Transcript Spine/Low Back Pain Update

Spine/Low Back Pain
Update
May 29, 2013
1
Goals for Today’s
Presentation
1. Provide update on Spine SCOAP proposal
2. Summarize the progress made by the
Spine/Low Back Pain workgroup
3. Get feedback about draft goals and
recommendations under consideration by the
Spine workgroup
2
Update on Spine
SCOAP Proposal
 In October 2012, the Bree unanimously voted
 At the March meeting, the Bree discussed the
use of “community standard” in response to
concerns from HCA
 Letter sent to HCA in mid-April clarifying the
Bree’s intent and proposing revised language
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Timeline of Spine SCOAP
Proposal
Action/Status
Recommendation
Bree approved Spine
SCOAP proposal
“To approve the Spine SCOAP
proposal – that the Collaborative
establish participation in Spine
SCOAP as a community standard,
starting with hospitals performing
spine surgery”
March 2013
HCA responds
Concerns with community standard
language
April 2013
Bree discussed HCA
response, revised
language based on
HCA concerns &
submits revision to
HCA
See next slide
October
2012
(sent to HCA in
Jan 2013)
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Revised Proposal
“To approve the Spine SCOAP proposal – that the
Collaborative strongly recommends establish
participation in Spine SCOAP as a community
standard, starting with hospitals performing spine
surgery* - with the following conditions:
1)
2)
3)
4)
Results are unblinded.
Results are available by group.
Establish a clear and aggressive timeline.
Recognize that more information is needed about
options for tying payment to participation.”
*Spine SCOAP will begin with hospitals performing spine
surgery and will expand to include procedures done at
Ambulatory Surgery Centers as well as other non-hospital
facilities such as interventional radiology suites.
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Update from HCA
 Have not received formal response yet
 Josh Morse from HCA will give a verbal update
at today’s meeting
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Spine/Low Back Pain
Workgroup Update
Populations of Interest
Report will target three patient populations:
1. Adult low back pain (LBP) patients that are at a low risk of
developing chronic pain and require minimal care
2. Adult LBP patients that are at a medium risk of developing
chronic pain and require additional care to overcome physical
obstacles to recovery
3. Adult LBP patients with psychosocial obstacles to recovery
(“yellow flags”) that are not responding to conservative
treatment and are at a high risk of developing chronic pain
Excludes patients with LBP associated with major trauma and
patients with “red flags” that suggest a serious underlying
condition
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Draft Primary Goal
Improve return to function for LBP patients
while reducing the cost of care by increasing
evidence-based evaluation and management of
patients in target populations
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Draft Secondary Goals
1. Reduce use of inappropriate interventions that do not
support return to function or improve health outcomes
2. Increase early identification and management of patients
who are at a higher risk of developing chronic pain
3. Provide tools and support to clinicians for the delivery of
evidence-based care
4. Increase adoption of both financial and non-financial
incentives to change provider practices and reward valuebased care
5. Increase public awareness that low back pain is a chronic
condition, and no “magic bullet” treatment exists
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Draft Measures of Success
Outcome Measure
Possible Data Source(s)
Improve return to function time
L&I, providers, patient surveys, others?
Improve functional status as measured
by the Oswestry Low Back Pain Scale
Providers/health plans that use
Oswestry to collect pre- and postfunction scores, employers (include in
medical leave paperwork?)
Improve patient experience
Still exploring options
Key challenge: How can the Bree (or any entity)
collect this data in the absence of a registry?
Thoughts?
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Draft Measures of Success
Process Measure
Possible Data Source(s)
Reduce inappropriate use of MRIs for
LBP patients in the first 28 days
NCQA, Puget Sound Health Alliance
(Community Checkup)
Reduce overall MRI and lumbar fusion
rates for LBP patients
L&I, Medicare, Spine SCOAP
Increase use of screening tools (e.g.
STarT Back or a similar tool)
Large health care systems that
implement these recommendations,
possibly health plans that have billing
codes assigned to the use of screening
tools
Any other measures that the workgroup
should consider?
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Draft Recommendations –
Hospitals/Clinics
 Support or sustain a LBP quality improvement program that
includes measuring patients’ functional status over time
using the Oswestry Low Back Pain Scale
 Use a validated screening tool like the STarT Back tool or
Functional Recovery Questionnaire (FRQ) no later than the
3rd visit to identify patients that are not likely to respond to
routine care
 Take steps to integrate evidence-based guidelines, scripts,
shared-decision making, and patient education material into
clinical practice and workflow (e.g., EMR, a clinical decision
support tool such as UpToDate, etc.)
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Draft Recommendations –
Hospitals/Clinics (cont’d)
 Sponsor evidence-based CME for staff on the best practices
for the evaluation and management of non-specific LBP
patients to prevent progression from acute to chronic pain
(in combination with operational changes that
support/reinforce best practices)
 Include information in lumbar spine MRI reports about the
frequency of similar findings in the general population
 Implement “hard stops” that require providers to
demonstrate appropriateness of imaging before ordering
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Draft Recommendations –
Individual Providers
 Commit to using evidence-based guidelines and tools
recommended by the Bree Collaborative, including the
ACP/APS guidelines and Oswestry
 Use a validated screening tool like the STarT Back tool
or Functional Recovery Questionnaire (FRQ) no later
than the 3rd visit to identify patients that are not likely to
respond to routine care
 Incorporate shared decision-making into clinical
practices
 Establish referral relationships with physiatrists
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Draft Recommendations –
HCA/Medicaid/DOH/L&I
 Sponsor an evidence-based education campaign about
low back pain (ideally modeled after an Australian
campaign with proven effectiveness)
 Partner with WSHA, WSMA, the Washington Academy of
Family Physicians, American Academy of Physical
Medicine and Rehabilitation, and other interested parties
 Provide subsidies/incentives to providers that use
shared decision-making with their LBP patients
 Sponsor a new payment methodology for LBP care
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Draft Recommendations –
Employers/Purchasers
 Encourage providers and delivery systems to track and
report return to function rates in a transparent manner
 Provide recommended patient education materials
about LBP to all employees and their families
 Negotiate tiered networks or other types of benefit
design that will encourage patients to go to providers
that have demonstrated evidence-based practices
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Draft Recommendations –
Health Plans
 Support new, innovative financial models for LBP care
 Require providers to demonstrate that they have had
patients complete a screening tool (such as STarT
Back or FRQ) as part of prior authorization process for
imaging, spinal injections, and/or spinal surgery
 Require patients with non-specific low back pain (and
no red flags) be evaluated by a physiatrist before
scheduling a visit with a surgeon
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Draft Recommendations –
Health Plans
 Consider establishing the collection of data on
functional outcomes as a requirement for payment
 Identify complex cases (e.g. a patient who is getting
opioid prescriptions from multiple doctors) and refer
them to a provider or case manager that can oversee
their care
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