A Hospital-Based Standardized Spine Care Pathway:
Report of a Multidisciplinary, Evidence-Based Process

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106 ~ FULL TEXT

Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD.

Medical Director, Medical Back Pain Program,
Jordan Hospital,
Plymouth, Mass.

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A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway, utilizing a multidisciplinary, evidence-based, standardized process, to improve clinical outcomes, and to reduce the costs associated with treatment and diagnostic testing. 518 consecutive patients were assessed and 83% (432) were classified and and then treated by doctors of chiropractic and/or physical therapists. 95% of patients treated by DCs rated their care as “excellent.” This was accomplished with a relatively low cost and with high patient satisfaction. The authors concluded that “interprofessional collaboration between doctors of chiropractic, physical therapists, and medical doctors within teams improved spine care; that promotion of care coordination reduced unnecessary testing and procedures; and the standardization of LBP management reduced practice variations and significantly reduced the costs of care.” Using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its framework, the SCP provided patients with the five care options cited as the most effective in the back pain literature: spinal manipulation, extension and flexion directional preference exercises, core stabilization exercises, and mechanical traction. “Lower back pain is a common condition affecting an estimated 90 percent of the population at some time,” says Ian C. Paskowski, DC, lead author and medical director, Medical Back Pain Program at Jordan Hospital, Plymouth, Mass., the site from which this study’s data was derived. “Current methods of relieving LBP are often uncoordinated, inefficient and expensive. However, our team of researchers was the first to implement an evidence-based, standardized SCP, which aligned individual patients with the appropriate conservative care option. As predicted, the results were improved patient health and satisfaction rates, with decreased costs.” The LBP program at Jordan Hospital, managed chiefly by chiropractors, treated 518 patients in the first six months of the program, using a two-tiered clinical management approach. Of the total patient population, 402 were exclusively cared for by DCs who achieved successful treatment outcomes in an average of just 5.2 visits at the extremely low cost of only $302 per case, while maintaining a patient satisfaction rate above 95 percent. Self-reported pain and disability scores were reduced by about 70% over the course of just a few weeks. Primary Care Physicians (PCPs) have traditionally been the providers to initially see LBP patients. “We have demonstrated that when this spine care pathway is offered to PCPs, they will utilize these evidence-based guidelines and chiropractic services” says Paskowski. “I largely credit our Doctors of Chiropractic for achieving these excellent clinical outcomes and attaining such high patient satisfaction rates. Their dedication to individual patient needs and a patient-centered approach aligns flawlessly with the medical home model and yields remarkable results. We anticipate that this SCP will become the globalized framework for uniformity and consistency in healthcare for LBP management, and that chiropractors will become the non-surgical spine care experts in the health care system.”

The Abstract:

OBJECTIVE:   A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The purpose of this report is to describe the implementation and results of a multidisciplinary, evidence-based, standardized process to improve clinical outcomes and reduce costs associated with treatment and diagnostic testing.

METHODS:   A standardized SCP was developed to improve the quality of back pain care. The NCQA BPRP provided the framework for the SCP to determine the standard of quality care delivered. Patients were triaged, and suitable patients were categorized into 1 of 5 classifications based upon history and examination, directional exercise flexion or "extension biases," spinal manipulation, traction, or spinal stabilization exercises.

RESULTS:   The findings for 518 consecutive patients were included. One hundred sixteen patients (10%) were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as "excellent."

CONCLUSIONS:   By adopting the NCQA BPRP as an SCP, training physicians in this SCP, and using a back pain classification, Jordan Hospital Spine Care demonstrated the quality and value of care rendered to a population of patients. This was accomplished with a relatively low cost and with high patient satisfaction.

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From the FULL TEXT Article

Introduction

Low back pain (LBP) is a substantial public health issue that puts pressure on the financial resources across the entire health care systems worldwide. [1–3] The lifetime prevalence of LBP in most industrialized countries varies between 60% and 85%; therefore, most adults can expect to experience an episode of LBP at least once during their lifetime. [1] Approximately 25% of American adults reported experiencing an episode of LBP during the previous 3 months. [2] According to the National Center for Complementary and Alternative Medicine, LBP is the fifth most common reason why people seek care from their primary care physicians, the leading cause of disability and missed days of work in working age adults, and the most common condition for which US adults seek complementary and alternative treatment. [3] A 2006 report estimated that the direct and indirect costs of LBP in the United States are more than $100 billion annually. [3] Patients with back pain incur 73% higher health care costs than those without back pain–related complaints. [4] Much of this cost is related to improper management of LBP, especially with respect to unnecessary diagnostic imaging, medications, and spinal injections. [5]

Improper and costly management of LBP is prevalent throughout the US health care delivery system, with widespread geographic variations documented in physician behavior and clinical practice that are not correlated with the geographic prevalence or incidence of the conditions being treated. [6–9] An analysis in 2008 by the Congressional Budget Office revealed wide geographic variation in per capita Medicare spending across a variety of conditions in the United States that could not be attributed solely to regional prices of health care services and the severity of illness. [10] This analysis suggests that much of this variation is because some regions of the country are more prone to adopt low-cost highly effective patterns of health care delivery, whereas others are more prone to adopt high-cost patterns of care and to deliver treatments that provide little benefit or are even harmful. [10] This unacceptably large geographic variation in health care delivery has led to calls for greater use of evidence-based practice guidelines to create a framework for more uniformity and consistency in the management of common health conditions.

Although these recent data suggest a current crisis in the management of LBP, this is not a new problem. The first attempt to develop a guideline for the management of LBP was the publication of a consensus report in 1987 by the Quebec Task Force on Spinal Disorders.11 Since that time, there have been many national and international guidelines published on the subject. [12–17]

Most recently, the Bone and Joint Decade Task Force published a comprehensive set of systematic reviews of the literature covering the many procedures used to treat LBP. [18] Perhaps Haldeman and Dagenais [18] best described the overall clinical approach to the management of LBP in the United States when he described current care as a “supermarket of spine-care services,” identifying more than 200 various treatment options available to patients for this condition. In addition, there are conservatively 12 separate provider types who treat patients with LBP (eg, doctors of chiropractic, physical therapists, orthopedists, etc). This is compounded by the fact that there are not generally accepted indications guiding the decision regarding which provider should be seen, at what time, and for which intervention. With this “supermarket” of options, the health care delivered to patients with LBP is uncoordinated and inefficient. Many patients are immediately escalated along the pathway of diagnostic testing and specialty consults, whereas efficacious, lower-cost interventions are explored late in the care pathway or ignored all together.

These issues raise questions regarding the management of LBP. Can a focus on quality through the application of the best available evidence coupled with processes designed to bring consistency to the delivery of health care services lead to excellent clinical outcomes, high patient satisfaction and less cost to the system? Therefore, the purpose of this descriptive report describes the internal and external development of a multidisciplinary, evidence-based, quality management program designed to standardize an LBP clinical care pathway in a community-based hospital.

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Discussion

This manuscript describes a clinical case series of 518 consecutive patients with LBP using a standardized 2-tiered SCP designed to manage these patients. Our preliminary data analysis demonstrated that adherence to this standardized approach by the clinicians at our facility appeared to produce good clinical outcomes at a low cost with a minimum number of visits while maintaining a high level of patient satisfaction. We believe that our clinical outcomes and cost data are particularly compelling when considering that these data were derived from patients composed of all payer types including Medicare, group health, workers' compensation, and auto accidents.

Despite the publication of numerous guidelines calling for evidence-based, standardized approaches to the clinical management of LBP, there is little indication that these guidelines have been followed or adopted by most or primary care providers. One recent analysis of the usual care provided to more than 3500 patients who visited general practitioners for a new episode of LBP revealed that the care provided did not match the care endorsed in international evidence-based guidelines. [23]

Our experience also shows that communication of this patient-centered approach to key stakeholders in the broader community can lead to increased referrals from external sources to facilities that follow evidence-based LBP management guidelines. Our hospital has experienced a surge of referrals for the treatment of LBP from the community, resulting in the need to hire 2 additional chiropractors, 1 additional pain physician, and 3 additional physical therapists. We believe that our success highlights 2 important points regarding the state of spine care in our community. First, clinicians in our service area recognize the need for as well as the value that can be obtained when patients with LBP are managed using a multidisciplinary standardized approach. Second, there is a gap in viable alternatives that offers patients a uniform, coordinated approach to management. Our program has effectively aggregated the supermarket of spine care services to improve communication and reduce inefficiencies in the delivery of care, which should lead to better patient outcomes at a reduced cost to society. It is unlikely that our community is unique. Therefore, this program has the potential to be replicated in other parts of the country with similar success by establishing a similar team of clinicians—lead chiefly by chiropractors and physical therapists—who are willing to follow current LBP guidelines and standardize their clinical approaches to the management of LBP.

Musculoskeletal conditions pose a substantial public health issue. [24] Unfortunately, this is not a new phenomenon. The pattern of usual care for LBP provided by many primary care physicians does not match the care recommended by evidence-based guidelines, may not provide the best clinical outcomes, and may be contributing to the high costs of managing LBP. [23] Despite the publication of numerous back pain guidelines calling for minimizing the number of magnetic resonance imagings (MRIs), spinal fusions, injections, and prescription medications, use rates of these procedures related to the management of LBP in the United States have increased dramatically. In fact, from 1994 to 2007, the following Medicare expenditure rates were observed in these key spine care interventions:

• diagnostic imaging —   a 307% increase in MRIs;
  
• spinal surgery —   a 220% increase in spinal fusion;
  
• spine injections —   a 629% increase in the use of epidural steroid injections; and
  
• prescription medications —   a 423% increase in the use of opiates. [4, 5]

      Limitations and Future Research Suggestions

There are several limitations to our data analysis, and we stress the point that these results must be considered preliminary at this time. We did not have a comparison group and therefore cannot rule out natural history (regression to the mean) as a potential confounder to our analysis. Patients with acute LBP often show spontaneous remission of their symptoms regardless of what type of treatment is rendered. We did not perform any long-term follow-up evaluations to track recurrence rates or other “downstream” medical costs that might have occurred after patients were released from care at our hospital. It is not known if patients treated in our Spine Care Program went on to seek additional treatment or diagnostic imaging for their LBP at other facilities. Lastly, we did not have the ability to modify our statistical analysis to adjust for other potential confounding variables such as baseline levels of age, race, sex, pain, function, psychosocial issues, medication usage, medical comorbidities, level of physical activity, and other. We plan to validate these preliminary results by examining the outcomes and total costs associated with patients treated using our standardized clinical pathways compared to those receiving usual care in other settings.

Despite these limitations, we successfully implemented a policy by which all of our clinicians followed a set of standardized processes and procedures for the management of LBP. We believe that this standardization improved the consistency and quality of the clinical care rendered to our patients with LBP.

The interpretation of the preliminary data analysis presented in this manuscript is subject to the limitations of any observational research design. This clinical model should be validated using more rigorous scientific research methods, including clinical trials comparing both long-term clinical outcomes and the cost-effectiveness of standardized vs nonstandardized approaches to the management of LBP in multidisciplinary settings. This research could potentially have important health care policy implications by serving as a model for the following:

• the interprofessional collaboration between doctors of chiropractic, physical therapists, and medical doctors within teams to provide excellent spine care;
  

• the promotion of care coordination to reduce unnecessary testing and procedures; and
  

• the standardization of LBP management to reduce practice variation and high costs of care.

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Conclusions

This manuscript has described how our hospital created a spine care program with a multidisciplinary team of clinicians who agreed to follow a set of standardized, evidence-based protocols and procedures in their management of LBP. We have presented a preliminary data analysis showing that we were able to treat several hundred cases of LBP at low cost, with good clinical outcomes, while maintaining a high level of patient satisfaction. In addition, we have been successful in a community outreach educational program that has led to increased referrals to our Spine Care Program from primary care physicians, the general public, and occupational health clinics. We believe that our program could possibly serve as model for other similar clinics around the country.

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Practical Applications

• An evidence-based, public health approach to a standardized SCP at a health care facility appeared to produce good clinical outcomes, at low cost and use rates, along with high patient satisfaction.
  

• The processes used by this clinic have the potential to be replicated in other parts of the country with similar success by establishing a similar team of clinicians who are willing to consistently follow current LBP guidelines, showing that they are committed to a patient-centered and public health approach in managing LBP.
  

• This model of spine care may have the potential for reducing downstream medical costs and disability from LBP, which is clearly in the public health interests of society; however, more research is needed.

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