The Changing Face of Spine Care: The MU Comprehensive Spine Center

Abstract

Back pain is extraordinarily common, and the current approach to treatment has yielded enormous financial burdens on health care systems and society in general. In addition, primary care providers and patients alike are often unsure where to seek further care, and what, if any, advanced tests or images are needed. As a result, spine surgeons often see a high percentage of non-operative patients when unnecessary, redundant, or incorrect imaging was obtained. At MU Health Care a team of physiatrists, orthopedic surgeons, neurosurgeons sought to address these issues by forming the MU Comprehensive Spine Center that offers a systematic, collaborative approach to spine care.

Introduction

Back pain and disability from spine-related issues are extremely common with upwards of 80% lifetime incidence.¹ It is one of the most common causes of missed work and visits to a primary care physician with direct and indirect costs approaching 100 billion dollars annually.² Faced with an unsustainable trajectory of spending and demand for high quality service, health care must evolve. More than ever, there is an emphasis on improving the patient experience, improving the quality of care, cost reduction, decreased utilization of resources, and benefit/cost ratio. While administrative burdens are increasing, physician satisfaction is decreasing. Physicians and patients alike are frustrated with long wait times and visits with multiple providers before finding the proper treatment or provider to deliver the most appropriate care. At MU Health Care, we are addressing these issues with collaborative care centers. The MU Comprehensive Spine Center has taken an evidenced-based approach to improve spine care, improve surgical access for appropriate surgical patients, decrease redundancy of testing and imaging, and decrease the confusion of referring a patient into the system. This model integrates multiple specialties including physiatrists, orthopedic surgeons, neurosurgeons, radiologists, physical therapists, pain management, anesthesiology, and rheumatology.

Goals

The impetus behind starting a comprehensive spine center came from University of Missouri orthopedic surgeons, neurosurgeons, and physical medicine and rehabilitation (PM&R) physicians aspiring to deliver more comprehensive, high quality spine care. The surgical specialties noticed a high number of non-surgical patients in their clinics, many without the needed imaging or needed work-up. This often led to dissatisfied patients and surgeons with long, less-productive clinic days. Physiatrists, who specialize in multidisciplinary non-operative care and appropriate triage of surgical patients, were experiencing a lack of utilization of their services prior to surgical referrals. Both groups recognized a relative lack of understanding and communication between the surgical and non-surgical physicians. This is a common occurrence in a traditional care model, where too often specialties function as “islands” of patient care. This leads to redundancy of services and often multiple visits with multiple providers until the appropriate care setting or provider is found to address each patient’s needs.

Our first goal was to have a single point of entry into the spine center in order to reduce confusion for both referring providers and self-referred patients into the system (See Figure 1). This was accomplished by directing all incoming spine calls to a single call center. Support staff fielded calls and triage to the appropriate physician, generally encouraging non-operative physician appointments unless an urgent surgical need was identified.

Figure 1.

The second goal of the Spine Center was to ensure that all patients would have a protocol-driven approach to their nonoperative care, shared decision making, access to appropriate imaging, and timely surgical evaluations when warranted. Physiatrists were the natural choice for delivering the initial evaluation and directing non-operative care and education. Spine care protocols, with a focus on evidence based care, were developed and implemented. To ensure timely access to surgical providers, a rotation was designed for non-assigned surgical patients to equally distribute those patients among the participating neurosurgeons and orthopedic surgeons. This immediately improved access for surgical patients, lowering wait times for surgical evaluation from over six weeks in some instances to two weeks or less.

Results

Whenever alternative care delivery systems are initiated, data and outcome collection is paramount. While data collection can be burdensome, advances to the electronic medical record (EMR) and other outcome data tracking software has offered new and less tedious ways to accomplish this task. One of the main outcome measures we have been tracking is the percentage of patients seen by a spine surgeon who were determined to be surgical candidates (i.e., offered surgery). In 2016, the percentage of patients referred for surgery through the MU Comprehensive Spine Center pathway was over twice as likely to be surgical candidates than those referred to orthopedic spine surgeons directly from either providers outside the University system or non-PM&R providers from within the University (outside the pathway slightly over 20% surgical candidates vs. over 50% surgical candidates through the Spine Center pathway) (See Figure 2). From a physician’s perspective, this leads to a much more satisfying clinic interaction. From a patient’s standpoint, it means he or she is with the right provider at the right time.

Figure 2.

Other health care systems also have explored collaborative care centers as a way to deliver more efficient and effective care. Priority Health, a Michigan-based insurance company, implemented a “Spine Centers of Excellence” program in part to curb the rising costs of spine care. The program essentially relied upon a physiatrist-led team approach to spine issues and, in non-emergency conditions, required a visit with a non-operative spine provider (physiatrist) prior to surgical consultation. Outcome and cost analysis were disseminated in a recent paper in the journal Spine and compared costs and procedures prior to and after the implementation of this pathway. They found that requiring a patient to see a non-operative provider first led to decreased utilization of advanced imaging, surgeries, and costs all while maintaining patient satisfaction. Their overall spine costs decreased by 12.1%, saving more than 14 million dollars in one year.³

Another study from the journal Spine looked into the concept of triaging patients through a non-operative pathway. This study compared traditional spine referrals directly to a spine surgeon to referrals to a Spine Pathway clinic that utilized a multidisciplinary spine triage to identify which patients were likely operative vs. non-operative candidates. Their results showed that patients referred to surgeons through the Spine Pathway were more likely to be surgical candidates than those referred directly to the surgeon.⁴ Again, there is an implication of cost savings as well as the potential for spine surgeons to adjust their clinics and OR time to accommodate for more surgical candidates, benefiting all parties involved.

Conclusion

Change is inevitable. The continued push from insurers, patients, physicians, and society in general to curb costs while delivering outstanding care will shape the way we practice medicine. We physicians need to be a part of this change, not just bystanders. Using collaborative care models like the MU Comprehensive Spine Center is an avenue to deliver on these goals while also improving the physician experience.

Biography

Mark Drymalski, MD, and Mohammad Agha, MD, MSMA member since 2014, are both Assistant Professors of Clinical PM&R, Department of Physical Medicine and Rehabilitation, University of Missouri Health care.

Contact: drymalskim@health.missouri.edu