Research Review By Dr. Shawn Thistle©

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Date Posted:

August 2011

Study Title:

A hospital-based standardized spine care pathway: Report of a multidisciplinary, evidence-based process

Authors:

Paskowski I, Schneider M, Stevans J et al.

Author's Affiliations:

Jordan Hospital, Plymouth MA; School of Health and Rehabilitative Sciences, University of Pittsburgh, USA

Publication Information:

Journal of Manipulative & Physiological Therapeutics 2011; 34(2): 98-106.

Background Information:

The prevalence of LBP is well known. The healthcare and associated costs are enormous. Mismanagement is unfortunately prevalent. Recent data paints a dreary picture, indicating that from 1994 to 2007 (1,2):
  1. MRIs have increased 307%
  2. spinal fusion surgery has increased 204%
  3. spinal injections have increased 629%
  4. opiate use has increased 423%
And guess what? Outcomes have not improved, and arguably worsened. It is also not difficult to estimate where much of the healthcare costs come from based on those percentages.

But there is hope, and perhaps a clear direction to improving the management of these patients. Although the title of this study may not excite readers, I feel it is a very important publication for a number of reasons:
  1. It represents an amalgamation of much of the research we have reviewed on RRS in recent years.
  2. It demonstrates that by integrating current evidence and adhering to clinical guidelines, patients benefit and healthcare costs are reasonable and contained.
  3. It also focuses on a multidisciplinary, team-based approach to the assessment and treatment of low back pain, an extremely common and costly condition that is frequently mismanaged by practitioners of all disciplines.
Perhaps Drs. Scott Haldeman and Simon Dagenais (3) described it best – for the patient, LBP management is a “supermarket of spine-care services”, with over 200 treatment options and (conservatively) 12 provider types who treat LBP. Compound this with the fact that there are no firmly established guidelines for clinical decision making, and the landscape becomes quite confusing. Inject individual practitioner bias or essential lack of knowledge, and it can become quite a minefield of mismanagement and high cost. Far too many patients are escalated along a damaging pathway of unnecessary imaging, specialty consults, fear and dread, while many low-cost treatment options are left unexplored. Something has to change!

This is not your typical LBP study. It essentially described the evidence-informed process of developing a Spine Care Program (SPC), then presented initial data on about 500 patients who were managed within this program. Although the results are encouraging on many fronts, the process of developing this program and the integration of emerging evidence is a key aspect of this paper that makes it very valuable moving forward.

Study Methods:

This is certainly a study that warrants a description of the methods first. This study was conducted at Jordan Hospital, a 160-bed community-based hospital in Massachusetts. The authors’ goal was to standardize a clinical pathway for LBP patients presenting to the facility with the ultimate goals of reducing variability and improving the value of services provided. This led to the development of Jordan Spine Care (JSC, or perhaps insert your clinic name here?) – an outpatient program following a multi-disciplinary, standardized clinical approach to the management of LBP. Important components of this program include:
  • A standardized approach to physical examination, case history and diagnostic triage as established by the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP - now retired) – see below and visit www.ncqa.org/bprp
  • Triage of patients using principles from the Clinical Prediction Rule research that we have discussed previously on RRS (see Related Reviews below). This step involves treatment classification into one of 5 categories as follows:
    1. Directional exercise – flexion-based
    2. Directional exercise – extension-based
    3. Spinal manipulation
    4. Traction
    5. Spinal stabilization exercise
  • Monitoring of clinical progress using a numeric pain rating scale (NPRS) and the Bournemouth Questionnaire
  • Descriptive statistics on total number of treatments and associated cost
The National Center for Quality Assurance (NACQ) Back Pain Recognition Program (BPRP):

Important requirements/components of the BPRP include:
  • Performing a comprehensive case history and physical examination to rule out “red flags” of serious pathology
  • Using validated measures of pain, function, and mental health periodically during treatment to monitor progress
  • Advise the patient to remain active, avoid bed rest, and quit smoking
  • Recommendation for exercise and patient reassurance about a favorable prognosis
  • Minimizing the use of unnecessary x-rays and/or advanced diagnostic imaging at the earlier stages of treatment
  • Appropriate timing of surgical and spinal injection procedures
Further components of the program are summarized below:
  • Risk factors associated with recurrence/chronicity of low back pain are discussed: obesity, smoking, alcohol consumption, sedentary lifestyle/activity, social satisfaction
  • Red flags indicative of potentially serious pathology: bowel/bladder compromise, back pain preceded by trauma, fever associated with back pain, progressive lower extremity weakness, pain/numbness radiating below the knee
  • Recommendations for acute onset low back pain: avoid bed rest, avoid activities that increase pain, perform activities that decrease pain, initial modification with gradual return to normal activity, use short course of NSAIDs/Tylenol, use ice 15 min/hr
The paper then reports on data from 518 consecutive patients treated through the SCP. There was a brief discussion on external promotion of this program to local physicians that will not be discussed in detail here.

Pertinent Results:

There are 2 main ‘thrusts’ of this project:
  1. The development and implementation of the SPC itself including the integration of current research; and
  2. Results of data collection from 518 consecutive patients that entered this program – this will be summarized below…
The results and data below come from patients entering the SPC between January-June, 2009. During this 6 month period:
  • Following the NCQA recommendations: only 5% of patients required medical referral and only 7% were referred for MRI or diagnostic imaging
  • After initial classification utilizing principles from the Clinical Prediction Rule (see Additional Reference #3 below for more information): 42% had an extension bias, 14% a flexion bias, 31% we allocated to receive SMT, 7% to core stabilization exercise (see bullet below), and 6% to traction
  • Regarding the seemingly low 7% assigned to core stabilization exercise - the authors note that these percentages were based only on the initial classification; many patients from the other groups were switch to core stability exercise after their initial forms of treatment. It is also worth noting that many patients in this dataset improved dramatically without any core stabilization exercise (adding to the controversy surrounding this intervention, but we’ll save that for another day!)
  • Of the 518 patients, 402 (78%) were seen by chiropractors. These patients required an average of 5.2 visits, experienced an average reduction in NPRS score of 4.2 (an improvement of 68%), an average improvement on the Bournemouth Questionnaire of 23 points (an improvement of 62%), had an average cost per case of $302, and > 95% reported an overall satisfaction with the program, reporting its quality as “Excellent”
  • The authors note that physiotherapists effectively implemented spinal stabilization exercise with the patients initially allocated to that treatment and those who crossed over after the initial period of care in the other classifications

Clinical Application & Conclusions:

This study, and the Jordan SPC in general are perfect examples of how emerging research can positively impact practice patterns and provide a hopeful, clear path to better care for LBP patients. Despite the controversy surrounding external validity and general applicability of the Clinical Prediction Rule for LBP, the combination of the CPR principles with those from the NCQA BPRP seemed very effective in this group of patients. Certainly a promising outcome, granted the limitations of this dataset discussed below. As RRS readers should know by now, there are no absolutes in research or clinical practice.

The very point of RRS, and the take home message from this study, are that the rational use and integration of emerging research findings should and can positively influence patient outcomes in a cost-effective and efficient manner. The development of a patient-centered, evidence-informed management strategy for LBP remains a key objective for our profession, and this study is certainly a building block in this process.

As a final note on this paper – the authors discussed the external development and community promotion of this program, reporting increased referrals and positive responses from the medical community at large. It seems, at least in their area, that physicians recognize the need for such a program and are confident in referring their patients to a facility employing evidence-informed methods. If I could extrapolate for a moment, this program (or a very similar one) could do the same on an individual clinic basis, couldn’t it?

Study Strengths / Weaknesses:

This study provided a starting point and some interesting insight into the following:
  • The potential value of inter-professional collaboration between doctors of chiropractic, physical therapists, and medical doctors
  • The promotion of care coordination to reduce unnecessary testing and procedures
  • The standardization of LBP management to reduce practice variation and high costs of care
  • As a stand-alone dataset using the CPR principles, patients assessed and classified using this strategy faired pretty well
The Jordan Hospital SCP has a lot to offer but this particular set of data has a few limitations that we should keep in mind:
  1. There was no control group – a logical next step would be to compare the SCP with a control and/or ‘typical’ medical intervention.
  2. Although the results in the treated patients were encouraging, we should remember that many patients with acute LBP experience symptom resolution in a relatively short period of time.
  3. Long-term follow-up was not conducted – further research on this SPC should address this shortcoming.

Additional References:

  1. Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656-64.
  2. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22: 62-8.
  3. Hebert J, Koppenhaver S, Fritz JM, Parent E. Clinical prediction for success of interventions for managing low back pain. Clin Sports Med 2008; 27: 463-79.