1. 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

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

3. 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

4. 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.

5. 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.

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

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

9. 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 *

10. 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 *

11. 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 *

12. 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.

13. 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)

14. 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)

15. Early Trends Among Seven Recommendations From the Choosing Wisely Campaign
JAMA Intern Med. 2015;175(12): doi: /jamainternmed
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)

16. 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

17. 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 *

18. 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.

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

20. 2,184 new consulters to primary care within one integrated healthcare system in Salt Lake City
Age > 18 at the index visit date
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.

21. 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

22. 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

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

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

25. 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)

26. 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)

27. Total 1-Year LBP-Related Health Costs

29. 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

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

32. 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 *

33. 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

34. Provider Type for Back Pain Visits

35. Utilization Outcomes by Initial Provider Type

36. Median Episode of Care Duration (days)*

37. 1-Year LBP-Related Costs Based on First Care Received*

38. Care Pathways: The Challenge of Implementation

39. 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 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.

40. 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)

41. 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)

42. … 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) *

43. 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

44. 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

45. 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)

46. 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…

47. Thank you