Transcript Spine/low back pain Update

Spine/Low Back Pain
Topic Update
March 27, 2013
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Two Tracks - RECAP
1. Spine SCOAP
 In October 2012, Bree Collaborative unanimously
approved Spine SCOAP proposal: “Establish participation
in Spine SCOAP as a community standard, starting with
hospitals performing spine surgery”
 Recommendation to HCA end of January
2. Spine/Low Back Pain Workgroup
 Established to identify and recommend strategies for
appropriate identification and management of acute low
back pain
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Endorsement of Spine SCOAP
Spine SCOAP recommendation sent to HCA on January
31st (copy of letter in meeting packet)
“To approve the Spine SCOAP proposal – that the Collaborative
establish participation in Spine SCOAP as a community
standard, starting with hospitals performing spine surgery* with the following conditions:
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2)
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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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HCA Response
 Legal and regulatory issues with “...that the Collaborative
establish participation in Spine SCOAP as a community
standard, starting with hospitals performing spine surgery...”
 “’Community Standard’ exceeds Collaborative’ s statutory
authority by potentially creating a legal standard and
participation mandate such that non-participation could be
used in other venues to create a presumed violation of a
community standard of care; the net effect could have
adverse effects in licensing, contracting, or professional
negligence litigation.”
 The Bree group (or the HCA’s Director if the proposal is
adopted “as is”) does not have the degree of regulatory
authority that would support such an action.
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Spine/Low Back Pain
Workgroup Update
Overview
 Have met twice since the last Bree Collaborative meeting (5
meetings total)
 RECAP – Focus on preventing transition from acute to
chronic pain, as requested by the Bree Collaborative
 Developing recommendations for 2 patient populations:
 Patients with non-specific low back pain (new onset or
recurrent)
 Patients with psychosocial factors
Excludes patients with nerve root problems or “red flags”
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Areas of Emphasis
 Identifying high-cost, complex patients as early as possible
 Operationalizing check lists, guidelines, and other best
practices
 Patient education/activation
 Managing patient expectations throughout care process
NOTE: The group discussed the importance of reducing
unnecessary imaging and effective management of opioid use, but
decided not to focus on either of these topics because both are
already the targeted by other efforts.
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Criteria for Workgroup Recommendations
(Adopted 2/20)
Addresses overall goals:
1) Reduce modalities that are
over-used in treatment of
low back pain in WA;
2) Increase early identification
of complex and chronic pain
patients and appropriate
evidence-based pathways
for treatment; and
3) Decrease patients’ return to
function time.
Based on criteria used by the
APM subgroup
 Somewhat simple to
implement and administer
 Built on
evidence/consensus-based
best practices
 Field tested (preferred)
 Aligned with proven national
metrics & programs
 Includes quality metrics
 Aligned with reducing the
cost of care
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Outline of General Approach
1. Recommend adoption of evidence-based guidelines
and check lists
2. Identify modalities that are over-used in treatment of
low back pain in WA
3. Identify best practices that would lead to
appropriate/reduced use of those modalities, which will
include some patient and provider education strategies
Recognize that it is important to avoid a “one size fits all”
approach and try to highlight diverse initiatives that can be
implemented in a broad range of settings
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Step 1: Guidelines
At 2/20 meeting, the workgroup discussed the following
proposal:
 Support the widespread adoption of the American College of
Physicians and American Pain Society (ACP/APS)
guidelines in primary care settings in WA
 Use the possible causes and key features from the
ACP/APS guidelines to define “red flags”
Consensus: Adopt the proposal while recognizing that the
ACP/APS guidelines are just a starting place; the group will
likely make more specific recommendations in areas such as
psychosocial screening and medication management
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Step 2: Over-used Modalities
 Identified the following modalities as ones that are
over-used in treatment of low back pain in WA:
 Epidural steroid and other spinal injections
 Opioids
 Lumbar MRIs
 Staff is working on getting data about overuse from L&I
and other sources
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Step 3: Best Practices
Innovative Approaches for Improving Spine Care
The 2/20 meeting included presentations about:
 VMMC and Intel’s Approach to Spine Care
 FastBack: program for treating pain in the ER
 BackQuack: online game for back pain doctors & patients
 Spine Team Assessment: multidisciplinary team care for
chronic pain patients
 Priority Health Experiment: patients must see a physiatrist
before a surgeon (unless it is an emergency)
Thank you to Dr. Andrew Haig (from Michigan) and Dr. Bob
Mecklenburg for giving presentations.
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Step 3: Best Practices
Chronic Back Pain Risk Screening
The 3/20 meeting included presentations about:
 L&I efforts to improve early identification and interventions for
injured workers at a high risk for chronic disability
 Functional Recovery Questionnaire
 Pilot in Centers of Occupational Health and Education (COHEs)
 “Activity Coaching”: Progressive Goal Attainment Program
 Chronic Pain Risk Score (plus Improved and Expanded
models)
 BOLD Back Pain Registry
 STarT Back Screening Tool
Thank you to Dr. Judith Turner from UW for presenting.
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Step 3: Best Practices
At 3/20, the workgroup adopted this proposal:
Support the widespread adoption of the STarT Back tool by spine
care providers in WA State
Rationale:
 Validated tool with strong evidence of predictive power and improved
outcomes
 Using & scoring the tool is very straightforward  reduced burden for both
patients and providers (9 item tool, 8 of the questions are yes or no)
 No cost to use materials – freely available for download online
The workgroup may identify other screening tools that meet these
criteria and/or include a list of recommended criteria in the report.
Staff will contact providers that currently use this tool to get more
information about its implementation and impact on their practice.
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Upcoming Plans and Goals
 Looking to invite a few primary care doctors to form a
subgroup to discuss strategies for operationalizing evidencebased guidelines
 4/17 meeting will focus on Patient Engagement/Education
and Innovative Technologies
 Staff hopes to increase the frequency of meetings as the
report starts to come together
 Plan to present outline or draft report at the next Bree
Collaborative meeting
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Questions? Comments?
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