Spine surgery referrals redirected through a multidisciplinary care pathway: effects of nonsurgeon triage including MRI utilization

Presented at the 2013 Joint Spine Section Meeting 

Danica R. Kindrachuk and Daryl R. Fourney M.D., F.R.C.S.C.
View More View Less
  • Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

The Saskatchewan Spine Pathway (SSP) was introduced to improve quality and access to care for patients with low-back and leg pain in the province. There is very limited data regarding the efficacy of nonsurgeon triage of surgical referrals. The objective of this early implementation study was to determine how the SSP affects utilization of MRI and spine surgery.

Methods

The authors performed a retrospective analysis of 87 consecutive patients with low-back and leg pain who were initially referred to a spine surgeon but were instead redirected to the SSP clinic between May 1, 2011, and November 30, 2011. The SSP clinic triaged patients into 2 groups: Group A (nonsurgical management) and Group B (referred back to the spine surgeon). The SSP classification was modified from the classification proposed by Hall et al. Pain and disability were scored by pain-related visual analog scale, modified Oswestry Disability Index, and EuroQol-5D.

Results

Sixty-two patients (Group A, 71.3%) were discharged after patient education, self-care advice, and/or referral for additional mechanical therapies. Although only 25 patients (Group B, 28.7%) were directed back to the surgeon, the final percentage (12.6%) offered surgery was similar to that of historic controls (15%). Total MRI utilization was significantly lower in Group A (25.8%) than Group B (92.0%) (p < 0.0001). Nonsurgeon triage captured all red flags detected by the surgeon. Patients in Group B were much more likely to have a leg-dominant pain (p = 0.0088) and had significantly higher Oswestry Disability Index (p = 0.0121) and EuroQol-5D mobility (p = 0.0484) scores.

Conclusions

The SSP significantly reduced MRI utilization and referrals seen by the surgeon for nonoperative care. Although this early implementation study suggests potential for cost savings, a more rigorous analysis of outcomes, costs, and patient satisfaction is required.

Abbreviations used in this paper:EQ-5D = EuroQol-5D; LBP = low-back pain; ODI = Oswestry Low Back Pain Disability Index; SSP = Saskatchewan Spine Pathway; SSPc = SSP clinical classification; VAS = visual analog scale.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Daryl R. Fourney, M.D., F.R.C.S.C., Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, 103 Hospital Dr., Saskatoon, SK S7N 0W8, Canada. email: daryl.fourney@usask.ca.

Please include this information when citing this paper: published online November 15, 2013; DOI: 10.3171/2013.10.SPINE13434.

  • 1

    Blackburn MS, , Cowan SM, , Cary B, & Nall C: Physiotherapy-led triage clinic for low back pain. Aust Health Rev 33:663670, 2009

  • 2

    Boden SD, , Davis DO, , Dina TS, , Patronas NJ, & Wiesel SW: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 72:403408, 1990

    • Search Google Scholar
    • Export Citation
  • 3

    Chou R, , Qaseem A, , Owens DK, & Shekelle P: Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 154:181189, 2011

    • Search Google Scholar
    • Export Citation
  • 4

    Chou R, , Qaseem A, , Snow V, , Casey D, , Cross JT Jr, & Shekelle P, : Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147:478491, 2007

    • Search Google Scholar
    • Export Citation
  • 5

    Dagenais S, , Caro J, & Haldeman S: A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 8:820, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Deis N, & Findlay JM: Appropriateness of lumbar spine referrals to a neurosurgical service. Can J Neurol Sci 37:843848, 2010

  • 7

    Deyo RA: Quality and its dimensions. Spine (Phila Pa 1976) 25:661, 2000

  • 8

    Di Iorio D, , Henley E, & Doughty A: A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med 9:10151021, 2000

    • Search Google Scholar
    • Export Citation
  • 9

    Donabedian A: Twenty years of research on the quality of medical care: 1964–1984. Eval Health Prof 8:243265, 1985

  • 10

    Emery DJ, , Shojania KG, , Forster AJ, , Mojaverian N, & Feasby TE: Overuse of magnetic resonance imaging. JAMA Intern Med 173:823825, 2013

  • 11

    Fourney DR: Waiting lists for lumbar spine referrals in Canada: what is the solution?. Can J Neurol Sci 37:719720, 2010

  • 12

    Fourney DR, , Dettori JR, , Hall H, , Härtl R, , McGirt MJ, & Daubs MD: A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan Spine Pathway. Spine (Phila Pa 1976) 36:21 Suppl S164S171, 2011

    • Search Google Scholar
    • Export Citation
  • 13

    Hall H, , McIntosh G, & Boyle C: Effectiveness of a low back pain classification system. Spine J 9:648657, 2009

  • 14

    Hourigan PG, & Weatherley CR: Initial assessment and followup by a physiotherapist of patients with back pain referred to a spinal clinic. J R Soc Med 87:213214, 1994

    • Search Google Scholar
    • Export Citation
  • 15

    Mayman D, & Yen D: Maximizing use of a surgical clinic for referrals of patients having back problems. Can J Surg 42:117119, 1999

  • 16

    McGuirk B, , King W, , Govind J, , Lowry J, & Bogduk N: Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine (Phila Pa 1976) 26:26152622, 2001

    • Search Google Scholar
    • Export Citation
  • 17

    Paskowski I, , Schneider M, , Stevans J, , Ventura JM, & Justice BD: A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process. J Manipulative Physiol Ther 34:98106, 2011

    • Search Google Scholar
    • Export Citation
  • 18

    Simon D, , Coyle M, , Dagenais S, , O'Neil J, & Wai EK: Potential triaging of referrals for lumbar spinal surgery consultation: a comparison of referral accuracy from pain specialists, findings from advanced imaging and a 3-item questionnaire. Can J Surg 52:473480, 2009

    • Search Google Scholar
    • Export Citation
  • 19

    van Tulder MW, , Assendelft WJ, , Koes BW, & Bouter LM: Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976) 22:427434, 1997

    • Search Google Scholar
    • Export Citation
  • 20

    Webster BS, , Courtney TK, , Huang YH, , Matz S, & Christiani DC: Physicians' initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica. J Gen Intern Med 20:11321135, 2005

    • Search Google Scholar
    • Export Citation
  • 21

    Weinstein JN, , Lurie JD, , Tosteson TD, , Tosteson AN, , Blood EA, & Abdu WA, : Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 33:27892800, 2008

    • Search Google Scholar
    • Export Citation
  • 22

    Weinstein JN, , Tosteson TD, , Lurie JD, , Tosteson A, , Blood E, & Herkowitz H, : Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 35:13291338, 2010

    • Search Google Scholar
    • Export Citation
  • 23

    Wilson L, , Hall H, , McIntosh G, & Melles T: Intertester reliability of a low back pain classification system. Spine (Phila Pa 1976) 24:248254, 1999

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 364 191 13
Full Text Views 687 34 1
PDF Downloads 286 27 0
EPUB Downloads 0 0 0