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Marotte L, Marsaa H, Robin N, Sellier A, Beucler N, Thefenne L, Dagain A, Joubert C. Neurosurgical Consultation Referral from the Forces: Regarding 328 Patients Referred to the Department of Neurosurgery, Sainte Anne Military Hospital, France. Mil Med 2024; 189:1114-1122. [PMID: 37032562 DOI: 10.1093/milmed/usad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/13/2022] [Accepted: 03/15/2023] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION There are little data regarding elective referral to the military specialist, especially considering common pathologies such as spinal diseases, which, in the French forces, involve military neurosurgeons. An overview of the management of the military patient referred to neurosurgery consultation, especially considering spinal diseases that both constitute an operational healthissue in the forces and appear of special interest. The objective was to describe the reasons, demographics, and care pathways, addressed to the neurosurgeon. MATERIALS AND METHODS This retrospective, single-center study focused on all military patients referred for neurosurgery consultation at Sainte Anne Military Hospital in Toulon. Extracted data included demographic characteristics, army, unit, military specialty, the reason for referral, the diagnosis by the neurosurgeon, treatment, and outcome. RESULTS From January 2018 to December 2019, 352 patients were referred for neurosurgical consultation by the unit general practitioner. Spinal disease (n = 297, 91%) was the most frequent reason. Lumbar degenerative disk disease accounted for 20% of consultations, regardless of the patient's unit or specialty. Most of the patients seen in consultation received nonsurgical management (n = 271, 82.6%). These patients mainly presented with cervical or lumbar degenerative disk disease (n = 99, 36.5%) or cervical or lumbar herniated discs (n = 57, 21.0%). Ninety-eight patients (29.9%) were referred exclusively for medical fitness assessment. Few patients experienced full resolution of their presenting complaint after management (n = 9, 2.8%). CONCLUSIONS This descriptive study demonstrates the predominance of degenerative spinal diseases in military patients referred to neurosurgery. It reflects the importance of the medical and military competence required to maintain operational capability upstream and downstream of war traumatology. The description of the care pathways invites us to define more proactive multidisciplinary pathways for the management of these diseases in the armed forces.
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Affiliation(s)
- Louis Marotte
- Department of neurosurgery, Sainte Anne Military Hospital, Toulon 83800, France
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris 75005, France
| | - Hélène Marsaa
- Antenne médicale 148, 9e Centre Médical des Armées, Hyères 83400, France
| | - Nicolas Robin
- Service Médical de la Force d'Action Navale, Toulon 83000, France
| | - Aurore Sellier
- Department of neurosurgery, Sainte Anne Military Hospital, Toulon 83800, France
| | - Nathan Beucler
- Department of neurosurgery, Sainte Anne Military Hospital, Toulon 83800, France
| | - Laurent Thefenne
- Department of Rehabilitation, Laveran Military Hospital, Marseille 13384, France
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris 75005, France
| | - Arnaud Dagain
- Department of neurosurgery, Sainte Anne Military Hospital, Toulon 83800, France
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris 75005, France
| | - Christophe Joubert
- Department of neurosurgery, Sainte Anne Military Hospital, Toulon 83800, France
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Duarte ST, Moniz A, Costa D, Donato H, Heleno B, Aguiar P, Cruz EB. Low back pain management in primary healthcare: findings from a scoping review on models of care. BMJ Open 2024; 14:e079276. [PMID: 38754873 PMCID: PMC11097853 DOI: 10.1136/bmjopen-2023-079276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Models of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the effectiveness and sustainability of healthcare services. OBJECTIVE To synthesise research evidence regarding core characteristics and key common elements of MoCs implemented in primary healthcare for the management of LBP. DESIGN Scoping review. DATA SOURCES Searches on MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were conducted. ELIGIBILITY CRITERIA Eligible records included MoCs implemented for adult LBP patients in primary healthcare settings. DATA EXTRACTION AND SYNTHESIS Data extraction was carried out independently by two researchers and included a summary of the studies, the identification of the MoCs and respective key elements, concerning levels of care, settings, health professionals involved, type of care delivered and core components of the interventions. Findings were investigated through a descriptive qualitative content analysis using a deductive approach. RESULTS 29 studies reporting 11 MoCs were included. All MoCs were implemented in high-income countries and had clear objectives. Ten MoCs included a stratified care approach. The assessment of LBP patients typically occurred in primary healthcare while care delivery usually took place in community-based settings or outpatient clinics. Care provided by general practitioners and physiotherapists was reported in all MoCs. Education (n=10) and exercise (n=9) were the most common health interventions. However, intervention content, follow-ups and discharge criteria were not fully reported. CONCLUSIONS This study examines the features of MoCs for LBP, highlighting that research is in its early stages and stressing the need for better reporting to fill gaps in care delivery and implementation. This knowledge is crucial for researchers, clinicians and decision-makers in assessing the applicability and transferability of MoCs to primary healthcare settings.
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Affiliation(s)
- Susana Tinoco Duarte
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
| | - Alexandre Moniz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Daniela Costa
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Department of Physiotherapy, Escola Superior de Saúde do Alcoitão, Alcabideche, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Bruno Heleno
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Pedro Aguiar
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
| | - Eduardo B Cruz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA University Lisbon, Lisboa, Portugal
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French ZP, Hundal RS, McGee AC, Winzenried AE, Williams SK. Spine surgeon triage of new patient referrals: quantification of surgical conversion rate by clinic referral source. Spine J 2024:S1529-9430(24)00112-8. [PMID: 38499065 DOI: 10.1016/j.spinee.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/28/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND CONTEXT In an effort to efficiently deliver high-value spine surgical care, spine surgery clinics may triage new patient referrals. A triage system with attending surgeon review of referred patient images may improve the surgical conversion rate (SCR) of a spine surgical clinic, and shift the distribution of new patients in clinic toward those most likely to derive benefit from surgery. PURPOSE To quantify SCR and number of triage steps by referral source in a tertiary referral spine clinic where all referrals are triaged by attending surgeons. DESIGN All spine surgery clinic patients seen for a new patient visit (NPV) at an academic medical center over a one-year period had their triage process and outcome (surgery or no surgery) reviewed. PATIENT SAMPLE The 1398 new adult patients seen for elective spine pathology were queried. OUTCOME MEASURES SCR was defined as the percentage of new patients who underwent elective spine surgery within 18 months of NPV. Triage steps were defined as an action item by triage staff (ie, obtaining patient records) or by the patient (ie, undergoing additional imaging). METHODS All new patient visits were evaluated for referral source, number of triage steps, and triage outcome. Time from referral to NPV, and time from NPV to surgery were also recorded. SCR, triage steps, and time-intervals were calculated for each surgeon and referral source and compared. Statistical analysis of variance (ANOVA) was used to ascertain differences. RESULTS The overall SCR for the 4-surgeon group was 41.6%. This ranged among the surgeons from 24.7% to 60.1%. The referral sources with the highest SCR were in-system spine advanced practice providers (APPs) and in-system physical medicine and rehabilitation providers. Spine APPs also demonstrated the smoothest referral process, requiring the fewest steps. CONCLUSIONS Our findings provide a framework for assessment of triage processes at other institutions, as well as the impact of upgrades to our triage process as we work to improve triage efficiency. In the present study, referrals from providers familiar with spine pathology resulted in the highest SCR and fewest triage steps.
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Affiliation(s)
- Zachary P French
- Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, 600 Highland Ave, Madison, WI 53792, USA.
| | - Rajbir S Hundal
- Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, 600 Highland Ave, Madison, WI 53792, USA; Department of Orthopaedic Surgery and Rehabilitation, Wake Forest School of Medicine, 611 Lindsay St. Suite 100, 102 and 200, High Point, NC 27262, USA
| | - Anna C McGee
- Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - Alec E Winzenried
- Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - Seth K Williams
- Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, 600 Highland Ave, Madison, WI 53792, USA
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Gu Y, Wang Z, Shi H, He Y, Yang Y, Li Y, Chen S, Wang Z, Mei Y, Xiao L. Global, Regional, and National Change Patterns in the Incidence of Low Back Pain From 1990 to 2019 and Its Predicted Level in the Next Decade. Int J Public Health 2024; 69:1606299. [PMID: 38450278 PMCID: PMC10915756 DOI: 10.3389/ijph.2024.1606299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/06/2024] [Indexed: 03/08/2024] Open
Abstract
Objectives: To analyze and describe the spatiotemporal trends of Low back pain (LBP) burdens from 1990 to 2019 and anticipate the following decade's incidence. Methods: Using data from the Global Burden of Disease (GBD) 2019 Study, we described net drifts, local drifts, age effects, and period cohort effects in incidence and forecasted incidence rates and cases by sex from 2020 to 2029 using the Nordpred R package. Results: LBP remained the leading cause of the musculoskeletal disease burden globally and across all socio-demographic index (SDI) regions. China is the top country. For recent periods, high-SDI countries faced unfavorable or worsening risks. The relative risk of incidence showed improving trends over time and in successively younger birth cohorts amongst low-middle-, middle- and high-middle-SDI countries. Additionally, the age-standardized incidence rates (ASIR) of LBP in both sexes globally showed a decreasing trend, but the incident cases would increase from 223 to 253 million overall in the next decade. Conclusion: As the population ages, incident cases will rise but ASIR will fall. To minimise LBP, public awareness and disease prevention and control are needed.
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Affiliation(s)
- Yong Gu
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Zhengming Wang
- Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Haiwei Shi
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Yanlin He
- Key Laboratory of Carbohydrate Chemistry and Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Yunshang Yang
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Yajun Li
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Shuangshuang Chen
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Zhirong Wang
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Yubo Mei
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Long Xiao
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
- Department of Orthopedics, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
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Mathieu J, Robert MÈ, Châtillon CÉ, Descarreaux M, Marchand AA. Appropriateness of specialized care referrals for LBP: a cross-sectional analysis. Front Med (Lausanne) 2024; 10:1292481. [PMID: 38249968 PMCID: PMC10797061 DOI: 10.3389/fmed.2023.1292481] [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: 09/12/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Background Low back pain (LBP) accounts for a significant proportion of primary care visits. Despite the development of evidence-based guidelines, studies point to the inefficient use of healthcare resources, resulting in over 60.0% of patients with LBP being referred to spine surgeons without any surgical indication. Centralized waiting lists (CWLs) have been implemented to improve access to specialized care by managing asymmetry between supply and demands. To date, no study has provided data on patients' clinical profiles and referral patterns to medical specialists for LBP in the context of a publicly funded healthcare system operating a prioritization model. The objective of this study was to evaluate the appropriateness of specialized care referrals for LBP after the implementation of a CWL. Methods A retrospective cross-sectional analysis of 500 randomly selected electronic health records of patients who attended the outpatient neurosurgery clinic of the administrative Mauricie-et-Centre-du-Québec region was performed. Inclusion criteria were neurosurgery consultation referrals for adults ≥18 years suffering from a primary complaint of LBP, and performed between September 1st, 2018, and September 1st, 2021. Data relevant for drawing a comprehensive portrait of patients referred to the neurosurgery service and for judging referrals appropriateness were manually extracted. Results Of the 500 cases analyzed, only 112 (22.4%) were surgical candidates, while 221 (44.2%) were discharge from the neurosurgery service upon initial assessment. Key information was inconsistently documented in medical files, thus preventing the establishment of a comprehensive portrait of patients referred to the neurosurgery service for LBP. Nevertheless, over 80.0% of referrals made during the study period were deemed inappropriate. Inappropriate referrals were characterized by higher proportion of patients symptomatically improved, presenting a back-dominant chief complaint, exhibiting no objective neurological symptoms, and diagnosed with non-specific LBP. Conclusion This study reveals a significant proportion of inappropriate referrals to specialized care for LBP. Further research is needed to better understand the factors that prompt referrals to medical specialists for LBP, and the criteria considered by neurosurgeons when selecting the appropriate management strategy. Recent studies suggest that triaging approaches led by musculoskeletal experts may improve referral appropriateness to specialized care.
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Affiliation(s)
- Janny Mathieu
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Marie-Ève Robert
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Claude-Édouard Châtillon
- Centre intégré universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, QC, Canada
- Division of Neurosurgery, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Martin Descarreaux
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Andrée-Anne Marchand
- Department of Chiropractic, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
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Clinical pathways for the management of low back pain from primary to specialised care: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1846-1865. [PMID: 35378631 DOI: 10.1007/s00586-022-07180-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Clinical pathways for low back pain (LBP) have potential to improve clinical outcomes and health service efficiency. This systematic review aimed to synthesise the evidence for clinical pathways for LBP and/or radicular leg pain from primary to specialised care and to describe key pathway components. METHODS Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) from 2006 onwards were conducted with further manual and citation searching. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. A narrative synthesis of findings is presented. RESULTS From 18,443 identified studies, 28 papers met inclusion criteria. Pathways were developed primarily to address over-burdened secondary care services in high-income countries and almost universally used interface services with a triage remit at the primary-secondary care boundary. Accordingly, evaluation of healthcare resource use and patient flow predominated, with interface services associated with enhanced service efficiency through decreased wait times and appropriate use of consultant appointments. Low quality study designs, heterogeneous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical- and cost-effectiveness. Pathways demonstrated basic levels of care integration across the primary-secondary care boundary. CONCLUSIONS The limited volume of research evaluating clinical pathways for LBP/radicular leg pain and spanning primary and specialised care predominantly used interface services to ensure appropriate specialised care referrals with associated increased efficiency of care delivery. Pathways demonstrated basic levels of care integration across healthcare boundaries. Well-designed randomised controlled trials to explore the potential of clinical pathways to improve clinical outcomes, deliver cost-effective, guideline-concordant care and enhance care integration are required.
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Belavy DL, Tagliaferri SD, Buntine P, Saueressig T, Sadler K, Ko C, Miller CT, Owen PJ. Clinician education unlikely effective for guideline-adherent medication prescription in low back pain: systematic review and meta-analysis of RCTs. EClinicalMedicine 2022; 43:101193. [PMID: 35028542 PMCID: PMC8741480 DOI: 10.1016/j.eclinm.2021.101193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Effectiveness of implementing interventions to optimise guideline-recommended medical prescription in low back pain is not well established. METHODS A systematic review and random-effects meta-analyses for dichotomous outcomes with a Paule-Mandel estimator. Five databases and reference lists were searched from inception to 4th August 2021. Randomised controlled/clinical trials in adults with low back pain to optimise medication prescription were included. Cochrane Risk of Bias 2 tool and GRADE were implemented. The review was registered prospectively with PROSPERO (CRD42020219767). FINDINGS Of 3352 unique records identified in the search, seven studies were included and five were eligible for meta-analysis (N=11339 participants). Six of seven studies incorporated clinician education, three studies included audit/feedback components and one study implemented changes in medical records systems. Via meta-analysis, we estimated a non-significant odds-ratio of 0·94 (95% CI (0·77; 1.16), I² = 0%; n=5 studies, GRADE: low) in favour of the intervention group. The main finding was robust to sensitivity analyses. INTERPRETATION There is low quality evidence that existing interventions to optimise medication prescription or usage in back pain had no impact. Peer-to-peer education alone does not appear to lead to behaviour change. Organisational and policy interventions may be more effective. FUNDING This work was supported by internal institutional funding only.
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Affiliation(s)
- Daniel L Belavy
- Hochschule für Gesundheit (University of Applied Sciences), Department of Applied Health Sciences, Division of Physiotherapy, Gesundheitscampus 6-8, 44801, Bochum, Germany
- Corresponding author. Prof. Daniel L Belavy, Hochschule für Gesundheit (University of Applied Sciences), Department of Applied Health Sciences, Division of Physiotherapy, Gesundheitscampus 6-8, 44801, Bochum, Germany. Tel: +49 234 77727 632
| | - Scott D Tagliaferri
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia
| | - Paul Buntine
- Eastern Health, Box Hill Hospital, Emergency Department, 5 Arnold St, Box Hill, Victoria 3128, Australia
- Monash University, Eastern Health Clinical School, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia
| | | | - Kate Sadler
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia
| | - Christy Ko
- Eastern Health, Box Hill Hospital, Emergency Department, 5 Arnold St, Box Hill, Victoria 3128, Australia
| | - Clint T Miller
- Deakin University, School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia
| | - Patrick J Owen
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia
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Fourney DR. Commentary: Predicting Spinal Surgery Candidacy From Imaging Data Using Machine Learning. Neurosurgery 2021; 89:E16-E17. [PMID: 33989412 DOI: 10.1093/neuros/nyab127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daryl R Fourney
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Canada
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Huschi Z, Neuburger L, Ahmed SU, Cheng Y, Fourney DR. Nerve root sedimentation sign on MRI: A triage screen for leg dominant symptoms? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3289-3296. [PMID: 34278520 DOI: 10.1007/s00586-021-06919-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/21/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Surgical indications for lumbar spinal stenosis are controversial, but most agree that leg dominant pain is a better predictor of success after decompression surgery. The objective of this study is to analyze the ability of the Nerve Root Sedimentation Sign (SedSign) on MRI to differentiate leg dominant symptoms from non-specific low back pain. METHODS This was a retrospective review of 367 consecutive patients presenting with back and/or leg pain. Baseline clinical characteristics included Oswestry disability index (ODI), visual analog pain scores, EuroQol Group 5-Dimension Self-Report (EQ5D) and Saskatchewan Spine Pathway Classification (SSPc). Inter- and intra-rater reliability for SedSign was 73% and 91%, respectively (3 examiners). RESULTS SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. On univariate analysis, a positive SedSign was correlated with age, male sex, several ODI components, EQ5D mobility, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and SSPc pattern 4 (intermittent leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI walking distance. Patients with a positive SedSign were more likely to be offered surgery after referral (OR 2.65). The sensitivity and specificity for detecting all types of leg dominant pain were 37.4 and 82.8, respectively (ppv 77.5%, npv 43.8%). CONCLUSIONS Patients with a positive SedSign were more likely to be offered surgery, in particular non-instrumented decompression. The SedSign has high specificity for leg dominant pain, but the sensitivity is poor. As such, its use in triaging appropriate surgical referrals is limited.
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Affiliation(s)
- Zachary Huschi
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Laura Neuburger
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Syed Uzair Ahmed
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yanzhao Cheng
- Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Daryl R Fourney
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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Abstract
STUDY DESIGN Single-center prospective non-randomized matched cohort comparison. OBJECTIVE To compare elective lumbar spine surgery outcomes for cases triaged through a multidisciplinary spine pathway versus conventional referral processes. SUMMARY OF BACKGROUND DATA Many health care systems have facilitated low back pain (LBP) guidelines into primary care practice by creating local or regional "pathways" with the goal of enhanced quality of care, improved patient satisfaction and optimal resource utilization, particularly for imaging and surgery. Few comparative outcomes exist for LBP pathways, particularly for surgical outcomes. METHODS One-hundred-fifty patients (SSP group n = 75; conventional group n = 75) undergoing elective lumbar surgery for degenerative conditions between 2011 and 2016 were analyzed with 1-year follow-up. Patient self-reported outcomes included the Oswestry disability index (ODI), visual analogue pain scores (VAS) for back and leg, and EuroQol Group 5-Dimension self-report (EQ-5D). We also assessed baseline clinical features, indications for surgery, therapies received prior to surgery, type of surgery, wait times, and overall patient satisfaction. RESULTS The groups had equivalent baseline demographics, body mass index, Saskatchewan Spine Pathway (SSP) classification of pain pattern, pain scores, functional scores, quality of life scores, indication for surgery, and type of surgery (instrumented or non-instrumented). There was no difference with respect to wait times to see the surgeon or for surgery. Wait time for magnetic resonance imaging (MRI) was significantly shorter for the SSP group (16.8 vs. 63.0 days, P < 0.001). Patients triaged through the SSP were significantly more likely to utilize multiple nonoperative treatment strategies prior to seeing the surgeon (P < 0.04). Patient satisfaction was significantly higher for SSP patients prior to surgical assessment (P = 0.03) but did not differ between groups after surgery. CONCLUSION The SSP facilitates significantly shorter wait times for MRI and promotes nonoperative treatment strategies. Preoperative patient satisfaction is significantly higher among SSP patients, but there were no significant differences in surgical outcomes.Level of Evidence: 3.
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Alhowimel A, Alodaibi F, Alotaibi M, Alamam D, Alsobayel H, Fritz J. Development of a Logic Model for a Programme to Reduce the Magnetic Resonance Imaging Rate for Non-Specific Lower Back Pain in a Tertiary Care Centre. Healthcare (Basel) 2021; 9:healthcare9020238. [PMID: 33672242 PMCID: PMC7926309 DOI: 10.3390/healthcare9020238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 11/16/2022] Open
Abstract
Tertiary care centres continue to experience over-utilisation of diagnostic imaging services for lower back pain cases that may not be required. Moreover, these services may require additional time and consequently delay access to services that offer conservative management, i.e., physiotherapy, and hence, increase the direct and indirect costs with no added quality of care. A logic model was developed based on qualitative and quantitative studies that explains the plan and process evaluation strategies to reduce imaging for lower back pain in tertiary hospitals. Logic models are useful tools for defining programme components. The delivery of the components is ensured by well-defined process evaluations that identify any needed modifications. The proposed logic model provides a road map for spine clinics in tertiary care hospitals to decrease the number of patient referrals for magnetic resonance imaging and waiting times for consultations and services and promote early access to physiotherapy services.
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Affiliation(s)
- Ahmed Alhowimel
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia;
- Correspondence:
| | - Faris Alodaibi
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Mazyad Alotaibi
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia;
| | - Dalyah Alamam
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Hana Alsobayel
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT 84112, USA;
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Coeckelberghs E, Verbeke H, Desomer A, Jonckheer P, Fourney D, Willems P, Coppes M, Rampersaud R, van Hooff M, van den Eede E, Kulik G, de Goumoëns P, Vanhaecht K, Depreitere B. International comparative study of low back pain care pathways and analysis of key interventions. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1043-1052. [PMID: 33427958 DOI: 10.1007/s00586-020-06675-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Low back pain (LBP) is a major public health problem worldwide. Significant practice variation exists despite guidelines, including strong interventionist focus by some practitioners. Translation of guidelines into pathways as integrated treatment plans is a next step to improve implementation. The goal of the present study was to analyze international examples of LBP pathways in order to identify key interventions as building elements for care pathway for LBP and radicular pain. METHODS International examples of LBP pathways were searched in literature and grey literature. Authors of pathways were invited to fill a questionnaire and to participate in an in-depth telephone interview. Pathways were quantitatively and qualitatively analyzed, to enable the identification of key interventions to serve as pathway building elements. RESULTS Eleven international LBP care pathways were identified. Regional pathways were strongly organized and included significant training efforts for primary care providers and an intermediate level of caregivers in between general practitioners and hospital specialists. Hospital pathways had a focus on multidisciplinary collaboration and stepwise approach trajectories. Key elements common to all pathways included the consecutive screening for red flags, radicular pain and psychosocial risk factors, the emphasis on patient empowerment and self-management, the development of evidence-based consultable protocols, the focus on a multidisciplinary work mode and the monitoring of patient-reported outcome measures. CONCLUSION Essential building elements for the construction of LBP care pathways were identified from a transversal analysis of key interventions in a study of 11 international examples of LBP pathways.
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Affiliation(s)
| | - Hilde Verbeke
- Leuven Center for Algology and Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Anja Desomer
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | | | - Daryl Fourney
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Paul Willems
- Department of Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maarten Coppes
- Groningen Spine Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Raja Rampersaud
- Department of Surgery, Division of Orthopaedics, University Health Network Toronto, Toronto, Canada
| | | | | | - Gerit Kulik
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Pierre de Goumoëns
- Department of Rheumatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KULeuven, Leuven, Belgium
| | - Bart Depreitere
- Neurosurgery, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.
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13
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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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Alhowimel AS, Alodaibi FA, Alotaibi MA, Alamam DM, Fritz J. Management of Low back pain in Saudi Arabia healthcare system. A Qualitative Study. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2021; 58:469580211060178. [PMID: 34865543 PMCID: PMC8646777 DOI: 10.1177/00469580211060178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Patients with chronic low back pain can contribute to a global socioeconomic burden. Current international recommendations emphasize that low back pain management should occur at the primary-care level. However, there is a lack of essential services for low back pain management at the primary-care level in Saudi Arabia. We explored the current state of low back pain management in Saudi Arabia from the perspective of spine surgeons and physiotherapists. Methods A qualitative study with semi-structured interviews was conducted on spine surgeons and physiotherapists. A total of 17 healthcare workers, 8 spine surgeons (age range 28–49 years) and 9 physiotherapists (age range 30–49 years) participated in the study. Data were recorded and analyzed thematically. Results Three main themes were identified from the interview data that outlined current low back pain management in Saudi Arabia: clinical guideline availability and pathways of care, utilization of primary care services, and overutilization of secondary care resources. Conclusions This study suggests underutilization of primary care services and overutilization of secondary care services in Saudi Arabia. Therefore, the implementation of local clinical guidelines could improve patient care as well as reduce the cost of low back pain management.
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Affiliation(s)
- Ahmed S. Alhowimel
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Alkarj, Saudi Arabi
| | - Faris A. Alodaibi
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Mazyad A. Alotaibi
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Alkarj, Saudi Arabi
| | - Dalyah M. Alamam
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
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Alhowimel A, Alotiabi M, Coulson N, Radford K. Feasibility study and process evaluation of MRI plus physiotherapy vs. physiotherapy alone in non-specific chronic low back pain among patients in Saudi Arabia. Pilot Feasibility Stud 2020; 6:188. [PMID: 33292710 PMCID: PMC7702682 DOI: 10.1186/s40814-020-00731-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/18/2020] [Indexed: 11/12/2022] Open
Abstract
Aim To determine the feasibility of conducting a definitive randomised control trial (RCT) to answer the following questions: (1) Is early physiotherapy treatment acceptable and feasible for patients and direct healthcare providers? and (2) Is early physiotherapy intervention associated with better disability and psychosocial outcomes compared with the practice of routine MRIs? Methods In a feasibility RCT in Riyadh City from 01 March 2018 until 29 July 2018, chronic low back pain (CLBP) patients presenting to spine clinics were randomised to receive an MRI (intervention) plus physiotherapy rehabilitation or physiotherapy alone (control group). The acceptability of randomisation to the control group (non-MRI) was tested during the recruitment by qualitatively interviewing study participants and referring physicians. Moreover, interviews with study participants explored the broader social, political, economic, and environmental (context) aspects that may influence trial delivery and intervention implementation. Results The recruitment target was not met: 16/24 (66%) participants were recruited in 4 months (12.4% of those screened); 33% declined. The process evaluation identified numerous factors that may affect the success of a definitive RCT in Saudi Arabia. These were research resources, the lack of research infrastructure to support recruitment to trials, limited research capacity in terms of knowledge and skills of the healthcare team, and limited funding. Conclusion A definitive RCT to test the influence of MRI diagnosis on the psychosocial and disability outcomes in people with CLBP treated with physiotherapy in Saudi Arabia is feasible. However, the lack of research infrastructure, research capacity, the impact of MRI on patient outcomes, and a lack of clinical equipoise in the treatment and management of CLBP in Saudi Arabia pose major barriers to clinical trials.
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Affiliation(s)
- Ahmed Alhowimel
- Physical Therapy and Rehabilitation Science Department, Prince Sattam Bin AbdulAziz University, Alkarj, Saudi Arabia.
| | - Mazyad Alotiabi
- Physical Therapy and Rehabilitation Science Department, Prince Sattam Bin AbdulAziz University, Alkarj, Saudi Arabia
| | - Neil Coulson
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kathryn Radford
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
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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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17
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Jensen MS, Olsen KR, Morsø L, Søndergaard J, Schiøttz-Christensen B. Does changed referral options affect the use of MRI for patients with low back pain? Evidence from a natural experiment using nationwide data. BMJ Open 2019; 9:e025921. [PMID: 31253612 PMCID: PMC6609080 DOI: 10.1136/bmjopen-2018-025921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES This study reports lumbar MRI referral patterns in the Region of Southern Denmark (RSD) and investigates the hypothesis that we will see an increase in imaging rates (MRI rates) following new referral options to lumbar MRI in the RSD in comparison with the other regions in Denmark from 2010 to 2013. DESIGN A difference-in-difference (DD) analysis, using general practitioners (GPs) in other regions as control, was used to test if the new referral options had an effect on the MRI rates. SETTING In 2010, RSD introduced organisational changes affecting the referral options for lumbar MRI. First, the possibility for direct referral to lumbar MRI was introduced GPs, and second, the region gathered all local spine departments into one specialist hospital called the Spine Centre. PARTICIPANTS We retrieved all lumbar MRIs performed on patients aged 18+ performed on Danish hospitals from 2008 to 2013 using the registries from Statistics Denmark. We use sociodemographic information from all Danish citizens aged 18+ aggregated to GP level. Primary and secondary outcome measures: lumbar MRI scans per 1000 capita enlisted with a GP (MRI rates) were calculated based on GPs patient list. Four referral types were made to describe changes in referral patterns. RESULTS In total 183 389 patients received 240 760 lumbar MRIs in the period. The use of the direct referral option by GPs in the RSD increased by 115% in the period from 2010 to 2013 and accounted for 34% of all referrals (n=6545) in 2013. MRI rates were significantly higher in RSD following the organisational changes (DD 1.389(0.925-1.852) lumbar MRI per 1.000 enlisted with a GP). CONCLUSIONS Introduction of organisational changes in RSD as direct referral to lumbar MRI from GPs and chiropractors as well as establishing a Spine Centre increase the lumbar MRI rate in comparison with other regions in Denmark.
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Affiliation(s)
- Morten Sall Jensen
- The Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- VIVE, The Danish Center of Social Science Research, Copenhagen, UK
| | - Kim Rose Olsen
- DaCHE, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Lars Morsø
- The Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Centre for Quality, Region of Southern Denmark, Middelfart, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Berit Schiøttz-Christensen
- The Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Spine Centre of Southern Denmark, Lillebaelt Hospital, Region of Southern Denmark, Middelfart, Denmark
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Hopkins BS, Mazmudar AS, Bomdica PR, Koski TR, Patel AA, Dahdaleh NS. A Financial Analysis of Procedural Revenue in Outpatient Spine Clinic: An Analysis of 36,312 Patient Appointments and Subsequent Surgeries at a Single Major Academic Institution. World Neurosurg 2019; 128:e938-e943. [PMID: 31096025 DOI: 10.1016/j.wneu.2019.05.040] [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: 03/30/2019] [Revised: 05/03/2019] [Accepted: 05/04/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The economic pressures widely discussed in health care have a large impact on spine practices. This current study is the first to look at characteristics associated with revenues from an outpatient spine clinic. METHODS All clinic visits to spine providers were identified at a single academic institution spanning the dates June 1, 2014, to June 1, 2018. All payment information was calculated using Medicare reimbursement values for Current Procedural Terminology codes. Relevant clinical, surgical, and cost structure data was collected for each patient. RESULTS On average, providers had 21.9 average appointments over the course of 7.6 hours per clinic day. The average ratio of new to follow-up patients was 39.3%, with an average new patient to surgery conversion rate of 15.0%. The adjusted average total procedural revenue per new patient, controlled for scheduled appointment length and actual appointment length, was $686.02. The adjusted average procedural revenue per surgery was $3444.64 and average procedural revenue per hour in spine clinic was $552.40. With a 1% and 5% increase in new patient visits, total procedural revenue increases 2.7% and 13.5%, respectively. With a 1% and 5% increase in conversion rate, total procedural revenue increases 6.7% and 33.3%, respectively. With a decrease in new patient appointment length from 30 minutes to 25 minutes, the opportunity for 1.7 new patient appointments per day was created resulting in a net increase in procedural revenue per clinic day of $837.57. CONCLUSIONS Incremental changes in practice structure can significantly affect procedural revenue. Significant heterogeneity also exists among spine providers.
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Affiliation(s)
- Benjamin S Hopkins
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | - Aditya S Mazmudar
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Prithvi R Bomdica
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tyler R Koski
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Greenwood-Lee J, Jewett L, Woodhouse L, Marshall DA. A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Serv Res 2018; 18:986. [PMID: 30572898 PMCID: PMC6302393 DOI: 10.1186/s12913-018-3745-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated. METHODS We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes. RESULTS We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies. CONCLUSION The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.
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Affiliation(s)
- James Greenwood-Lee
- Centre for Science, Athabasca University, 6th Floor, 345 6 Avenue SE, Calgary, Alberta, T2G 4V1, Canada
| | - Lauren Jewett
- Geography & Planning, University of Toronto, Sidney Smith Hall, Rm 594, 100 St George St., Toronto, Ontario, M5S 3G3, Canada
| | - Linda Woodhouse
- Faculty of Rehabilitation Medicine, University of Alberta, 3-10 Corbett Hall, 8205 114 Street, Edmonton, Alberta, T6G 2G4, Canada
| | - Deborah A Marshall
- Canada Research Chair, Health Services and Systems Research, Arthur J.E. Child Chair in Rheumatology Outcomes Research, Department of Community Health Sciences, University of Calgary, Calgary, Canada.
- 3C56 Health Research Innovation Centre (HRIC), 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.
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Coyle MJ, Roffey DM, Phan P, Kingwell SP, Wai EK. 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. J Bone Joint Surg Am 2018; 100:2125-2131. [PMID: 30562293 DOI: 10.2106/jbjs.18.00423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Matthew J Coyle
- Division of Orthopaedic Surgery (M.J.C., P.P., S.P.K, and E.K.W.), Department of Surgery, and the Combined Adult Spinal Surgery Program (D.M.R., P.P., S.P.K., and E.K.W.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Darren M Roffey
- Division of Orthopaedic Surgery (M.J.C., P.P., S.P.K, and E.K.W.), Department of Surgery, and the Combined Adult Spinal Surgery Program (D.M.R., P.P., S.P.K., and E.K.W.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Philippe Phan
- Division of Orthopaedic Surgery (M.J.C., P.P., S.P.K, and E.K.W.), Department of Surgery, and the Combined Adult Spinal Surgery Program (D.M.R., P.P., S.P.K., and E.K.W.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephen P Kingwell
- Division of Orthopaedic Surgery (M.J.C., P.P., S.P.K, and E.K.W.), Department of Surgery, and the Combined Adult Spinal Surgery Program (D.M.R., P.P., S.P.K., and E.K.W.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Eugene K Wai
- Division of Orthopaedic Surgery (M.J.C., P.P., S.P.K, and E.K.W.), Department of Surgery, and the Combined Adult Spinal Surgery Program (D.M.R., P.P., S.P.K., and E.K.W.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Zarrabian M, Bidos A, Fanti C, Young B, Drew B, Puskas D, Rampersaud R. Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings. Can J Surg 2018. [PMID: 30246685 DOI: 10.1503/cjs.016116] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammad Zarrabian
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Andrew Bidos
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Caroline Fanti
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Barry Young
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Brian Drew
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - David Puskas
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Raja Rampersaud
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
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Moi JHY, Phan U, de Gruchy A, Liew D, Yuen TI, Cunningham JE, Wicks IP. Is establishing a specialist back pain assessment and management service in primary care a safe and effective model? Twelve-month results from the Back pain Assessment Clinic (BAC) prospective cohort pilot study. BMJ Open 2018; 8:e019275. [PMID: 30309987 PMCID: PMC6252686 DOI: 10.1136/bmjopen-2017-019275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To report on the design, implementation and evaluation of the safety and effectiveness of the Back pain Assessment Clinic (BAC) model. DESIGN BAC is a new, community-based specialist service for assessing and managing neck and low back pain (LBP). The BAC pilot was supported by a Victorian Department of Health and Human Services grant and was evaluated using the Victorian Innovation Reform Impact Assessment Framework (VIRIAF). Data were obtained by auditing BAC activity (22 July 2014 to 30 June 2015) and conducting surveys and interviews of patients, stakeholders and referrers. SETTING Tertiary and primary care. PARTICIPANTS Adult patients with neck and LBP referred for outpatient surgical consultation. MAIN OUTCOME MEASURES VIRIAF outcomes: (1) access to care; (2) appropriate and safe care; (3) workforce optimisation and integration; and (4) efficiency and sustainability. RESULTS A total of 522 patients were seen during the pilot. Most were referred to hospital services by general practitioners (87%) for LBP (63%) and neck pain (24%). All patients were seen within 10 weeks of referral and commenced community-based allied health intervention within 2-4 weeks of assessment in BAC. Of patients seen, 34% had medications adjusted, 57% were referred for physiotherapy, 3.2% to pain services, 1.1% to rheumatology and 1.8% for surgical review. Less MRI scans were ordered in BAC (6.4%) compared with traditional spinal surgical clinics (89.8%), which translated to a cost-saving of $52 560 over 12 months. Patient and staff satisfaction was high. There have been no patient complaints or adverse incidents. CONCLUSION Evaluation of the BAC pilot suggests it is a potentially safe and cost-saving alternative model of care. Results of the BAC pilot merit further evaluation to determine the potential cost-effectiveness, longer term and broader societal impact of implementing BAC more widely.
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Affiliation(s)
- John H Y Moi
- Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Uyen Phan
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam de Gruchy
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tanya I Yuen
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - John E Cunningham
- Department of Orthopaedics, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ian P Wicks
- Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Inflammation, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
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Liew I, Dean F, Anderson G, Murray O. Requesting spinal MRIs effectively from primary care referrals. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2436-2441. [PMID: 29637264 DOI: 10.1007/s00586-018-5578-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/03/2018] [Accepted: 03/30/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey. The demand for outpatient spinal appointments significantly exceeds our services' ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation. METHODS During routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters. RESULTS 149 patients were included [101 females, 48 males, mean age 49 (16-87)]. There were 125 routine, 21 urgent, and 3 'urgent-suspected cancer' referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits. CONCLUSIONS MRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Ignatius Liew
- Department of Spine, Trauma and Orthopaedics, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Fraser Dean
- Department of Spine, Trauma and Orthopaedics, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Gillian Anderson
- Department of Management Science, University of Strathclyde Business School, Glasgow, UK
| | - Odhrán Murray
- Department of Spine, Trauma and Orthopaedics, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK.
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Exploration of the Inter-Relationships Between Obesity, Physical Inactivity, Inflammation, and Low Back Pain. Spine (Phila Pa 1976) 2018; 43:1218-1224. [PMID: 29419713 DOI: 10.1097/brs.0000000000002582] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis wherein 103 patients were considered, and 76 patients were included: 49 were classified as chronic non-specific low back pain (CNSLBP) (Study group) and 27 had identifiable cases of specific chronic low back pain (LBP) (Control group). OBJECTIVE Elucidate markers of systemic inflammation in patients with CNSLBP. SUMMARY OF BACKGROUND DATA Mechanisms of LBP are poorly understood. Pro-inflammatory cytokines are increased in obesity and involved with pain modulation; we previously proposed a theoretical model of their mediating role in LBP. METHODS Demographic information was acquired via questionnaire, chart review, and blood test data. Univariate analysis identified factors associated with CNSLBP and markers of systemic inflammation. A receiver operating curve and Youden Index were used to select optimal cut-off points for elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Multivariable logistic regression analysis calculated the adjusted strength of relationship between factors that were proposed in our theoretical model for CNSLBP. RESULTS Unadjusted CRP was significantly correlated with ESR (R = 0.63, P < 0.0001) and body mass index (BMI) (R = 0.38, P = 0.0015). Physically inactive patients had significantly higher CRP (6.1 vs. 1.2, P = 0.0050). ESR was significantly correlated with number of comorbidities (R = 0.34, P = 0.0047), BMI (R = 0.38, P = 0.0014), and age (R = 0.36, P = 0.0026). Physically inactive patients (10.4 vs. 3.6, P = 0.0001) and females (11.2 vs. 6.4, P = 0.0422) had significantly higher ESR. Adjusted analyses indicated significant relationships between physical inactivity and markers of systemic inflammation (adjusted odds ratios for ESR and CRP: 15.9, P = 0.0380; 15.2, P = 0.0272, respectively), and between elevated CRP and CNSLBP (adjusted odds ratio: 8.0, P = 0.0126). CONCLUSION Systemic inflammation may act as a mediator for physical inactivity and obesity in the pathogenesis of CNSLBP. LEVEL OF EVIDENCE 2.
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Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018; 391:2368-2383. [PMID: 29573872 DOI: 10.1016/s0140-6736(18)30489-6] [Citation(s) in RCA: 1183] [Impact Index Per Article: 197.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 07/18/2017] [Accepted: 10/20/2017] [Indexed: 12/15/2022]
Abstract
Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
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Affiliation(s)
- Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
| | - Johannes R Anema
- Department of Public and Occupational Health and Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
| | - Dan Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
| | - Paulo H Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Bart W Koes
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wilco Peul
- Department of Neurosurgery, Leiden University, Leiden, Netherlands
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, NSW, Australia
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Layne EI, Roffey DM, Coyle MJ, Phan P, Kingwell SP, Wai EK. Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines? Spine J 2018; 18:614-619. [PMID: 28882524 DOI: 10.1016/j.spinee.2017.08.259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/03/2017] [Accepted: 08/29/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Clinical practice guidelines (CPGs) are designed to ensure that evidence-based treatment is easily put into action. Whether patients and clinicians follow these guidelines is equivocal. PURPOSE The objectives of this study were to examine how many patients complaining of low back pain (LBP) underwent evidence-based medical interventional treatment in line with CPG recommendations before consultation with a spine surgeon, and to evaluate any associations between adherence to CPG recommendations and baseline factors. STUDY DESIGN/SETTING This is a cross-sectional cohort analysis at a tertiary care center. PATIENT SAMPLE A total of 229 patients were referred for surgical consultation for an elective lumbar spinal condition. OUTCOME MEASURES The outcome measures include the number of CPG-recommended treatments undertaken by patients at or before the time of referral, the validated pain score, the EuroQol-5D (EQ-5D) health status, and the Oswestry Disability Index (ODI) score. METHODS Questionnaires assessing demographic and functional characteristics as well as overall health care use were sent to patients immediately after their referral was received by the surgeon's office. RESULTS Medications were the most common modality before consultation (74.2% of patients), of which 46.3% received opioids. The number of medications taken was significantly related to a higher ODI score (R=0.23, p=.0004), a higher pain score (R=0.15, p=.026), and a lower EQ-5D health status (R=-0.15, p=.024). In contrast, a lower pain score (7.2 vs. 7.7, p=.037) and a lower ODI score (26.6 vs. 29.9, p=.0023) were associated with performing adequate amounts of exercise. There was a significant association between lower numbers of treatments received and higher numerical pain rating scores (R=-0.14, p=.035). The majority (61.1%) of patients received two or less forms of treatment. CONCLUSIONS Evidence-based medical interventional treatments for patients with LBP are not being taken advantage of before spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health system pathway changes are necessary.
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Affiliation(s)
- Elliot I Layne
- Ottawa Hospital Combined Spinal Surgery Program, Department of Surgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Darren M Roffey
- Ottawa Hospital Combined Spinal Surgery Program, Department of Surgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Matthew J Coyle
- Faculty of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Philippe Phan
- Ottawa Hospital Combined Spinal Surgery Program, Department of Surgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada; Faculty of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Stephen P Kingwell
- Ottawa Hospital Combined Spinal Surgery Program, Department of Surgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada; Faculty of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Eugene K Wai
- Ottawa Hospital Combined Spinal Surgery Program, Department of Surgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada; Faculty of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
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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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Robarts S, Stratford P, Kennedy D, Malcolm B, Finkelstein J. Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction. Can J Surg 2017; 60:266-272. [PMID: 28730987 DOI: 10.1503/cjs.013416] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Susan Robarts
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Paul Stratford
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Deborah Kennedy
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Barry Malcolm
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Joel Finkelstein
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
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Derakhshan A, Miller J, Lubelski D, Nowacki AS, Wells BJ, Milinovich A, Benzel EC, Mroz TE, Steinmetz MP. The Impact of Socioeconomic Status on the Utilization of Spinal Imaging. Neurosurgery 2016. [PMID: 26214318 DOI: 10.1227/neu.0000000000000914] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population. OBJECTIVE To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed. METHODS Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status. RESULTS A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs. CONCLUSION Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.
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Affiliation(s)
- Adeeb Derakhshan
- *Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Center for Spine Health, and Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio; ‡Cleveland Clinic Department of Quantitative Health Sciences, Cleveland, Ohio
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30
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Stynes S, Konstantinou K, Dunn KM. Classification of patients with low back-related leg pain: a systematic review. BMC Musculoskelet Disord 2016; 17:226. [PMID: 27215590 PMCID: PMC4877814 DOI: 10.1186/s12891-016-1074-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The identification of clinically relevant subgroups of low back pain (LBP) is considered the number one LBP research priority in primary care. One subgroup of LBP patients are those with back related leg pain. Leg pain frequently accompanies LBP and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back-related leg pain (LBLP) is important for clinical management and research applications, but there is currently no clear agreement on how to define and identify LBLP due to nerve root involvement. The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP, and summarise how leg pain due to nerve root involvement is described and diagnosed in the various systems. METHODS The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were appraised independently by two reviewers using a standardised scoring tool. RESULTS Of 13,358 initial potential eligible citations, 50 relevant papers were identified that reported on 22 classification systems. Papers were grouped according to purpose and criteria of the classification systems. Five themes emerged: (i) clinical features (ii) pathoanatomy (iii) treatment-based approach (iv) screening tools and prediction rules and (v) pain mechanisms. Three of the twenty two systems focused specifically on LBLP populations. Systems that scored highest following quality appraisal were ones where authors generally included statistical methods to develop their classifications, and supporting work had been published on the systems' validity, reliability and generalisability. There was lack of consistency in how LBLP due to nerve root involvement was described and diagnosed within the systems. CONCLUSION Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. Further work is needed to identify clinically meaningful subgroups of LBLP patients, ideally based on large primary care cohort populations and using recommended methods for classification system development.
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Affiliation(s)
- Siobhán Stynes
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
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Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes. Spine (Phila Pa 1976) 2014; 39:S129-35. [PMID: 25299256 DOI: 10.1097/brs.0000000000000574] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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