Spine/Low Back Pain - PowerPoint Presentation

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Spine/Low Back Pain Update

May 29, 2013

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Goals for Today’s Presentation

Provide update on Spine SCOAP proposal

Summarize the progress made by the Spine/Low Back Pain workgroup

Get feedback about draft goals and recommendations under consideration by the Spine workgroup

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Update on Spine SCOAP Proposal

In October 2012, the Bree unanimously voted

At the March meeting, the Bree discussed the use of “community standard” in response to concerns from HCA

Letter sent to HCA in mid-April clarifying the Bree’s intent and proposing revised language

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Timeline of Spine SCOAP Proposal

Action/Status

Recommendation

October

2012

(sent to HCA in

Jan 2013)

Bree

approved Spine SCOAP proposal“To approve the Spine SCOAP proposal – that the Collaborative establish participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery”March 2013HCA respondsConcerns with community standard languageApril 2013Bree discussed HCA response, revised language based on HCA concerns & submits revision to HCASee next slide

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Revised Proposal

“To approve the Spine SCOAP proposal – that the Collaborative

strongly recommends

establish

participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery* - with the following conditions:

1)     Results are

unblinded

.

2)     Results are available by group.

3)     Establish a clear and aggressive timeline.

4)     Recognize that more information is needed about options for tying payment to participation.”*Spine SCOAP will begin with hospitals performing spine surgery and will expand to include procedures done at Ambulatory Surgery Centers as well as other non-hospital facilities such as interventional radiology suites.5Slide6

Update from HCA

Have not received formal response yetJosh Morse from HCA will give a verbal update at today’s meeting

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Spine/Low Back Pain Workgroup UpdateSlide8

Populations of Interest

Report will target three patient populations:

Adult low back pain (LBP) patients that are at a

low risk

of developing chronic pain and require minimal careAdult LBP patients that are at a medium risk

of developing chronic pain and require additional care to overcome physical obstacles to recovery

Adult LBP patients with psychosocial obstacles

to

recovery (

“yellow flags”

) that are not responding to conservative treatment and are at a high risk of developing chronic painExcludes patients with LBP associated with major trauma and patients with “red flags” that suggest a serious underlying condition8Slide9

Draft Primary Goal

Improve return to function

for LBP patients while reducing the cost of care by increasing evidence-based evaluation and management of patients in target populations

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Draft Secondary Goals

Reduce use of inappropriate interventions that do not support return to function or improve health outcomes

Increase early identification and management of patients who are at a higher risk of developing chronic pain

Provide tools and support to clinicians for the delivery of evidence-based care

Increase adoption of both financial and non-financial incentives to change provider practices and reward value-based care

Increase public awareness that low back pain is a chronic condition, and no “magic bullet” treatment exists

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Draft Measures of Success

Key challenge:

How can the Bree (or any entity) collect this data in the absence of a registry?

Thoughts?

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Outcome Measure

Possible Data Source(s)

Improve return to function time

L&I

, providers, patient surveys, others?

Improve functional status as measured by the Oswestry Low Back Pain Scale

Providers/health plans that use

Oswestry to

collect pre- and post- function scores, employers (include in medical leave paperwork?)

Improve patient experience

Still exploring optionsSlide12

Draft Measures of Success

Any other measures that the workgroup

should consider?

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Process Measure

Possible Data Source(s)

Reduce inappropriate use of MRIs for LBP patients in the

first 28 days

NCQA, Puget Sound Health Alliance (Community Checkup)

Reduce

overall MRI and lumbar fusion rates for LBP patientsL&I, Medicare, Spine SCOAP

Increase use of screening tools (e.g.

STarT Back or a similar tool)

Large health care systems

that implement these recommendations, possibly health plans that have billing codes assigned to the use of screening toolsSlide13

Draft Recommendations – Hospitals/Clinics

Support or sustain a LBP quality improvement program that includes measuring patients’ functional status over time using the Oswestry Low Back Pain Scale

Use a validated screening tool like the STarT Back tool or Functional Recovery Questionnaire (FRQ) no later than the 3

rd

visit to identify patients that are not likely to respond to routine careTake steps to integrate evidence-based guidelines, scripts, shared-decision making, and patient education material into clinical practice and workflow (e.g., EMR, a clinical decision support tool such as

UpToDate

, etc.)

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Draft Recommendations – Hospitals/Clinics (cont’d)

Sponsor evidence-based CME for staff on the best practices for the evaluation and management of non-specific LBP patients to prevent progression from acute to chronic pain (in combination with operational changes that support/reinforce best practices)

Include information in lumbar spine MRI reports about the frequency of similar findings in the general population

Implement “hard stops” that require providers to demonstrate appropriateness of imaging before ordering

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Draft Recommendations – Individual Providers

Commit to using evidence-based guidelines and tools recommended by the Bree Collaborative, including the ACP/APS guidelines and Oswestry

Use

a validated screening tool like the STarT Back tool or Functional Recovery Questionnaire (FRQ) no later than the 3

rd visit to identify patients that are not likely to respond to routine careIncorporate shared decision-making into clinical

practices

Establish referral relationships with physiatrists

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Draft Recommendations – HCA/Medicaid/DOH/L&I

Sponsor an evidence-based education campaign about low back pain (ideally modeled after an Australian campaign with proven effectiveness)

Partner with WSHA, WSMA, the Washington Academy of Family Physicians, American Academy of Physical Medicine and Rehabilitation, and other interested parties

Provide subsidies/incentives to providers that use shared decision-making with their LBP patients

Sponsor a new payment methodology for LBP care

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Draft Recommendations – Employers/Purchasers

Encourage providers and delivery systems to track and report return to function rates in a transparent manner

Provide recommended patient education materials about LBP to all employees and their families

Negotiate tiered networks or other types of benefit design that will encourage patients to go to providers that have demonstrated evidence-based practices

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Draft Recommendations – Health Plans

Support new, innovative financial models for LBP care

Require providers to demonstrate that they have had patients complete a screening tool (such as STarT Back or FRQ) as part of prior authorization process for imaging, spinal injections, and/or spinal surgery

Require patients with non-specific low back pain (and no red flags) be evaluated by a physiatrist before scheduling a visit with a

surgeon

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Draft Recommendations – Health Plans

Consider establishing the collection of data on functional outcomes as a requirement for payment

Identify complex cases (e.g. a patient who is getting opioid prescriptions from multiple doctors) and refer them to a provider or case manager that can oversee their care

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