Oct 29, 2018 | Insights
A new study shows that immediate referral to and initiation (within 3 days) of physical therapy may lead to reduced utilization and costs for acute LBP patients.
You’ve injured your back on the job, and you’re waiting on a call back for a referral to a PT. A day goes by, then three days, then a week. What does this mean for your future treatment?
Nearly 1 of 55 patients with low back pain (LBP) are referred for physical therapy by physicians; however, there is a lack of consensus regarding when that referral should happen.1 A study of Medicare beneficiaries with new-onset LBP found that of those who received PT, 52% received physical therapy within 4 weeks, 18% between 4 weeks and 3 months, and 30% after 3 months.2 Some researchers have expressed concern that patients could experience subsequent recurrences when intervention is delayed, leading to additional healthcare utilization and increased costs.
A 2018 study in Physical Therapy set out to determine whether timely PT intervention affected the treatment patterns of LBP patients in New York state over a one-year period. Examining commercial claims data, Liu et al found that referral and initiation of treatment with a physical therapist within 3 days may lead to less service utilization – and reduced LBP-related costs – down the road.3
The study’s participants, low back pain (LBP) patients, were divided into cohorts based on whether they received physical therapy and the timing of PT treatment. Researchers also analyzed the likelihood of service utilization and LBP-related health care costs over a 1-year period.
Results showed that following the group that did not receive physical therapy, patients with immediate physical therapy initiation (within 3 days) had the lowest utilization rates and cost measures, with some exceptions. Data supports MedRisk’s operating model, which prioritizes timely treatment for injured workers, ensuring that appointments are scheduled within 4 hours, with an average wait time of 2.6 days to first appointment.
Click here to read the complete article.
1 Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA internal medicine, 173(17), 1573-1581.
2 Gellhorn, A. C., Chan, L., Martin, B., & Friedly, J. (2012). Management patterns in acute low back pain: the role of physical therapy. Spine, 37(9), 775.
3 Liu, X., Hanney, W. J., Masaracchio, M., Kolber, M. J., Zhao, M., Spaulding, A. C., & Gabriel, M. H. (2018). Immediate physical therapy initiation in patients with acute low back pain Is associated with a reduction in downstream health care utilization and costs. Physical therapy, 98(5), 336-347.
Oct 29, 2018 | Insights
A new breed of spine care professionals strives to deliver more efficient, value-based care for those suffering from low back pain and other spine-related disorders.
The recent push to transform a historically volume-based healthcare system to one focused on value has been felt across disciplines and specialties. Spine care has been no exception, although it does present some unique challenges.
As of January 1, 2015, all 50 states, the District of Columbia, and the US Virgin Islands allow patients to seek some level of treatment from a licensed physical therapist without a prescription or referral from a physician. However, some limitations remain baked into several state laws, and primary care practitioners continue to be on the front lines when signs of low back pain emerge.
Primary care physicians are not trained extensively on spine care, which stands apart from internal medicine in both the nature of its ailments and the mechanisms of its treatment. When a spine care patient begins his or her treatment with a family doctor, the pathway of care can be inefficient and costly.
But what if there were a healthcare professional dedicated to being the first point of contact for all spine problems and who could coordinate care of the patient from his or her very first visit?
Dr. Donald Murphy, DC, FRCC, chiropractor, research scientist, consultant and MedRisk advisory board member, has tackled this question in his recent work helping to establish a new breed of spine care professionals called primary spine practitioners (PSPs). PSPs are intended to serve as doctor, educator and care coordinator for those with spine-related disorders. We sat down with Dr. Murphy to discuss how the primary spine practitioner movement has progressed over the last three years and how he sees the pathway of care evolving for low back pain and other spine-related disorders.
Training Tomorrow’s Spine Care Professionals
Dr. Murphy is an instructor in the University of Pittsburgh’s PSP Certification Program™, which is geared toward current practitioners who want to expand their skill set to serve as first contact for patients with spine problems. The curriculum, which includes units on treating psychosocial and chronic pain as well as clinical management, is a blend of online education modules and a weekend workshop, comprising upwards of 20-course hours. The program concludes with a final practical competency exam.
“Those working in healthcare are realizing the dire need for high-value care for spine,” Murphy said. “Spine care in our country can be very expensive while often achieving low value and poor outcomes. And for many patients, being directed to different types of practitioners, it can feel like the wild west.”
So far, one cohort has completed the training, and another is set to finish in December 2018. While the program has drawn the most interest from physical therapists and chiropractors, Dr. Murphy says it is profession-agnostic and open to physical medicine doctors, primary care physicians and nurse practitioners who meet the prerequisites and want to provide a higher level of coordination for spine care patients.
Plotting an Integrated Pathway
The number of PSPs in the healthcare system is bound to grow in years ahead, but how will patients connect with them? Dr. Murphy works with hospital systems to redefine the care pathway for spine patients so their clinical experience can be more streamlined and less costly.
“Will the patient recover quickly or head in a direction toward chronic pain?” Murphy said. “Often, what you do upfront dictates what happens down the road.”
As it stands, without an experienced spine care professional to greet them, it’s not uncommon for patients to get lost in what Dr. Murphy refers to as the “spine supermarket,” wandering through unfamiliar territory, meeting with spine surgeons, physical therapists, and chiropractors, unsure of which treatment’s best for them. The role of the primary spine practitioner is to not only apply treatment but also to educate the patient and provide a referral in the event they need to see a specialist, such as a surgeon.
Dr. Murphy sees this streamlined pathway as a boon to workers’ compensation as well.
“Workers’ compensation presents a uniquely challenging dynamic between the patient, provider, employer, and payer. It’s important that we have professionals who are well-trained and an efficient pathway through which they can treat patients with work-related back and neck pain. It will bring a front-end value to workers’ comp that we are currently lacking,” Murphy said.
A Look to the Future
How can we expect spine care to evolve in the years ahead? Murphy anticipates an increased adoption of a best-practice spine care pathway in health systems across the country. He is currently working with colleagues to publish their collective findings on how such a pathway can support patient outcomes (chronicity risk, disability pain), reduce cost, and boost patient satisfaction. Murphy also hopes that certified primary spine practitioners gain distinction in the field as they enter the workforce in greater numbers.
“We are headed toward critical mass,” said Murphy. “People are recognizing that we have a problem in the spine area, and the only way it is going to change is if we implement a solution.”
Aug 27, 2018 | Insights
A new sports medicine study has identified early predictors of successful 2-year outcomes in those who opt for nonsurgical treatment of an anterior cruciate ligament (ACL) injury.
Conservative care (i.e., physical therapy) is becoming a more mainstream first-line treatment for many workers’ compensation injuries – but not all. Treatment plans must be designed to meet the needs of the injured worker, taking into consideration the severity of the injury and the circumstances of the patient, in order to achieve optimal outcomes.
This concept is not unique to the workers’ comp industry, and in one recent study of ACL-injured athletes in the Orthopaedic Journal of Sports Medicine, we see that by studying the outcomes of nonsurgical treatment – and the commonalities of the patients involved – practical models can be developed to better predict conservative care success.
The study’s participants were ACL-injured athletes who hailed from 2 sites: Oslo, Norway, and Delaware, USA. All participated in pivoting sports and none had significant related injuries. Demographic and knee function data were collected at baseline or after a 5-week neuromuscular and strength (NMST) rehabilitation program and were used to build multivariable logistic regression models.
After a 2-year period, 52 of 97 (53.6%) patients had a successful outcome, which was defined as having 2-year International Knee Documentation Committee (IKDC) scores ≥15th normative percentile and not undergoing ACL reconstruction. The study data suggest that clinicians can be more confident in nonsurgical treatment (i.e., active rehabilitation alone) in athletes who are female, are older in age and have good knee function. Through predictive models that incorporate knee function metrics from either before or after rehabilitation, 2-year prognoses for nonsurgical treatment can be estimated and aid in a shared decision-making process.
Click here to read the complete article.
Grindem, Hege, Elizabeth Wellsandt, Mathew Failla, Lynn Snyder-Mackler, and May Arna Risberg. “Anterior Cruciate Ligament Injury—Who Succeeds Without Reconstructive Surgery? The Delaware-Oslo ACL Cohort Study.” Orthopaedic journal of sports medicine 6, no. 5 (2018): 2325967118774255.
Jul 31, 2018 | Insights
Can these three progressive care models bring us closer to standardized treatment for LBP patients?
This blog is part 3 of a three-part series titled “How We Treat Low Back Pain: Emerging Research, Frameworks and Care Models.”
Despite technological advances in a range of specialties, healthcare in America – rehabilitative medicine included – can still feel quite fragmented. Three patients exhibiting the same symptoms of low back pain (LBP) may see a family doctor and be prescribed an anti-inflammatory, go to a chiropractor for manipulation three times a week, visit a PT and begin doing rehabilitative exercises – or all of the above. So, how do we get from today’s inconsistent care pathways to a unified model of LBP treatment?
When used together, these three progressive care models may bring us closer to standardized care for LBP patients.
1. Managed Care
Navigating today’s healthcare system can often be a confusing experience for patients. Although there are organizational recommendations guiding care practices, each practitioner comes to the table with a unique approach and their own opinions on what first-line care should be. As it currently stands, many patients are left to advocate for themselves and coordinate their own care among specialists.
Specialty managed care organizations like MedRisk look to bridge this gap by coordinating care through evidence-based care guidelines. In today’s volume-based healthcare system, physicians, PTs and chiropractors are not always set up or incentivized to read from the same playbook – especially when it comes to workers’ compensation. An evidence-based care model with a return-to-work focus encourages a more unified approach. Patients are evaluated for level of injury, severity and risk and then progress through the appropriate pathway of treatment and rehabilitation. This results in a clearer direction for providers, a streamlined experience for patients and a more direct path to quality care.
2. Telemedicine
A big part of effective care is keeping patients actively involved in the management of their own condition. Keeping patients engaged on their road to recovery and facilitating the performance of at-home exercises can be critical to successful return to work. Many providers, payers and managed care organizations achieve these goals through the use of telerehabilitation, whereby health assessments and consultations are delivered through a virtual platform in lieu of an in-person visit. Research has shown clinical outcomes to be similar between telemedicine services and in-person clinical services. Not all treatment plans translate well to telerehabilitation, such as those for patients who require special exercise equipment or who have unusual or heavy work demands. However, in some instances, in-clinic PT sessions can be supplemented with valuable remote offerings including online education and virtual home exercise supervision to create a hybrid treatment plan. Telerehabilitation is a low-cost method for providing targeted education, individualized consultation and increased clinician facetime to support positive patient outcomes.
3. Direct Access
When you consider the number of providers who can initiate treatment for a musculoskeletal injury, it is easy to see how treatment plans can vary among those with similar injuries. However, there is an emerging field of professionals who aim to change all that.
Practitioners who hold the Primary Spine Practitioner certification (like the one offered by the University of Pittsburgh) specialize in the frontline diagnosis, management and triage of spine-related disorders such as LBP. In a 2011 article by a group led by Donald Murphy, DC, FRCC, a well-known expert on spinal care and a member of the MedRisk advisory board, primary spine care providers are compared to general dentists, whose domain is understood to be the oral health of our society. According to Murphy, the primary spine care practitioner’s role is to “apply evidence-based procedures, appropriately educate and motivate patients and effectively prevent and manage disability related to [spine related disorders].” Only time will tell whether primary spine practitioners will become a new direct access point for LBP patients. But if they do, according to Murphy et al, we can look forward to improved outcomes of care, increased patient satisfaction, and reduced costs (i.e., high-value care).
Want to help standardize care for your injured workers? Learn more about MedRisk’s managed physical medicine services.
May 29, 2018 | Insights
Recent studies on biological and psychological processes are informing how we understand low back pain. How does this new research translate to the clinic?
This blog is part 2 of a three-part series titled “How We Treat Low Back Pain: Emerging Research, Frameworks and Care Models.”
In the last decade, mainstream treatment of low back pain (LBP) has broadened from a sole biomechanical focus to a more holistic approach informed by how pain is processed in the brain.
New evidence-based frameworks have emerged to help guide conversations about pain between providers and patients. We interviewed MedRisk Advisory Board member and a leader in low back pain treatment, Dr. Philip W. McClure, PT, PhD, FAPTA, about this developing shift in the field.
How has our understanding of LBP evolved over the years?
Twenty years ago, patients who presented complaining of pain with no physical evidence were often labeled as looking for secondary gain. It was believed that low back pain was solely caused by excessive mechanical load injuring the tissues – and so the treatment was focused primarily on mechanical methods as well. We have learned a lot over the last decade, and now we understand that pain can be experienced without ongoing tissue damage or harm. We call this phenomenon central sensitization. The nervous system is recognized as an active part of the pain process that can change over time and, therefore, contribute to persistent pain conditions. Rather than a simple mechanical model of tissue overload, we now recognize that pain can also be the result of complex interaction between inflammatory and biochemical processes as well as the psychosocial environment.
How has this informed LBP treatment?
Up until recently, only providers who were really in tune with their patients may have dug deeper than the physical exam to understand contributors to their pain. Now, that process is far closer to mainstream. This is due in part to simple classification schemes that are being embraced by practitioners to help assess patients’ pain early on. The STarT Back Screening Tool is a nice example; it’s been shown to decrease disability from back pain, reduce time off work and reduce costs by making better use of health resources. STarT Back is a simple survey you can run through with patients that helps put them into categories of low, medium or high risk of poor outcome by asking questions about how their low back pain has affected their daily habits as well as how they perceive the severity of their injury. Being able to do this helps a general practitioner say, “This is a high-risk patient; they need more than the usual” versus “This is a low-risk patient, and they are likely to do well.”
How do providers go about discussing this new understanding of pain with patients?
The science of how to most effectively communicate about pain with patients is growing dramatically, but there is still a lot of work to be done to ensure best practice becomes common practice. Essentially, we need to teach LBP patients that, based on what we know about how the brain processes pain, pain does not always equal harm. We need to avoid fear-invoking words and images that are common medical terminology and instead use words that promote the ability to engage in activity and encourage confidence. For some patients, practitioners need to explain that it is safe to keep moving despite the pain and that actual physical activity can make you feel better. But there is an art to saying, “We believe you hurt, and we are going to give you our best care” while also saying “You need to stay active.” The reality is the best care includes staying engaged and staying active. Unfortunately, patients aren’t always getting this message.
What implications does this have for workers’ comp patients?
How an employee’s injury is managed early on may have significant effects on their recovery downstream. A common example is a patient who has injured their back at work. If the company says we only want you back when you’re 100%, then the patient is out of work, gets used to being out work and gains an identity as an injured worker. For some patients, this may lead them to think, “It’s not safe for me to work, so it must not be safe for me to be active” when, as we’ve discussed, this is usually not the case. Companies and patients benefit when employers are able to find modified duty to help keep workers engaged even if they are not at full duty yet. Those involved in work-related social activities have a far better prognosis for durable return to work.
