Transcript STarT Back - University of Virginia

STarT Back
Zoe Fisher Solent Healthcare
Chris Blythin Southern Health
December 18th 2012
What is it?
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A brief validated tool designed to screen primary care
patients with low back pain for prognostic indicators
that are relevant to initial decision making
Poorly managed back pain has a huge economic and
societal cost
This new model results in greater health benefits:
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Better outcomes for patients
Improved staff satisfaction
Effective use of resources
This model results in lower average health-care cost
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Average saving to health services of £34.39 per patient
Societal savings of £675 per patient.
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The STarTBack tool is a risk stratifying tool
The patient can be treated according to their
level of risk
Conventionally
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High risk patient
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Medium risk patient
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Many appointments, clinicians, investigations
Secondary care – spinal surgery
Pain team management
Physiotherapy
Low risk patient
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Physiotherapy
The Keele STarT Back Screening Tool
Patient name: _______________________________
Date: _____________
Thinking about the last 2 weeks tick your response to the following questions:
Disagree Agree
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My back pain has spread down my leg(s) at some time in the last 2 weeks □
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I have had pain in the shoulder or neck at some time in the last 2 weeks
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I have only walked short distances because of my back pain
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In the last 2 weeks, I have dressed more slowly than usual
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because of back pain
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It’s not really safe for a person with a condition like mine to be physically active
Worrying thoughts have been going through my mind a lot of the time
I feel that my back pain is terrible and it’s never going to get any better
In general I have not enjoyed all the things I used to enjoy
Overall, how bothersome has your back pain been in the last 2 weeks?
Not at all Slightly Moderately Very much Extremely
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0
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0
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0
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1
Total score (all 9): __________________
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Sub Score (Q5-9):______________
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STarTBack Tool
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Low Risk
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Medium Risk
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30 minute assessment- Subjective and Physical
Advice on self management plus leaflets
Up to 6 treatments
Exercise and manual therapy
High Risk
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More specialist Rx, CBT informed care
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This was a Pilot study with an aim to have
the STarTBack tool adopted in Primary
Care
The tool has been clinically driven,
establishing best practice musculoskeletal
pathway, and is supported by
commissioners
Its use will help avoid inappropriate
referral of patients into secondary care
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3 Physiotherapy leads from the Solent
Healthcare, Hampshire Hospitals Trust and
Southern Health took this forwards with a
Pilot
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Expanded training of physios in CBT and
motivational interviewing to improved
management of high risk patients
GPs were communicated with through face to
face meetings, clinical practice meetings and
letters to discuss this tool and implement
within their practice
Outcomes
Audit of referrals from GPs
June – August 2012
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6.75% of referrals had STarT Back score
completed
Outcomes
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STarT back used consistently in physiotherapy
depts – completed on arrival if not previously
Identification of low risk patients resulted in
fewer appts
Improved waiting times
Targeted management for medium and high risk
patients
Patient satisfaction with care is good
Variations within 3 sites
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Southern Health
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Solent Healthcare
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Using with self referral
Training with pain team lead by Dr Neil Berry, quarterly
meetings. 2 clinicians trained from each site, 8 altogether
Training of 6 physios with Dr Rob Shannon, psychologist
Rob meets 6/52, taped assessments and discusses cases
Emphasis now is for trained physios to support other members
of staff
Hampshire Hospitals Trust
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Sent a team of 5 to Keele for training – last day 14th Dec
Comparative referrals of patients
(3 month period June – Aug)
Low Risk
Medium
Risk
High Risk
Solent
Healthcare
27.8%
34.5%
37.7%
Southern
Health
41%
33%
20%
Hampshire
Hospitals
37%
35%
28%
Roland Morris (0 - 24)
Pain self-efficacy questionnaires (0 – 60)
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Roland Morris: Significant change lowering of 2 points
PSEQ: 40+ indicates confidence to manage
Low risk
Medium risk
High risk
RMD
PSEQ
RMD
PSEQ
RMD
PSEQ
6.68 –
4.34
= 2.34
43.66 –
49.9
9.14 –
4.12
= 5.02
35.17 –
49.38
11.53 –
4.56
= 6.97
29.76 –
48.04
Already
scoring > 40
Average number of appointments
Low risk
Medium risk
High risk
2.84
3.55
4.02
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Why > 1 appt for low risk patients?
Patient Satisfaction of assessment
and treatment (6 high score)
Low risk
Medium risk
High risk
5.7
5.29
5.235
Lessons learned from the Pilot
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Access to primary care takes time to achieve
Challenge to get STarT Back tool completed
prior to physiotherapy appointment
Management of low risk patients
Contrast of high – low risk group of patients
referred in different demographic areas
Overall patient and clinician satisfaction with tool
high
Challenges 1
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Commissioners
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Cost management:
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Saving of money - low risk patients managed in one 30
minute comprehensive assessment with supporting literature
on self management
Keeping patients out of secondary care, avoidance of
operations
Keeping patients away from Pain services
A need to support demographic areas where high risk
patients are dominant – more expensive, higher skill mix
Challenges 2
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Managers
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Match skill mix of clinician to demographics
and patient STarT Back tool risk – KSF
Agenda for Change
Allow time, training and clinical support for
the caseload
Challenges 3
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Clinicians; GPs, Physiotherapists, Psychologists
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Communication
Use of online sites for the tool
Challenge to minimize low risk patient intervention
Appropriate referral of medium and high risk patients
to physiotherapy, no delay for high risk
Tailor treatment for patients according to their risk
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www.paintoolkit.org
www.sheffieldbackpain.com
www.britishpainsociety.org
www.painconcern.org.uk
http://tinyurl.com/chap346
Vision is a change of back pain
management in primary care
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A common sense of purpose:
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Improving patient care and outcome
Improving clinician satisfaction
Ensuring appropriate use of resources
Cultural change in the management of
back pain across the UK
STarT Back tool becomes established in
primary practice