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Optimal & Efficient Spine Care:
Physiatrists Taking the Lead
Andrew Lederman MD
Chief Resident
Department of PM&R
Montefiore Medical Center
Albert Einstein College of Medicine
Disclosures
• I have NO RELEVANT financial disclosures
Thank you
• Dr. Ian Paskowski: Medical Director of Spine Center BIDPlymouth LBP Clinical Care Pathway (Chiropractor)
• Dr. Michael Goertz: Vice Chairman Medical Services Review
Board, ICSI Guideline author (Occupational & Preventive Med)
• Dr Timothy Houden: Interventional Pain & Anesthesiology,
Medical Director, Intermountain Health Care Pain Management Services
(Pain, Anesthesia)
• Dr. Alok Sharan: Chief of Orthopedic Spine Surgery, Montefiore
Medical Center (Ortho Spine)
• Dr. Ralph Gay: Assoc Professor PM&R, Mayo Clinic CPGs (PM&R)
• Dr. Soo Yeon Kim: Asst. Professor Dept. of PM&R, Div.
Interventional Pain, Montefiore Medical Center (Pain, PM&R)
Objectives
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Scope of the Problem
Intro to Clinical Practice Guidelines
Guideline Quality
STarT Back Screening Tool
Spine Care at Montefiore
Different Approaches
– BID Plymouth, MA & Intermountain Health, UT
Define Spine Care
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Pathology: Diagnostic tools
Treatment: conservative/invasive, evidence?
Settings: ED, Inpatient, Outpatient, Home
Stakeholders:
– PMD & EM
– PM&R
– Spine/NeuroSx
– Neurology, Psychiatry
– Sports/Interventional Pain
– Hospital Admin/Insurance Co.
• Lifetime prevalence 80% - 85%
• LBP second only to URI leading to symptom
related physician visits; 5th most common reason
for all physician visits
• Point prevalence 11.9%, Lifetime 39.9% ±24.3%
• 80-90% resolved after 6 wks
• Recurrence 10-75% patients over the next year, and lasts for
a year or more in 10%
Optimizing Spine Care
• Patient outcomes
– Pain Relief
– Disability
– Return to work
– Satisfaction (patient experience, life…)
• Cost
– Country/Gov/Tax Payers/Patient (who pays)
– Hospital (imaging, procedures, admissions,
consults)
– Office Visits
– Physician (time, satisfaction, $$$)
Imaging Cost
Imaging Use/Radiation
To image or not to image:
Radiating pain without neuro deficit
• Recommendation #4: “…MRI (preferred) or CT only if
they are potential candidates for surgery or
epidural steroid injection (for suspected
radiculopathy) (strong recommendation, moderatequality evidence)”
• Back pain in workers 40-65 cost employers an estimated
$7.4 billion per year
• 2006, back and neck pain cost $86 billion in health care
expenditure ($104 billion direct, $500 billion indirect)
• 1997 – 2006, a 49% increase (to 18.2 million) in patients
seeking spine related care
Attention to back pain
• 1987, Quebec Task Force, recognize absence of
high quality evidence to guide decision making
– Back pain:
• With or without radiation
• Below the knee or above
• With or without neurological deficit
– Biologic Plausibility:
– Exhaustive classification:
– Mutually exclusive categories:
– Reliability:
– Clinical usefulness:
– Simplicity:
“Evidence” overload!!
• 1987, Spitzer guideline 108 RCTs for PT
• April 2009, 958 RCTs, 2500 CTs (Cochrane) on
treatment of back/neck pain
• Overwhelming amount of information on Dx, Rx for
back pain
• …led to protocols
Guidelines are like opinions…
Everyone’s got one…
…actually they’re all about the same.
Concensus: Acute/Sub-Acute
• Reassure of favorable prognosis
• Advise to stay active
• Rx: first line paracetamol?, then NSAID, possibly
adjuvants
• Discourage bed rest
• Do not advise a supervised exercise program
Consensus: Chronic
• Discourage use of modalities: Ultrasound,
electrotherapy (not in the US)
• Short-term use of meds/manipulation
• Supervised exercise therapy (PT)
• CBT
• Multidisciplinary treatment
Paracetamol?
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Dosing: continuous vs PRN vs placebo
Recovery: Pain score 0-1/10, 7 days straight
Median recovery time 17, 17, 16 (days)
No better than placebo
Quality Protocols
• Appraisal of Guidelines Research
and Evaluation
• 6 main categories
1. Scope and Purpose
2. Stakeholder Involvement
3. Rigor and Development
4. Clarity and Presentation
5. Applicability
6. Editorial Independence
Scope & Purpose
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Streamline Spine Care at Montefiore
Optimize care flow – work efficiency
Decrease medical costs
Optimize patient health outcomes
Ultimately, Spine Care at all locations
Back Pain @ Montefiore
ED/Inpatient
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Preliminary data from Jan 2010 – Dec 2012
38,786 ED visits
Approx 16,000 visits for back pain (LB/Neck)
1392 MRI and CTs
5288 admissions for back pain, 872 inpatient MRI
and CTs
• >$1,000,000 on spine imaging
• Inpatient admission costs???
Montefiore
ER Back Pain Visits
13500
13222
Back Pain Admissions
13000
12000
2000
12361
12500
1800
311
11662
11500
1600
11000
1400
10500
1200
91
242
79
259
81
2010
2011
2012
556:
Musculoskeletal
Problems
1000
800
Inpatient MRIs
170
1467
165
1471
1287
600
166
162
400
160
155
200
150
144
145
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2010
140
135
130
2010
2011
2012
551: Medical Back
Problems (MCC)
2011
2012
552: Medical Back
Problems
Spine “Stakeholders” & Patient Flow
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Internist/Hospitalists
Family Practioners
Emergency
PM&R
Ortho – Spine
Anesthesia
Neurosurgery
Neurology
Psychiatry
Korner et al., Interprofessional teamwork in medical rehabilitation:
a comparison of multidisciplinary and interdisciplinary
team approach. Clin. Rehabilitation (2010) 24: 745–755
Rigor &
Development
Goertz M, et al., Institute for Clinical Systems Improvement.
Adult Acute and Subacute Low Back Pain. Updated November
2012, 15th ed.
Red Flags
- Age onset <20 or >50
- Hx CA, weight loss
- Fever, night sweats,
immunosupression, IVDA
- Saddle parasthesia,
incontinence, major motor
weakness
Clarity & Presentation
• Physician (attending, housestaff) education
• Patient information: pamphlets, discussion
Care Process Model: Primary Management of Low Back Pain.
Intermountain Healthcare. Updated Aug 2014. Salt Lake City, UT
https://intermountainhealthcare.org/ext/Dcmnt?ncid=522579081
Intermountain Healthcare, Utah
• Evidence based approach
for most patients
• Should be adapted for
each patient; not to replace
clinical judgment
Care Process Model: Primary Management of Low Back Pain.
Intermountain Healthcare. Updated Aug 2014. Salt Lake City, UT
https://intermountainhealthcare.org/ext/Dcmnt?ncid=522579081
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Imaging is NOT necessarily needed to diagnose acute LBP
In most cases, red flags can be identified through patient H&P
For most LBP, conservative treatment and self-care is adequate and
effective
Recommend everyday activity and exercise
Unless indicated, Tylenol and NSAIDs are first line medications
Consider referral to PT
Other interventions should wait until conervsative attempts have been
made
Care Process Model: Primary Management of Low Back Pain.
Intermountain Healthcare. Updated Aug 2014. Salt Lake City, UT
https://intermountainhealthcare.org/ext/Dcmnt?ncid=522579081
Applicability
• Organizational changes
• Cost implications
• Measures of success:
– Imaging
– Admissions
– Consults
– Other??
– Database?
Editorial
Independence
• “stakeholders” reduces
interdepartmental bias
• Nothing financial to disclose
Don’t reinvent it…
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BID Plymouth Clinical Pathway
STarT Back Questionnaire
ED referral to spine center if score ≥3
Patient satisfaction and appointment within
48hrs of ED visit
• # admissions for DRG 551 & 552
DRG 551 & 552: Medical back problem w/ and w/out medical comorbidity & complication
STarT Back
Hill JC, et al. Comparison of stratified primary care management
for low back pain with current best practice (STarT Back): a
randomised controlled trial. Lancet (2011), 378: 1560-71
• 1573 patients, 2:1 intervention:control
• Intervention by stratification based on STarT
• Outcomes: RMDQ, QALYs, health care costs related
to back pain
• Significant increase in RMDQ at 6 and 12 months,
increased QALYs and cost savings
• Heavy reliance on therapist and patient education
RMDQ: Roland Morris Disability Questionnaire; QALYs: Quality Adjusted Life Years
BID Plymouth LBP Clinical Pathway
• Problem: lack of adherence to
LBP guidelines results deficits in IOM
dimension of quality
– Inefficient, Ineffective &
Inappropriate care
• Aim/Goal:
– Hospital-wide continuum of care
for LBP
– STarT Back for referral to Spine
Center
– Decrease admissions for LBP
Paskowski I, et al. BID - Plymouth Low Back Pain Clinical
Pathway. 2014. Plymouth, MA.
http://bidmc.omeka.net/items/show/713
“I think I see the cause of your back pain
but lets run a few tests to be sure.”
Thank You