The Bree Collaborative’s Role in Spine/Low Back Pain Care:A Proposal

Presentation to the Bree Collaborative

August 2, 2012

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Purpose of Presentation

•Present proposed approach for Bree’s role in Spine care/Low Back Pain topic -where Bree can add value, improve outcomes, and reduce costs

•Discuss and adopt general approach

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Experts met July 2nd

Invited Participants• Gary Franklin, MD, L&I• Leah Hole-Curry, L&I• Vickie Kolios-Morris, Spine SCOAP, FHCQ• Mary Kay O’Neill, MD, Cigna• John Robinson, MD, First Choice Health• Terry Rogers, MD, FHCQ

Invited guest• Rick Deyo, MD, OHSU

Staff: Steve Hill & Rachel Quinn

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Low Back Pain is common, costly, and complex• One of the most common reasons for patients to

see physicians

• Leading cause of work-related disability and workers’ compensation for people under age 45

• Medical costs are in excess of $25 billion per year; commercially, musculoskeletal top expenditure

• There’s a huge psycho/social element to low back pain - one of the strongest predictors of onset of low back pain and transition from acute to chronic is patient’s emotional status and presence of work-life issues

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Variation in Treatment and Management among Patients with Acute and Chronic Back PainAcute/Subacute (symptoms lasting less than 12 weeks)

• Unnecessary use of imaging and surgery without improved outcomes

• Patients seen by wide variety of practitioners with different treatment approaches

• Most acute & subacute low back pain patients could be managed and screened in outpatient primary care setting

Chronic (symptoms lasting more than 12 weeks)

• Huge variability in lumbar fusion surgeries, and they are very expensive

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Bree and History of Spine Care

Presentations/discussons to date, at 3 Bree Collaborative meetings, have focused on lumbar spinal fusions – treatment for chronic, not acute back pain▫September 30, 2011▫January 30, 2012▫March 29, 2012

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Bree Topic Goals & Guidelines • Goal:

▫ Improve quality, outcomes for patients and cost-effectiveness 

• Topic Selection▫ Significant safety, efficacy or cost-effectiveness concerns  ▫ Substantial variation in practice patterns or high utilization

trends can be indicators of poor quality and potential waste in the health care system, without producing better care outcomes 

• Outcome: ▫ Identify topics with variation or quality concerns, and

recommend evidence-based strategies to improve quality and cost-effectiveness

Yes, both acute and chronic spine care fit criteria

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Low Back Pain Initiatives in WAPuget Sound

Health Alliance Low Back Pain

Clinical Improvement

Team Recommendation (2007): focus on

outpatient management of acute low back

pain

UW/Spine SCOAP conducts spine forums to discuss spine issues

WA Technology Assessment Project will not pay for fusions for

degenerative disc disease

unless failure of

multidisciplinary program

ACUTE

(< 6 weeks)

CHRONIC

( > 3 months)

Spine SCOAP compiles data on all spine surgeries

UW Comparative Effectiveness Research Pilot on lumbar fusions and spine care in general

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Recommendations

• Create a spine subgroup

• Initial focus of spine workgroup: how to appropriately manage patients with acute low back pain, and prevent transition of acute/subacute to chronic low back pain▫ Gather evidence-based guidelines, emerging best practices &

data on how to appropriately manage acute St. Joseph’s, Virginia Mason Medical Center Institute for Clinical Systems Improvement (ICSI) Evidence-based business practices (Intel/Oregon program) Centers of Occupational Health & Education (COHE)

▫ Gather education of alternatives (shared decision aids)▫ How to support/align with existing efforts, whether focus is

acute or chronic (e.g., comparative effectiveness registry)

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Recommendation: Spine Subgroup

•Members of exploratory group▫Gary Franklin▫Mary Kay O’Neill▫John Robinson

•Subgroup recommendations▫Bob Moots, associate director for

chiropractics, L&I▫A spine surgeon▫Others?

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Recommendation: Registry

Subgroup to consider the following recommendation:• All hospitals and ASCs (that perform discectomy, fusion,

and/or disc replacement) participate in a publicly reported, prospective, benchmarking registry of spine surgical and interventional procedures

• Participation in such a registry will generate needed information about the appropriateness of surgical/intervention spine care that can be used to support future HTA and payer decisions related to spine care.

• The registry should focus its public reporting on progress in reducing variation in the use of less indicated procedures, as well as in improving the quality, effectiveness and cost-effectiveness of care.