Woodhouse L1, Khan H2, Wolfaardt U3, Slomp M4, Lei V1, Tawiah A1, Miciak M1,5
1University of Alberta, Rehabilitation Medicine, Edmonton, Canada, 2Covenant Health, Institute for Reconstructive Sciences in Medicine, Edmonton, Canada, 3Alberta Innovates, Edmonton, Canada, 4Alberta Health Services, Bone and Joint Health Strategic Clinical Network, Edmonton, Canada, 5Alberta Innovates, Cy Frank Post-Doctoral Fellow in Impact Assessment, Edmonton, Canada

Background: The majority of back pain resolves within weeks without surgery or imaging. Yet, it is still the single most costly musculoskeletal health condition and the second leading cause of reduced quality of life in developed nations. This paradox suggests a need to change how back pain is managed to reduce cost and burden to individuals and the health care system.

Purpose: Currently, there is a 2-year wait time for patients with low back pain to access care within our province, with many receiving diagnostic imaging and tests they don't need. The purpose of this project was to evaluate whether a new program that provided early access to assessment and triage of patients reduced back pain, improved function, and was more cost effective than the current system. We specifically compared the costs among different care providers (i.e. physicians, physiotherapists, chiropractors) and models of care (i.e. primary/secondary/tertiary setting).

Methods: We evaluated the outcomes and cost of implementing the new model at the 3 different sites:
(1) adjacent to an emergency department in a Community Hospital,
(2) co-located with an orthopaedic surgeon's clinic in a hospital, and
(3) in a primary care network (PCN) with physicians and private practice physiotherapists or chiropractors.
Time-Driven Activity Based Costing (TDABC), in combination with discrete event simulation, was used to estimate costs. Outcomes (initial visit and 12 weeks later) included the StarT Back Tool, Opioid Risk Tool, Oswestry Low Back Pain Disability Questionnaire, Numeric Pain Rating Scale (NPRS), Pain Catastrophizing Scale, EuroQol-5D to measure of quality of life, and a patient satisfaction questionnaire (VSQ-9).

Results: Patients who attended the assessment sites ranged in age from 20-73 years of age (mean 47 yrs), more were male (61%), had more severe back pain according to the STarT Back tool (86, 94, 100% were classified as high risk at sites, 1, 2 and 3, respectively), and had moderate levels of pain (5-6/10) and disability. Costs were significantly less in the models that used hospital-based physiotherapists and in the PCN model that used private practice physiotherapists and chiropractors to triage patients compared to models that used family physicians and surgeons. These costs ranged from $20 to manage patients identified to have low severity of back pain to $175-$200 for those with moderate to severe back pain. Models that implemented the care pathway using family physicians and surgeons to review non-surgical patients were more expensive at $339 and $514, respectively. Patient satisfaction with the program was high.

Conclusion(s): Models of care that use the skills of physiotherapists and chiropractors to assess and triage patients with back pain adjacent to emergency departments and in the primary care sector provide greater value (outcome/cost per patient) than traditional physician-led models.

Implications: These data provide evidence that non-physician led triage teams provide cost-effective care for patients with back pain. These data should be used to inform policy and practice changes that enable this type of care to be scaled and spread.

Keywords: low back pain, non-physician led triage, economic evaluation

Funding acknowledgements: This study was funded by a Partnership for Research and Innovation in the Health System (PRIHS) Grant from Alberta Innovates

Topic: Service delivery/emerging roles; Musculoskeletal: spine; Musculoskeletal

Ethics approval required: Yes
Institution: University of Alberta
Ethics committee: Human subjects research board
Ethics number: RES0020188

All authors, affiliations and abstracts have been published as submitted.

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