trials to explore the potential of clinical pathways to improve clinical outcomes, deliver cost-effective, guideline-concordant care and enhance care integration are required.

Physical Function in Amateur Athletes with Lumbar Disc Herniation and Chronic Low Back Pain: A Case-Control Study

This study aimed to analyze if chronic low back pain (LBP) and lumbar disc herniation induce biomechanics, flexibility, body balance, physical activity, and muscular function alterations compared to a similar asymptomatic cohort. Fifty male volunteers (n = 25 with chronic LBP and lumbar disc herniation and n = 25 pain-free subjects) were enrolled. Range of motion (internal and external hip rotation, ankle dorsiflexion, and active straight leg raise, ASLR), trunk flexibility (finger−floor distance), body balance (Y-balance test) and muscle function (Biering−Sorensen test, prone and lateral bridges) outcomes were assessed. Comparative analyses between sides and group were conducted. Results: Patients showed greater weight and BMI compared with controls (p < 0.05). None of the outcomes bilaterally assessed showed side-to-side differences for pain-free participants (all, p > 0.05) or LBP patients (all, p > 0.05). Regarding the differences between groups, LBP patients showed limited internal hip rotation (p < 0.001), finger−floor distance (p < 0.001), body balance (p < 0.001), and muscle endurance (planks p < 0.001; Biering−Sorensen test p < 0.05). External hip rotation, ASLR, and ankle dorsiflexion range of movement were comparable in both groups (p > 0.05). The sample of pain-free amateur athletes showed greater range of movement for internal hip rotation, lower finger−floor distance, better body balance, and muscle function. However, the external hip rotation, ankle dorsiflexion, and ASLR tests showed no difference between cases and controls.

Second opinions for spinal surgery: a scoping review

BACKGROUND

Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain.

METHODS

We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.

RESULTS

We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections).

CONCLUSIONS

Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.

The primary spine practitioner as a new role in healthcare systems in North America

Background

In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies.

Main body

The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly.

Conclusion

Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.

Nerve root sedimentation sign on MRI: A triage screen for leg dominant symptoms?

PURPOSE

Surgical indications for lumbar spinal stenosis are controversial, but most agree that leg dominant pain is a better predictor of success after decompression surgery. The objective of this study is to analyze the ability of the Nerve Root Sedimentation Sign (SedSign) on MRI to differentiate leg dominant symptoms from non-specific low back pain.

METHODS

This was a retrospective review of 367 consecutive patients presenting with back and/or leg pain. Baseline clinical characteristics included Oswestry disability index (ODI), visual analog pain scores, EuroQol Group 5-Dimension Self-Report (EQ5D) and Saskatchewan Spine Pathway Classification (SSPc). Inter- and intra-rater reliability for SedSign was 73% and 91%, respectively (3 examiners).

RESULTS

SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. On univariate analysis, a positive SedSign was correlated with age, male sex, several ODI components, EQ5D mobility, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and SSPc pattern 4 (intermittent leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI walking distance. Patients with a positive SedSign were more likely to be offered surgery after referral (OR 2.65). The sensitivity and specificity for detecting all types of leg dominant pain were 37.4 and 82.8, respectively (ppv 77.5%, npv 43.8%).

CONCLUSIONS

Patients with a positive SedSign were more likely to be offered surgery, in particular non-instrumented decompression. The SedSign has high specificity for leg dominant pain, but the sensitivity is poor. As such, its use in triaging appropriate surgical referrals is limited.

Effectiveness of a coordinated support system linking public hospitals to a health coaching service compared with usual care at discharge for patients with chronic low back pain: protocol for a randomised controlled trial

Background

Although many people with chronic low back pain (LBP) improve following conservative treatment, one in five will experience worsening symptoms after discharge from treatment and seek health care again. The current LBP clinical care pathway in many health services lacks a well-integrated, systematic approach to support patients to remain physically active and self-manage their symptoms following discharge from treatment. Health coaching can support people to improve physical activity levels and may potentially reduce health care utilisation for LBP. The primary aim of this study is to evaluate the effect of introducing a coordinated support system (linking hospital outpatient physiotherapy services to a public health coaching service) at discharge from LBP treatment, on the future use of hospital, medical, and health services for LBP, compared with usual care provided at discharge.

Methods

Three hundred and seventy-four adults with chronic non-specific LBP will be recruited from the outpatient physiotherapy departments of public hospitals in New South Wales, Australia. Participants will be individually randomised to a support system (n = 187) or usual care group (n = 187). All participants will receive usual care provided at discharge from treatment. Participants allocated to the support system will also receive up to 10 telephone-based health coaching sessions, delivered by the Get Healthy Service®, over a 6-month period. Health coaches will monitor and support participants to improve physical activity levels and achieve personal health-related goals. The primary outcome is the total number of encounters with hospital, medical, and health services for LBP, at 12 months from baseline. A within-trial economic evaluation will quantify the incremental costs and benefits of the support system from a health system perspective, to support reimbursement decision making.

Discussion

This study will establish the effect of a coordinated support system, introduced at discharge from treatment, on the future use of hospital, medical, and health services for LBP and various health outcomes.

Conclusion

Innovative community-driven solutions to support people with chronic LBP after discharge from treatment are urgently needed. Study findings will help inform health care policy and clinical practice in Australia.

Trial Registration

Prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12620000889954) on 10/09/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04479-z.

Does a Multidisciplinary Triage Pathway Facilitate Better Outcomes After Spine Surgery?

STUDY DESIGN

Single-center prospective non-randomized matched cohort comparison.

OBJECTIVE

To compare elective lumbar spine surgery outcomes for cases triaged through a multidisciplinary spine pathway versus conventional referral processes.

SUMMARY OF BACKGROUND DATA

Many health care systems have facilitated low back pain (LBP) guidelines into primary care practice by creating local or regional "pathways" with the goal of enhanced quality of care, improved patient satisfaction and optimal resource utilization, particularly for imaging and surgery. Few comparative outcomes exist for LBP pathways, particularly for surgical outcomes.

METHODS

One-hundred-fifty patients (SSP group n = 75; conventional group n = 75) undergoing elective lumbar surgery for degenerative conditions between 2011 and 2016 were analyzed with 1-year follow-up. Patient self-reported outcomes included the Oswestry disability index (ODI), visual analogue pain scores (VAS) for back and leg, and EuroQol Group 5-Dimension self-report (EQ-5D). We also assessed baseline clinical features, indications for surgery, therapies received prior to surgery, type of surgery, wait times, and overall patient satisfaction.

RESULTS

The groups had equivalent baseline demographics, body mass index, Saskatchewan Spine Pathway (SSP) classification of pain pattern, pain scores, functional scores, quality of life scores, indication for surgery, and type of surgery (instrumented or non-instrumented). There was no difference with respect to wait times to see the surgeon or for surgery. Wait time for magnetic resonance imaging (MRI) was significantly shorter for the SSP group (16.8 vs. 63.0 days, P < 0.001). Patients triaged through the SSP were significantly more likely to utilize multiple nonoperative treatment strategies prior to seeing the surgeon (P < 0.04). Patient satisfaction was significantly higher for SSP patients prior to surgical assessment (P = 0.03) but did not differ between groups after surgery.

CONCLUSION

The SSP facilitates significantly shorter wait times for MRI and promotes nonoperative treatment strategies. Preoperative patient satisfaction is significantly higher among SSP patients, but there were no significant differences in surgical outcomes.Level of Evidence: 3.

International comparative study of low back pain care pathways and analysis of key interventions

PURPOSE

Low back pain (LBP) is a major public health problem worldwide. Significant practice variation exists despite guidelines, including strong interventionist focus by some practitioners. Translation of guidelines into pathways as integrated treatment plans is a next step to improve implementation. The goal of the present study was to analyze international examples of LBP pathways in order to identify key interventions as building elements for care pathway for LBP and radicular pain.

METHODS

International examples of LBP pathways were searched in literature and grey literature. Authors of pathways were invited to fill a questionnaire and to participate in an in-depth telephone interview. Pathways were quantitatively and qualitatively analyzed, to enable the identification of key interventions to serve as pathway building elements.

RESULTS

Eleven international LBP care pathways were identified. Regional pathways were strongly organized and included significant training efforts for primary care providers and an intermediate level of caregivers in between general practitioners and hospital specialists. Hospital pathways had a focus on multidisciplinary collaboration and stepwise approach trajectories. Key elements common to all pathways included the consecutive screening for red flags, radicular pain and psychosocial risk factors, the emphasis on patient empowerment and self-management, the development of evidence-based consultable protocols, the focus on a multidisciplinary work mode and the monitoring of patient-reported outcome measures.

CONCLUSION

Essential building elements for the construction of LBP care pathways were identified from a transversal analysis of key interventions in a study of 11 international examples of LBP pathways.

Operationalization of the new Pain and Disability Drivers Management model: A modified Delphi survey of multidisciplinary pain management experts

BACKGROUND

We recently proposed the Pain and Disability Drivers Management (PDDM) model, which was designed to outline comprehensive factors driving pain and disability in low back pain (LBP). Although we have hypothesized and proposed 41 elements, which make up the model's five domains, we have yet to assess the external validity of the PDDM's elements by expert consensus.

RESEARCH OBJECTIVES

This study aimed to reach consensus among experts regarding the different elements that should be included in each domain of the PDDM model.

RELEVANCE

The PDDM may assist clinicians and researchers in the delivery of targeted care and ultimately enhance treatment outcomes in LBP.

METHODS

Using a modified Delphi survey, a two-round online questionnaire was administered to a group of experts in musculoskeletal pain management. Participants were asked to rate the relevance of each element proposed within the model. Participants were also invited to add and rate new elements. Consensus was defined by a greater than or equal to 75% level of agreement.

RESULTS

A total of 47 (round 1) and 33 (round 2) participants completed the survey. Following the first round, 38 of 41 of the former model elements reached consensus, and 10 new elements were proposed and later rated in the second round. Following this second round, consensus was reached for all elements (10 new + 3 from first round), generating a final model composed of 51 elements.

CONCLUSION

This expert consensus-derived list of clinical elements related to the management of LBP represents a first step in the validation of the PDDM model.

Implementation of a Spine-Centered Care Pathway at a Regional Academic Spine Center

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To describe the early implementation of an inpatient spinal surgery unit and measure the impact on cost and length of stay (LOS).

METHODS

A retrospective case review was performed for frequent spine-related diagnosis-related groups (DRGs) cared for by a dedicated multidisciplinary team: combined anterior/posterior (AP) spinal fusion with major complicating or comorbid condition (MCC), combined (AP) spinal fusion with CC, combined (AP) spinal fusion without complicating or comorbid (CC)/MCC, cervical spinal fusion with MCC, cervical spinal fusion with CC, and cervical spinal fusion without CC/MCC. Four time periods were compared: historical control, initial pathway implementation, full pathway implementation, and spine unit opening. Mean hospital LOS, mean and median total costs (USD), and ratio of costs-to-charges were analyzed.

RESULTS

The number of spine cases per interim ranged from 219 to 258. The mean overall hospital LOS and mean cost varied from 3.8 to 4.3 days for all DRGs across the time periods and was not significant. Cost also did not vary significantly throughout. Median variable cost per anterior/posterior spinal fusion procedure with a CC or MCC declined by 16 311, first with the institution of a spine pathway protocol by USD8738 and then USD7423 with the establishment of a spine care unit but did not reach significance.

CONCLUSIONS

The use of a standardized, inpatient spine care pathway implemented by a multidisciplinary team may reduce the hospital length of stay and decrease overall costs.

Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Background

Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors.

Methods

Individual telephone interviews, underpinned by the Theoretical Domains Framework (TDF), explored beliefs and attitudes about, and identified barriers and facilitators to the use of stratified care approaches for managing non-specific LBP in a purposive sample of 13 chiropractors and 14 physiotherapists between September 2015 and June 2016. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using directed content analysis.

Results

Three and seven TDF domains were identified as likely relevant for physiotherapists and chiropractors, respectively. Shared key beliefs (and relevant domains of the TDF) for both physiotherapists and chiropractors included: lack of time, cost, and expertise (Environmental Context and Resources); and consulting more experienced colleagues and chronic patients with important psychological overlay (Social Influences). Unique key domains were identified among physiotherapists: incompatibility with achieving other objectives (Goals), and chiropractors: confidence in using stratified care approaches (Beliefs about Capabilities); intention to use stratified care approaches (Intentions); awareness and agreement with stratified care approaches (Knowledge); assessment of readiness for change and intentional planning behaviour (Behavioural Regulation); and improving the management of non-specific LBP patients and the uptake of evidence-based practice (Beliefs about Consequences).

Conclusions

Several shared and unique barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors were identified. Findings may help inform the design of tailored theory-based knowledge translation interventions to increase the uptake of stratified care approaches in clinical practice.

The pivotal role for the multidisciplinary approach at all phases and at all levels in the national pathway for the management of low back pain and radicular pain in Belgium

INTRODUCTION

High level evidence on management of spinal disorders is scarce, which results in guidelines being of limited practical use for practitioners. Care pathways are complex interventions intended for the mutual decision making of organization of care processes for a well-defined group of patients. The goal of this project was to design a pathway for the management of low back pain and radicular pain for national implementation in Belgium.

EVIDENCE ACQUISITION

An international and Belgian study on characteristics of low back pain care pathways was performed along with a literature study and focus group interrogation. Based on essential building elements identified and a consensus approach among all relevant stakeholders in primary, hospital and reintegration care, a national pathway was constructed. The process was endorsed by the Belgian Health Care Knowledge Center, Belgian National Institute of Health and Disability Insurance and the Spine Society of Belgium.

EVIDENCE SYNTHESIS

Eleven international pathways were identified, varying in implementation width from hospital-based to region/province-based. Seven Belgian pathway initiatives were detected. Notwithstanding differences, consistent building elements were identified. Three groups of caregivers, divided in primary care, hospital care and reintegration and including all relevant medical/paramedical disciplines, worked on integrating the essential building elements into a single concrete patient pathway of direct use to any caregiver and patient and based on a consensus model including reference to the 2017 Belgian adaptation of the 2016 NICE guidelines. The resulting pathways on management of low back pain and radicular pain underpin the importance of multidisciplinary teamwork.

CONCLUSIONS

Essential building elements were identified from literature and established pathways and were successfully integrated in a Belgian national low back pain and radicular pain pathway using an integrative consensus approach. The pathways are consultable at www.lowbackpain.kce.be.

A Financial Analysis of Procedural Revenue in Outpatient Spine Clinic: An Analysis of 36,312 Patient Appointments and Subsequent Surgeries at a Single Major Academic Institution

OBJECTIVE

The economic pressures widely discussed in health care have a large impact on spine practices. This current study is the first to look at characteristics associated with revenues from an outpatient spine clinic.

METHODS

All clinic visits to spine providers were identified at a single academic institution spanning the dates June 1, 2014, to June 1, 2018. All payment information was calculated using Medicare reimbursement values for Current Procedural Terminology codes. Relevant clinical, surgical, and cost structure data was collected for each patient.

RESULTS

On average, providers had 21.9 average appointments over the course of 7.6 hours per clinic day. The average ratio of new to follow-up patients was 39.3%, with an average new patient to surgery conversion rate of 15.0%. The adjusted average total procedural revenue per new patient, controlled for scheduled appointment length and actual appointment length, was $686.02. The adjusted average procedural revenue per surgery was $3444.64 and average procedural revenue per hour in spine clinic was $552.40. With a 1% and 5% increase in new patient visits, total procedural revenue increases 2.7% and 13.5%, respectively. With a 1% and 5% increase in conversion rate, total procedural revenue increases 6.7% and 33.3%, respectively. With a decrease in new patient appointment length from 30 minutes to 25 minutes, the opportunity for 1.7 new patient appointments per day was created resulting in a net increase in procedural revenue per clinic day of $837.57.

CONCLUSIONS

Incremental changes in practice structure can significantly affect procedural revenue. Significant heterogeneity also exists among spine providers.

Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings

BACKGROUND

The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This study aims to determine the effect of ISAEC on access for surgical assessment, referral appropriateness and efficiency for patients meeting a priori referral criteria in rural, urban and metropolitan settings.

METHODS

We conducted a retrospective review of prospective data from networked ISAEC clinics in Thunder Bay, Hamilton and Toronto, Ontario. For patients meeting surgical referral criteria, wait times for surgical assessment, surgical referral-related magnetic resonance imaging (MRI) scans and appropriateness of referral were recorded.

RESULTS

Overall 422 patients, representing 10% of all ISAEC patients in the study period, were referred for surgical assessment. The average wait times for surgical assessment were 5.4, 4.3 and 2.2 weeks at the metropolitan, urban and rural centres, respectively. Referral MRI usage for the group decreased by 31%. Of the patients referred for formal surgical assessment, 80% had leg-dominant pain and 96% were deemed appropriate surgical referrals.

CONCLUSION

Contrary to geographic concentration of health care resources in metropolitan settings, the greatest decrease in wait times was achieved in the rural setting. A networked, shared-cared model of care for patients with low back pain-related symptoms significantly improved access for surgical assessment despite varying geographic practice settings and barriers. The greatest reductions were noted in the rural setting. In addition, significant improvements in referral appropriateness and efficiency were achieved compared with historical reports across all sites.

Implementation of an Alternative Pathway for Patients Seeking Care for Low Back Pain: A Prospective Observational Cohort Study

BACKGROUND

In the United States, low back pain (LBP) is among the most common symptoms prompting a health care visit. Patients can receive escalated care, such as advanced imaging or invasive procedures, before guideline-recommended options offered by physical therapists. A guideline-concordant alternative care pathway (RapidAccess) that emphasized early physical therapy for patients with LBP before they consulted a physiatrist was implemented. Evaluating the implementation of care pathways, such as RapidAccess using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, provides a broader understanding of the barriers to implementation.

OBJECTIVE

The purpose of this study was to evaluate the implementation of a guideline-concordant care pathway for patients with LBP using a RE-AIM framework.

DESIGN

This study used a prospective observational cohort design.

METHODS

Patients with a chief complaint of LBP who were scheduling a new appointment with physiatry were eligible. Eligible patients chose whether or not to participate in RapidAccess before a consultation with a physiatrist. Implementation outcomes were evaluated using the RE-AIM framework.

RESULTS

During the study period, 1556 patients with LBP called to schedule a new visit with a physiatrist. Of these, 400 (25.7%) were eligible for RapidAccess, and 124 (31% of those eligible) participated in the program (reach). Of the 400 eligible patients, 225 (56.3%) were offered RapidAccess (adoption). Compared with patients who were managed in physical therapy following a consultation with a physiatrist, RapidAccess participants demonstrated improvement in physical function with physical therapist management (effectiveness); 58.9% cancelled their physiatrist visit (implementation), and rates of imaging and injections were lower (effectiveness). Reach and adoption (maintenance) trended downward beyond the first 6 months of the project.

LIMITATIONS

The results are from a single health system and might not be broadly generalizable.

CONCLUSIONS

The RE-AIM framework was useful in evaluating the implementation of RapidAccess. Factors influencing reach and adoption must be further examined.

Patient Predictors of Surgical Candidacy in Elective Spine Disorders

BACKGROUND

The expansion of age-related degenerative spine pathologies has led to increased referrals to spine surgeons. However, the majority of patients referred for surgical consultation do not need surgery, leading to inefficient use of healthcare resources. This study aims to elucidate preoperative patient variables that are predictive of patients being offered spine surgery.

METHODS

We conducted an observational cohort study on patients referred to our institution between May 2013 and January 2015. Patients completed a detailed preclinic questionnaire on items such as history of presenting illness, quality-of-life questionnaires, and past medical history. The primary end point was whether surgery was offered. A multivariable logistical regression using the random forest method was used to determine the odds of being offered surgery based on preoperative patient variables.

RESULTS

An analysis of 1194 patients found that preoperative patient variables that reduced the odds of surgery being offered include mild pain (odds ratio [OR] 0.37, p=0.008), normal walking distance (OR 0.51, p=0.007), and normal sitting tolerance (OR 0.58, p=0.01). Factors that increased the odds of surgery include radiculopathy (OR 2.0, p=0.001), patient's belief that they should have surgery (OR 1.9, p=0.003), walking distance &lt;50 ft (OR 1.9, p=0.01), relief of symptoms when bending forward (OR 1.7, p=0.008) and sitting (OR 1.6, p=0.009), works more slowly (OR 1.6 p=0.01), aggravation of symptoms by Valsalva (OR 1.4, p=0.03), and pain affecting sitting/standing (OR 1.1, p=0.001).

CONCLUSIONS

We identified 11 preoperative variables that were predictive of whether patients were offered surgery, which are important factors to consider when screening outpatient spine referrals.

Tackling low back pain in Brazil: a wake-up call

BACKGROUND

Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society.

OBJECTIVE

This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.

Requesting spinal MRIs effectively from primary care referrals

OBJECTIVE

To define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey. The demand for outpatient spinal appointments significantly exceeds our services' ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation.

METHODS

During routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters.

RESULTS

149 patients were included [101 females, 48 males, mean age 49 (16-87)]. There were 125 routine, 21 urgent, and 3 'urgent-suspected cancer' referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits.

CONCLUSIONS

MRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: care pathway for people with spine-related concerns

PURPOSE

The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally.

METHODS

The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used.

RESULTS

After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records.

CONCLUSION

A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material.

Prevention and treatment of low back pain: evidence, challenges, and promising directions

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines?

BACKGROUND CONTEXT

Clinical practice guidelines (CPGs) are designed to ensure that evidence-based treatment is easily put into action. Whether patients and clinicians follow these guidelines is equivocal.

PURPOSE

The objectives of this study were to examine how many patients complaining of low back pain (LBP) underwent evidence-based medical interventional treatment in line with CPG recommendations before consultation with a spine surgeon, and to evaluate any associations between adherence to CPG recommendations and baseline factors.

STUDY DESIGN/SETTING

This is a cross-sectional cohort analysis at a tertiary care center.

PATIENT SAMPLE

A total of 229 patients were referred for surgical consultation for an elective lumbar spinal condition.

OUTCOME MEASURES

The outcome measures include the number of CPG-recommended treatments undertaken by patients at or before the time of referral, the validated pain score, the EuroQol-5D (EQ-5D) health status, and the Oswestry Disability Index (ODI) score.

METHODS

Questionnaires assessing demographic and functional characteristics as well as overall health care use were sent to patients immediately after their referral was received by the surgeon's office.

RESULTS

Medications were the most common modality before consultation (74.2% of patients), of which 46.3% received opioids. The number of medications taken was significantly related to a higher ODI score (R=0.23, p=.0004), a higher pain score (R=0.15, p=.026), and a lower EQ-5D health status (R=-0.15, p=.024). In contrast, a lower pain score (7.2 vs. 7.7, p=.037) and a lower ODI score (26.6 vs. 29.9, p=.0023) were associated with performing adequate amounts of exercise. There was a significant association between lower numbers of treatments received and higher numerical pain rating scores (R=-0.14, p=.035). The majority (61.1%) of patients received two or less forms of treatment.

CONCLUSIONS

Evidence-based medical interventional treatments for patients with LBP are not being taken advantage of before spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health system pathway changes are necessary.

Rehabilitation management of low back pain - it's time to pull it all together!

In the past, rehabilitation research initiatives for low back pain (LBP) have targeted outcome enhancement through personalized treatment approaches, namely through classification systems (CS). Although the use of CS has enhanced outcomes, common management practices have not changed, the prevalence of LBP is still high, and only selected patients meet the CS profile, namely those with a nociceptive context. Similarly, although practice guidelines propose some level of organization and occasionally a timeline of care provision, each mainly provides best practice for isolated treatment approaches. Moreover, there is no theoretical framework that has been proposed that guides the rehabilitation management process of mechanical LBP. In this commentary, we propose a model constituted of five domains (nociceptive drivers, nervous system dysfunction drivers, comorbidities drivers, cognitive–emotional drivers, and contextual drivers) grounded as mechanisms driving pain and/or disability in LBP. Each domain is linked to the International Classification of Functioning, Disability and Health, where once a patient is deemed suitable for rehabilitation, the clinician assesses elements of each domain in order to identify where the relative treatment efforts should be focused. This theoretical model is designed to provide a more comprehensive management overview, by appreciating the relative contribution of each domain driving pain and disability. Considering that the multiple domains driving pain and disability, and their interaction, requires a model that is comprehensive enough to identify and address each related issue, we consider that the proposed model has several positive implications for rehabilitation of this painful and highly prevalent musculoskeletal disorder.

Implementation and improvement of clinical pathway for colorectal polyps

AIM

To evaluate the effect of the clinical pathway for colorectal polyps and try to improve its effect.

METHODS

The clinical data of patients with colorectal polyps treated at the Department of Gastroenterology of the First Hospital of Jilin University were retrospectively analyzed. Patients with colorectal polyps treated via the clinical pathway were included in a clinical pathway group and the others in a control group. The hospitalization cost, medicine cost, hospitalization time, and satisfaction degree of the two groups were compared. The PDCA cycle theory was applied to the management of the clinical pathways, and then the trend of changes in evaluation indexes was assessed.

RESULTS

The hospitalization cost, medicine cost, and duration of hospitalization in the clinical pathway group were significantly lower than those in the control group (P < 0.01), but the degree of patients' satisfaction was significantly higher than that in the control group (P < 0.01).The evaluation indicators including length of stay, preoperative hospital stay, total cost, bed fee, special care cost and medicine cost showed a gradual downward trend after the application of the PDCA cycle theory to the clinical pathway for colorectal polyps.

CONCLUSION

Clinical pathway can effectively reduce hospitalization cost, shorten hospitalization days, and increase the degree of patients' satisfaction. The application of the PDCA cycle theory to the clinical pathway can result in a continuous quality improvement.

Classification of patients with low back-related leg pain: a systematic review

BACKGROUND

The identification of clinically relevant subgroups of low back pain (LBP) is considered the number one LBP research priority in primary care. One subgroup of LBP patients are those with back related leg pain. Leg pain frequently accompanies LBP and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back-related leg pain (LBLP) is important for clinical management and research applications, but there is currently no clear agreement on how to define and identify LBLP due to nerve root involvement. The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP, and summarise how leg pain due to nerve root involvement is described and diagnosed in the various systems.

METHODS

The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were appraised independently by two reviewers using a standardised scoring tool.

RESULTS

Of 13,358 initial potential eligible citations, 50 relevant papers were identified that reported on 22 classification systems. Papers were grouped according to purpose and criteria of the classification systems. Five themes emerged: (i) clinical features (ii) pathoanatomy (iii) treatment-based approach (iv) screening tools and prediction rules and (v) pain mechanisms. Three of the twenty two systems focused specifically on LBLP populations. Systems that scored highest following quality appraisal were ones where authors generally included statistical methods to develop their classifications, and supporting work had been published on the systems' validity, reliability and generalisability. There was lack of consistency in how LBLP due to nerve root involvement was described and diagnosed within the systems.

CONCLUSION

Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. Further work is needed to identify clinically meaningful subgroups of LBLP patients, ideally based on large primary care cohort populations and using recommended methods for classification system development.

Triage for Patients with Spinal Complaints: A Systematic Review of the Literature

BACKGROUND AND PURPOSE

The aim of this study is to provide a systematic overview of the past decade of literature on processes of triage for patients with spinal pain, outcomes measured and markers of effectiveness.

METHODS

A systematic search of the literature with narrative synthesis of findings was conducted. Studies in English language of any design concerning spinal triage programmes for adults with acute or chronic spinal complaints were considered for inclusion. Electronic database searches were conducted in OVID, Medline, Embase, CINAHL, Health Source Nursing, Scopus and Web of Science. Additional references were sourced through pearling reference lists, and expert input. Findings were synthesized descriptively.

RESULTS

Of 216 potentially relevant records, 21 papers (20 studies) were included. There was little commonality in triage activities/programmes and outcomes, although physiotherapists were common members of triage programmes. Positive outcomes were reported most commonly for wait times, with several studies also reporting high levels of patient and physician satisfaction. Outcomes such as surgical conversion rates and selection accuracy were less clear.

DISCUSSION

Spinal triage programmes have the potential to improve efficiency of care for outpatients with spinal complaints. The evidence gaps in health outcomes, service models and cost effectiveness should be addressed by more robust prospective research designs. Copyright © 2015 John Wiley & Sons, Ltd.

Implications of early and guideline adherent physical therapy for low back pain on utilization and costs

BACKGROUND

Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS).

METHODS

Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models.

RESULTS

753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs.

CONCLUSIONS

The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.

Effects of thoracic mobilization and manipulation on function and mental state in chronic lower back pain

[Purpose] The aim of this study was to evaluate the changes in function and mental state after thoracic mobilization and manipulation in patients with chronic lower back pain (LBP). [Subjects and Methods] Thirty-six subjects were randomly divided into mobilization group (group A), manipulation group (group B) and control group (group C). The Oswestry disability index (ODI) was used to measure the functional impairment of patients with LBP. A multiple spinal diagnosis was used to measure the range of motion (ROM) of vertebra segments. The Fear-avoidance beliefs questionnaire (FABQ) was used to investigate the mental state of LBP patients. [Results] Group A and group B were significantly different from group C in terms of the ODI. Between groups, there was no difference in ROM during trunk flexion. Group A and group B were also significantly different from the control group in extension ROM. The FABQ of group B was significantly different from that of group A. [Conclusion] Application of mobilization or manipulation to thoracic lumbar vertebrae has a positive effect on function, mental state, and ROM in patients with lower back pain.

Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes

STUDY DESIGN

Retrospective medical record review.

OBJECTIVE

To (1) determine if outpatient referrals for low back pain (LBP) and leg pain triaged through a multidisciplinary spine care pathway (group A) were more likely to be candidates for surgery than conventional physician referrals (group B); (2) compare relevant clinical differences in the 2 groups (e.g., diagnosis, pain scores, level of disability); and (3) compare wait times for magnetic resonance imaging and surgical assessment.

SUMMARY OF BACKGROUND DATA

The Saskatchewan Spine Pathway was introduced on the basis of evidence that a co-ordinated, multidisciplinary, and stratified approach to the assessment and management of LBP may improve quality. During early implementation, some physicians began to refer patients to Saskatchewan Spine Pathway clinics, whereas others continued to refer patients directly to the surgeon through the conventional process.

METHODS

We retrospectively analyzed consecutive new outpatient referrals for LBP and leg pain, June 1, 2011 through May 30, 2012 for 2 surgeons.

RESULTS

We identified 215 referrals, including 66 (30.7%) in group A and 149 (69.3%) in group B. There was no difference in overall health (mean EuroQol Group 5-Dimension Self-Report Questionnaire visual analogue scale) or lower back-related disability score (Oswestry Disability Index). Group A patients were significantly more likely to be candidates for surgery (59.1% vs. 37.6% for group B; P = 0.0034, χ test), had significantly poorer scores for EuroQol Group 5-Dimension Self-Report Questionnaire mobility, a higher proportion of leg dominant pain, and a lower proportion of back dominant pain. Group A patients also had significantly shorter wait times for magnetic resonance imaging and surgical assessment.

CONCLUSION

A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs.

LEVEL OF EVIDENCE

3.

Spine surgeons' requirements for imaging at the time of referral: a survey of Canadian spine surgeons

BACKGROUND

Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals.

METHODS

We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints.

RESULTS

Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints.

CONCLUSION

Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.

Spine surgery referrals redirected through a multidisciplinary care pathway: effects of nonsurgeon triage including MRI utilization

Object

The Saskatchewan Spine Pathway (SSP) was introduced to improve quality and access to care for patients with low-back and leg pain in the province. There is very limited data regarding the efficacy of nonsurgeon triage of surgical referrals. The objective of this early implementation study was to determine how the SSP affects utilization of MRI and spine surgery.

Methods

The authors performed a retrospective analysis of 87 consecutive patients with low-back and leg pain who were initially referred to a spine surgeon but were instead redirected to the SSP clinic between May 1, 2011, and November 30, 2011. The SSP clinic triaged patients into 2 groups: Group A (nonsurgical management) and Group B (referred back to the spine surgeon). The SSP classification was modified from the classification proposed by Hall et al. Pain and disability were scored by pain-related visual analog scale, modified Oswestry Disability Index, and EuroQol-5D.

Results

Sixty-two patients (Group A, 71.3%) were discharged after patient education, self-care advice, and/or referral for additional mechanical therapies. Although only 25 patients (Group B, 28.7%) were directed back to the surgeon, the final percentage (12.6%) offered surgery was similar to that of historic controls (15%). Total MRI utilization was significantly lower in Group A (25.8%) than Group B (92.0%) (p < 0.0001). Nonsurgeon triage captured all red flags detected by the surgeon. Patients in Group B were much more likely to have a leg-dominant pain (p = 0.0088) and had significantly higher Oswestry Disability Index (p = 0.0121) and EuroQol-5D mobility (p = 0.0484) scores.

Conclusions

The SSP significantly reduced MRI utilization and referrals seen by the surgeon for nonoperative care. Although this early implementation study suggests potential for cost savings, a more rigorous analysis of outcomes, costs, and patient satisfaction is required.

Conservative spine care: opportunities to improve the quality and value of care

Low back pain (LBP) has received considerable attention from researchers and health care systems because of its substantial personal, social, work-related, and economic consequences. A narrative review was conducted summarizing data about the epidemiology, care seeking, and utilization patterns for LBP in the adult US population. Recommendations from a consensus of clinical practice guidelines were compared to findings about the current state of clinical practice for LBP. The impact of the first provider consulted on the quality and value of care was analyzed longitudinally across the continuum of episodes of care. The review concludes with a description of recently published evidence that has demonstrated that favorable health and economic outcomes can be achieved by incorporating evidence-informed decision criteria and guidance about entry into conservative low back care pathways.

Value drivers: an approach for estimating health and disease management program savings

Health and disease management (HDM) programs have faced challenges in documenting savings related to their implementation. The objective of this eliminate study was to describe OptumHealth's (Optum) methods for estimating anticipated savings from HDM programs using Value Drivers. Optum's general methodology was reviewed, along with details of 5 high-use Value Drivers. The results showed that the Value Driver approach offers an innovative method for estimating savings associated with HDM programs. The authors demonstrated how real-time savings can be estimated for 5 Value Drivers commonly used in HDM programs: (1) use of beta-blockers in treatment of heart disease, (2) discharge planning for high-risk patients, (3) decision support related to chronic low back pain, (4) obesity management, and (5) securing transportation for primary care. The validity of savings estimates is dependent on the type of evidence used to gauge the intervention effect, generating changes in utilization and, ultimately, costs. The savings estimates derived from the Value Driver method are generally reasonable to conservative and provide a valuable framework for estimating financial impacts from evidence-based interventions.

Publication patterns of comparative effectiveness research in spine neurosurgery

OBJECT

The purpose of this study was to investigate publication patterns for comparative effectiveness research (CER) on spine neurosurgery.

METHODS

The authors searched the PubMed database for the period 1980-2012 using the key words "cost analysis," "utility analysis," "cost-utility," "outcomes research," "practical clinical research," "comparator trial," and "comparative effectiveness research," linked with "effectiveness" and "spine neurosurgery."

RESULTS

From 1980 through April 9, 2012, neurosurgery CER publications accounted for 1.38% of worldwide CER publications (8657 of 626,330 articles). Spine neurosurgery CER accounted for only 0.02%, with 132 articles. The journal with the greatest number of publications on spine neurosurgery CER was Spine, followed by the Journal of Neurosurgery: Spine. The average annual publication rate for spine neurosurgery CER during this period was 4 articles (132 articles in 33 years), with 68 (51.52%) of the 132 articles being published within the past 5 years and a rising trend beginning in 2008. The top 3 contributing countries were the US, Turkey, and Japan, with 68, 8, and 7 articles, respectively. Only 8 regular articles (6.06%) focused on cost analysis.

CONCLUSIONS

There is a paucity of publications using CER methodology in spine neurosurgery. Few articles address the issue of cost analysis. The promotion of continuing medical education in CER methodology is warranted. Further investigations to address cost analysis in comparative effectiveness studies of spine neurosurgery are crucial to expand the application of CER in public health.

A health care system in transformation: making the case for chiropractic

There are a number of factors that have conspired to create a crisis in healthcare. In part, the successes of medical science and technologies have been to blame, for they have led to survival where lives would previously have been cut short. An informed public, aware of these technological advances, is demanding access to the best that healthcare has to offer. At the same time the burden of chronic disease in an increasing elderly population has created a marked growth in the need for long term care. Current estimates for expenditure predict a rapid escalation of healthcare costs as a proportion of the GDP of developed nations, yet at the same time a global economic crisis has necessitated dramatic cuts in health budgets. This unsustainable position has led to calls for an urgent transformation in healthcare systems.This commentary explores the present day healthcare crisis and looks at the opportunities for chiropractors as pressure intensifies on politicians and leaders in healthcare to seek innovative solutions to a failing model. Amidst these opportunities, it questions whether the chiropractic profession is ready to accept the challenges that integration into mainstream healthcare will bring and identifies both pathways and potential obstacles to acceptance.

Pathoanatomy and classification of low back disorders

Over the past decade research into the effectiveness of low back disorders (LBDs) has focused on the classification of subgroups more likely to respond to specific treatment. Much of this research has explicitly excluded a focus on pathoanatomical factors based on a questionable interpretation of the biopsychosocial model. Common justifications and potential issues with this approach are explored with recommendations made for future clinical and research practice.