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Feinstein AB, Brown K, Dunn AL, Neville AJ, Sokol O, Poupore-King H, Sturgeon JA, Kwon AH, Griffin AT. Where do we start? Health care transition in adolescents and young adults with chronic primary pain. Pain 2024:00006396-990000000-00645. [PMID: 38981053 DOI: 10.1097/j.pain.0000000000003324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/27/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Amanda B Feinstein
- Department of Anesthesiology, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Kimberly Brown
- Department of Psychology, Palo Alto University, Palo Alto, CA, United States
| | - Ashley L Dunn
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Alexandra J Neville
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | | | - Heather Poupore-King
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - John A Sturgeon
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Albert H Kwon
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Anya T Griffin
- Department of Pediatrics & Department of Psychiatry and Behavioral Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
- Children's Hospital Los Angeles, Los Angeles, CA, United States
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Benton JA, Mowrey WB, Ramos RDLG, Weiss BT, Gelfand Y, Castro-Rivas E, Williams L, Headlam M, Udemba A, Gitkind AI, Krystal JD, Cho W, Kinon MD, Yassari R, Yanamadala V. A Multidisciplinary Spine Surgical Indications Conference Leads to Alterations in Surgical Plans in a Significant Number of Cases: A Case Series. Spine (Phila Pa 1976) 2021; 46:E48-E55. [PMID: 32991516 DOI: 10.1097/brs.0000000000003715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case series. OBJECTIVE To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries. SUMMARY OF BACKGROUND DATA Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making. METHODS We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeon's initial proposed surgery for a patient with the conference attendees' consensus decision on the best treatment and measured compliance rates with the group's recommended treatment. RESULTS The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range [IQR] 1-4). Participating surgeons complied with the group's recommendation in 96.5% of cases. CONCLUSION In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Joshua A Benton
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Wenzhu B Mowrey
- Department of Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Rafael De La Garza Ramos
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Brandon T Weiss
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Yaroslav Gelfand
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Erida Castro-Rivas
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Lavinia Williams
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Mark Headlam
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Adaobi Udemba
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Andrew I Gitkind
- Department of Rehabilitation Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Jonathan D Krystal
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Woojin Cho
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Merritt D Kinon
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Reza Yassari
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Vijay Yanamadala
- Center for Surgical Optimization, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Spinal Disorders Study Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY
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Is there bias in the treatment of degenerative spine disease? Analysis of anonymous voting via a multidisciplinary conference. J Clin Neurosci 2020; 82:141-146. [PMID: 33317723 DOI: 10.1016/j.jocn.2020.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 09/07/2020] [Accepted: 10/18/2020] [Indexed: 11/20/2022]
Abstract
Many institutions have developed shared decision-making conferences as a mechanism for reducing treatment costs and improving patient outcomes. Little is known about the process of shared decision-making that takes place in these conferences, and there is the possibility of bias among surgeons and nonsurgeons for treatment within their respective specialties. This study was conducted to determine who is contributing to the decision-making process in a multidisciplinary spine conference and to what extent treatment biases exist among the surgical and nonsurgical members of this conference. Voting data were collected during weekly multidisciplinary spine conferences. Descriptive statistics were calculated on the cases presented and the number and type of physicians voting for each case. The likelihood of a particular vote in the surgeon and nonsurgeon cohorts was evaluated using relative risk calculation and multinomial logistic regression. A total of 262 consecutive cases were analyzed. No significant differences in treatment recommendation were observed between surgery and nonsurgical management (relative risk, 1.1; 95% CI, 0.97-1.25) when comparing votes from the surgeon and nonsurgeon cohorts. Multinomial logistic regression showed the odds of nonsurgeons recommending nonsurgical management over surgery was 20% greater than receiving that recommendation from their surgeon colleagues. Individual surgeon and nonsurgeon voters were evenly distributed above and below the mean for treatment recommendation. Individual and group biases exist among surgeons and nonsurgeons treating degenerative spine diseases. Multidisciplinary conferences may or may not level these biases, depending on how they are conducted.
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Choi HS, Lee YJ, Kim MR, Cho JH, Kim KW, Kim EJ, Ha IH. Survey of Integrative Treatment Practices of Korean Medicine Doctors for Cervical Disc Herniation: Preliminary Data for Clinical Practice Guidelines. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2019; 2019:2345640. [PMID: 31534461 PMCID: PMC6732643 DOI: 10.1155/2019/2345640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/18/2018] [Accepted: 12/03/2018] [Indexed: 01/08/2023]
Abstract
A survey study was conducted in Korean medicine doctors who provide nonsurgical integrative treatment for cervical disc herniation (CDH) at spine-specialty hospitals to assess usual treatment practices, diagnosis and treatment methods, and related adverse events for CDH. The questionnaire was jointly developed by clinical experts and methodology experts and was administered to 197 Korean medicine doctors (response rate: 84.9% (n = 197/232)) practicing at spine-specialty Korean medicine hospitals for analysis of general sociodemographic information, practice patterns of CDH including diagnosis and treatment strategies, CDH prognosis, and treatment safety. The average clinical experience of respondents was 9.3±6.4 years, and 4.0±1.8 weeks were regarded to be needed for CDH pain to decrease by 50% and 9.1±3.4 weeks to decrease by 80%. Eight-Principle Pattern and Meridian System Identification were the most commonly used Korean medicine syndrome differentiation methods, and CDH was most often considered to be a result of Qi stagnation and Blood coagulation. The Spurling test was reported to be important in physical examination, and magnetic resonance (MR) images were mostly used for diagnosis and treatment of CDH of various diagnostic tools. Treatment mainly consisted of a nonsurgical, integrative multimodal approach comprising acupuncture, pharmacopuncture, herbal medicine, and Chuna manual therapy. Shinbaro pharmacopuncture and Chungpa-jun, which are well-established herbal treatments supported by evidence, were considered to be of high importance in CDH treatment. With regard to safety, acupuncture was considered to be the safest, while bee venom pharmacopuncture was of highest concern due to potential hypersensitivity. This study is the first report to investigate current practice patterns and approach of Korean medicine doctors to CDH treatment. This data may be of significance to Korean medicine doctors in drawing clinical guidelines and conducting randomized controlled trials (RCTs) to generate high-level evidence on the effectiveness of nonsurgical integrative medicine treatments for CDH.
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Affiliation(s)
- Hee Seung Choi
- Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Me-riong Kim
- Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Jae-Heung Cho
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Koh-Woon Kim
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Eun-Jung Kim
- Department of Acupuncture & Moxibustion, College of Korean Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
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Louw A, Farrell K, Choffin B, Foster B, Lunde G, Snodgrass M, Sweet R, Weitzel M, Wilder R, Puentedura EJ. Immediate effect of pain neuroscience education for recent onset low back pain: an exploratory single arm trial. J Man Manip Ther 2019; 27:267-276. [PMID: 31161919 DOI: 10.1080/10669817.2019.1624006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Study Design: A prospective, single-arm, pre-postintervention study.Objective: To determine the preliminary usefulness of providing pain neuroscience education (PNE) on improving pain and movement in patients presenting with non-chronic mechanical low back pain (LBP).Background: PNE has been shown to be an effective intervention for the treatment of chronic LBP but its usefulness in patients with non-chronic LBP has not been examined.Methods: A single group cohort pilot study was conducted. Eighty consecutive patients with LBP < 3 months completed a demographics questionnaire, leg and LBP rating (Numeric Pain Rating Scale - NPRS), disability (Oswestry Disability Index), fear-avoidance (Fear-Avoidance Beliefs Questionnaire), pain catastrophizing (Pain Catastrophizing Scale), central sensitization (Central Sensitization Inventory), pain knowledge (Revised Neurophysiology of Pain Questionnaire), risk assessment (Keele STarT Back Screening Tool), active trunk flexion and straight leg raise (SLR). Patients received a 15-minute verbal, one-on-one PNE session, followed by repeat measurement of LBP and leg pain (NPRS), trunk flexion and SLR.Results: Immediately after intervention, LBP and leg pain improved significantly (p < 0.001), but the mean change did not exceed minimal clinically important difference (MCID) of 2.0. Active trunk flexion significantly improved (p < 0.001), with the mean improvement (4.7 cm) exceeding minimal detectible change (MDC). SLR improved significantly (p = 0.002), but mean change did not exceed MDC.Conclusions: PNE may be an interesting option in the treatment of patients with non-chronic mechanical LBP. The present pilot study provides the rationale for studying larger groups of patients in controlled studies over longer periods of time.
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Affiliation(s)
- Adriaan Louw
- International Spine and Pain Institute, Story City, IA, USA.,Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Kevin Farrell
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Breanna Choffin
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Brooke Foster
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Grace Lunde
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Michelle Snodgrass
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Robert Sweet
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Matthew Weitzel
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Rebecca Wilder
- Department of Physical Therapy Education, Residency Program, St. Ambrose University, Health Sciences Center, Davenport, IA, USA
| | - Emilio J Puentedura
- International Spine and Pain Institute, Story City, IA, USA.,Doctor of Physical Therapy Program, Baylor University Graduate School, Waco, TX, USA
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Traeger AC, Buchbinder R, Elshaug AG, Croft PR, Maher CG. Care for low back pain: can health systems deliver? Bull World Health Organ 2019; 97:423-433. [PMID: 31210680 PMCID: PMC6560373 DOI: 10.2471/blt.18.226050] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/14/2019] [Accepted: 03/18/2019] [Indexed: 12/29/2022] Open
Abstract
Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients’ self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.
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Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health, University of Sydney, PO Box M179, Missenden Road, Camperdown NSW 2050, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - Peter R Croft
- Institute of Primary and Health Care Sciences, Keele University, Newcastle, England
| | - Chris G Maher
- Institute for Musculoskeletal Health, University of Sydney, PO Box M179, Missenden Road, Camperdown NSW 2050, Australia
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Andraka-Christou B, Rager JB, Brown-Podgorski B, Silverman RD, Watson DP. Pain clinic definitions in the medical literature and U.S. state laws: an integrative systematic review and comparison. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2018; 13:17. [PMID: 29789018 PMCID: PMC5964673 DOI: 10.1186/s13011-018-0153-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/19/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND In response to widespread opioid misuse, ten U.S. states have implemented regulations for facilities that primarily manage and treat chronic pain, called "pain clinics." Whether a clinic falls into a state's pain clinic definition determines the extent to which it is subject to oversight. It is unclear whether state pain clinic definitions model those found in the medical literature, and potential differences lead to discrepancies between scientific and professionally guided advice found in the medical literature and actual pain clinic practice. Identifying discrepancies could assist states to design laws that are more compatible with best practices suggested in the medical literature. METHODS We conducted an integrative systematic review to create a taxonomy of pain clinic definitions using academic medical literature. We then identified existing U.S. state pain clinic statutes and regulations and compared the developed taxonomy using a content analysis approach to understand the extent to which medical literature definitions are reflected in state policy. RESULTS In the medical literature, we identified eight categories of pain clinic definitions: 1) patient case mix; 2) single-modality treatment; 3) multidisciplinary treatment; 4) interdisciplinary treatment; 5) provider supervision; 6) provider composition; 7) marketing; and 8) outcome. We identified ten states with pain clinic laws. State laws primarily include the following definitional categories: patient case mix; single-modality treatment, and marketing. Some definitional categories commonly found in the medical literature, such as multidisciplinary treatment and interdisciplinary treatment, rarely appear in state law definitions. CONCLUSIONS This is the first study to our knowledge to develop a taxonomy of pain clinic definitions and to identify differences between pain clinic definitions in U.S. state law and medical literature. Future work should explore the impact of different legal pain clinic definitions on provider decision-making and state-level health outcomes.
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Affiliation(s)
- Barbara Andraka-Christou
- Department of Health Management and Informatics, College of Health and Public Affairs, University of Central Florida, 4364 Scorpius Street, Orlando, FL, 32816, USA.
| | - Joshua B Rager
- School of Medicine, Indiana University, 340 W 10th St #6200, Indianapolis, IN, 46202, USA
| | - Brittany Brown-Podgorski
- Department of Social and Behavioral Sciences, Indiana University Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA
| | - Ross D Silverman
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA
| | - Dennis P Watson
- Department of Social and Behavioral Science, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA
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Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study. Spine (Phila Pa 1976) 2017; 42:E1016-E1023. [PMID: 28067696 DOI: 10.1097/brs.0000000000002065] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational cohort pilot study. OBJECTIVE To determine the impact of a multidisciplinary conference on treatment decisions for lumbar degenerative spine disease. SUMMARY OF BACKGROUND DATA Multidisciplinary decision making improves outcomes in many disciplines. The lack of integrated systems for comprehensive care for spinal disorders has contributed to the inappropriate overutilization of spine surgery in the United States. METHODS We implemented a multidisciplinary conference involving physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopaedic spine surgeons, physical therapists, and nursing staff. Over 10 months, we presented patients being considered for spinal fusion or who had a complex history of prior spinal surgery. We compared the decision to proceed with surgery and the proposed surgical approach proposed by outside surgeons with the consensus of our multidisciplinary conference. We also assessed comprehensive demographics and comorbidities for the patients and examined outcomes for surgical patients. RESULTS A total of 137 consecutive patients were reviewed at our multidisciplinary conference during the 10-month period. Of these, 100 patients had been recommended for lumbar spine fusion by an outside surgeon. Consensus opinion of the multidisciplinary conference advocated for nonoperative management in 58 patients (58%) who had been previously recommended for spinal fusion at another institution (χ = 26.6; P < 0.01). Furthermore, the surgical treatment plan was revised as a product of the conference in 28% (16 patients) of the patients who ultimately underwent surgery (χ = 43.6; P < 0.01). We had zero 30-day complications in surgical patients. CONCLUSION Isolated surgical decision making may result in suboptimal treatment recommendations. Multidisciplinary conferences can reduce the utilization of lumbar spinal fusion, possibly resulting in more appropriate use of surgical interventions with better candidate selection while providing patients with more diverse nonoperative treatment options. Although long-term patient outcomes remain to be determined, such multidisciplinary care will likely be essential to improving the quality and value of spine care. LEVEL OF EVIDENCE 3.
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Mino DE, Munterich JE, Castel LD. Lumbar fusion surgery for degenerative conditions is associated with significant resource and narcotic use 2 years postoperatively in the commercially insured: a medical and pharmacy claims study. JOURNAL OF SPINE SURGERY (HONG KONG) 2017; 3:141-148. [PMID: 28744493 PMCID: PMC5506322 DOI: 10.21037/jss.2017.04.02] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/22/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chronic back pain is one of the costliest and most complex medical conditions to manage, involving physiological, psychological, mechanical, social, and environmental factors. An increasing trend of lumbar fusion (LF) surgery for chronic back pain continues despite conflicting evidence for pain relief or improved long-term outcomes. Our goal was to assess medical and pharmacy utilization (including continued use of pain medication) over a 2-year period among patients receiving LF to relieve back pain for degenerative conditions without instability. METHODS We conducted a 2-year longitudinal cohort study of 1,422 commercially insured patients who received LF from January through September 2009, and who had continuous benefit eligibility through 2011. We assessed resource use among patients with ICD-9-CM diagnostic codes consistent with a degenerative condition, identified from Cigna's national claim database (CPT codes 22612, 22630 and/or 22558). Patients with fracture, tumor, infection, spondylolisthesis, inflammatory arthritis, or deformity diagnostic codes were excluded. RESULTS Over the 2 years following LF, 992 patients (70%) incurred $9.0 million in additional medical claims payments which averaged $9,383 per patient. These payments included pain management interventions and long term therapy services in 30% of patients. A subset of 850 patients (60%) also had pharmacy benefits and 829 (97.5%) received multiple pain-related classes of medication over the same period. The majority of patients continued on chronic narcotic use (62.5%), and 95% of patients on narcotics preoperatively continued narcotic utilization at two years. This pharmacy benefit subset incurred an additional $2.2 million for pain-related medications at an average cost of $2,600 per patient. Total average payment for patients with combined medical and pharmacy benefits was $12,283. CONCLUSIONS LF for patients with a degenerative lumbar diagnosis incurred significant resources postoperatively, and was followed by long-term pain and psychotropic medication utilization.
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Affiliation(s)
| | | | - Liana D. Castel
- Department of Healthcare Management, Mount Olive Tillman School of Business, Mt Olive, NC, USA
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Systematic Review of Multidisciplinary Chronic Pain Treatment Facilities. Pain Res Manag 2016; 2016:5960987. [PMID: 27445618 PMCID: PMC4904600 DOI: 10.1155/2016/5960987] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/29/2015] [Indexed: 11/18/2022]
Abstract
This study reviewed the published literature evaluating multidisciplinary chronic pain treatment facilities to provide an overview of their availability, caseload, wait times, and facility characteristics. A systematic literature review was conducted using PRISMA guidelines following a search of MEDLINE, PsycINFO, and CINAHL databases. Inclusion criteria stipulated that studies be original research, survey more than one pain treatment facility directly, and describe a range of available treatments. Fourteen articles satisfied inclusion criteria. Results showed little consistency in the research design used to describe pain treatment facilities. Availability of pain treatment facilities was scarce and the reported caseloads and wait times were generally high. A wide range of medical, physical, and psychological pain treatments were available. Most studies reported findings on the percentage of practitioners in different health care professions employed. Future studies should consider using more comprehensive search strategies to survey facilities, improving clarity on what is considered to be a pain treatment facility, and reporting on a consistent set of variables to provide a clear summary of the status of pain treatment facilities. This review highlights important information for policymakers on the scope, demand, and accessibility of pain treatment facilities.
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12
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Psychiatry and chronic pain: Examining the interface and designing a structure for a patient-center approach to treatment. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eujps.2009.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
BACKGROUND There are limited population-based studies of determinants of physical therapy use for chronic low back pain (LBP) and of the types of treatments received by individuals who see a physical therapist. OBJECTIVE The purposes of this study were: (1) to identify determinants of physical therapy use for chronic LBP, (2) to describe physical therapy treatments for chronic LBP, and (3) to compare use of treatments with current best evidence on care for this condition. DESIGN This study was a cross-sectional, population-based telephone survey of North Carolinians. METHODS Five hundred eighty-eight individuals with chronic LBP who had sought care in the previous year were surveyed on their health and health care use. Bivariate and multivariable analyses were conducted to identify predisposing, enabling, and need characteristics associated with physical therapy use. Descriptive analyses were conducted to determine the use of physical treatments for individuals who saw a physical therapist. Use of treatments was compared with evidence from systematic reviews. RESULTS Of our sample, 29.7% had seen a physical therapist in the previous year, with a mean of 15.6 visits. In multivariable analyses, receiving workers' compensation, seeing physician specialists, and higher Medical Outcomes Study 12-Item Short-Form Health Survey questionnaire (SF-12) physical component scores were positively associated with physical therapy use. Having no health insurance was negatively associated with physical therapy use. Exercise was the most frequent treatment received (75% of sample), and traction was the least frequent treatment received (7%). Some effective treatments were underutilized, whereas some ineffective treatments were overutilized. LIMITATIONS Only one state was examined, and findings were based on patient report. CONCLUSIONS Fewer than one third of individuals with chronic LBP saw a physical therapist. Health-related and non-health-related factors were associated with physical therapy use. Individuals who saw a physical therapist did not always receive evidence-based treatments. There are potential opportunities for improving access to and quality of physical therapy for chronic LBP.
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