One of fastest growing segments of healthcare is that related to spine disorders. Over the past three decades the direct costs of spine care have risen from approximately $20 billion per year to well over $90 billion per year, with the indirect costs at least that much. This exponential rise in indirect costs suggests that healthcare status relative to spine pain has not improved in spite of exponentially rising direct costs, and this was the very conclusion of an article by Dagenais et al. (1) In addition, the quality of any process or service can often be evaluated based upon the variation inherent within the process or the delivery of the service, with greater variation suggesting lower quality. Spine care is replete with geographic and professional variation.
We suggest a new model for spine care which begins with patient centered care — a model of spine that first and foremost places the patient at the center. Only then are providers added who bring value to the model.
Recently, models of spine care such as the NCQA back pain recognition program have evaluated the quality of care based upon the physician's ability to follow a process. Newer models of spine care will determine value of the care, with value being measured by quality outcomes/cost. To provide maximum value, the initial contact provider must have a specific skill set that allows for him/her to provide appropriate evaluation and when necessary referral of the patient. Most importantly, this practitioner must also be able to effectively and efficiently manage the majority of patients without the need for referral. We refer to this initial contact provider as the Primary Spine Practitioner — PSP. (2)
The specific skill set necessary to function in this role includes the following:
1. Differential diagnosis of spine related disorders: Because 'red flags' constitute only a very small minority of all spine related pain they may be easily overlooked, and the PSP must be vigilant in detecting these problems when they do present.
2. Effective and efficient management of the majority of spine conditions: The PSP must be able to provide evidence based care (those procedures with a known evidence base) for the majority of spine conditions without referral to another provider.
3. Effective communication and motivation of patients: Patient satisfaction is often tied to how effectively the provider explains what is wrong, what treatment options are available, what the PSP can do to help alleviate the condition and what role the patient plays in recovery. Effective communication skills extend beyond those with the patient and include all parties involved, such as other providers, employers, insurers and family members.
4. Identify and manage the psychological aspects of spine related disorders: Spine pain is a biopsychosocial condition. The PSP must have the tools to expediently identify psychosocial overlay and apply strategies to manage these issues.
5. Standardization of patient centered, evidence based model of care: The PSP must be the leader in a team approach which follows a clinical care pathway that is consistent with the evidence and that places primary focus on the needs of the patient. This pathway should have a distinct classification; utilize electronic health records; facilitate communication among all stakeholders; continuously monitor process, outcomes and patient satisfaction; and appropriately allocate resources. (3)
Readiness to change the approach based upon availability of new evidence and new technologies
We previously discussed how the principles of the patient centered medical home could be applied to the evaluation and management of spine related disorders. (4) The Primary Spine Practitioner is the logical provider to apply these principles to spine care. The success of utilization of the PSP is noted in the Jordan Hospital Spine Center model. (5) In this model we have demonstrated that care for spine related complaints is delivered with high patient satisfaction at a very reasonable cost to the system. We believe that broad utilization of the Primary Spine Practitioner will bring the immense costs and inefficiencies of spine related disorders to a much more manageable level.
John M Ventura
Donald R Murphy
Degenais S. et al. A systematic review of low back pain cost of illness studies in the United States and internationally. The Spine Journal 2008; 8: 8-20.
Murphy D. et al. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropractic and Manual Therapies 2011; 19(17).
Fourney D. et al. A systematic review of clinical pathways for low back pain and introduction of the Saskatchewan Spine Pathway Spine 2011; 36(21): S164-S171.
Ventura J et al. Spine care for the patient centered medical home: 6 points on developing a spine center of quality. Becker’s Orthopedic, Spine and Pain Management Review April 12, 2011.
Paskowski I. et al. A hospital based, standardized spine care pathway: report of a multidisciplinary evidence based process. J Manipulative and Physio Ther 2011; 34(2): 98-106.
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5 Points of Value Primary Spine Practitioners Bring to Spine Care FeaturedWritten by John M. Ventura and Donald R. Murphy of Spine Care Partners | Thursday, 08 November 2012 16:17
This article is written by John M. Ventura and Donald R. Murphy of Spine Care Partners, LLC.
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