Try as we might to move the conversation away from back pain, for which there is evidence aplenty, a new study has taken aim at the management of spine-related disorders in the primary care environment. It’s an interesting take on a complex issue, as management of spine-related disorders (SRDs), including back pain, remains the largest contributing factor to increased outpatient healthcare utilisation and expenditures. Spending for low back and neck pain has now become accountable for the highest costs in US health care and increased expenditures for spine care interventions have not correlated with improved outcomes. Moreover, research now reveals that there is insufficient evidence to justify the use of many invasive and expensive spine care procedures [1].
We know that the medical management of back pain can also be fraught, as back pain is the most common condition for which opioids are prescribed [1]. Hence, it is important to implement guideline-concordant clinical pathways that improve outcomes, improve the efficiency of care, and reduce escalation of care (EoC) (the unnecessary use of healthcare resources – for the management of patients with SRDs.
According to the present study, a promising solution is to embed, within the primary care environment, “a dedicated spine care clinician who has the requisite knowledge and skills needed to manage patients with SRDs and provide guidance through the maze of spine treatment options.” This approach is known as Primary Spine Care (PSC), is an innovative model for the management of SRDs.
The PSC provides non-pharmacological care and coordinates the primary spine care of patients with spine problems from presentation through discharge. Thus, they can serve as the initial or early point of contact for spine patients, and as an alternative to the usual primary care pathway, which often requires referral for non-pharmacological care.
The study
The retrospective study aimed to evaluate outcomes for PSC vs conventional primary care following the implementation of the PSC model. It was thought that the amount of patients with SRDs who received PSC care would have lower rates of escalation of care (EoC). EoC for this study included factors such as hospitalisations, visits to the emergency department, spinal injections, visits to a specialist, and prescription fills for opioid analgesics.
The study looked at 6-month outcomes for 2 groups of patients who were seen and treated for an SRD over a 3-year period. The PSC services were provided by a Doctor of Chiropractic (DC) with a MS degree in sport science and rehabilitation and 5 years’ experience in clinical practice. The PSC clinician was embedded within the primary face facilities of an academic medical centre. Embedding the PSC within the primary care team facilitated real-time, two-way communication and enhanced management of LBP. The PSC could easily share findings, diagnosis, and treatment plans with the referring clinician, in addition to the internal communication via the electronic medical record. The study design aimed to exclude patients with ongoing complaints of an SRD, but allow referral to the PSC clinician, and capture patients with new complaints of SRD.
One DC provided the PSC while 79 clinicians provided primary care within the academic medical centre, these PC clinicians included family medicine or internal medicine physicians, physician assistants, or nurse practitioners. In the context of this study conventional primary care typically consisted of self-care advice, prescriptions for medications, and referrals to other clinicians, most often a physical therapist. Data collection for the study spanned the 12-month period preceding the introduction of the PSC model, and included the 42-month period following.
It is to be expected that the implementation of a complementary or alternative health practitioner into a primary care environment is going to face challenges. The barriers identified by the authors of the current study included explicit bias, structural bias, and implicit bias. Explicit bias is the belief that providers other than medical physicians are ill-suited or untrained to assume such a role in primary care. This was addressed by communicating the evidence supporting the suitability of non-physicians in training pain from spine disorders.
Structural bias stems from the limited insurance reimbursement for non-medical providers. This was overcome as the availability of the PSC clinician effectively reduced leakage of patients to external providers, and the primary care facility realised cost savings in the care of the self-insured employee population. A physician or administrator’s lack of familiarity with the PSC clinician’s training, expertise, and competencies can create implicit bias. The authors pre-emptively tackled this through one-on-one education of physicians and administrators using evidence-based literature.
So, what happened?
In the end, data from 2692 patients was included in the analysis. These patients formed the two groups that were compared with each other; primary care (PC) group of 1363 patients and the PSC group of 1329 patients. The two patient populations were similar in marital status and race/ethnicity, however the mean age and Charleston score was higher in the PC group compared to the PSC group. A higher frequency of females were in the PSC group as well.
It was found a significantly smaller percentage of PSC patients;
- Filled prescriptions for opioid analgesics
- Had hospitalisations
- Had surgeries
- Had referrals to a specialist (e.g., the facility’s spine centre)
- Had spinal diagnostic imaging
- Had spinal injections
The main findings for the PSC group were as follows:
- 53% less likely to be hospitalised
- 57% less likely to fill a prescription for an opioid analgesic
- 44% less likely to obtain spinal injections
- 52% less likely to have a visit with a specialist
When controlling for patient characteristics, PSC patients were less likely to experience escalation of spine care compared to PC patients. These findings were overall consistent with previous literature, cited by the authors, that demonstrate implementation of the PSC model is associated with a trend toward reduced total expenditures for spine care, and lower odds of diagnostic imaging of the spine, as compared with PC. Similarly other studies cited have found the transition from acute to chronic LBP was substantial and early exposure to guideline non-concordant care was significantly associated with this transition to chronic LBP.
Things to consider
Although this study did support the potential of the PSC model to be successful, it did not examine spine care outside of the academic health centre. The data available also contained few variables pertaining to other related patient outcomes that may have influenced clinical outcomes, such as the patient’s general psychological state. It would be interesting to see future studies also include measures assessing patients’ levels of disability, patient self-reports of pain ratings, or global index of change, which may be useful for examining the differences between the two groups of patients. There is also the risk that unmeasured factors, such as additional patient characteristics, may have influenced or driven the differences observed.
From an internal performance improvement survey conducted within the study, it is encouraging to see that 88% of primary care physicians reported that PSC made it easier for them to care for patients with spine pain, and 100% accepted the PSC clinician as the first or initial contact for an SRD.
The study’s authors said, “In our evaluation of this innovative model of spine care, patients who were seen and treated by a PSC clinician embedded in an academic primary care clinic experienced significantly less escalation of their spine care within six months of their initial visit and filled significantly fewer prescriptions for opioid pain medication. The PSC model facilitates greater compliance with current evidence-based guidelines for the management of spine care and may offer a more efficient approach to the primary care of spine problems, as compared to conventional primary care”
While certainly the US healthcare system varies significantly from other countries with socialised healthcare, it certainly does deliver a prompt for thought. Anyone know any well-educated, qualified, spine/nervous system certified health practitioners? We can certainly think of a few.
Reference:
- Bezdjian, S., Whedon, J.M., Russell, R. et al. Efficiency of primary spine care as compared to conventional primary care: a retrospective observational study at an Academic Medical Center. Chiropr Man Therap. 2022 30(1) https://doi.org/10.1186/s12998-022-00411-x
