Woodhouse L.1, Slomp M.2, Dick D.2,3, Miciak M.1,4, Schneider G.5, Bostick G.1, McMorland G.6, Lei V.1, Woodhouse B.1, Norton A.1, Gazankas M.7, Martens Van-Hilst Y.8, Espersen K.9, Manolescu A.-R.10, Tsui K.11, Qayyum A.12, Komant C.13, Fernando N.14, Phung A.14
1University of Alberta, Physical Therapy, Edmonton, Canada, 2Alberta Health Services, Bone and Joint Health Strategic Clinical Network, Edmonton, Canada, 3University of Alberta, Orthopaedic Surgery, Edmonton, Canada, 4Alberta Innovates, Performance and Evaluation, Edmonton, Canada, 5University of Calgary, Radiology, Calgary, Canada, 6Private Chiropractic Practice, Cochrane, Canada, 7Foothills Primary Care Network, Cochrane, Canada, 8Calgary Foothills Primary Care Network, Cochrane, Canada, 9Northern Lights Health Centre, Allied Health, Alberta Health Services, Fort McMurray, Canada, 10Northern Lights Health Centre, Orthopaedic Surgery, Alberta Health Services, Fort McMurray, Canada, 11Northern Lights Health Centre, Occupational Therapy, Alberta Health Services, Fort McMurray, Canada, 12Northern Lights Health Centre, Physical Therapy, Alberta Health Services, Fort McMurray, Canada, 13Strathcona Community Hospital, Allied Health, Alberta Health Services, Edmonton, Canada, 14Strathcona Community Hospital, Physical Therapy, Alberta Health Services, Edmonton, Canada
Background: The high prevalence, disability and work absenteeism associated with low back pain (LBP) in developed countries make it the single most costly category of musculoskeletal health conditions and the second leading cause of reduced quality of life. However, the majority of back pain (80-90%) has no identifiable pathological cause (i.e. is non-specific LBP), and resolves within weeks without surgery or imaging. This paradox suggests that we need to change how LBP is managed in order to reduce unnecessary burden to individuals and the health care system.
The challenge is that many patients fear that their back pain falls into the 10-20% of cases of specific LBP that is serious and requires diagnostic imaging and/or specialist consultation. As many primary care clinicians are not comfortable performing a clinical examination of a patient with LBP, they request inappropriate surgical consults or advanced diagnostic imaging. This results in significant backlogs and bottlenecks accessing care for those who do have significant pathology.
The challenge is that many patients fear that their back pain falls into the 10-20% of cases of specific LBP that is serious and requires diagnostic imaging and/or specialist consultation. As many primary care clinicians are not comfortable performing a clinical examination of a patient with LBP, they request inappropriate surgical consults or advanced diagnostic imaging. This results in significant backlogs and bottlenecks accessing care for those who do have significant pathology.
Purpose: The purpose of this study was to design, implement and evaluate a new model of early triage-based interprofessional care for patients with LBP. The goal was to eliminate inappropriate use of diagnostic imaging and emergency room visits in the management of patients with LBP.
Methods: We engaged patients with LBP (trained to do research), clinicians involved in their care (physiotherapists, chiropractors, physiatrists, orthopaedic surgeons, neurosurgeons, rheumatologists), and stakeholders (health care policy and decision makers) to develop an evidence-informed non-surgical care pathway for patients with LBP. These individuals were from across a province in Canada that uses a single health system to deliver care to just over 4 million people. Implementation of the care pathway involved creating a new model of interprofessional care in the primary care sector (primary care networks) and acute care hospitals (partnered with emergency departments). Two urban and one rural site were selected to implement and evaluate (structure, process and outcomes) the impact of the new model of care. Physiotherapists and chiropractors underwent training to standardize classification and triaging of patients with LBP. The care plan was communicated to the patients primary care provider.
Results: Implementation of an evidence-informed care pathway using physiotherapy and chiropractic-led triage clinics in primary care helps to reduce, by at least 10%, the high rate of inappropriate diagnostic imaging (66%) and emergency room visits (55,000 per year) in a population of about 4 million patients with LBP. Savings from the elimination of even this conservative amount of inappropriate care can fund non-physician led team-based health care delivery (private and public) in the primary care sector.
Conclusion(s): A model of care primary care where physiotherapists assess, classify, and triage patients with LBP to appropriate non-surgical care can reduce inappropriate diagnostic imagine and emergency room visits, safe inappropriate care and costs.
Implications: Reassessment strategies to de-adopt inappropriate health care delivery can be used to fund effective non-surgical models of care for patients with LBP.
Funding acknowledgements: This study was funded by Alberta Innovates Health Solutions (AIHS) and Alberta Health Services.
Topic: Musculoskeletal: spine
Ethics approval: Ethics approval was granted by the University of Alberta human subjects research board.
All authors, affiliations and abstracts have been published as submitted.
