President's Column: Primary Care Low Back Pain

By F. Todd Wetzel posted 04-25-2017 10:03 AM

At a recent meeting of the British Association of Spine Surgeons (BASS—too good a name not to somehow be partnered with NASS), I had the opportunity to learn a bit about the National Health Service (NHS)of Britain from some very knowledgeable individuals. One of the cost issues plaguing the NHS is, not surprisingly, related to low back pain (LBP). The perspective that I gained by listening to how this is being addressed by the NHS was quite valuable. That perspective, however, was a bit skewed as it was exclusively surgical. Nonetheless, several interesting issues, directly applicable to surgical practices worldwide (perhaps?) were raised.

Despite my designation as a spine surgeon, I have always thought of my role as more of a spine care provider and have always had a strong interest in nonoperative care. In the model in which I practice, it is becoming increasingly difficult to devote a sizeable percentage of my clinical time to this. In a university RVU-based practice model, there is significant pressure for me to do what a surgeon is “supposed” to do: surgery. The only way to continue providing nonsurgical care is to increase the number of outpatient visits, also good for RVUs, but at the expense of less time per visit and increased stress on the clinic staff. I suspect that these pressures are felt by most (read: all) practicing NASS members.

In the center model in which I practiced at a previous institution, patient access could occur via practitioners of any specialty, who would evaluate the patient and then determine the most appropriate practitioner to provide ongoing care. If a patient had a “surgical problem” which was effectively treated nonsurgically, well and good; if not, the patient would be scheduled for a surgical consultation at the next visit. The advantages of this system were many, including the ability to retain the patient and provide treatment for “primary care LBP” (PCLBP), ie, patients with short duration of symptoms, no “red flags” and normal neurological examinations. Good thing, as this heterogenous group comprises the clear majority of spine patients.

Obviously, the goal is to provide appropriate value-based care early and, along with patient education and modification or elimination of risk factors for recurrence, to decrease the percentage who will go on to be chronic. Amid the resource crisis in which we find ourselves, one of the questions worth asking is who should be taking care of this acute/subacute group. Should they be seeing specialists during this time, say with fewer than six weeks of LBP, at all? Indeed, are these referrals “inappropriate”?
One of the first questions I asked my British colleagues concerned PCLBP patients. To see an orthopedic or neurosurgical consultant, a patient must first be seen and evaluated by the primary care provider if the patient is covered by the National Health Service (NHS), as 64.6 million patients are.1 Despite widespread, but not ubiquitous primary care treatment of LBP, the number of early specialist referrals increased across all specialties, prompting the creation of the National Institute for Health and Care Excellence (NICE) in 1999.2

NICE has produced voluminous evidence-based material addressing many issues, rather similar, in fact, to our NASS coverage guidelines. At the BASS meeting, the results of a recent NICE project to decrease unnecessary referrals for LBP to surgical consultants were presented. Using evidence-based data, a “pyramid” of care for LBP was formulated, with levels of specialization increasing as one ascends the pyramid. The apex of the pyramid was surgical consultation (sorry, again). The question asked was how many patients will get to the surgical consultation level compared to parallel or historical data without the pyramid? Ten thousand patients entered the study. None went to surgical consultation before resolution of their back pain. Comparing this to conventional referral rates, the cost savings were not insignificant: £829,000.3 Good news for the Fleet Street types to be sure, and probably for the surgeons.

Was this finding having any impact on the practicing surgeon? Unhesitatingly, I turned to level of evidence favored by surgeons, anecdotal. My colleague and I turned over our napkins, retrieved our most recent clinic data via cell and had at it. N = 1 day, patients reviewed by our infallible recollections, no data pre-NICE. Results . . .
- FTW:
* 44 visits of 52 booked
* 15 new patient visits of 18 booked
* 9 new PCLBP patients

- BASS colleague:
* 32 visits of 33 booked
* 14 new patient visits of 14 booked
* 4 PCLBP patients
As I had over twice as many “primary care LBP” referrals as my colleague, it became clear to us that NICE works.

* This is an excerpt from the March/April 2017 SpineLine. Click here to read the full column.