The Spine Blog

Friday, March 10, 2017

The role of non-physicians in spine care

Non-physician providers are playing an increasingly important role across healthcare, and spine care is no exception. In fact, spine care may be an excellent field in which to utilize non-physician providers (i.e. physician assistants, nurse practitioners, physical therapists, etc.) given that the majority of spine patients do not require surgical treatment. There are many motivations to employ non-physicians in a spine practice, namely to reduce wait times to evaluation and to increase the efficiency of a surgeon’s time in clinic such that they are seeing primarily patients with surgical pathology. While healthcare system and clinic efficiency may be improved with non-physician providers, it is unclear if patients are willing to see them instead of a spine surgeon when determining the appropriateness of surgery for their case. Given this uncertainty, Rempel et al. surveyed 80 Canadian spine patients referred for surgical evaluation to evaluate their opinions about the role of non-physician providers in the care of their spine problem. Over 85% of patients completed the survey, and they were relatively neutral regarding their willingness to be evaluated by a non-physician. On a 0-4 scale judging their willingness to see a non-physician, the median response was 2, and 45% answered 3 or 4. Only 11.2% answered 0, indicating an absolute unwillingness to see a non-physician. However, 70% responded they would want a second opinion from the surgeon if the non-physician concluded that surgery was not indicated. 45% of patients were willing to pay out of pocket to see a non-physician if they could be evaluated within 2 weeks of referral. Canadians are apparently accustomed to long wait times to see specialists, with 73% being willing to wait up to 3 months for spine surgeon evaluation. Written comments on the survey indicated a willingness to see non-physicians if it could reduce the waiting time for evaluation, but many patients were concerned that the non-physician might evaluate their case differently than a surgeon.

This is an important paper as it analyzes a question facing most spine practices at this time. My practice, like many American spine practices, utilizes midlevel providers (i.e. physician assistants, nurse practitioners) to evaluate patients referred to us. However, some patients find this dissatisfying and would be prefer to see a surgeon during their evaluation. Patient satisfaction needs to be weighed against clinic efficiency, and, given that over 90% of spine patients do not meet indications for surgery, spine surgeon evaluation of an unscreened population will result in the surgeon evaluating primarily patients who need non-operative care. In Canada, where spine surgeons are in short supply and waiting lists are long, non-physician providers could help reduce this wait time and allow for surgical patients to be treated more expeditiously. In the United States, where there is no lack of spine surgeons, such a model would increase efficiency of the spine surgeon in clinic. It could also improve patient satisfaction as the surgeon could potentially spend more time with patients that meet the indications for surgery, while non-operative patients can avoid an unnecessary evaluation by a surgeon. The results of this paper suggest that Canadian patients are willing to see non-physician providers if it helps them access the system faster. It is unclear if the results generalize to the United States, where access to spine surgeons is much quicker. The authors suggest an RCT to determine the effectiveness of a model in which spine patients are initially evaluated by a non-physician. While this would yield interesting results, these models are already in place and seem to be here to stay. The key going forward is to make sure that the non-physicians are well-trained and provide the same or better quality evaluation and patient experience. If that is the case, patients will probably increase their enthusiasm for non-physician providers.

What role do non-physician providers play in your practice? Let us know by leaving a comment on The Spine Blog.

Adam Pearson, MD, MS

Associate Web Editor