Evidence Based Low Back Pain – Concord Hospital Pilot Project

1. Evidence Based Low Back Pain – Concord Hospital Pilot Project Diane Olimpio, PT, MS October 21, 2014

2. Pilot Project Goal • To implement a quality initiative for treatment of non-specific low back pain, utilizing a standardized clinical pathway and early referral to physical therapy to improve outcomes and reduce unwarranted imaging

3. Hypotheses • Standardizing evidence-based treatment for patients with non-specific low back pain will improve patient outcomes and decrease unwarranted variation in care • Utilizing a standardized pathway will reduce imaging rates/costs and patients’ exposure to radiation • Early PT referral will reduce LBP recurrence and chronicity and associated costs • Patients will be more willing to accept a plan of care that does not involve imaging if offered prompt treatment or phone consult with a physical therapist • Following evidence based practice will yield more predictable outcomes and more predictable cost to manage this population

4. Virginia Mason Model • Virginia Mason collaborated with Starbucks (Aetna WC carrier) to work on a plan to improve quality and reduce cost for employees with low back pain (LBP). • The study concluded that 85 percent of back patients suffered uncomplicated back pain that required treatment different from those afflicted with serious spine or disc problems. [Patients were determined to have complicated or uncomplicated back pain based on their answers to a series of screening questions.] • According to Virginia Mason physician, R. Mecklenburg, MD, “90 percent of what we did was no help at all. Does an appointment with an orthopedic surgeon, a neurologist, a neurosurgeon help for uncomplicated back pain? The evidence says no. Does an MRI help? No. As far as we could tell, the only thing the evidence showed [that] was worth anything was physical therapy.”

5. Virginia Mason Model • Care redesigned to include same day access to a physical therapist and a physical medicine physician • From 2004-2007 changes yielded: • 50% reduction in lost work time • $2 million in savings • At the same time, Virginia Mason was loosing money on each patient as a result of fewer billed tests and services. To offset, Aetna increased reimbursement for physical therapy sessions.

6. Concord Hospital Mandate • Concord Hospital Board of Trustees set a goal of decreasing MRI’s at Concord Hospital • Data demonstrates many MRI’s are unnecessary

7. Concord Hospital Outcomes • Data collected on a QI study group of 54 patients with an inclusive ICD 9 code related to LBP (excluding surgery and fractures) who were referred by one of 4 pilot primary care practices to a subgroup of 4 pilot PT practices between May 1, 2013 and October 31, 2013 • 11 patients referred for phone consult, 5 resulted in PT treatment (included in total of 54) • Data analyzed for: • Imaging rate • Average cost for all CH services within an episode of care for LBP • Average Physical Therapy visits per episode of care for LBP • Patient Outcomes

8. Imaging Rates <6 weeks from Onset of Care

9. Average Cost LBP Episode of Care – All Costs Including Surgery and Imaging* * Imaging cost only includes CH (excludes CIC and all other)

10. PT Outcomes: Length of Stay

11. PT Outcomes: GROC

12. PT Outcomes: MODI

13. In Summary • CH data trending in the right direction • Pilot project outcomes: • Decreased imaging rates • Lower overall cost • Fewer visits in PT with decreased therapy cost • Outcome data supports positive outcomes in the study subgroup

14. Suggestion Need to create incentives to create best treatment and outcome models. • Narrow networks: • Abide by evidence based treatment guidelines • Committed to value based care • Focus on outcomes • Targeted fee schedule • Reduce payment for passive treatment such as hot/cold packs, electrical stimulation and ultrasound • Reduce payment for imaging which is non emergent and performed in the first 6 weeks of an injury