1. Extended Back Assesment Quality development project in physiotherapy primary care clinics. 2003 – 2012 Danish Regions © Nils-Bo de Vos Andersen 2012

2. Extended Back Assesment (EBA) Definition : Extended back assesment in the primary care sector, performed by specially trained physiotherapists, is an evidence-based assessment of the lumbar spine and pelvis, that offers the general practitioner a supplementary assessment within a limited time range © Nils-Bo de Vos Andersen 2012

3. Extended Back Assesment (EBA): Low back pain is the leading cause of activity limitation and work absence throughout much of the world Low back pain is the leading cause of activity limitation and work absence throughout much of the world Expert opinion has likened the frequency of low back pain to an “epedemic” Expert opinion has likened the frequency of low back pain to an “epedemic” - and it associates with an enormous economic burden - and it associates with an enormous economic burden Hoy 2010 Hoy 2010 © Nils-Bo de Vos Andersen 2012

4. Extended Back Assesment (EBA): A recent systematic review estimated the 1-year prevalence of a first-ever episode of low back pain to range between 6,3% and 15,3% A recent systematic review estimated the 1-year prevalence of a first-ever episode of low back pain to range between 6,3% and 15,3% Individuals who have experienced activity- limitying low back pain experience reoccurring episodes with estimates ranging between 24% and 33% Individuals who have experienced activity- limitying low back pain experience reoccurring episodes with estimates ranging between 24% and 33% Chronic low back pain has demonstrated rapid increases from 3.9 % in 1992 to 10,2 % in 2006 Chronic low back pain has demonstrated rapid increases from 3.9 % in 1992 to 10,2 % in 2006 Stanton 2008, Freburger 2009 Stanton 2008, Freburger 2009 © Nils-Bo de Vos Andersen 2012

5. Extended Back Assesment (EBA): Psychosocial factors appear to play a larger prognostic role than physical factors in low back pain Psychosocial factors appear to play a larger prognostic role than physical factors in low back pain Changes in behavioral variables and improvement in function seem to be more important than physical performance factors for succesful treatment Changes in behavioral variables and improvement in function seem to be more important than physical performance factors for succesful treatment Wessels 2006 Wessels 2006 © Nils-Bo de Vos Andersen 2012

6.  Utilisation of validated patient self-report questionaires  Identification of risk factors that indicate the development of chronicity  Evidence-based standardised clinical assessment EBA starting point = Danish Medical Technological Evaluation Reports (MTV) recommondations 1999/ 2003 © Nils-Bo de Vos Andersen 2012

7.  Patient-information and instruction in self mangement  IT-based reports and communication  Improved co-work among primary care sector personel EBA starting point = MTV recommondations © Nils-Bo de Vos Andersen 2012

8. Aims of the EBA project:  Offer the general practitioner a supplementary assessment of patients with low back pain within a limited time range  Enhance care taking of LBP patients in primary health care sector in order to reduce the number of people going on to secondary care.  Possibly reduced cost as early patient-specific treatment, go back to work earlier and no need for 2ndary HC. © Nils-Bo de Vos Andersen 2012

9. Inclusion criteria for EBA project Subacute or chronic low back pain patients With or without sciatica Activity-limitying low back pain In the phase of evaluation © Nils-Bo de Vos Andersen 2012

10. Participating physiotherapists Assessment to be initiated within 1 week of receiving GP referral Assessment to be initiated within 1 week of receiving GP referral An IT – based report of examination findings classification and recommendations of the patient has to be sent to the referring GP within 2 weeks from the initial assessment An IT – based report of examination findings classification and recommendations of the patient has to be sent to the referring GP within 2 weeks from the initial assessment © Nils-Bo de Vos Andersen 2012

11. Participating physiotherapists (cont’d) Must have a minimum of 5 years clinical experience of working with LBP patients. Underwent supplementary postgraduate education in assessment and classification of patients with low back and referred pain. Have signed a contract stating they will use the EBA assessment forms and consent to have their work reviewed. Have signed a contract stating they will use the EBA assessment forms and consent to have their work reviewed. © Nils-Bo de Vos Andersen 2012

12. Participating physiotherapists Four practice consultants overview the project and ensure that minimum quality standards are met by the participating physiotherapists. In 2008 a quality database retrieving data from the project was developed. From sept. 2009 the physiotherapists could register their patients electronically and enter all clinical data on the database FysDB © Nils-Bo de Vos Andersen 2012

13. Internet-based IT - database – FYSDB Patient-questionaires, assessment, classification © Nils-Bo de Vos Andersen 2012

14. Internet-based IT - database FYSDB – text is automatically generated to the patient report © Nils-Bo de Vos Andersen 2012

15. The database FysDB contains a mailbased retest- function, using patient self-report questionaires after 3 - 6 and 12 month. © Nils-Bo de Vos Andersen 2012

16. The database FysDB contains statistics.The physiotherapists have the possibility to compare their own results with the general results of the Region © Nils-Bo de Vos Andersen 2012

17. 30.07.2012 : 3038 patients are registered in the database Inclusion criteria for the EBA project meet demands 70% of all assessments are performed in areas with less specialized doctors 217 participating physiotherapists in the 4 Regions are oblige to use the database FysDB Status EBA project © Nils-Bo de Vos Andersen 2012

18. The EBA has been evaluated by physiotherapy practice consultants. The evaluation contains quantitative and qualitative elements. Evaluation was based on subjective questionnaires to patients, doctors and physiotherapists Evaluationresults: high degree of satisfaction among all groups EBA project 2004 to 2006 © Nils-Bo de Vos Andersen 2012

19. The contend and set up of the EBA has been evaluated by researcher Tom Pedersen Copen- hagen Backcenter in a report 2009, stating that the assessment meet best practice standards. An evaluation report has been set up by the Public health and Qualitydevelopment Center- Marselisborgcenter Region Midtjylland 2011 stating improvements on activity-limitations, but not on reduced sickleave. EBA project 2007 to 2012 © Nils-Bo de Vos Andersen 2012

20. Perspectives for the future EBA quality development is presently implemented in 4 out of 5 Regions: Region Midtjylland, Region Nordjylland, Region Syddanmark and as a project in Region Hovedstaden. 2011 in the Region Midtjylland and Syddanmark the EBA has been accepted as a part of the Regional programme for low back patients during their course in the primary care sector. © Nils-Bo de Vos Andersen 2012

21. Perspectives for the future Proposal for the EBA: The setup of a prospective longitudinal randomized study including a control group. It is necessary for evaluation of effect, that the target group is randomly divided into 2 groups. © Nils-Bo de Vos Andersen 2012

22. Perspectives for the future Different aspects can be evaluated: Data or questionnaires at 3/12 and 6/12, 12/12 - or longer. Stay at work during episode; return to work + period of sick leave; evaluate by HC Register Pattern of Health Care utilization Social Welfare benefits; evaluate by HC Register Self-estimated health status and functional ability, especially work capacity, patient satisfaction Self-estimated health status and functional ability, especially work capacity, patient satisfaction © Nils-Bo de Vos Andersen 2012

23. Thank you for your attention. Contact and networking please write: nils-bo.andersen@stab.rm.dk nils-bo.andersen@stab.rm.dk © Nils-Bo de Vos Andersen 2012