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
Outline
• Describe care pathways
• Distinguish pathways – guidelines
• Research related to role of physical therapy in
care pathways for LBP
• The challenge of implementation
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
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.
• 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.
What
a Spine
What
is a is
Spine
Pathway?
Pathway?
What
a Spine
What
is a is
Spine
Pathway?
Pathway?
What is a Spine Pathway?
Patient decides
to seek care
Health
Outcome
Entry:
Primary Care
Cycle
Complete
Are Lab Tests
Indicated?
Is Imaging
Indicated?
Is Surgical
Consult
Indicated?
Is Medication
Indicated?
Is PT
Indicated?
What is a Spine Pathway?
Patient decides
to seek care
Health
Outcome
Entry:
Primary Care
Cycle
Complete
Are Lab Tests
Indicated?
Is Imaging
Indicated?
Is Surgical
Consult
Indicated?
Is Medication
Indicated?
Is PT
Indicated?
GUIDELINES
What is a Spine Pathway?
Patient decides
to seek care
Entry:
Primary Care
Are Lab Tests
Indicated?
Is Imaging
Indicated?
Is Medication
Indicated?
PATHWAY
Health
Outcome
Cycle
Complete
Is Surgical
Consult
Indicated?
Is PT
Indicated?
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.
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)
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)
Early Trends Among Seven Recommendations
From the Choosing Wisely Campaign
JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441
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)
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
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
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.
The right care for the right
patient at the right time.
How Much Does it Matter?
2,184 new consulters to primary care within one integrated
healthcare system in Salt Lake City
Age > 18 at the index visit date
2004-2008
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 1year from index primary care visit.
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
Initial Management Strategies and Risk for
Subsequent Utilization
opioids
Spinal Injections
imaging
PT
Specialist Visit
Surgical Procedure
0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
Statistics represent aOR (95% CI) adjusted for age, sex, BMI, prior surgery, specific diagnosis, and
other initial management variables
Where do patients go first beyond primary care?
Fritz JM, Brennan GP, Hunter SJ. Health Serv Res, 2015
Initial Management Strategies and Risk for Subsequent
Utilization
IMAGING VS. PT
Spinal Injections
Surgeon Visit
Surgery
0
1.0
3.0
5.0
7.0
9.0
11.0
13.0
15.0
17.0
Mean Cost Difference = $4,793 (95% CI: $3,707, $5,879)
19.0
Initial Management Strategies and Risk for Subsequent
Utilization
Spinal Injections
IMAGING VS. PT
IMAGING VS. PCP
Surgeon Visit
Surgery
0
1.0
3.0
5.0
7.0
9.0
11.0
13.0
15.0
17.0
Mean Cost Difference = $4,663 (95% CI: $3,703, $5,623)
19.0
Initial Management Strategies and Risk for Subsequent
Utilization
Spinal Injections
IMAGING VS. PT
IMAGING VS. PCP
PT VS. PCP
Surgeon Visit
Surgery
0
1.0
3.0
5.0
7.0
9.0
11.0
13.0
15.0
Mean Cost Difference = $1,080 (95% CI: $885, $1,275)
17.0
19.0
Total 1-Year LBP-Related Health Costs
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
The Initial Choice of Who to See
for Back Pain.
How Much Does it Matter?
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
• 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
Provider Type for Back Pain Visits
Utilization Outcomes by Initial Provider Type
Median Episode of Care Duration (days)
1-Year LBP-Related Costs Based on First Care Received
Care Pathways:
The Challenge of Implementation
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 2012. 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.
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)
Traditional 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)
… a troublesome pattern emerged: The more costeffective 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)
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
to appointment: 16 days
Avg. time
AVERAGE PROCESS TIME– 74 days
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
to appointment: 16 days
Avg. time
1. Initial Contact – patient with
uncomplicated LBP calls scheduling for
appointment.
a)Screened
with checklist for eligibility,
offered rapid PT access.
b)If
YES – schedule PT within 72 hrs
c)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
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)
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…
Thank you