The Role of Spinal Triage Beyond Offering Surgery Spine Therapy Network March 2, 2018 D. DOS SANTOS, B.SC., DC, FCCPOR(C), FCCO(C)

Disclosure of Potential for Conflict of Interest Dr. D. Dos Santos, March 2, 2018 Disclosure of Potential for Conflict of Interest Speaker’s name, Credentials D. Dos Santos, B.Sc.,D.C.,FCCPOR(C),FCCO(C) Advanced Practice Clinician - Trillium Spine Centre Financial Disclosure: Grants/Research Support: N/A Speaker’s Bureau/Honoria: N/A Consulting Fees: N/A Other: N/A

Disclosure of Commercial Support Dr. D. Dos Santos, March 2, 2018 Disclosure of Commercial Support This program has not received financial or in-kind support. There are no actual or potential conflicts-of-interest identified in the presentation of this program. Procedures discussed are for clinical and academic purposes. Dr. Dos Santos does not endorse any specific brand related to procedures discussed.

LBP: A different approach is needed Dr. D. Dos Santos, March 2, 2018 LBP: A different approach is needed 40% annual prevalence One of commonest reasons for consultation with a physician (10-15% of all visits) High utilization of unnecessary imaging and management Number one cause of years lived with disability 25% of patients with LBP responsible for 75% of cost to health care system

Spine Care in Ontario – Wait Times (hqo) Dr. D. Dos Santos, March 2, 2018 Spine Care in Ontario – Wait Times (hqo) Provincial Wait Times for Diagnostic Imaging CT scans: 49 days (target is 28 days) MRI: 102 days (target is 28 days) Provincial Wait Times for Orthopedic Surgery: Lumbar Disc Surgery: 301 days (target is 182 days) Bone/Spine: 223 days (target is 182 days)

Spine Care in Ontario – Wait Times Dr. D. Dos Santos, March 2, 2018 Spine Care in Ontario – Wait Times Wait Times for Lumbar Disc Surgery (time from receiving a referral from a family doctor to the specialist appointment): Priority 2 patients (high probability of disease progression and morbidity affecting function) - 17 days Priority 3 patients (the progress of the disability/disease is moderate) - 76 days Priority 4 patients (the progress of the disability/disease is minimal) -120 days

Spine Care in Ontario – Wait Times Dr. D. Dos Santos, March 2, 2018 Spine Care in Ontario – Wait Times Surgical Wait Time (time from specialist and patient decide surgery is the appropriate option until the day of surgery): Priority 2 patients – 63 days Priority 3 patients – 125 days Priority 4 patients – 139 days 57% of patients seen within the target time

Provincial Initiatives - PCLBP Dr. D. Dos Santos, March 2, 2018 Provincial Initiatives - PCLBP Primary Care Low Back Pain (PCLBP) Pilots launched in 2015 as part of MHLTC LBP strategy. 7 Sites in 7 LHIN’s (CHCs, NPLCs, FHTs). Assessment and care plan model. (PT, DC, Kin). Can be referred for community care Serves uninsured and/or vulnerable patient populations. (significant co-morbitities – diabetes, mental health and addiction issues). No restrictions for accepting patients who are already opioid dependent, and no restriction on duration of LBP

Provincial Initiatives – Rapid Access Dr. D. Dos Santos, March 2, 2018 Provincial Initiatives – Rapid Access Rapid Access Clinics announced December 2017 Builds on ISAEC and hip and knee central intake and assessment centres. Meant to help with surgical wait times and to ensure prompt access to right treatment needed for hip, knee and low back pain

Provincial Initiatives - ISAEC Dr. D. Dos Santos, March 2, 2018 Provincial Initiatives - ISAEC Inter-professional Spine Assessment and Education Clinics (ISAEC) Shared care model. Distinct patient cohort. Objectives: improved outcomes and patient satisfaction decrease MRI utilization, reduce unnecessary referrals for LBP, improve access to specialist care

Provincial Initiaties - ISAEC Dr. D. Dos Santos, March 2, 2018 Provincial Initiaties - ISAEC Risk Stratification Surgical Inflammatory Risk of Narcotic Dependency Risk of Chronicity

Provincial Initiatives - ISAEC Dr. D. Dos Santos, March 2, 2018 Provincial Initiatives - ISAEC Data Avg wait time to consult – 12 days Avg wait time for surgical consult - < 6 weeks Reduction in MRI over 30% Less than 7% of ISAEC patients have gone on to imaging or specialist intervention

Other Provincial Initiatives Dr. D. Dos Santos, Oct. 29, 2015 Other Provincial Initiatives ECHO (Extensions for Community Healthcare Outcomes) Ontario programs Chronic Pain and Opioid Stewardship Rheumatology Living a Health Life With Chronic Pain/Chronic Conditions Quality Standards Advisory Committee on Low-Back Pain Core (clinically oriented relevant examination) Back Tool. Core Neck Tool and Headache Manager – Centre for Effective Practice

“With great power comes great responsibility” Uncle Ben- Spiderman I Dr. D. Dos Santos, March 2, 2018 Assessment and Triage “With great power comes great responsibility” Uncle Ben- Spiderman I Corollary: With great responsibility comes great power

Dr. D. Dos Santos, March 2, 2018 Triage Is not easy as it appears: Administrative data is not enough Specialist screening adds unnecessary costs PCPs lack knowledge and confidence Principle stakeholders can’t agree Focus is usually in the wrong place

Dr. D. Dos Santos, March 2, 2018 Trillium AP program (Advanced Role Chiropractor and Advanced Practice Physiotherapist Model) Development Plan Phases of implementation Observation of Surgeon Clinics Identification of Required Competencies Assessment of Learning Needs Development of Medical Directives and MAC approval Documentation and Communication Process Changes Surgeon Eval of Competence/Ongoing Supervision Radiology Review and Learned Objectives

Dr. D. Dos Santos, March 2, 2018 AP program Utilization rate for advanced imaging by APP/APC very low (5.4%) High rates of satisfaction with report, diagnosis and recommendations Approx 8% referred for surgical consultation High levels of agreement between APC/APP High levels of satisfaction with neurosurgeon/orthopaedic surgeons

Dr. D. Dos Santos, March 2, 2018 Triage Everyone is looking at the altered anatomy and when that is not obvious, the low back pain is classified as “non-specific” 90% of patients are ”non-specific”. Clinically they are not all the same and shouldn’t all be treated the same way

Triage Questions – The big 5 Dr. D. Dos Santos, March 2, 2018 Triage Questions – The big 5 1. “Where is your pain the worst”? “Is it back or leg dominant”? It is not “where do you hurt”? It is ”where is your pain the most intense?” “Is the pain constant or intermittent”? Does bending forward make your typical pain worse

Dr. D. Dos Santos, March 2, 2018 Triage Questions “Has there been any change in your bowel or bladder function”? “What can’t you do now because of your pain that you could do before and why”?

Dr. D. Dos Santos, March 2, 2018 Triage The history is confirmed or refuted by the physical examination: Observation and movement Selected nerve root tension/irritation tests Selected nerve root conduction tests Upper motor neuron involvement tests Saddle sensation test

Triage - Summary Spinal triage is not easy Dr. D. Dos Santos, March 2, 2018 Triage - Summary Spinal triage is not easy Requires specialized training and system changes Can produce significant cost savings to the system, improved outcomes and patient satisfaction Remember: With great power comes great responsibility!