Outcomes Analysis of Low Back Pain Patients Managed Through a Spine Center Clinical Care Redesign Pathway: An Initial Retrospective Cohort Study.

Abstract

Background context: Back pain affects a large portion of the U.S. population, and delivering care in an efficient manner without compromising outcomes is of utmost importance for quality of life. One potential approach is to reinvent clinical pathways to streamline care and reduce the gaps evident between recommendation and actual practice, such as high uses of surgery and imaging.

Purpose: To compare outcomes of acute or acute-on-chronic low back pain patients treated through a value-based structured clinical care redesign spine pathway at The Hospital of Central Connecticut (THOCC) Spine Center versus patients treated by Hartford HealthCare (HHC) ambulatory care providers/clinics that did not participate in the clinical care redesign spine pathway.

Study design/setting: Retrospective cohort study in the setting of ambulatory care referrals from primary care or community providers, urgent care, emergency department, walk-ins, or self-referral within HHC.

Patient sample: Acute or acute-on-chronic lumbar pain patients conservatively treated with at least three physical therapy (PT) visits OUTCOME MEASURES: Initial and follow-up Modified Oswestry Low Back Pain Disability Questionnaire (MDQ) and numeric pain rating scale scores; days of first provider to first PT visit, first provider visit to completion of the acute care episode; number of provider, PT, and outside specialist visits (orthopedics, neurosurgery, neurology), and imaging studies (x-rays) METHODS: Patients were identified by querying the rehabilitation outcomes management system (ROMS) database. Variables were collected via chart and ROMS database review. Mann-Whitney-U tests with α set at 0.05 were performed. Differences in dichotomous data between the two groups were analyzed with contingency Chi-square tests or Fisher's Exact tests. Because this was a retrospective analysis of an existing cohort, no a priori sample-size calculation was performed. The final sample represents all available patients meeting the prespecified eligibility criteria during the study period.

Results: There were no statistically significant differences between the 41 patients treated through the THOCC clinical care redesign spine pathway and the 33 patients treated in the standard non-spine care pathway regarding sex, race, ethnicity, diagnosis, initial pain or disability score, or Subgroups for Targeted Treatment (STarT) Back Tool risk category. Spine Center participants were significantly older than controls (median age 52 vs 43 years, p=0.0004, effect size 0.414). Compared with controls, Spine Center patients demonstrated significantly shorter median time from first provider visit to PT (2.5 days [IQR 1-6.5] vs. 19 days [IQR 8-39], z=-4.98, p<0.0001, effect size 0.591), shorter median episode duration (70 days [IQR 47.5-93.75] vs. 132 days [IQR 71-311], z=-3.04, p=0.0023, effect size 0.361), greater median improvement in pain scores (3- [IQR 1-5.5] vs. 2-points [IQR -0.75-3.75], z=2.07, p=0.0486, effect size 0.231), greater median number of provider visits (2 [IQR 2-3] vs. 1 visit [IQR 1-2.75], z=3.40, p=0.0007, effect size 0.398), fewer lumbar x-rays (0.073 per patient, median 0 [IQR 0-0], vs. 0.394 per patient, median 0 [IQR 0-1], z=-2.15, p=0.0313, effect size 0.250), and fewer outside specialist visits (0.463 visits per patient, median 0 [IQR 0-0], vs. 0.935 visits per patient, median 0 [IQR 0-2], z=-2.23, p=0.0258, effect size 0.263).

Conclusions: A clinical care redesign spine pathway may be associated with improved care efficiency and decreased use of selected services such as imaging and outside specialist visits. Additional studies with larger cohorts and multivariable analysis are warranted to further characterize the relationship between integrated spine center models and functional outcomes.