Care Pathways for Back Pain: The Role of Physical Therapy Julie M. Fritz, PT, PhD, FAPTA Professor, Department of Physical Therapy Associate Dean for Research, College of health University of Utah Salt Lake City, Utah, USA

Outline Describe care pathways Distinguish pathways – guidelines Research related to role of physical therapy in care pathways for LBP The challenge of implementation

What is a Care Pathway? A set of defined steps for management of a patient during delivery of care for a disease entity. More focused on sequencing and timing than practice guidelines. Pathway goals: The right people Doing the right things At the right time With the right outcome With attention to the patient experience

Care Pathways – Practice Guidelines Guidelines – statements that include recommendations intended to optimize patient care, that are informed by systematic reviews of evidence and assessments of benefits and harms. Pathways - pragmatic translations of guidelines with specific directions for delivering care extending over the continuum. In the U.S., fragmented care and wide variations in utilization and costs focuses attention on pathways as a strategy to manage utilization.

Timeliness is increasingly recognized as an important factor in quality of care. Measuring the amount of time it takes for a patient to have access to an appointment and see a clinician, has emerged as a key indicator of overall system performance. Strategies for improving access call for continuous supply and demand assessment and monitoring as well as implementation of alternatives to in-office physician visits. This will lead to process redesign to improve workflow and match patient needs with available staff skills.

What is a Spine Pathway? What is a Spine Pathway? * Example of a process map *

What is a Spine Pathway? What is a Spine Pathway? * Example of a process map *

What is a Spine Pathway? Health Outcome Are Lab Tests Indicated? Patient decides to seek care Are Lab Tests Indicated? Is Imaging Indicated? Is Medication Indicated? Entry: Primary Care Is Surgical Consult Indicated? Is PT Indicated? Health Outcome Cycle Complete Example of a process map *

What is a Spine Pathway? Health Outcome Are Lab Tests Indicated? Patient decides to seek care Are Lab Tests Indicated? Is Imaging Indicated? Is Medication Indicated? Entry: Primary Care Is Surgical Consult Indicated? Is PT Indicated? Health Outcome Cycle Complete Example of a process map GUIDELINES *

PATHWAY What is a Spine Pathway? Health Outcome Patient decides to seek care Are Lab Tests Indicated? Is Imaging Indicated? Is Medication Indicated? Entry: Primary Care Is Surgical Consult Indicated? Is PT Indicated? Health Outcome Cycle Complete Example of a process map *

Why Focus on Spine Pathways? Numerous guidelines have not impacted overuse, unwarranted variation and increasing costs. Implementation of guidelines is hard. Shifts focus from specific provider behaviors to patient flow. Collaborative efforts are necessary to overcome tribalism in spine care.

Mafi et al. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med, 2013 Percentage of visits for acute or acute-on-chronic low back pain (NAMCS and NHAMCS surveys) (red lines represent guideline concordant care)

Mafi et al. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med, 2013 Percentage of visits for acute or acute-on-chronic low back pain (NAMCS and NHAMCS surveys) (red lines represent guideline concordant care)

Early Trends Among Seven Recommendations From the Choosing Wisely Campaign JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441 Trends for Selected Low-Value Services from retrospective analysis of Anthem-affiliated commercial claims plans. Imaging for low back pain remained high throughout the study (53.7%) with no statistically significant changes (P = .71)

Changing Clinician Behavior When Less is More Choosing Wisely was intended to support conversations between clinicians and patients about what care is necessary. It is generally acknowledged that awareness of guidelines or health-related information is insufficient to change clinician or patient behavior. Convincing patients and clinicians to stop doing something is especially challenging. Gonzales and Cattamanchi, JAMA Intern Med, 2015;175:1921-2

Perspective The Science of Choosing Wisely — Overcoming the Therapeutic Illusion “In recent years, the United States has seen increasing efforts to reduce inappropriate use of medical treatments and tests. Perhaps the most visible has been the Choosing Wisely campaign… The success of such efforts, however, may be limited by the tendency of human beings to overestimate the effects of their actions…In medicine, [this tendency] may be called the “therapeutic illusion”, a label first applied in 1978 to “the unjustified enthusiasm for treatment on the part of both patients and doctors”. Casarett D, New Eng J Med, 2016;374:1203-5 *

The Fundamental Challenge: “Who you see is what you get” Cherkin, et al. Physician variation in diagnostic testing for low back pain. Arth & Rheum 1994 There is little consensus, either within or among specialties, on the use of diagnostic tests for patients with back pain. Thus, the diagnostic evaluation depends heavily on the individual physician… and not just the patient's symptoms and findings. Furthermore, many physicians may be ordering imaging studies too early and for patients who do not have the appropriate clinical indications.

The right care for the right patient at the right time. How Much Does it Matter?

2,184 new consulters to primary care within one integrated healthcare system in Salt Lake City Age > 18 at the index visit date 2004-2008 No claims related to LBP for 1 year preceding index date. Excluded those with likely non-musculoskeletal of serious cause for LBP (UTI, kidney stones, fracture, tumor, etc.) Examined early utilization variables and subsequent costs over 1- year from index primary care visit.

INITIAL MANAGEMENT STRATEGIES (within 14 days): Physical Therapy 13.0% Advanced Imaging 12.3% Lumbar Radiographs: 23.0% Opioid Medication: 39.8% OUTCOME VARIABLES Specific services in 12 months following the index visit: Specialist Physician Visit Epidural Injections Surgical Procedures

Initial Management Strategies and Risk for Subsequent Utilization opioids imaging PT Statistics represent aOR (95% CI) adjusted for age, sex, BMI, prior surgery, specific diagnosis, and other initial management variables

Where do patients go first beyond primary care? Fritz JM, Brennan GP, Hunter SJ. Health Serv Res, 2015

Initial Management Strategies and Risk for Subsequent Utilization IMAGING VS. PT Mean Cost Difference = $4,793 (95% CI: $3,707, $5,879)

Initial Management Strategies and Risk for Subsequent Utilization IMAGING VS. PT IMAGING VS. PCP Mean Cost Difference = $4,663 (95% CI: $3,703, $5,623)

Initial Management Strategies and Risk for Subsequent Utilization IMAGING VS. PT IMAGING VS. PCP PT VS. PCP Mean Cost Difference = $1,080 (95% CI: $885, $1,275)

Total 1-Year LBP-Related Health Costs

Spine pathway implemented at Jordan Hospital Spine pathway implemented at Jordan Hospital. Goal – standardize initial evaluation and management (Tier 1) Tier 2 – apply evidence-based management for appropriate patients. Promote interdisciplinary collaborative maangement

The Initial Choice of Who to See for Back Pain. How Much Does it Matter?

Number of spine episodes by entry point, 2010 data. Source: Elton D., et al. OptumHealth Published in Kosloff et al, Popul Health Manag, Dec, 2013 *

Retrospective review of claims data from 2012 for employee health plan 747 unique patients with new consultation for back pain Identified the provider type for entry into health care Examined outcomes over following 12 months: Utilization outcomes (imaging, injections, surgeon consult, surgery, ED visit) Episode of care duration Total LBP-related health care costs

Provider Type for Back Pain Visits

Utilization Outcomes by Initial Provider Type

Median Episode of Care Duration (days) *

1-Year LBP-Related Costs Based on First Care Received *

Care Pathways: The Challenge of Implementation

The Employer Led Health Care Revolution Patricia McDonald, Robert Mecklenburg, Lindsay Martin, HBR, July 2015 Like most U.S. companies Intel faced soaring healthcare costs — estimated to reach $1 billion by 2012. None of the approaches it tried: high-deductible/low-premium plans, on-site clinics, employee wellness—addressed the root of the problem: steadily rising cost of care. In 2009, Intel tried another option – use its purchasing power in markets where it had operations to influence healthcare players to rise above their competing self-interests and work together to redesign the local health care system. Specifically, Intel decided to tackle the problem as it would a manufacturing challenge: by using lean improvement methods to rigorously manage the quality and cost of its health care suppliers.

The Employer Led Health Care Revolution Patricia McDonald, Robert Mecklenburg, Lindsay Martin, HBR, July 2015 Uncomplicated back pain was selected as the first value stream to improve because it was high on Intel’s list in terms of frequency and total costs. Virginia Mason had used lean process to treat back patients since 2005 and had solid experience standardizing the clinical process at multiple sites Wall Street Journal (1/12/07)

Traditional Process: HMC Process: Delivery is physician-focused. Patient runs a gauntlet of physician visits or tests before any treatment begins PROCESS DURATION: 52 days HMC Process: Screened by rehab Office assistant. Uncomplicated problems go directly to PT. Physicians and Specialists freed up to manage more complex cases PROCESS DURATION: 22 days Wall Street Journal (1/12/07)

… a troublesome pattern emerged: The more cost-effective it became, the bigger financial hit the medical center took. "Everyone gained but Virginia Mason," says its chief of medicine, Robert Mecklenburg. A novel solution, crafted with the help of the big employers, ultimately let Virginia Mason share in some of the savings it created -- by paying the medical center more for some cheaper treatments. Wall Street Journal (1/12/07) *

CURRENT PROCESS – Initial Contact – patient with uncomplicated LBP calls scheduling for appointment. PMR Visit – evaluation, imaging and/or injections ordered Avg. time to appointment: 21 days Follow-up PMR visit (31% have injection, 62% x-rays, 31% MRI/CT) Avg. time to appointment: 18 days Referral to Physical Therapy Avg. time to appointment: 16 days AVERAGE PROCESS TIME– 74 days

CURRENT PROCESS – RAPID ACCESS PROCESS – Initial Contact – patient with uncomplicated LBP calls scheduling for appointment. PMR Visit – evaluation, imaging and/or injections ordered Avg. time to appointment: 21 days Follow-up PMR visit (31% have injection, 62% x-rays, 31% MRI/CT) Avg. time to appointment: 18 days Referral to Physical Therapy Avg. time to appointment: 16 days Initial Contact – patient with uncomplicated LBP calls scheduling for appointment. Screened with checklist for eligibility, offered rapid PT access. If YES – schedule PT within 72 hrs If NO – schedule next available PMR visit 2. Physical Therapy Care Time to appointment: 3 days 15% radiographs 5% advanced imaging 2% injections AVERAGE PROCESS TIME– 74 days AVERAGE PROCESS TIME– 40 days

First 50 eligible patients offered the Program: RAPID ACCESS PROCESS – Early Results First 50 eligible patients offered the Program: 32 (64%) agreed to begin PT 20 (63%) attended first PT visit 18 (90%) were seen within 72 hours Mean number of sessions: 3.3 (range 1-7)

Summary Organizing care to get the right people doing the right things at the right time: Relatively easy to map Potential to reduce over-use, improve patient-centered outcomes Very challenging to implement Partnerships with colleagues, payers, patients…

Thank you