1. The Role of Spinal Triage Beyond Offering Surgery
Spine Therapy Network
March 2, 2018
D. DOS SANTOS, B.SC., DC, FCCPOR(C), FCCO(C)

2. Disclosure of Potential for Conflict of Interest
Dr. D. Dos Santos, March 2, 2018
Disclosure of Potential for Conflict of Interest
Speaker’s name, Credentials D. Dos Santos, B.Sc.,D.C.,FCCPOR(C),FCCO(C) Advanced Practice Clinician - Trillium Spine Centre Financial Disclosure: Grants/Research Support: N/A Speaker’s Bureau/Honoria: N/A Consulting Fees: N/A Other: N/A

3. Disclosure of Commercial Support
Dr. D. Dos Santos, March 2, 2018
Disclosure of Commercial Support
This program has not received financial or in-kind support.
There are no actual or potential conflicts-of-interest identified in the presentation of this program.
Procedures discussed are for clinical and academic purposes. Dr. Dos Santos does not endorse any specific brand related to procedures discussed.

4. LBP: A different approach is needed
Dr. D. Dos Santos, March 2, 2018
LBP: A different approach is needed
40% annual prevalence
One of commonest reasons for consultation with a physician (10-15% of all visits)
High utilization of unnecessary imaging and management
Number one cause of years lived with disability
25% of patients with LBP responsible for 75% of cost to health care system

5. Spine Care in Ontario – Wait Times (hqo)
Dr. D. Dos Santos, March 2, 2018
Spine Care in Ontario – Wait Times (hqo)
Provincial Wait Times for Diagnostic Imaging
CT scans: 49 days (target is 28 days)
MRI: 102 days (target is 28 days)
Provincial Wait Times for Orthopedic Surgery:
Lumbar Disc Surgery: 301 days (target is 182 days)
Bone/Spine: 223 days (target is 182 days)

6. Spine Care in Ontario – Wait Times
Dr. D. Dos Santos, March 2, 2018
Spine Care in Ontario – Wait Times
Wait Times for Lumbar Disc Surgery (time from receiving a referral from a family doctor to the specialist appointment):
Priority 2 patients (high probability of disease progression and morbidity affecting function) - 17 days
Priority 3 patients (the progress of the disability/disease is moderate) - 76 days
Priority 4 patients (the progress of the disability/disease is minimal) -120 days

7. Spine Care in Ontario – Wait Times
Dr. D. Dos Santos, March 2, 2018
Spine Care in Ontario – Wait Times
Surgical Wait Time (time from specialist and patient decide surgery is the appropriate option until the day of surgery):
Priority 2 patients – 63 days
Priority 3 patients – 125 days
Priority 4 patients – 139 days
57% of patients seen within the target time

8. Provincial Initiatives - PCLBP
Dr. D. Dos Santos, March 2, 2018
Provincial Initiatives - PCLBP
Primary Care Low Back Pain (PCLBP) Pilots launched in as part of MHLTC LBP strategy. 7 Sites in 7 LHIN’s (CHCs, NPLCs, FHTs).
Assessment and care plan model. (PT, DC, Kin). Can be referred for community care
Serves uninsured and/or vulnerable patient populations. (significant co-morbitities – diabetes, mental health and addiction issues).
No restrictions for accepting patients who are already opioid dependent, and no restriction on duration of LBP

9. Provincial Initiatives – Rapid Access
Dr. D. Dos Santos, March 2, 2018
Provincial Initiatives – Rapid Access
Rapid Access Clinics announced December 2017
Builds on ISAEC and hip and knee central intake and assessment centres.
Meant to help with surgical wait times and to ensure prompt access to right treatment needed for hip, knee and low back pain

10. Provincial Initiatives - ISAEC
Dr. D. Dos Santos, March 2, 2018
Provincial Initiatives - ISAEC
Inter-professional Spine Assessment and Education Clinics (ISAEC)
Shared care model. Distinct patient cohort.
Objectives: improved outcomes and patient satisfaction
decrease MRI utilization, reduce unnecessary referrals for LBP, improve access to specialist care

11. Provincial Initiaties - ISAEC
Dr. D. Dos Santos, March 2, 2018
Provincial Initiaties - ISAEC
Risk Stratification
Surgical
Inflammatory
Risk of Narcotic Dependency
Risk of Chronicity

12. Provincial Initiatives - ISAEC
Dr. D. Dos Santos, March 2, 2018
Provincial Initiatives - ISAEC
Data
Avg wait time to consult – 12 days
Avg wait time for surgical consult - < 6 weeks
Reduction in MRI over 30%
Less than 7% of ISAEC patients have gone on to imaging or specialist intervention

13. Other Provincial Initiatives
Dr. D. Dos Santos, Oct. 29, 2015
Other Provincial Initiatives
ECHO (Extensions for Community Healthcare Outcomes) Ontario programs
Chronic Pain and Opioid Stewardship
Rheumatology
Living a Health Life With Chronic Pain/Chronic Conditions
Quality Standards Advisory Committee on Low-Back Pain
Core (clinically oriented relevant examination) Back Tool. Core Neck Tool and Headache Manager – Centre for Effective Practice

14. “With great power comes great responsibility” Uncle Ben- Spiderman I
Dr. D. Dos Santos, March 2, 2018
Assessment and Triage
“With great power comes great responsibility”
Uncle Ben- Spiderman I
Corollary: With great responsibility comes great power

15. Dr. D. Dos Santos, March 2, 2018
Triage
Is not easy as it appears: Administrative data is not enough Specialist screening adds unnecessary costs PCPs lack knowledge and confidence Principle stakeholders can’t agree Focus is usually in the wrong place

16. Dr. D. Dos Santos, March 2, 2018
Trillium AP program (Advanced Role Chiropractor and Advanced Practice Physiotherapist Model)
Development Plan Phases of implementation Observation of Surgeon Clinics Identification of Required Competencies Assessment of Learning Needs Development of Medical Directives and MAC approval Documentation and Communication Process Changes Surgeon Eval of Competence/Ongoing Supervision Radiology Review and Learned Objectives

17. Dr. D. Dos Santos, March 2, 2018
AP program
Utilization rate for advanced imaging by APP/APC very low (5.4%) High rates of satisfaction with report, diagnosis and recommendations Approx 8% referred for surgical consultation High levels of agreement between APC/APP High levels of satisfaction with neurosurgeon/orthopaedic surgeons

18. Dr. D. Dos Santos, March 2, 2018
Triage
Everyone is looking at the altered anatomy and when that is not obvious, the low back pain is classified as “non-specific” 90% of patients are ”non-specific”. Clinically they are not all the same and shouldn’t all be treated the same way

19. Triage Questions – The big 5
Dr. D. Dos Santos, March 2, 2018
Triage
Questions – The big 5
1. “Where is your pain the worst”? “Is it back or leg dominant”?
It is not “where do you hurt”?
It is ”where is your pain the most intense?”
“Is the pain constant or intermittent”?
Does bending forward make your typical pain worse

20. Dr. D. Dos Santos, March 2, 2018
Triage
Questions
“Has there been any change in your bowel or bladder function”?
“What can’t you do now because of your pain that you could do before and why”?

21. Dr. D. Dos Santos, March 2, 2018
Triage
The history is confirmed or refuted by the physical examination:
Observation and movement
Selected nerve root tension/irritation tests
Selected nerve root conduction tests
Upper motor neuron involvement tests
Saddle sensation test

22. Triage - Summary Spinal triage is not easy
Dr. D. Dos Santos, March 2, 2018
Triage - Summary
Spinal triage is not easy
Requires specialized training and system changes
Can produce significant cost savings to the system, improved outcomes and patient satisfaction
Remember: With great power comes great responsibility!