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Weekly UpdatesABSTRACT
Back disorders encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The use of a traditional spine center model of patient flow, in which the patient is scheduled the first available appointment without an initial assessment of spine-related symptoms at West Virginia University Spine Center, Morgantown, West Virginia, resulted in frustration and delays for the spine patient and referring physician dissatisfaction. Today, the use of a software-assisted spine patient triage and registered nurse care coordinator patient navigation system in this multidiscipline, multimodality comprehensive spine program provides quick and efficient patient triage to the appropriate level of spine care (surgeon vs. nonsurgeon). The model consists of five major steps, which are explored in this article: medical history intake; films or studies retrieval; rapid review of the patient's medical condition and diagnostics by a spine specialist preappointment and subsequent triage to the appropriate level of spine care; registered nurse care coordinator patient education and guided navigation through the patient's preferred treatment plan; and last, diagnostic study, pain injection, and provider scheduling. Patient satisfaction scores, referring physician satisfaction scores, and resultant impact on referral volumes, ancillary utilization, workload productivity, and surgical yield demonstrate that this new approach to patient triage has made significant improvements in efficiency, productivity, and service.
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Over 80% of adults experience one or more episodes of back pain in their lifetime (Sg2 Health Care Intelligence, 2007). Physician visits for back pain rose 94% from 1994 to 2004 and will increase by 15% over the next 10 years (Sg2 Health Care Intelligence, 2007). Medical Expenditure Panel Survey data from 1997 to 2005 reflect that the average expenditure for respondents reporting spine problems was 73% greater than that of those without spine problems (Martin et al., 2008). Multiplying the mean incremental expenditures for spine problems in 2005 ($2,850; 95% confidence interval) by the estimated number of persons with spine problems in 2005 yields $85.9 billion (95% confidence interval) in additional health expenditures among those with spine problems. This represents 9% of the total national expenditure estimated from Medical Expenditure Panel Survey (Martin et al., 2008). These data suggest that spine problems are expensive, due both to large numbers of affected persons and to high costs per person.
The cause of back pain is often unclear, and patient needs differ according to the presenting symptoms, diagnosis, psychosocial factors, and goals for recovery. Approximately 90% of back pain cases have no identifiable cause and are designated as nonspecific (Manek & MacGregor, 2005). Van den Bosch, Hollingworth, Kinmonth, and Dixon (2004) reported that the probability that a particular case of back pain has a specific cause (spinal fractures, cancers, infections, and cauda equine syndrome) identified on back radiographs is less than 1%. Diagnostic triage of low back pain is useful in screening for red flags, those warning signs that should lead the clinician to investigate for a serious pathology in need of immediate diagnosis and treatment, and in weighing the urgency of medicosurgical treatment (Poitras et al., 2008).
Treatment of back pain should begin with conservative, nonoperative treatment, especially when the source of pain cannot be identified. Surgical treatments should be explored when indicated by diagnostic tests and imaging findings and in consideration of patient comorbidities and psychological status.
Comprehensive Spine Programs
A comprehensive spine program can serve as a model of cost-effective, patient-centered care within an academic medical center (Chen & Yang, 2008). The ideal spine center would serve back or spine pain patients expeditiously, providing a comprehensive range of imaging and physiological testing; offer timely surgical or nonsurgical treatment options; and include professionals who are good communicators and can provide patients with appropriate explanation 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 (Chen & Yang, 2008).
Through multidisciplinary collaboration, comprehensive spine programs allow patients to receive seamless care across multiple locations and provide a strong communication link to all stakeholders, including referring physicians, patients, payors, and employers. Patient access to spine care, specific scheduling with the appropriate spine specialist for his or her specific spinal issue, collection of previous relevant spine studies and tests, and obtainment of the necessary authorizations can result in miscommunications, delays in treatment, patient and referring physician frustration, and loss of subsequent referrals. To be successful, a spine program must enhance continuity of care for the patient, provide two-way communication with the patient's referring and primary physicians, and schedule visits and procedures quickly.
Multidisciplinary Collaboration
Although many spine programs focus solely on surgical spinal care, the West Virginia University (WVU) Spine Center recognized that diagnostics and nonoperative treatments also play critical roles in spine care. Nationwide, fewer than 10% of back pain patients require surgical intervention (Sg2 Health Care Intelligence, 2007). At WVU, prior to June 2005, a newly referred patient was scheduled the first available appointment with a spine surgeon without initial assessment of presenting spine-related symptoms. The registered nurse (RN) played no role in this process.
As a result, it was not unusual to have a spine surgeon's clinic overbooked and patient wait times to range from 2 to 6 months. Many patients came to their initial appointment without attempting conservative treatment or completing appropriate testing, leaving the initial patient appointment with the need for additional diagnostic testing and a subsequent return appointment. Under this traditional approach, the WVU spine surgeon medically managed the patient's nonsurgical spine issues, often impeding access for those patients whose conditions did require surgical intervention. More specifically, surgical yield per clinic for at least one spine surgeon at WVU was one surgery per 67 scheduled clinic visits or one surgery per clinic day. Patients who required surgery waited in line with patients who did not require surgery. Both referring physicians and patients verbalized frustration with the delays in care.
Integrated Systems
At WVU, the hiring of a neurology-neurorehabilitation spine specialist and use of other existing nonsurgical spine specialists (occupational medicine, osteopathic medicine, and pain specialists) provides additional avenues for conservative treatment of spine-related issues. A central point of access, elimination of service duplication, utilization of nonsurgical treatments such as physical therapy and pain management, and the use of nurse navigators as care coordinators were incorporated in the WVU Spine Center program to promote continuity and to ensure triage to the appropriate spine specialist on the first patient visit. The RN care coordinators use clinical algorithms and policies and procedures to assure standardization of care and to guide appropriate patient migration through the spine care delivery system.
Patient Triage
In consultation with the Mayfield Clinic & Spine Institute in Cincinnati, the WVU Spine Center implemented the Priority Consult[TM] spine patient triage process on June 1, 2005. An innovative program, Priority Consult[TM] is a software application used by the spine center staff and physicians to assist patients with spine problems to access appropriate treatment quickly, efficiently, and easily (Gilligan, 2006).
This software system was selected by the WVU Spine Center because it would not only allow for electronic capturing of each patient encounter but also support paperless care coordination and patient navigation across the full continuum of sites and services preappointment. This system also allowed for data reporting of volume indexes such as treatment utilization, noncompliance rates, and spine specialist practice patterns and electronic capturing of a rapid review of the patient's medical condition and diagnostics by a spine specialist, preappointment, and subsequent triage to the appropriate spine specialist (Fig 1). A typical patient prior to this approach might have spent up to 6 months awaiting treatment to obtain resolution of symptoms, whereas now patient treatment begins, in collaboration with the referring physician, pre-spine specialist appointment (Table 1) within 1 week of films or studies receipt and spine specialist case review and triage.
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It is important to note that this approach is solely used for preappointment patient triage and care coordination and is offered at no charge to the patient. Once a patient's appointment is scheduled with a spine specialist, all subsequent care, including referring MD communication, is managed through the respective spine specialists' clinic and administrative department (WVU Orthopedic Clinic, WVU Department of Neurosurgery Clinic, Medical Specialties Clinic, and WVU Pain Center).
The use of this approach allows for a seamless stream of data between spine specialist physicians and the Spine Center office and is viewed as an invaluable component of the spine care system at WVU. Communication surrounding the patient's care is electronically recorded including the medical history, treatment modalities completed, arrival and current location of films or studies, initial spine specialist impression and recommendations for treatment, RN care coordination notes, referring physician written communications, all patient telephone encounters, and scheduling discussions providing fingertip access to important patient care information and eliminating the perception of fragmented care across the continuum.
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