1. Evidence Based Low Back Pain – Concord Hospital Pilot Project Diane Olimpio, PT, MS October 21, 2014

2. Pilot Project Goal To implement a quality initiative for treatment of non-specific low back pain, utilizing a standardized clinical pathway and early referral to physical therapy to improve outcomes and reduce unwarranted imaging

3. Hypotheses Standardizing evidence-based treatment for patients with non-specific low back pain will improve patient outcomes and decrease unwarranted variation in care Utilizing a standardized pathway will reduce imaging rates/costs and patients’ exposure to radiation Early PT referral will reduce LBP recurrence and chronicity and associated costs Patients will be more willing to accept a plan of care that does not involve imaging if offered prompt treatment or phone consult with a physical therapist Following evidence based practice will yield more predictable outcomes and more predictable cost to manage this population

4. Virginia Mason Model Virginia Mason collaborated with Starbucks (Aetna WC carrier) to work on a plan to improve quality and reduce cost for employees with low back pain (LBP). The study concluded that 85 percent of back patients suffered uncomplicated back pain that required treatment different from those afflicted with serious spine or disc problems. [Patients were determined to have complicated or uncomplicated back pain based on their answers to a series of screening questions.] According to Virginia Mason physician, R. Mecklenburg, MD, “90 percent of what we did was no help at all. Does an appointment with an orthopedic surgeon, a neurologist, a neurosurgeon help for uncomplicated back pain? The evidence says no. Does an MRI help? No. As far as we could tell, the only thing the evidence showed [that] was worth anything was physical therapy.”

5. Virginia Mason Model Care redesigned to include same day access to a physical therapist and a physical medicine physician From 2004-2007 changes yielded: 50% reduction in lost work time $2 million in savings At the same time, Virginia Mason was loosing money on each patient as a result of fewer billed tests and services. To offset, Aetna increased reimbursement for physical therapy sessions.

6. Concord Hospital Mandate Concord Hospital Board of Trustees set a goal of decreasing MRI’s at Concord Hospital Data demonstrates many MRI’s are unnecessary

7. Concord Hospital Outcomes Data collected on a QI study group of 54 patients with an inclusive ICD 9 code related to LBP (excluding surgery and fractures) who were referred by one of 4 pilot primary care practices to a subgroup of 4 pilot PT practices between May 1, 2013 and October 31, 2013 11 patients referred for phone consult, 5 resulted in PT treatment (included in total of 54) Data analyzed for: Imaging rate Average cost for all CH services within an episode of care for LBP Average Physical Therapy visits per episode of care for LBP Patient Outcomes

8. Imaging Rates <6 weeks from Onset of Care

9. Average Cost LBP Episode of Care – All Costs Including Surgery and Imaging* * Imaging cost only includes CH (excludes CIC and all other)

10. PT Outcomes: Length of Stay

11. PT Outcomes: GROC

12. PT Outcomes: MODI

13. In Summary CH data trending in the right direction Pilot project outcomes: Decreased imaging rates Lower overall cost Fewer visits in PT with decreased therapy cost Outcome data supports positive outcomes in the study subgroup

14. Suggestion Need to create incentives to create best treatment and outcome models. Narrow networks: Abide by evidence based treatment guidelines Committed to value based care Focus on outcomes Targeted fee schedule Reduce payment for passive treatment such as hot/cold packs, electrical stimulation and ultrasound Reduce payment for imaging which is non emergent and performed in the first 6 weeks of an injury