Spine/Low Back Pain Topic Update

1. Spine/Low Back Pain Topic Update March 27, 2013

2. Two Tracks - RECAP • Spine SCOAP • In October 2012, Bree Collaborative unanimously approved Spine SCOAP proposal: “Establish participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery” • Recommendation to HCA end of January • Spine/Low Back Pain Workgroup • Established to identify and recommend strategies for appropriate identification and management of acute low back pain

3. Endorsement of Spine SCOAP Spine SCOAP recommendation sent to HCA on January 31st(copy of letter in meeting packet) “To approve the Spine SCOAP proposal – that the Collaborative 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.

4. HCA Response • Legal and regulatory issues with “...that the Collaborative establish participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery...” • “’Community Standard’ exceeds Collaborative’ s statutory authority by potentially creating a legal standard and participation mandate such that non-participation could be used in other venues to create a presumed violation of a community standard of care; the net effect could have adverse effects in licensing, contracting, or professional negligence litigation.”  • The Bree group (or the HCA’s Director if the proposal is adopted “as is”) does not have the degree of regulatory authority that would support such an action.

5. Spine/Low Back Pain Workgroup Update

6. Overview • Have met twice since the last Bree Collaborative meeting (5 meetings total) • RECAP – Focus on preventing transition from acute to chronic pain, as requested by the Bree Collaborative • Developing recommendations for 2 patient populations: • Patients with non-specific low back pain (new onset or recurrent) • Patients with psychosocial factors Excludes patients with nerve root problems or “red flags”

7. Areas of Emphasis • Identifying high-cost, complex patients as early as possible • Operationalizingcheck lists, guidelines, and other best practices • Patient education/activation • Managing patient expectations throughout care process NOTE: The group discussed the importance of reducing unnecessary imaging and effective management of opioid use, but decided not to focus on either of these topics because both are already the targeted by other efforts.

8. Criteria for Workgroup Recommendations(Adopted 2/20) Addresses overall goals: 1) Reduce modalities that are over-used in treatment of low back pain in WA; 2) Increase early identification of complex and chronic pain patients and appropriate evidence-based pathways for treatment; and 3) Decrease patients’ return to function time. Based on criteria used by the APM subgroup • Somewhat simple to implement and administer • Built on evidence/consensus-based best practices • Field tested (preferred) • Aligned with proven national metrics & programs • Includes quality metrics • Aligned with reducing the cost of care

9. Outline of General Approach • Recommend adoption of evidence-based guidelines and check lists • Identify modalities that are over-used in treatment of low back pain in WA • Identify best practices that would lead to appropriate/reduced use of those modalities, which will include some patient and provider education strategies Recognize that it is important to avoid a “one size fits all” approach and try to highlight diverse initiatives that can be implemented in a broad range of settings

10. Step 1: Guidelines At 2/20 meeting, the workgroup discussed the following proposal: • Support the widespread adoption of the American College of Physicians and American Pain Society (ACP/APS) guidelines in primary care settings in WA • Use the possible causes and key features from the ACP/APS guidelines to define “red flags” Consensus: Adopt the proposal while recognizing that the ACP/APS guidelines are just a starting place; the group will likely make more specific recommendations in areas such as psychosocial screening and medication management

11. Step 2: Over-used Modalities • Identified the following modalities as ones that are over-used in treatment of low back pain in WA: • Epidural steroid and other spinal injections • Opioids • Lumbar MRIs • Staff is working on getting data about overuse from L&I and other sources

12. Step 3: Best Practices Innovative Approaches for Improving Spine Care The 2/20 meeting included presentations about: • VMMC and Intel’s Approach to Spine Care • FastBack: program for treating pain in the ER • BackQuack: online game for back pain doctors & patients • Spine Team Assessment: multidisciplinary team care for chronic pain patients • Priority Health Experiment: patients must see a physiatrist before a surgeon (unless it is an emergency) Thank you to Dr. Andrew Haig (from Michigan) and Dr. Bob Mecklenburg for giving presentations.

13. Step 3: Best Practices Chronic Back Pain Risk Screening The 3/20 meeting included presentations about: • L&I efforts to improve early identification and interventions for injured workers at a high risk for chronic disability • Functional Recovery Questionnaire • Pilot in Centers of Occupational Health and Education (COHEs) • “Activity Coaching”: Progressive Goal Attainment Program • Chronic Pain Risk Score (plus Improved and Expanded models) • BOLD Back Pain Registry • STarT Back Screening Tool Thank you to Dr. Judith Turner from UW for presenting.

14. Step 3: Best Practices At 3/20, the workgroup adopted this proposal: Support the widespread adoption of the STarT Back tool by spine care providers in WA State Rationale: • Validated tool with strong evidence of predictive power and improved outcomes • Using & scoring the tool is very straightforward  reduced burden for both patients and providers (9 item tool, 8 of the questions are yes or no) • No cost to use materials – freely available for download online The workgroup may identify other screening tools that meet these criteria and/or include a list of recommended criteria in the report. Staff will contact providers that currently use this tool to get more information about its implementation and impact on their practice.

15. Upcoming Plans and Goals • Looking to invite a few primary care doctors to form a subgroup to discuss strategies for operationalizing evidence-based guidelines • 4/17 meeting will focus on Patient Engagement/Education and Innovative Technologies • Staff hopes to increase the frequency of meetings as the report starts to come together • Plan to present outline or draft report at the next Bree Collaborative meeting

16. Questions? Comments?