DITHA's Summary and Conclusions
Introduction
The purpose of this HTA is to adjust international technology assessments, already published on diagnosis, treatment and prevention of low-back pain, into Danish conditions, in order to improve a better decision making in the health care system.
Methods
A broadly composed working group of relevant professionals made this report as a result of a systematic consensus process based on a thorough evaluation of published scientific evidence and clinical expertise.
In the first place the quality of the scientific basis of using each individual technology was assessed - carefully guided by equivalent foreign HTA-reports. Based on scientific documentation the statements regarding the technology was evaluated on a 4-step scale. Based on estimates a graduation in three degrees was made of the expected economic consumption of resources that the use of each single technology would release.
In addition, the group suggested a recommendation/non-recommendation of future use of the individual technology. Explanations are linked to each recommendation, so it is clear under which circumstances the recommendation is valid.
Technology
A thorough examination carried out at the very first visit is the most important activity in the handling of the low-back pain patient. The main purpose of the clinical examination is to make a specific diagnosis and to exclude the existence of serious back diseases. Furthermore, it forms the basis for preparation of the most suitable programme of examination- and treatment for the patient concerned.
The past ten years' science has clearly shown that a patient activating treatment strategy, both for the acute and the chronic low-back pain patient is of great importance to ensure a stable effect of the treatment. For a successful treatment result a motivated participation chosen by the patient is important.
Organisation
Interdisciplinary agreements exist among the experts upon the following general principles on the organisation of care in the low-back pain area:
Irrespective of how the patient chooses to contact the health care system, it is important that examination and treatment procedures are the same.
All treatment should, if possible, take place in the primary sector and in the patient's own area. This is important in order to avoid unnecessary labelling of the patient and to avoid needless costs for the patient and/or to the health care system, as for example long transports.
Referral to specialist care or to a specialist centre should generally not occur before other relevant diagnosis/treatment in the primary sector has been tried.
Referral to specialist care or a specialist centre is recommended at once if alarming symptoms of back disease appear or if the patient does not recover within 4 weeks in spite of regular treatment in the primary sector.
Normally, patients with acute low-back pains are recommended not to consult emergency wards, as most of the emergency wards are unable to carry out a thorough evaluation of the problem.
In suspicion of bone fracture after trauma the patient is recommended to contact the emergency services.
Hospitalisation of patients with low-back pain is not recommended. Hospitalisation causes unnecessary labelling of the patient and often also a feeling of inactivity and loss of self-determination.
If serious back disease occurs e.g. bad pains, hospitalisation will often be necessary.
During the treatment course a close co-operation is important among the relevant professionals in primary care, for exchange of notes from case records (after permission from the patient is obtained), x-rays, treatment results etc.
Individual patient information during the diagnosis-/treatment efforts should always be a key activity.
The formal and informal routes of referrals should in general be kept unchanged.
The organisation of care should enable a division of work, which derives from professions' - by authorisation - defined business areas. This prevents or minimises the occurrence of multiple parallel episodes of care.
It should be ensured that the content of the individual treatment course is homogenous, irrespective if the patient consults his or hers general practitioner or chiropractor. Similarity in information given to the patient should be ensured, irrespective of the kind of practitioner that evaluates, informs and advises the patient.
Economy
Implementation of improved care programmes, besides causing savings at the budget in the health care system, will also bring about savings of public costs in areas such as transfer payments (sickness benefits and pensions). Overall factors in obtaining savings are:
To avoid costly waiting time.
To obtain the best possible communication and co-ordination between professionals involved and with other parties e.g. especially the social authorities.
To avoid that unnecessary or needless diagnosis- and treatment procedures are carried out.
DIHTA's Conclusions
If the documentation and recommendations of this report are followed, a range of treatments will definitively disappear from the health care system's handling of low-back pain, and more effective patient episodes of care will represent far a bigger fraction of cases.
In crucial areas implementation of the results of the report should go through interdisciplinary formed reference programmes and clinical guidelines. One obvious subject could be a reference programme with guidelines for the work out of "correct x-ray procedures"of the low back, carried out in co-operation with radiologists, surgeons, chiropractors, reumatologists, general practitioners etc. In addition reference programmes describing in which cases blood tests are necessary, should be worked out.
Economic aspects influence practice behaviour, and changes in collective agreements and contracts may cause great effect.
Broad implementation strategies that form a combination of printed material, (local, small-group based) problem oriented education, collegiate influence from opinion leaders, audit-feed back of actual treatment activity and visit by colleagues to the clinic is best suited in order to obtain changes in clinical behaviour. The working group was not asked to deal with future division of work between the caregivers. There is, however, a need for such a clarification, which could be made through discussions and negotiations with public agreement parties such as Sygesikringens Forhandlingsudvalg (The Board of Public Health Insurance).
It is important that the patient early in the treatment course takes an active part by receiving a thorough information. Information about the problem and treatment is most often repeated several times before the patient gets full insight into the matter. Individual information is recommended and should be based on the individual situation and need. A strengthened individual information effort towards the patient - both in the primary - and in the secondary sector - is an important aspect for the strengthening of future efforts. The collective agreements' possibility to promote this information effort should be analysed critically.
A shared patient record and electronic communication should be developed and tested so that the practitioners can share information about diagnosis and treatment already carried out.
Common and improved training of physicians, chiropractors and physiotherapists should be developed so the professions get a more equal approach to the individual patient and a technical language that is more common than it is today. These courses should also include other relevant professional groups such as teachers of relaxation and psychologists. Relevant professional academic environments should support the training.
Particular courses for social-/rehabilitation staff should be given higher priority than it is in the care today. The newest well-documented professional know how should also form the basis for decisions about social measures for patients with low-back problems.
The professional groups' thorough work has revealed a big need for a broad scientific effort in the field of clinical science research and health services research. Methodological competence at high levels is necessary for valid and reliable results. There is, therefore, a need for supporting academic centres, which are willing to undertake education of scientists and methodology advisers.
The evidence basis for decisions on treatment is regularly changed. Thus, the low-back pain-report must be updated after four years at the latest, in order to preserve its relevance.
