1. The Bree Collaborative’s Role in Spine/Low Back Pain Care: A Proposal
Presentation to the Bree Collaborative
August 2, 2012

2. Purpose of Presentation
Present proposed approach for Bree’s role in Spine care/Low Back Pain topic -where Bree can add value, improve outcomes, and reduce costs
Discuss and adopt general approach

3. Experts met July 2nd Invited Participants Invited guest
Gary Franklin, MD, L&I
Leah Hole-Curry, L&I
Vickie Kolios-Morris, Spine SCOAP, FHCQ
Mary Kay O’Neill, MD, Cigna
John Robinson, MD, First Choice Health
Terry Rogers, MD, FHCQ
Invited guest
Rick Deyo, MD, OHSU
Staff: Steve Hill & Rachel Quinn

4. Low Back Pain is common, costly, and complex
One of the most common reasons for patients to see physicians
Leading cause of work-related disability and workers’ compensation for people under age 45
Medical costs are in excess of $25 billion per year; commercially, musculoskeletal top expenditure
There’s a huge psycho/social element to low back pain - one of the strongest predictors of onset of low back pain and transition from acute to chronic is patient’s emotional status and presence of work-life issues

5. Variation in Treatment and Management among Patients with Acute and Chronic Back Pain
Acute/Subacute (symptoms lasting less than 12 weeks)
Unnecessary use of imaging and surgery without improved outcomes
Patients seen by wide variety of practitioners with different treatment approaches
Most acute & subacute low back pain patients could be managed and screened in outpatient primary care setting
Chronic (symptoms lasting more than 12 weeks)
Huge variability in lumbar fusion surgeries, and they are very expensive
One of the strongest predictors of onset of low back pain and transition from acute to chronic is patient’s emotional status and presence of work-life issues

6. Bree and History of Spine Care
Presentations/discussons to date, at 3 Bree Collaborative meetings, have focused on lumbar spinal fusions – treatment for chronic, not acute back pain
September 30, 2011
January 30, 2012
March 29, 2012

7. Bree Topic Goals & Guidelines
Improve quality, outcomes for patients and cost- effectiveness 
Topic Selection
Significant safety, efficacy or cost-effectiveness concerns 
Substantial variation in practice patterns or high utilization trends can be indicators of poor quality and potential waste in the health care system, without producing better care outcomes 
Outcome:
Identify topics with variation or quality concerns, and recommend evidence-based strategies to improve quality and cost-effectiveness
Yes, both acute and chronic spine care fit criteria

8. Low Back Pain Initiatives in WA
Puget Sound Health Alliance Low Back Pain Clinical Improvement Team Recommendation (2007): focus on outpatient management of acute low back pain
UW/Spine SCOAP conducts spine forums to discuss spine issues
WA Technology Assessment Project will not pay for fusions for degenerative disc disease unless failure of multidisciplinary program
UW Comparative Effectiveness Research Pilot on lumbar fusions and spine care in general
ACUTE
(< 6 weeks)
CHRONIC
( > 3 months)
Spine SCOAP compiles data on all spine surgeries

9. Recommendations Create a spine subgroup
Initial focus of spine workgroup: how to appropriately manage patients with acute low back pain, and prevent transition of acute/subacute to chronic low back pain
Gather evidence-based guidelines, emerging best practices & data on how to appropriately manage acute
St. Joseph’s, Virginia Mason Medical Center
Institute for Clinical Systems Improvement (ICSI)
Evidence-based business practices (Intel/Oregon program)
Centers of Occupational Health & Education (COHE)
Gather education of alternatives (shared decision aids)
How to support/align with existing efforts, whether focus is acute or chronic (e.g., comparative effectiveness registry)

10. Recommendation: Spine Subgroup
Members of exploratory group
Gary Franklin
Mary Kay O’Neill
John Robinson
Subgroup recommendations
Bob Moots, associate director for chiropractics, L&I
A spine surgeon
Others?

11. Recommendation: Registry
Subgroup to consider the following recommendation:
All hospitals and ASCs (that perform discectomy, fusion, and/or disc replacement) participate in a publicly reported, prospective, benchmarking registry of spine surgical and interventional procedures
Participation in such a registry will generate needed information about the appropriateness of surgical/intervention spine care that can be used to support future HTA and payer decisions related to spine care.
The registry should focus its public reporting on progress in reducing variation in the use of less indicated procedures, as well as in improving the quality, effectiveness and cost-effectiveness of care.