The Bree Collaborative’s Role in Spine/Low Back Pain Care: A Proposal Presentation to the Bree Collaborative August 2, 2012

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

Experts met July 2nd Invited Participants Invited guest 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

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

Variation in Treatment and Management among Patients with Acute and Chronic Back Pain Acute/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 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

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

Bree Topic Goals & Guidelines 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

Low Back Pain Initiatives in WA Puget 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 UW Comparative Effectiveness Research Pilot on lumbar fusions and spine care in general ACUTE (< 6 weeks) CHRONIC ( > 3 months) Spine SCOAP compiles data on all spine surgeries

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)

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?

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.