Over the past two decades we have witnessed exponential growth in the costs of spine care. (1) Concurrent with these increased costs has been exponential growth in impairment and disability related to the spine. (2) The added costs do not appear to be providing improved outcomes for spine patients. While some of these added costs are related to new technologies and an ever expanding senior population, much can be done to manage these expenditures while providing greater clinical benefit.
Each level of organization, from a hospital-based spine center, to an individual practitioner, can bring their focus down to the 3 Cs of spine care:
1. Compassion
2. Classification
3. Context
Compassion
The foundation of compassionate care is that of patient centered care. When considering use of scientific evidence in the evaluation and treatment of a spine patient, the ultimate goal is to improve the experience and clinical outcome for the patient. Evidence-based medicine is not an end unto itself – it serves the best interests of the patient. An article in the British Medical Journal, describes some of the key attributes of patient centered care: define patient’s main reason for the visit, seeks understanding of whole person, agreement between patient and provider on the problem and best course of action, enhanced prevention and health promotion and enhanced relationship between patient and provider. (3) And quite interestingly, the patient’s perceptions of how patient centered the care provided was, is an even stronger predictor of health outcomes and efficiency of care than researcher observation of the clinical encounter.
Classification
While establishing a pathoanatomical diagnosis may prove difficult in spine care (4), some type of vetting process is necessary to help get the patient to the right provider at the right time. We can no longer afford to treat back and neck pain patients as a homogeneous group. Differentiating spine patients into subcategories is vital to clinical and cost management. Classification of spine patients based upon National Committee for Quality Assurance back pain recognition program for physicians followed by utilization of clinical prediction rules has provided a clinically effective and cost efficient model. (5) The initial categorization seeks to identify those patients with ‘red flags,’ evidence of serious underlying pathology and those with ‘yellow flags,’ signs of significant psychosocial overlay. (6) Clinical prediction rules allow classification of those patients not requiring pain management or surgery into treatment arms consisting of traction, manipulation, flexion preference, extension preference and rehabilitation.
Context
Context refers to the information provided to the patient, the provider who offers this information and the manner in which the information is delivered. A key aspect is that information is expressed in terms of which the information presented can be fully understood and assessed by the provider and the patient. Often in spite of conflicting research evidence (eg. does post-operative rehabilitation improve clinical outcomes for spine surgery patients?) (7, 8) the clinician and patient are forced to make choices. Standardization of the contextual process of giving information to spine patients will help to identify those pieces of information most important to good outcomes.
As an example, some patients, while obviously not surgical by reasonable standards, may need to hear from a surgeon that their case will best be managed more conservatively. Any effort by a provider other than a surgeon to convey this information will be met with resistance, demands for advanced testing and poor compliance to treatment recommendations. In addition, shared decision making truly becomes meaningful if appropriate context is considered from the patient’s perspective. And context must address the motivating variables of both the provider and the patient.
While compassion, classification and context are described individually, our feeling is that these are interdependent attributes of spine care and provide the greatest advantage when considered in concert. To deliver optimal outcomes, a care flow pathway must embrace all three elements.
1. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8–20.
2. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and Health Status among adults with back and neck problems. JAMA 2008; 299(6):656-64.
3. Stewart M. Towards a global definition of patient centered care: the patient should be the judge of patient centered care. BMJ 2001; 322(7284): 444-45.
4. Haldeman S. North American Spine Society: failure of the pathology model to predict back pain. Spine 1990; 15(7): 718-24
5. Paskowski I, Schneider M, Stevans J, Ventura J, Justice B. A hospital based standardized spine care pathway: report of a multidisciplinary evidence based process.
6. www.ncqa.org
7. Carragee EJ, Jan MY, Yang B, et al. Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 152 cases with no postoperative restrictions. Spine 1999; 24(22): 2346-51.
8. Christensen FB. Lumbar spine fusion. Outcome in relation to surgical methods, choice of implant and postoperative rehabilitation. Acta Orthop Scand Suppl 2004; 75(313): 2-43.
