A Look Inside an Interdisciplinary Spine Center at an Academic Medical Center

INTRODUCTION

An interdisciplinary spine center can serve as a model of cost-effective, patient-centered care within an academic medical center. The ideal spine center would serve back or spine pain patients expeditiously, provide a comprehensive range of imaging and physiologic testing, and offer timely surgical or nonsurgical treatment options. Most importantly, however, the ideal spine center should include professionals who are good communicators who can provide patients with appropriate explanations of the cause of their symptoms, take into account the patient preferences and encourage patients to become more actively involved in treatment of their back pain.

Only a minority of back pain patients ultimately needs surgical intervention. The typical yield of spine surgery cases from spine surgery clinics can vary from a low of five percent to a high of 50 percent anecdotally, depending on surgeon preference and whether a successful triage mechanism is in place. If a spine center does not have patient triage, it could be viewed as a “factory,” churning out high-cost spine surgeries or procedures, yet not offering much to the majority who do not want or need surgery. We describe herein how the University of Iowa (UI) Spine Center has developed programs to insure that patients are seen by the right provider at the right time, while providing appropriate treatment for each patient. All these programs can improve patient and provider satisfaction. We reviewed the operation of a spine center in an academic medical center over the past 20 years to identify some of the important factors required for success. The most important factor appeared to be dedicated professionals with extensive experience in dealing with complex, difficult, and frustrated patients with chronic back pain.

HISTORY

Iowa’s first interdisciplinary spine clinic was developed in 1985 by Dr. James Weinstein and Dr. Ernest Found, Jr. These well-known orthopaedic spine surgeons realized the complexity of spine care required not only expertise in surgical technique, but also acknowledgement of the physical and psychosocial factors that contribute to chronic back pain. A rehabilitation team was developed that included dedicated professionals from physical therapy, psychology, medical social work, and vocational counseling to help patients manage their chronic back pain.

Initially, the Spine Diagnostic and Treatment Center surgeons evaluated whether surgical intervention would be helpful, while the interdisciplinary team helped teach non-surgical chronic back pain patients how to mange their pain and to take a more active role in their rehabilitation. The team used an innovative one-day evaluation process, and a two-week outpatient rehabilitation program¹ filled with physical activities and cognitive-behavioral activities. Favorable results have been published for similar rehabilitation programs and have been studied extensively and validated as being effective in treatment of patients with chronic back pain.² In 2000, the Spine Diagnostic and Treatment Center was renamed to UI Back Care to become more consistent with internal naming policies. A physical medicine and rehabilitation physician (physiatrist) was hired to assist the spine surgeons in the timely evaluation of back pain patients and serve as medical director of the interdisciplinary team. The physiatrist provided leadership for the entire rehabilitation team as well as the one-day evaluation process and the two-week rehabilitation program. The rehabilitation physician evaluated new musculoskeletal conditions arising during the patient’s rehabilitation process, assisted in teaching group educational sessions on pain and spine anatomy, or simply reassured patients that continued active participation despite increases in pain were both appropriate and a necessary step in their rehabilitation. Now the title “UI Spine Center” best describes the three orthopaedic spine surgeons, three physical medicine and rehabilitation physicians, five physical therapists, vocational counselor, medical social worker, and health psychologist as well as multiple program and secretarial support staff.

COMPONENTS OF SUCCESS

Orthopaedic spine surgeons at the UI Spine Center accept referred patients from local orthopaedic surgeons and physicians from across Iowa. In distinction from several local and regional spine care providers, the UI Spine Center also accepts self-referred patients with back pain. Surgeons may be asked to provide a recommendation for surgical treatment for acute radiculopathy, or a second opinion regarding further surgery for spine symptoms, or they may attempt to help manage reconstruction or revision of prior failed spine surgeries. Many patients do not need surgery or prefer not to be treated with surgical intervention. Studies now confirm that episodes of acute disc herniation, radiculopathy or spondylolysis may be treated successfully without surgical intervention.³

SPINE PHYSIATRISTS

Physical medicine and rehabilitation physicians (physiatrists) are trained in the management of patients with neuromusculoskeletal conditions. Physiatrists in the UI Spine Center evaluate patients with acute and chronic back pain to determine whether additional diagnostic testing is needed. Frequently, diagnostic imaging may be necessary for patients with chronic pain. All too often, however, diagnostic imaging identifies structural abnormalities that are asymptomatic⁴ or may not be a cause of pain. Physiatrists serve an important role in determining the course of treatment as well as explaining whether any findings are truly worrisome or warrant further intervention. Some patients may then be referred for surgical consultation, additional diagnostic testing (such as EMG/nerve conduction studies, diagnostic injections) or development of an initial or revised course of physical medicine treatments or therapy.

INTERVENTIONAL PROCEDURES

Interventional procedures, including transforaminal or interlaminar epidural steroid injections, may be helpful for patients with disc herniation and acute back pain. Professionals throughout the medical center, including physiatrists, anesthesiologists, orthopaedic surgeons, radiologists, or neurologists perform these injections using fluoroscopic guidance. Although recent studies criticize over-utilization of spine injections for chronic back pain,⁵ evidence-based treatment of patients with radiculopathy and back pain suggests that epidural steroid injections are helpful for many of these patients.⁶

PHYSICAL THERAPY

It is universally agreed that moderate exercise plays an effective role in the management of chronic back pain.⁷ Physical therapists can tailor an exercise program for patients with back pain. While the focus of specific exercises is difficult to prove, a combination of abdominal strengthening, pelvic tilt, flexion or extension exercises, and hip abductor strengthening can be helpful for many patients.⁸ Patients with chronic pain can be especially difficult to treat. A team of professionals is needed who are comfortable in educating and reassuring patients to continue their exercise program despite temporary mild or moderate increases in their back pain.

HEALTH PSYCHOLOGY

Chronic pain can cause stress and stress can cause chronic pain. Effective management of chronic pain (cognitive behavioral techniques and exercises) has been shown to reduce unnecessary and often expensive health care utilization.⁹ Health psychologists can demonstrate for patients the benefits of self-management techniques for chronic pain. Patients dissatisfied with their care or with the explanation of their symptoms can continue to seek expensive medical treatments.¹⁰ Frequently, they hope some new “magical” treatment will cure their back pain and revitalize their aging backs and discs. Depending on the payor mix status, this can be helpful or harmful to a hospital’s bottom line, but in either case, this behavior is likely responsible for escalating health care costs and inappropriate use of medical services.

VOCATIONAL COUNSELING

There is no doubt that many patients with physically demanding jobs have back pain. Many patients worry that because of back pain, they will be unable to return to work. These issues commonly result in additional medical testing which can frequently lead to excessive time off work, and even prolong disability. In certain circumstances, patients who have physically demanding occupations may need to consider alternative work options. A physician who says, “If you can’t work, then just find another job,” doesn’t understand the complexities of finding career employment. It is truly a goal for the chronic back pain patient to be able to return to a productive role in society. Patient education, both about back pain and strategies to become a productive participant in society, are essential goals of successful rehabilitation. The most complex situation can be dealing with medical behavior, and long-standing educational factors. These factors could be addressed by a busy spine surgeon, but a vocational counselor has more experience in providing meaningful direction. Return-to-work and vocational issues are important determinants of successful back pain treatment.

MEDICAL SOCIAL WORK

Many patients in chronic pain need community resources. When patients understand their eligibility for services, this can help them actively manage their personal lives and healthful choices. Many patients believe that if they do not work for 12 months or more, because of their back pain, they can become eligible for federal disability services. Once patients are reassured that they are not likely to be doomed to a life of chronic pain and disability due to back pain, they are more able to take an active role in their medical treatment and rehabilitation.

KEYS TO SUCCESS

While back pain can be surgically treated in a minority of patients, successful management of the majority not requiring surgery is the key to a successful spine center. Over the past several years, we have identified several keys to a successful interdisciplinary spine center. One of these keys is having a common mission for the treatment of all patients with spine conditions, regardless of whether they have a surgical indication or non-surgical treatment plan. Another key is an integrated scheduling or triage mechanism to insure that patients see the right physician or provider at the right time. Patient preference is becoming more and more important and patients frequently want to know whether all of their options have been explored. An interdisciplinary team that is in close physical proximity to each other is also important. Weekly interdisciplinary team meetings to discuss a range of treatment options is also an important facet of success.

METRICS OF SUCCESS

A variety of metrics of success can be relatively easily obtained with modern hospital accounting methods. The number of clinic visits per provider per specialty can be tracked. The relative value units (RVUs) per provider per specialty can also be followed. Medical Group Management Association (MGMA) data for clinical effort is available for academic health centers. Decisions regarding overall financial productivity should be based on contributions from physician and hospital revenue as well as surgical, non-surgical, imaging and rehabilitation treatments. A focus on only a particular service line’s contribution will unnecessarily lead to more inefficient or excess utilization of services that may not be in the patient’s best interest. A vocational counselor will never generate the same magnitude of revenue that a surgeon generates. If an interventional spine specialist is generating more revenue than a spine surgeon, this may indicate over-utilization of spinal injections. Efficiencies of clinics and the operating room also need to be evaluated.

BARRIERS TO SUCCESS

Barriers to success include intra-mural competition among different departments providing similar services. Neurosurgery and orthopaedics may both be able to provide spine surgery. Physicians from anesthesia, radiology, physiatry, and neurology may provide spinal injection expertise. Physiatrists and neurologists may also provide electrodiagnostic testing. A common mission and collaborative value system among all these providers are essential to the success of a spine center. A lack of administrative support within a department or within the hospital can lead to unrecognized losses in market share, referral patterns, clinic efficiency, or operating room efficiency. All of these factors are critical to the successful spine center.

CONCLUSION

Although in the near future there will likely be a never-ending source of patients with back pain, a medical center that has an effective method of managing chronic spine pain patients will deliver cost-effective and patient-centered care and should achieve financial success. Not addressing the majority of patients who do not require back surgery will not make them go away, and can actually result in excessive utilization of scarce health care resources and the failure of even the most successful spine center.