How Team Medicine Can
Transform Spine Care
James R. Babington, MD
Medical Co-Director, Comprehensive Spine Program
AAPMR Spine Summit
October 2, 20015
Virginia Mason Spine Summit
© 2014 Virginia Mason Medical Center
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Spine Care Continuum
Back Pain Data:
•
•
•
75 to 85% of all Americans will experience some
form of back pain during their lifetime
Affects many employees and their ability to return to
work
Virginia Mason’s patients are affected by back pain
•
•
22,300 unique visits per year
52,300 visits per year
© 2014 Virginia Mason Medical Center
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Stepped Care Approach
© 2014 Virginia Mason Medical Center
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Pathways: Specialty Care
Self-Care
Toolkit
Surgical
Longitudinal
Care
Pathway
Patient
Primary
Care
PMR & Spine Clinic
Spinal Injections
Functional Restoration
Multidisciplinary Spine Conference
© 2014 Virginia Mason Medical Center
Patient Reported Outcome Measures
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Any time scientists disagree
it’s because we have
insufficient data. Then we
agree on what kind of data
to get; we get the data; and
the data solves the problem.
Either I’m right, or you’re
right, or we are both wrong.
And we move on.
– Neil deGrasse Tyson
Triage: STarT Back
• Clinicians are inconsistent in risk estimations based on
intuition alone
• SBST did not adequately address patient preferences,
expectations, history
• May be a helpful tool within context of a clinical
assessment
© 2014 Virginia Mason Medical Center
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Triage: STarT Back
• Mean changes in RMDQ between group differences
1.81 (95% CI 1.06-2.57)
• Increase in generic health benefit 0.039 QALY
© 2014 Virginia Mason Medical Center
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Triage: Chronic Pain Risk Score
Pain 154 (2013) 1391-1401.
© 2014 Virginia Mason Medical Center
Patient Reported Outcomes: Utility
• Enhance history component of the
medical database
• Facilitate communication amongst
multidisciplinary teams
• Provide Outcome Measures for
Quality
© 2014 Virginia Mason Medical Center
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PRO: Measurement Tools
• PROMIS 10 Mental and Physical
Health measures
• Computer assisted design models
• 1-2 min to complete
• Aged Norms
• Oswestry Disability Index
• PHQ-9
• GAD-7
© 2014 Virginia Mason Medical Center
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PRO: Current Studies
• Determine if PRO can help predict
development of chronic pain or
surgery
• Seattle Spine Team Approach to
simple lumbar fusion
© 2014 Virginia Mason Medical Center
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Pathways: Specialty Care
Self-Care
Toolkit
Surgical
Longitudinal
Care
Pathway
Patient
Primary
Care
PMR & Spine Clinic
Spinal Injections
Functional Restoration
Multidisciplinary Spine Conference
© 2014 Virginia Mason Medical Center
Patient Reported Outcome Measures
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5 Specifications
1. Proven best care
2. 100% patient satisfaction
3. Care when you want it
4. Rapid return to usual activity
5. More affordable cost
© 2014 Virginia Mason Medical Center
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Treatment Approach
• Education
• Medications
• Physical Therapy
• Discuss self care measures
• Encourage active approach
• CAM (Manipulation, Massage,
Acupuncture)
• Appropriate Spinal Injections
• Rare surgery
© 2014 Virginia Mason Medical Center
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Pathways: Surgical
Spine Deformity 2(2014) 95-103.
© 2014 Virginia Mason Medical Center
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Pathways: Surgical
• Multidisciplinary spine conference for
simple fusion surgery
• Lumbar Fusion Bundle and Warranty
• Shared decision making tools
© 2014 Virginia Mason Medical Center
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Pathways: Self-Care
Self-Care
Toolkit
Turner et al. Spine 1996; 21:2851-2859.
© 2014 Virginia Mason Medical Center
Patient
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Pathways: Primary Care
Self-Care
Toolkit
© 2014 Virginia Mason Medical Center
Patient
Primary
Care
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Pathways: Primary Care
• Agency for Healthcare Research and
Quality
• Institute for Clinical Systems
Improvement
• American Academy of Family
Physicians
• ACP and American Pain Society
• European Guidelines for the
Management of Acute Nonspecific
Low Back Pain
© 2014 Virginia Mason Medical Center
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Pathways: Primary Care
• 440 million visits reviewed
• NSAID or APAP use decreased 36.9% → 24.5%
• Narcotic use increased 19.3% → 29.1%
• Imaging use increased from 7.2% → 11.3%
• Demonstrates systemic guideline discordant care
JAMA Intern Med. 2013; 173(17):1573-1581.
© 2014 Virginia Mason Medical Center
Pathways: Primary Care
Virginia Mason Medical Center
CHIEF COMPLAINT:
Back pain _
ASSESSMENT:
[_] Muscular strain/spasm
[_] Discogenic/ radicular pain
PLAN:
[_] Reassurance, recommended reasonable restrictions on lifting, bending but return to normal walking as tolerated.
[_] Advised to use acetaminophen or nonprescription NSAIDS, (holding for dyspepsia), for pain relief for up to 7 days.
[_] Back care instructions are given verbally and/or in pamphlet form.
[_] Patient is advised to return for reevaluation if symptoms worsen, are not improving within the next week or persist 6
weeks past onset.
[_] Imaging (xray, MRI) is not indicated at this time, explained.
[_] Physical Therapy referral recommended in one week if symptoms fail to improve as expected, patient will call for an
appointment..
[_] Consult Spine clinic
[_] no radiculopathy but patient has significant pain or concerns
[_] no motor weakness but conservative care ineffective
[_] pain and motor deficits are chronic and relapsing
[_] Other : _
Plan if there are red flag issues
[_] Imaging indicated and ordered because one or more of these criteria are met:
[_] Xray of L-spine – presence of red flags (or age >50)
[_] MRI – Motor deficit
[_] MRI – Unremitting pain despite 6 weeks of appropriate therapy (defined as 2 weeks of NSAIDs AND advice to
stay active AND documentation of lack of improvement)
© 2014 Virginia Mason Medical Center
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Pathways: Specialty Care
Self-Care
Toolkit
Surgical
Longitudinal
Care
Pathway
Patient
Primary
Care
PMR & Spine Clinic
Spinal Injections
Functional Restoration
Multidisciplinary Spine Conference
© 2014 Virginia Mason Medical Center
Patient Reported Outcome Measures
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Thank you!
Physical Medicine and Rehabilitation:
Andrew Friedman, MD, Section Head
Thomas Curtis, MD
Matthew Grierson, MD
Julie Hodapp, MD
Ali Putnam, DO
Our team of dedicated Therapists
Tricia Feely, OTR, Clinic Director
Neurosurgery:
Raj Sethi, MD, Medical Director NSI
Farrokh Farrokhi, MD, Section Head
Charlie Nussbaum, MD
JC Levesque, MD
Joe Serrone, MD
Karen McHenry, RN, Clinic Director
Virginia Mason Institute & Kaizen
Promotion Office:
Robert Mecklenburg, MD
Karen Blankenship
Edward Stutzman
Joleen Bishop
Interventional Pain:
Daniel Warren, MD, Section Head
Christine Carqueville, MD
James Helman, MD
Wyndam Strodtbeck, MD
Kevin Vorenkamp, MD