This hospital-based study is interesting for several reasons:

• First, they utilized an evidence-based program for treating low back pain (LBP)

• Based on that evidence, they assigned 83% of those who sought care to chiropractic management.

• Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, and

• 95% of those patients rated their care as “excellent.”

The Abstract:

OBJECTIVE: A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The purpose of this report is to describe the implementation and results of a multidisciplinary, evidence-based, standardized process to improve clinical outcomes and reduce costs associated with treatment and diagnostic testing.

METHODS: A standardized SCP was developed to improve the quality of back pain care. The NCQA BPRP provided the framework for the SCP to determine the standard of quality care delivered. Patients were triaged, and suitable patients were categorized into 1 of 5 classifications based upon history and examination, directional exercise flexion or “extension biases,” spinal manipulation, traction, or spinal stabilization exercises.

RESULTS: The findings for 518 consecutive patients were included. One hundred sixteen patients (10%) were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as “excellent.”

CONCLUSIONS: By adopting the NCQA BPRP as an SCP, training physicians in this SCP, and using a back pain classification, Jordan Hospital Spine Care demonstrated the quality and value of care rendered to a population of patients. This was accomplished with a relatively low cost and with high patient satisfaction.

From the FULL TEXT Article

Low back pain (LBP) is a substantial public health issue that puts pressure on the financial resources across the entire health care systems worldwide. The lifetime prevalence of LBP in most industrialized countries varies between 60% and 85%; therefore, most adults can expect to experience an episode of LBP at least once during their lifetime. Approximately 25% of American adults reported experiencing an episode of LBP during the previous 3 months. According to the National Center for Complementary and Alternative Medicine, LBP is the fifth most common reason why people seek care from their primary care physicians, the leading cause of disability and missed days of work in working age adults, and the most common condition for which US adults seek complementary and alternative treatment. A 2006 report estimated that the direct and indirect costs of LBP in the United States are more than $100 billion annually. Patients with back pain incur 73% higher health care costs than those without back pain–related complaints. Much of this cost is related to improper management of LBP, especially with respect to unnecessary diagnostic imaging, medications, and spinal injections. [5]

Improper and costly management of LBP is prevalent throughout the US health care delivery system, with widespread geographic variations documented in physician behavior and clinical practice that are not correlated with the geographic prevalence or incidence of the conditions being treated.

Although these recent data suggest a current crisis in the management of LBP, this is not a new problem. The first attempt to develop a guideline for the management of LBP was the publication of a consensus report in 1987 by the Quebec Task Force on Spinal Disorders. [11] Since that time, there have been many national and international guidelines published on the subject.

Most recently, the Bone and Joint Decade Task Force published a comprehensive set of systematic reviews of the literature covering the many procedures used to treat LBP. [18] Perhaps Haldeman and Dagenais best described the overall clinical approach to the management of LBP in the United States when he described current care as a “supermarket of spine-care services,” identifying more than 200 various treatment options available to patients for this condition. In addition, there are conservatively 12 separate provider types who treat patients with LBP (eg, doctors of chiropractic, physical therapists, orthopedists, etc). This is compounded by the fact that there are not generally accepted indications guiding the decision regarding which provider should be seen, at what time, and for which intervention. With this “supermarket” of options, the health care delivered to patients with LBP is uncoordinated and inefficient. Many patients are immediately escalated along the pathway of diagnostic testing and specialty consults, whereas efficacious, lower-cost interventions are explored late in the care pathway or ignored all together.

These issues raise questions regarding the management of LBP. Can a focus on quality through the application of the best available evidence coupled with processes designed to bring consistency to the delivery of health care services lead to excellent clinical outcomes, high patient satisfaction and less cost to the system? Therefore, the purpose of this descriptive report describes the internal and external development of a multidisciplinary, evidence-based, quality management program designed to standardize an LBP clinical care pathway in a community-based hospital.

Methods

Jordan Hospital is a 160-bed community-based hospital in Southeastern Massachusetts, serving 12 communities with a combined population of approximately 26,0000 people. Our hospital recognized that large geographic variation existed in the way that health care services were delivered not only around the nation but also within our own local community, and even within our own institution.

A decision was therefore made to address this challenge of practice variation and to improve the value of the health care services we provide to patients at our hospital, in our affiliated outpatient clinics, and within our community. Importantly, this decision was not limited solely to the treatment of LBP. We embarked on a process to standardize the way in which the hospital staff provided condition-based health care services to all patients and to eventually have 85% to 90% of all our patients managed through defined clinical care pathways, with the ultimate goals of reducing practice variation and improving the value of our health care services.

Our first step was to identify the clinical conditions in our patient population that showed the widest practice variation and required the most significant amount of time and money to manage. These conditions included congestive heart failure, transient ischemic attack, alcohol withdrawal, chest pain, hip fracture, sleep disorders, breast cancer care, and LBP.

After identification of these priority conditions, the next step was the internal development of defined clinical care pathways based upon the best available evidence and clinical experience.

The goal was to develop clinical care pathways that would standardize the clinical algorithms and processes used in the management of each of these conditions thereby reducing individual practice variation between the providers at our institution.

We then instituted a comprehensive training process for all hospital staff in the appropriate implementation and execution of these clinical care pathways. This educational process was supported by systematic monitoring of the staff for compliance with these standardized clinical processes along with tracking of our clinical outcomes, costs, and level of patient satisfaction.

Finally, we undertook a broad-based external outreach effort to disseminate the principles of evidence-based LBP management to physicians and the public within the communities we serve.

Internal Development

Low back pain was one of the priority conditions identified for development of a standardized clinical care pathway. It was recognized that the problem of wide variation in our management of LBP was occurring across many different health care disciplines; therefore, we decided that the solution would require a standardized clinical care pathway that would apply to all providers universally.

The goal was to devise and implement a high-quality, outcome-driven, evidence-based clinical algorithm for patients with LBP that could be applied consistently across all provider specialties.

This led to the development of Jordan Spine Care (JSC), an outpatient program implemented within our hospital that followed a multidisciplinary, team-based, standardized clinical approach to the management of LBP. The JSC group includes providers from the disciplines of occupational health, neurosurgery, physical medicine, pain management, chiropractic, rheumatology, neurology, physical therapy, and occupational therapy.

The strategy and goal were to have all members of the multidisciplinary team agree to follow a set of standardized procedures with the intent of reducing the need for unnecessary medications, diagnostic testing, and invasive spinal injections and surgery while maintaining high patient satisfaction and good clinical outcomes.

A multidisciplinary team of clinical leaders from the JSC group of providers were charged with developing a clinical care pathway designed to standardize the diagnostic and treatment strategies used to the manage patients with LBP at JSC.

Our review of the literature found that many of the important concepts regarding quality management of LBP had already been addressed by others. For example, a standardized approach to physical examination, case history, and diagnostic triage for LBP had already been established by the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) (see Table 1 below).

The team also found several clinical prediction rules and clinical trials that substantiated the clinical effectiveness of several nonsurgical treatment options for LBP. This information was used by the JSC team to develop a 2-tiered spine care pathway (SCP) that defined the diagnostic and treatment algorithms used to standardize the clinical management of patients with LBP at JSC.

Tier 1 of the SCP simply addressed the need to have all JSC team members follow a uniform approach to the evaluation and management of any new patient presenting with LBP by using the NCQA BPRP guidelines.

National Center for Quality Assurance established the BPRP in 2006 as a mechanism to recognize medical and chiropractic physicians who demonstrate the use of evidence-based principles in the management LBP.

Their guidelines focus on the processes of care and specify aspects of the physical examination and case management that should be performed and documented in the clinical record. Important BPRP requirements 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 advanced diagnostic imaging at the earlier stages of treatment; and

• appropriate timing of surgical and spinal injection procedures.

It is beyond the scope of this manuscript to provide a comprehensive review of the NCQA BPRP; however, additional details regarding this program can be found at www.ncqa.org/bprp.

During the tier 1, patients are triaged to identify those who require immediate medical attention due to severe pain, neurologic deficit, or signs of potentially serious medical illness as well as those who may benefit from conservative care.

Because most patients with LBP do not require urgent medical attention, they can appropriately be managed conservatively.

Patients who can appropriately be managed conservatively are further evaluated using the clinical procedures outlined in the second tier of the SCP.

Tier 2 involves a treatment classification algorithm designed to place the patient with LBP into 1 of 5 treatment-based approaches based upon their history and physical examination findings. The treatment categories are as follows:

1.directional preference exercise: flexion bias;

2.directional preference exercise: “extension bias”; (McKenzie assessment)

3.spinal manipulation;

4.traction; and

5.spinal stabilization exercises.