Surgeon attitudes toward nonphysician screening of low back or low back-related leg pain patients referred for surgical assessment: a survey of Canadian spine surgeons

The clinical course of symptoms during wait time for lumbar spinal stenosis surgery and its effect on postoperative outcome: a retrospective cohort study

BACKGROUND CONTEXT

Wait time for surgeries can be lengthy and its effect on postoperative outcome remains largely unknown.

PURPOSE

We evaluated the effect of wait time on postoperative outcome and on clinical course while awaiting surgery for lumbar spinal stenosis.

STUDY DESIGN/SETTING

This was a retrospective cohort study.

PATIENT SAMPLE

A convenience sample (n=134) from prospective longitudinal studies that provided preoperative Oswestry Disability Index (ODI) data at two different time points and follow-up of ≥12 months.

METHODS

Wait time was the period between the initial consultation and immediately preoperatively.

OUTCOME MEASURES

The primary outcome was the ODI minimal clinically important difference (MCID) (<30% vs ≥30% improvement) at 1 year.

RESULTS

The median wait time was 5.9 (interquartile range (IQR) 8.2) months and postoperative follow-up was 19.2 (IQR 8.1) months. Wait time was not associated with absolute postoperative change in ODI scores, but patients with wait times <12 months were significantly more likely to reach the ODI MCID at last follow-up (66 (73.3%) for <12 months versus 13 (46.4%) for ≥12 months, p=.008; odds ratio=0.29 (95% confidence interval 0.12-0.75), p=.011). During wait time, there was no difference in patients deteriorating above the MCID for each time point (10 [9.7%] versus 5 [16.1%], p=.320).

CONCLUSIONS

Longer wait times did not negatively influence postoperative outcome in patients with lumbar spinal stenosis using absolute values, but may impact individual patients' ability to achieve MCID. Patient-reported pain-related disability from the initial surgical consultation to surgery is relatively stable in most patients for at least 6 to 12 months.

Patient-Reported Outcomes Following Surgery for Lumbar Disc Herniation: Comparison of a Universal and Multitier Health Care System

STUDY DESIGN

Ambispective cohort study.

OBJECTIVE

Canada has a government-funded universal health care system. The United States utilizes a multitier public and private system. The objective is to investigate differences in clinical outcomes between those surgically treated for lumbar disc herniation in a universal health care and multitier health system.

METHODS

Surgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient-reported outcomes (PROs) were compared at 3 months and 1 year post-operatively.

RESULTS

The CSORN cohort consisted of 443 patients; the SPORT cohort had 763 patients. Patients in the CSORN cohort were older (46.4 ± 13.5 vs 41.0 ± 10.8, P < .001) and were more likely to be employed (69.5% vs 60.3%, P = .003). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 months (87.2% vs 64.8%, P < .0001) and 1 year (85.6% vs 69.6%, P < .0001). Improvements in back and leg pain followed similar trajectories in the two cohorts, but there was less improvement on ODI in the CSORN cohort (P < .01). On multivariable logistic regression, the CSORN cohort was a significant independent predictor of patient satisfaction at 1-year follow-up (P < .001).

CONCLUSIONS

Despite less improvement on ODI, patients enrolled in CSORN, as part of a universal health care system, reported higher rates of satisfaction at 3 months and 1 year post-operatively compared to patients enrolled within a multitier health system.

Cost consequence analysis of waiting for lumbar disc herniation surgery

The economic repercussions of waiting for lumbar disc surgery have not been well studied. The primary goal of this study was to perform a cost-consequence analysis of patients receiving early vs late surgery for symptomatic disc herniation from a societal perspective. Secondarily, we compared patient factors and patient-reported outcomes. This is a retrospective analysis of prospectively collected data from the CSORN registry. A cost-consequence analysis was performed where direct and indirect costs were compared, and different outcomes were listed separately. Comparisons were made on an observational cohort of patients receiving surgery less than 60 days after consent (short wait) or 60 days or more after consent (long wait). This study included 493 patients with surgery between January 2015 and October 2021 with 272 patients (55.2%) in the short wait group and 221 patients (44.8%) classified as long wait. There was no difference in proportions of patients who returned to work at 3 and 12-months. Time from surgery to return to work was similar between both groups (34.0 vs 34.9 days, p = 0.804). Time from consent to return to work was longer in the longer wait group corresponding to an additional $11,753.10 mean indirect cost per patient. The short wait group showed increased healthcare usage at 3 months with more emergency department visits (52.6% vs 25.0%, p < 0.032), more physiotherapy (84.6% vs 72.0%, p < 0.001) and more MRI (65.2% vs 41.4%, p < 0.043). This corresponded to an additional direct cost of $518.21 per patient. Secondarily, the short wait group had higher baseline NRS leg, ODI, and lower EQ5D and PCS. The long wait group had more patients with symptoms over 2 years duration (57.6% vs 34.1%, p < 0.001). A higher proportion of patients reached MCID in terms of NRS leg pain at 3-month follow up in the short wait group (84.0% vs 75.9%, p < 0.040). This cost-consequence analysis of an observational cohort showed decreased costs associated with early surgery of $11,234.89 per patient when compared to late surgery for lumbar disc herniation. The early surgery group had more severe symptoms with higher healthcare utilization. This is counterbalanced by the additional productivity loss in the long wait group, which likely have a more chronic disease. From a societal economic perspective, early surgery seems beneficial and should be promoted.

Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study

BACKGROUND CONTEXT

An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system.

PURPOSE

Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting.

DESIGN/SETTING

Cross-sectional analysis of administrative health data for the fiscal year 2013-2014 from the province of Ontario, Canada.

PATIENT SAMPLE

Adult population aged 18+ years (N=10,841,302).

OUTCOME MEASURES

Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined.

METHODS

Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs.

RESULTS

Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions.

CONCLUSIONS

Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.

Utility of Specialized Imaging for Diagnosis of Chronic Wrist Pain

Background  Patients with chronic wrist pain often undergo imaging (such as magnetic resonance imaging [MRI], computed tomography [CT], or ultrasound [US]) prior to specialist assessment. Questions  Is specialized wrist imaging performed prior to expert consultation necessary? Are there demographic differences between patients who do or do not receive preconsultation imaging? Patients and Methods  A total of 115 patients referred to a tertiary hand center for chronic wrist pain and assessed by a hand surgeon were included. At initial consultation, surgeons were blinded to referral information and previous imaging results. The specialist performed a history, physical examination and reviewed X-rays. They established a clinical diagnosis and whether any additional investigations were needed. Prior MRI, CT, and/or US results were then reviewed and the specialists' clinical diagnosis was compared with the blinded referral diagnosis. Preconsultation imaging was categorized as having no value for diagnosis/management, some value, or high value. Results  A total of 82 patients had imaging prior to specialist referral (69 MRIs, 11 CTs, and 16 ultrasounds). The majority of additional imaging (73%) was classified as unnecessary, including 77% of the MRIs and 100% of the ultrasounds. Of all the investigations performed, two CT scans were labeled highly valuable clinical aids. Older patients and those with radial-sided pain were less likely to receive preconsultation imaging. Six patients required further imaging after consultation. Conclusion  Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain and few patients require additional imaging. Level of Evidence  This is a Level III study.

Utilization and Outcomes for Spine Surgery in the United States and Canada

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to examine variation in spine surgery utilization between the province of Ontario and state of New York among all patients and pre-specified patient subgroups.

SUMMARY OF BACKGROUND DATA

Spine surgery is common and costly. Within-country variation in utilization is well studied, but there has been little exploration of variation in spine surgery utilization between countries.

METHODS

We used population-level administrative data from Ontario (years 2011-2015) and New York (2011-2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery using relevant procedure codes. Patients were stratified according to age and surgical urgency (elective vs. emergent). We calculated standardized utilization rates (procedures per-10,000 population per year) for each jurisdiction. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared utilization rates of spinal decompression and fusion surgery in Ontario and New York among all patients and after stratifying by surgical urgency and patient age.

RESULTS

Patients in Ontario were older than patients in New York for both decompression (mean age 58.8 vs. 51.3 years; P < 0.001) and fusion (58.1 vs. 54.9; P < 0.001). A smaller percentage of hospitals in Ontario than New York performed decompression (26.1% vs. 54.9%; P < 0.001) or fusion (15.2% vs. 56.7%; P < 0.001). Overall, utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 16.5 per-10,000 per-year (P < 0.001). Ontario-New York differences in utilization were smaller for emergent cases (2.0 per 10,000 in Ontario vs. 2.5 in New York; P < 0.001), but larger for elective cases (4.6 vs. 13.9; P < 0.001). The lower utilization in Ontario was particularly large among younger patients (age <60 years).

CONCLUSION

We found significantly lower utilization of spine surgery in Ontario than in New York. These differences should inform policy reforms in both jurisdictions.

LEVEL OF EVIDENCE

3.

The Use of a Self-Administered Questionnaire to Reduce Consultation Wait Times for Potential Elective Lumbar Spinal Surgical Candidates: A Prospective, Pragmatic, Blinded, Randomized Controlled Quality Improvement Study

BACKGROUND

In a public health-care system, patients often experience lengthy wait times to see a spine surgeon for consultation, and most patients are found not to be surgical candidates, thereby prolonging the wait time for those who are. The aim of this study was to evaluate whether a self-administered 3-item questionnaire (3IQ) could reprioritize consultation appointments and reduce wait times for lumbar spinal surgical candidates.

METHODS

This prospective, pragmatic, blinded, randomized controlled quality improvement study was conducted at a single Canadian academic health-care center. This study enrolled 227 consecutive eligible participants with an elective lumbar condition who were referred for consultation with a spine surgeon. All participants were mailed the 3IQ after their referral was received. Patients were randomized into the intervention group, in which leg-dominant pain reported on the 3IQ resulted in an upgrade in priority to be seen, or into the control group, in which no change to wait-list priority occurred. The main outcome measured was time to consultation for participants who were deemed surgical candidates following consultation.

RESULTS

There were no significant differences between groups with regard to demographics, overall group wait times, proportion of surgical candidates, or disability. A total of 33 patients were deemed surgical candidates after consultation. The median wait from referral to consultation was shorter for the 16 surgical candidates in the intervention group (2.5 months; interquartile range [IQR]: 2.0 to 4.8 months) compared with the 17 surgical candidates in the control group (4.5 months; IQR: 3.4 to 6.9 months; p = 0.090). The odds of seeing a surgical candidate within the acceptable time frame of 3 months were 5.4 times greater (95% confidence interval: 1.2 to 24.5 times; p = 0.024) in the intervention group.

CONCLUSIONS

The use of a simple, self-administered questionnaire to reprioritize referrals resulted in shorter consultation wait times for patients who required a surgical procedure and significantly increased the number of surgical candidates seen within the acceptable time frame. It may be valuable to consider adding the 3IQ to clinical care practices to better triage these patients on waiting lists.

Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings

BACKGROUND

The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This study aims to determine the effect of ISAEC on access for surgical assessment, referral appropriateness and efficiency for patients meeting a priori referral criteria in rural, urban and metropolitan settings.

METHODS

We conducted a retrospective review of prospective data from networked ISAEC clinics in Thunder Bay, Hamilton and Toronto, Ontario. For patients meeting surgical referral criteria, wait times for surgical assessment, surgical referral-related magnetic resonance imaging (MRI) scans and appropriateness of referral were recorded.

RESULTS

Overall 422 patients, representing 10% of all ISAEC patients in the study period, were referred for surgical assessment. The average wait times for surgical assessment were 5.4, 4.3 and 2.2 weeks at the metropolitan, urban and rural centres, respectively. Referral MRI usage for the group decreased by 31%. Of the patients referred for formal surgical assessment, 80% had leg-dominant pain and 96% were deemed appropriate surgical referrals.

CONCLUSION

Contrary to geographic concentration of health care resources in metropolitan settings, the greatest decrease in wait times was achieved in the rural setting. A networked, shared-cared model of care for patients with low back pain-related symptoms significantly improved access for surgical assessment despite varying geographic practice settings and barriers. The greatest reductions were noted in the rural setting. In addition, significant improvements in referral appropriateness and efficiency were achieved compared with historical reports across all sites.

Musculoskeletal Disorders a Universal Source of Pain and Disability Misunderstood and Mismanaged: A Critical Analysis Based on the U.S. Model of Care

Musculoskeletal disorders are the leading source of pain and disability globally but are especially prevalent in the industrialized nations including the U.S. In addition to the substantial individual suffering caused the rising monetary costs of these disorders are noteworthy. In the U.S. alone the annual costs have been estimated to be $874 billion 5.7% of the annual U.S. G.D.P. Despite these expenditures the care provided to patients with musculoskeletal disorders is highly variable and has regularly been shown to have suboptimal outcomes. The many reasons for this ineffective care include the mutable nature of the prevailing syndromes and their limited and variable understanding. The care rendered by a broad and incongruent group of providers who practice disparate methodologies and employ variable treatments. Disorderedly triage comprised of arbitrary selection of providers, care methodologies, and treatments, which is prone to a range of extraneous influences. Treatments that are unable to apprehend the causative pathological processes, which are therefore progressive, cause irreversible damage to the respective musculoskeletal structures, and result in enduring pain and disability. The overall lack of preventative care and the consequent prevalence of these disorders especially in specific work environments and with certain high-risk life styles. This article makes recommendations for better understanding, prevention, early recognition, timely employment of disease altering therapies, streamlining the existing care, and policy initiatives for waste confinement and improvement. These discernments may improve the overall quality of care provided to these patients, diminish the staggering pain and disability caused, and can reduce the immense costs incurred.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction

BACKGROUND

Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience.

METHODS

An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire.

RESULTS

The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100).

CONCLUSION

In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.

Patients' Attitudes Toward Nonphysician Screening of Low Back and Low Back Related Leg Pain Complaints Referred for Surgical Assessment

STUDY DESIGN

A questionnaire survey.

OBJECTIVE

The aim of this study was to explore patient attitudes toward screening to assess suitability for low back surgery by nonphysician health care providers.

SUMMARY OF BACKGROUND DATA

Canadian spine surgeons have shown support for nonphysician screening to assess and triage patients with low back pain and low back related leg pain. However, patients' attitudes toward this proposed model are largely unknown.

METHODS

We administered a 19-item cross-sectional survey to adults with low back and/or low back related leg pain who were referred for elective surgical assessment at one of five spine surgeons' clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician health care providers.

RESULTS

Eighty low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a nonphysician health care provider to establish whether they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician health care provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons' and nonphysicians' determination of surgical candidates.

CONCLUSION

Patients referred for surgical consultation for low back or low back related leg pain are largely willing to accept screening by nonphysician health care providers. Future research should explore the concordance of screening results between surgeon and nonphysician health care providers.

LEVEL OF EVIDENCE

3.

Differences among primary care patients with different mechanical patterns of low back pain: a cross-sectional investigation

OBJECTIVES

To characterise and compare a persistent low back pain (LBP) population based on 4 clinical pain patterns.

DESIGN

Cross-sectional analysis of patient-reported data.

SETTING

Patients from 220 primary care practitioners in 3 cities in Ontario, Canada.

PARTICIPANTS

1020 individuals seeking LBP care.

INCLUSION CRITERIA

LBP symptoms lasting 1½-12 months, or unmanageable recurrent symptoms; ages 18+years.

EXCLUSION CRITERIA

pregnant/1-year postpartum; involved in active litigation or motor vehicle injury; emergent spinal presentations; pain disorder diagnosis; work injury claim; or constant symptoms persisting >12 months postonset.

MAIN OUTCOME MEASURE

Hall pain pattern subgroups: back dominant pain aggravated by flexion (P1) or extension (P2), or leg dominant constant (P3) or intermittent (P4) pain (multinomial logistic outcome; referent: P1).

RESULTS

Groups P1 and P2 had the highest proportion of women. P2 and P4 had higher mean ages and comorbidity counts. P3 and P4 had higher proportions of overweight/obese individuals and lower general health scores. Adjusted models: being male and overweight/obese was associated with increased odds of being in P3 (OR 1.64 (95% CI 1.10 to 2.46), and OR 1.74 (1.13 to 2.68), respectively) and P4 (OR 1.87 (1.11 to 3.15) and OR 1.91 (1.06 to 3.42), respectively), and increasing age with increased odds of being in P2 (OR 1.02 (1.01 to 1.03)) and P4 (OR 1.06 (1.04 to 1.08)). Increasing comorbidity count was associated with increased odds of being in P2 (OR 1.14 (1.0 to 1.3)), and better general health scores with decreased odds of being in P3 (OR 0.40 (0.18 to 0.93)).

CONCLUSIONS

This is the first study to examine the 'Hall system' in a non-rehab primary care population. Subgroups classified according to this system appear to have distinct profiles. Further research is needed to better characterise and determine the prognostic implication of these clinically derived subgroups.

Reliability among clinicians diagnosing low back-related leg pain

PURPOSE

To investigate agreement and reliability among clinicians when diagnosing low back-related leg pain (LBLP) in primary care consulters.

METHODS

Thirty-six patients were assessed by one of six physiotherapists and diagnosed as having either leg pain due to nerve root involvement (sciatica) or referred leg pain. Assessments were video recorded. In part one, the physiotherapists each viewed videos of six patients they had not assessed. In part two, videos were viewed by another six health professionals. All clinicians made an independent differential diagnosis and rated their confidence with diagnosis (range 50-100 %).

RESULTS

In part one agreement was 72 % with fair inter-rater reliability (K = 0.35, 95 % CI 0.07, 0.63). Results for part two were almost identical (K = 0.34, 95 % CI 0.02, 0.69). Agreement and reliability indices improved as diagnostic confidence increased.

CONCLUSION

Reliability was fair among clinicians from different backgrounds when diagnosing LBLP but improved substantially with high confidence in clinical diagnosis.

The McAndrews Leadership Lecture: February 2015, by Dr Scott Haldeman. Challenges of the Past, Challenges of the Present

The McAndrews Leadership Lecture was developed by the American Chiropractic Association to honor the legacy of Jerome F. McAndrews, DC, and George P. McAndrews, JD, and their contributions to the chiropractic profession. This article is a transcription of the presentation made by Dr Scott Haldeman on February 28, 2015, in Washington, DC, at the National Chiropractic Leadership Conference.

Improving health care efficiency through the integration of a physician assistant into an infectious diseases consult service at a large urban community hospital

Physician assistants have recently been introduced into the Canadian health care system. The impact of the integration of physician assistants into various health care fields in the United States has been studied in detail; however, there is a lack of Canadian data regarding this topic. Accordingly, this study compared outcomes related to health care efficiency in the two-year period before the integration of a physician assistant at an infectious diseases consult service with the two-year period after integration.

BACKGROUND:

Physician assistants (PAs) have recently been introduced into the Canadian health care system in some provinces; however, there are little data demonstrating their impact.

METHODS:

A retrospective case-control study was conducted between January 2010 and December 2013. Length of stay (LOS) and mortality were examined in the infectious diseases consult service (IDCS) compared with hospital-wide controls. The two-year period before the introduction of the PA to the IDCS of a large urban community hospital in Canada (2010 to 2011) was compared with the two-year period following the introduction of the PA (2012 to 2013).

RESULTS:

Following the introduction of a PA to the IDCS, there was a decrease in time to consultation from 21.4 h to 14.3 h (P<0.0001). LOS was significantly decreased among IDCS patients by 3.6 days more than that seen in matched hospital-wide controls (P=0.0001). Mortality did not significantly change after PA introduction in either cases or controls.

DISCUSSION/CONCLUSION:

PAs can improve health efficiencies in the Canadian health care setting, leading to reduction in LOS.

The Chiropractic Hospital-Based Interventions Research Outcomes Study: Consistency of Outcomes Between Doctors of Chiropractic Treating Patients With Acute Lower Back Pain

OBJECTIVE

The aim of this study was to determine if effectiveness differs between community-based doctors of chiropractic administering standardized evidence-based care that includes high-velocity low-amplitude spinal manipulative therapy (SMT) for acute low back pain (LBP).

METHODS

A secondary analysis of randomized controlled trial and observational pilot study data was performed with nonrandom allocation to 4 DCs. Patients included those with Quebec Task Force categories less than or equal to 2 and acute LBP of 2 to 4 weeks' duration. The intervention provided was clinical practice guidelines-based care including high-velocity low-amplitude SMT. Primary outcomes included changes from baseline in modified Roland Disability Questionnaire (RDQ) at 24 weeks. Comparisons of simple main effects at 24 weeks and of marginal main effects in repeated-measures analyses were performed.

RESULTS

Between groups, adjusted point-specific differences in RDQ change were minimally clinically important but not statistically significant at 24 weeks (largest pairwise difference, -3.1; 95% confidence interval, -6.3 to 0.1; overall P = .10). However, in optimal analyses that considered the repeated nature of the measurements for each outcome, significant differences in marginal mean RDQ changes were found between groups (largest pairwise difference, -3.8; 95% confidence interval, -4.9 to 2.6; overall P = .03).

CONCLUSIONS

Overall, DCs differed modestly in their effectiveness in improving LBP-specific disability. The point estimates mirrored typically reported effect sizes from recent systematic reviews of SMT; however, confidence limits did not exclude clinically negligible effects.

What is orthopaedic triage? A systematic review

RATIONALE, AIMS AND OBJECTIVES

Complex and chronic disease is placing significant pressure on hospital outpatient departments. Novel ways of delivering care have been developed recently and are often described as 'triage' services. This paper reviews the literature pertaining to definitions and descriptions of orthopaedic/musculoskeletal triage processes, in order to provide information on 'best practice' to assist health care facilities.

METHOD

A comprehensive open-ended search was conducted using electronic databases to identify studies describing models of triage clinics for patients with a musculoskeletal/orthopaedic complaint, who have been referred to hospital outpatient clinics for a surgical consultation. Studies were critically appraised using the McMaster quality appraisal tool and ranked using the National Health and Medical Research Council hierarchy of evidence. A thematic analysis of the definitions, processes and procedures of triage described within the literature was undertaken.

RESULTS

1930 studies were identified and 45 were included in the review (including diagnostic and evaluative research). The hierarchy of evidence ranged from I to IV; however, the majority were at low levels of evidence and scored poorly on the critical appraisal tool. Three broad themes of triage were identified: presence of a referral, configuration of the triage (who, how and where) and the aim of triage. However, there were significant inconsistencies across these themes.

CONCLUSIONS

This systematic review highlighted the need for standardization of the definition of triage, the procedures of assessment and management and measures of outcome used in orthopaedic/musculoskeletal triage to ensure best-practice processes, procedures and outcomes for triage clinics.

Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes

STUDY DESIGN

Retrospective medical record review.

OBJECTIVE

To (1) determine if outpatient referrals for low back pain (LBP) and leg pain triaged through a multidisciplinary spine care pathway (group A) were more likely to be candidates for surgery than conventional physician referrals (group B); (2) compare relevant clinical differences in the 2 groups (e.g., diagnosis, pain scores, level of disability); and (3) compare wait times for magnetic resonance imaging and surgical assessment.

SUMMARY OF BACKGROUND DATA

The Saskatchewan Spine Pathway was introduced on the basis of evidence that a co-ordinated, multidisciplinary, and stratified approach to the assessment and management of LBP may improve quality. During early implementation, some physicians began to refer patients to Saskatchewan Spine Pathway clinics, whereas others continued to refer patients directly to the surgeon through the conventional process.

METHODS

We retrospectively analyzed consecutive new outpatient referrals for LBP and leg pain, June 1, 2011 through May 30, 2012 for 2 surgeons.

RESULTS

We identified 215 referrals, including 66 (30.7%) in group A and 149 (69.3%) in group B. There was no difference in overall health (mean EuroQol Group 5-Dimension Self-Report Questionnaire visual analogue scale) or lower back-related disability score (Oswestry Disability Index). Group A patients were significantly more likely to be candidates for surgery (59.1% vs. 37.6% for group B; P = 0.0034, χ test), had significantly poorer scores for EuroQol Group 5-Dimension Self-Report Questionnaire mobility, a higher proportion of leg dominant pain, and a lower proportion of back dominant pain. Group A patients also had significantly shorter wait times for magnetic resonance imaging and surgical assessment.

CONCLUSION

A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs.

LEVEL OF EVIDENCE

3.

Spine surgeons' requirements for imaging at the time of referral: a survey of Canadian spine surgeons

BACKGROUND

Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals.

METHODS

We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints.

RESULTS

Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints.

CONCLUSION

Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.