As healthcare-resources become more limited, the spine community has focused more on improving the value of care. Value is defined as quality/cost, so either improving quality without increasing cost or maintaining quality while decreasing cost can both increase value. Many efforts towards improving value have involved creating evidence-based pathways to standardize care in a manner that maximizes quality in a cost-effective manner. In the treatment of low back pain (LBP), advanced imaging and surgeon referral are two high cost items, and current guidelines suggest that most LBP patients need neither.1 In the United States, there are no formal controls over advanced imaging or surgeon referral, and both are readily available without long wait times. However, in many single-payer systems such as in Canada, MRI scanners and spine surgeons are in relatively short supply, which creates long wait times for both. While efficient use of expensive resources should be the goal of any health system, the motivation for improved triage of LBP patients to advanced imaging and spine surgery consultation is stronger if access is difficult. In order to improve the rate of appropriate use of advanced imaging and surgeon referral, the Saskatchewan Ministry of Health created the Saskatchewan Spine Pathway that allows PCPs to classify patients as having one of four pain patterns (LBP worsened with flexion, LBP worsened with extension, predominant leg pain that is constant and mechanical, and predominant leg pain with extension) based on the history and a brief physical exam. They then suggest self-care exercises specific for each pain pattern and refer patients to a physical therapist-run spine clinic if they fail to improve quickly. The therapists then re-assess the patients and refer the leg pain predominant patients for MRI and surgical referral if self-care is not helping, while they coordinate non-surgical care of the predominant back pain patients. After instituting this pathway, the authors retrospectively evaluated the rate of appropriate surgical referrals for patients treated on the pathway and those referred via the traditional process. They found that 60% of patients referred via the pathway were surgical candidates compared to 37% referred via the traditional process. The authors noted that historically only 15% of surgeon referrals were surgical candidates, though prior to the start of the study, the PCPs had undergone training in appropriate surgical referrals, which seemed to have improved the process to some degree. Additionally, 75% of the patients referred via the pathway had predominant leg pain compared to 55% referred via the traditional process.
This study suggests that the use of scarce and expensive resources such as MRI scanning and spine surgeon referral can be made more efficient through the use of a non-MD staffed triage clinic, which has likely improved the value of spine care in Saskatchewan. While health services research such as this is outside the realm of traditional basic science or clinical outcomes studies, this type of work is going to become increasingly important as we strive to improve value in healthcare. This analysis was unblinded, non-randomized, and retrospective, so the results should be viewed as preliminary, but the findings support the experience of most spine surgeons. The majority of spine surgeons in the United States have likely developed some form of triage system within their practice to increase the likelihood that the patients they see are candidates for surgery. However, very little has been written about this topic that is very important to providers trying to run an efficient clinic. The challenge in the United States with its decentralized healthcare system is to motivate referring PCPs to engage in such a program. It is much easier for a PCP to simply order an MRI and refer a patient with chronic LBP to a spine surgeon than trying to classify their pain pattern and start a self-care program. While such PCP engagement may not be possible outside of centralized health systems, the establishment of algorithm-driven, non-MD triage clinics could potentially improve the rate of appropriate imaging and surgical referral and substantially decrease costs. Quality may also improve as chronic LBP patients would probably be less likely to be subjected to ineffective pharmacological and interventional treatments, and patients with radiculopathy and claudication could be referred to a surgeon more rapidly. As individual practices consolidate into larger practice organizations in the United States, developing more organized care pathways such as this may become more of a reality. Hopefully further data from Saskatchewan will be emerging including the effect of the pathway on appropriate use of advanced imaging and on the cost of treating these patients.
Please read Ms. Wilgenbusch’s article in the October 15 issue. Does this article change how you view the triage of LBP patients? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91.