A successful, cost-effective low back pain triage system: a pilot study

Hamilton Hall; E Richard Prostko; Katie Haring; Michael Fischer; Boyle C Cheng

doi:10.1016/j.xnsj.2021.100051

A successful, cost-effective low back pain triage system: a pilot study

N Am Spine Soc J. 2021 Feb 1:5:100051. doi: 10.1016/j.xnsj.2021.100051. eCollection 2021 Mar.

Authors

Hamilton Hall¹, E Richard Prostko², Katie Haring³, Michael Fischer⁴, Boyle C Cheng⁵

Affiliations

¹ Department of Surgery, University of Toronto, Canada.
² Neurosurgery Department, Allegheny Health Network, United States.
³ Care Model Analytic Design, Highmark Health, United States.
⁴ Clinical Analytics, Living Health, Highmark Health, United States.
⁵ Neuroscience Institute, Allegheny Health Network Research Institute, United States.

Abstract

Effective triage - directing patients with low back pain to appropriate treatment or correct referral - is fundamental to quality care. Without guidelines, a physician's initial decision may lead to unnecessary investigation, unneeded intervention or unwarranted consultation. Methods: To compare the functional outcomes of patients triaged by a classification based on clinical presentation with those of patients selected at the clinicians' discretion, an insurance-owned hospital network employed forty-seven specially-trained physical therapists, working within participating primary care practices, to classify low back pain patients into specific Patterns of Pain. Between October 2017 and April 2019, the primary care physicians used this classification, derived entirely from the patient's history and physical examination, to direct subsequent treatment for 260 consecutive low back pain patients. Patients with systemic symptoms, recent substantial trauma or non-mechanical diagnoses indicative of spinal infections or possible malignancy were excluded. Functional outcome measures were spinal imaging, opioid use, length of treatment and number of visits, back-related unplanned care, frequency of spinal surgery and back-related episode cost. These were compared with a control group of 256 propensity-matched patients and, for assessing the financial impact, with a historic cohort of 111 previously treated, non-classified patients. Results: Spinal imaging: study group 24.5%; controls 42.2% (P< .001). Narcotic use: study group 4.6%; controls 13.3% (P< .001). Treatment length: study group 62.2 days; controls 74.5 days (P=.10). Treatment visits: study group 1528 visits; controls 2,046 visits (P=.003). Unplanned care: study group 1.9%; controls 12.8% (P< .001). Spine surgery: study group 15.4%; controls 26.2% (P=.005). Episode cost: study group $1453; controls $2334 (P=.005). Conclusions: A well-defined clinically-based triage system produced meaningful reductions in imaging, opioid use, treatment duration, unplanned interventions, surgery and cost of care.

Keywords: Classification; Cost effective; Imaging; Low back pain; Opioids; Outcomes; Triage.