1. Rising to the Challenge Spine 10 x 25 Initiative Research Summit North American Spine Foundation July 18, 2015 Dan Cherkin, PhD Group Health Research Institute and University of Washington Seattle

2. Initially Skeptical Very ambitious undertaking even under ideal circumstances Circumstances of spine care world are far from ideal Numerous players/no coordination Controversy and distrust Lack of vision for improvement 2

3. Convinced Worth Trying Visionary and innovative Extremely important goal Feasible and sensible approach Our shared desire and commitment to reducing spine-related disability bodes well

4. Spine Problems Globally 1 in 10 people have spine pain Spine pain the leading cause of disability Situation deteriorating 9% increase in spine-related disability per capita (1990 – 2010) [Hoy D, et al., Ann Rheum Dis, 2013] [Vos T, et al. Lancet, 2012]

5. Spine Problems in U.S. Although health care expenditures for spine problems increased 60% between 1997 and 2005 in the U.S….. …..Spine-related disability increased! [BI Martin et al, JAMA, 2008] Raises red flags about care for spine problems in new era of “value-based” care Important to get our act together!

6. Relieving Pain in America A Blueprint for Transforming Prevention, Care, Education and Research (Institute of Medicine, 2011) Major Conclusions of IOM Report “Given the burden of pain in human lives, dollars, and social consequences, reliving pain should be a national priority.” Need for comprehensive strategy to overcome barriers that limit access to effective care “A cultural transformation is necessary to better prevent, assess, treat, and understand pain of all types.”

7. Key Elements of Cultural Transformation Heighten clinician and public awareness about pain, including its complex biological and psychosocial aspects Tailor pain care to each person Promote self-management Increase collaboration between primary care physicians and pain specialists Include gov. agencies, providers, professional assoc., educators, insurers, patients in transformation process Useful lessons for Spine 10 x 25 Initiative

8. Key to Success of Spine 10 x 25 Initiative Understanding the importance of: Collaboration in complex/disconnected world Focusing on what will most benefit patients Evidence from solid and relevant research Taking a bio-psycho-social (as opposed to a biomedical) perspective

9. Context MACRO ENVIRONMENT (social, cultural, political, economic) HEALTH CARE ENVIRONMENT Regulatory, market, and policy framework (regulators, insurers, purchasers, workforce, etc.) HEALTH CARE ORGANIZATION Infrastructure/resources CARE TEAM (health care professionals, family members, and others) PATIENTS/ PERSONS

10. Patient-Centered v. Medical Models of Care

11. Evidence-supported Numerous untested, expensive, sometimes harmful tests and treatments for spine problems To benefit patients, need to encourage use of safe and effective treatments and discourage use of unproven, ineffective, and harmful treatments. Promising tests/treatments should be rigorously studied

12. Bio-Psycho-Social Perspective Research shows psychosocial measures better predictors of outcomes of care for pain than physical measures (e.g., imaging, ROM) Fear of increased pain with movement Pessimism about likelihood of improvement Depression Catastrophizing Need for more whole-person approach (i.e., mind and social circumstances as well as body)

13. Challenge to the Group To maximize our chances of success, remember importance of: Collaborating with diverse stakeholders Taking a patient-centered approach Valuing solid relevant evidence Expanding biomedical perspective to include psychological and social factors