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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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Psychosom Med 2001;63(3):335-343.
communication and problem solving to prevent back disability: Results of a randomized
controlled trial among high-risk workers and their supervisors. J Occup Rehabil
2016;26(2):150-159.
Interventions aimed at both the worker and the workplace achieved substantially larger
improvements in work absence caused by pain, health perception, and healthcare use
than usual treatment in workers at high risk for disability from back pain.
of low back and low back related leg pain complaints referred for surgical assessment.
Spine (Phila Pa 1976) 2017;42(5):E288-E293.
Patients referred for surgical consultation for low back pain or low back–related leg
pain are largely willing to accept screening by nonphysician healthcare providers.
magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine
(Phila Pa 1976) 2015;40(6):392-398.
Cervical disk bulging, spinal cord compression, and increased signal intensity changes
were evaluated with cervical MRI for 1,211 healthy volunteers. Disk bulging, spinal
cord compression, and increased signal intensity were found in 87.6%, 5.3%, and 2.3%
subjects, respectively. The frequency of spinal cord compression and increased signal
intensity increased after age 50 years.
deliver higher-value physical therapy for patients with low back pain: case report. Phys
Ther 2015;95(12):1712-1721.
Implementation of a quality improvement process was measured by year-over-year
improved clinical outcomes, decreased utilization, and increased adherence to evidencebased physical therapy, which was associated with higher-value care.
of biopsychosocial perspectives. Aust Occup Ther J 2006;53(2):67-77.
delivery of spinal healthcare. World J Orthop 2015;6(5):409-412.
The bundled episode reimbursement has gained popularity as a potential alternative to
the current fee-for-service system. In the newer model, the spine surgeon will become
increasingly responsible for controlling costs. The evolving interests of hospital systems
could result in the devaluation of the surgeons’ services. Buy-in by all involved
healthcare providers will be necessary to ensure that quality of care does not suffer
while efforts for cost containment continue.
Chapter 10
Interdisciplinary Care for
Lumbar Spine Disorders
Michael L. Reed, DPT, OCS S. Raymond Golish, MD, PhD, MBA
Jerome Schofferman, MD
Abstract
Spinal impairment is the leading cause of disability worldwide, with lumbar
spine–related problems the most common cause of disability among all the
axial skeletal disorders. The medical and socioeconomic burdens of spinal
disorders have outpaced those related to depressive disorders, cardiac
syndromes, chronic obstructive pulmonary disease, migraines, diabetes, and
falls. Although specialties in other fields such as cardiology have
successfully reduced disease-related disability rates, spine specialists have
not achieved the same success. The incidence of spinal disability has
continued to escalate despite advances in diagnostics and nonsurgical and
surgical care.
It is helpful to be familiar with the potential stakeholders involved in an
episode of spine-related dysfunction and to explore the needs and
expectations of the stakeholder groups and the value proposition for each in
a coordinated system of care. Understanding the interdisciplinary model of
care for patients with spinal disorders, evidence for and against an
interdisciplinary care system, established guidelines that support the
concept of an integrated model, along with an examination of organizations
that have achieved extraordinary success by establishing their own versions
of an interdisciplinary process of spine care will benefit those who care for
patients with lumbar spine disorders. Physicians also should be familiar
with the role of medication in the care of patients with acute and chronic
low back pain.
Keywords: antidepressant; anti-inflammatory drug;
interdisciplinary; lumbar spine; medication; multidisciplinary;
NSAID; patient navigator; patient triage; performance
improvement; opioid; stakeholder; value equation; value
proposition
Dr. Reed or an immediate family member serves as a board member, owner,
officer, or committee member of the North American Spine Society. Dr. Golish or
an immediate family member serves as a paid consultant to the FDA, Icotec AG,
Intrinsic Therapeutics, Medacta, and Simplify Medical; serves as an unpaid
consultant to and has stock or stock options held in Cytonics; and serves as a
board member, owner, officer, or committee member of the American Academy of
Orthopaedic Surgeons, ASTM International, and the North American Spine
Foundation. Dr. Schofferman or an immediate family member serves as a board
member, owner, officer, or committee member of the North American Spine
Society.
Introduction
In the United States, 51 million individuals report having a disability, of
which 14 million (27.5%) report spine impairment as the primary cause.
1
Disabled individuals are 71% more likely to experience an economic decline
to the poverty level compared with their healthy peers.2 Spine-related
impairment is the most common cause of disability in the United States.
3,4
In the United States, $357 billion of public funds is spent annually
supporting those who are disabled.5 Total costs associated with spine-related
impairment in the United States have been estimated at between $253 billion
and $600 billion, which represents a cost increase of at least 91% in just over
a decade.6 Over the past 20 years, the cost of spine-related impairment and
associated musculoskeletal disorders has escalated by nearly four times the
rate of increase in the gross domestic product.6 Sixty-six percent of the total
cost associated with spine-related impairment in the United States is
attributed to productivity loss and absenteeism, which accounts for annual
losses for US employers of $28 billion.
5,7
The Social Security Disability Insurance Program pays out $144 billion
per year, with approximately $40 billion paid to beneficiaries with spinerelated impairments.
1,8
The total number of these beneficiaries increased by
43% between 2003 and 2013.9 Approximately 40% of work absence is
caused by back pain, and 20% of those with spine pain report they cannot
continue working.10 Back pain caused 671 million bed days and 385 million
lost work days in 2008.11 Spine-related impairment affects women more
frequently than men.
6
Spine impairment is currently the leading cause of disability of veterans
of the US Army.12 During deployment, 7% of noncombat-related medical
evacuations are for episodes of spinal pain, which is the most common
cause.13 Among Iraq and Afghanistan veterans, 10 times as many discharges
from the military occurred because of long-term spine pain that was unrelated
to a combat injury compared with discharges that were attributed to blast
injuries.
14
Millions of children have spine deformities and conditions that reduce
their quality of life and longevity, with 94% of children with spine-related
impairment reporting some level of associated disability.
15,16
The relative
risk of becoming disabled for a young individual of working age in the
United States is 25%.17 It is estimated that 30.7% of occupational disability
claims are related to musculoskeletal disorders, and most can be attributed to
spine-related complaints.
18
The evolving value-based medical system is encouraging spine specialists
and spine care delivery systems to become better integrated, coordinated,
efficient, and cost-effective. Along with patients and their families, many
other stakeholders are now demanding meaningful, measurable, and rapid
improvement in spine care outcomes and associated costs. An aging
population, the increase in the number of beneficiaries covered under the
Patient Protection and Affordable Care Act, and a contracting physician
workforce have resulted in an urgent need for effective and less expensive
interdisciplinary spine care.
Having a comprehensive platform of primary care support in a medical
system is the most critical step to ensuring appropriate and efficient
management of community health and wellness.19 Leveraging the support of
ancillary providers within a primary care hub in coordination with primary
physicians and information systems can secure adequate access and
coordinated care resulting in optimal care quality, reduced utilization, and
improved cost control. Access, reassurance, education, alignment of
expectations, care coordination, intraprofessional and extraprofessional
communication, outcomes tracking, and feedback for systematic learning and
refinement are all lacking in the current spine management model, except for
some notably successful examples.
A “second curve” of change in the delivery of US health care has been
described.20 Silos of traditional specialty departments that grow and contract
based on patient demand are antiquated. It is predicted that medical systems
will evolve to function as integrated units that collectively and cooperatively
manage medical conditions with shared accountability. Value will be derived
by ensuring optimal outcomes, efficiently using resources, and coordinating
care across various disciplines in a manner that engages patients and their
families to be active participants.
Definitions and Distinctions
In any system of shared communication, an established understanding of
terminology, meanings, and context is of critical importance. For the purpose
of ensuring clarity and preventing misunderstandings, the definitions and
distinctions presented in Table 1 will apply in this chapter.
The differences between the terms “multidisciplinary” and
“interdisciplinary” have been described in the literature.21 Multidisciplinary
systems often reference fragmented and uncoordinated patient care through
cross referrals between multiple specialties. As a result, the clinical pathways
become redundant and costly. More importantly, without adequate care
management and communication between and among specialists, patients are
ushered down a corridor of care that becomes increasingly more complex,
invasive, and expensive. Omissions related to the psychosocial contributing
factors may be missed or ignored if they do not fit within a specialty area,
leading to unnecessary treatments and chronicity.
Interdisciplinary care now represents the preferred integrated system and
has won acclaim from prestigious organizations. In an interdisciplinary care
model, despite professional heterogeneity, team members coordinate and
communicate the care process through a collaborative and purposeful
process. Patients often enter the system early after the onset of spine-related
symptoms by interfacing with a spine navigator. This affords the patient an
opportunity to receive rapid attention and consideration, regardless of the
urgency of the case. Early counsel can mitigate the risk for the development
of a chronic issue or disability.22 The navigator also assumes the
responsibility of triage, ensuring that the patient-care pathway is most
efficient and follow-through is achieved.
In addition to the navigator role, an interdisciplinary team approach
includes a physician team leader who further stratifies a case based on risk
(medical comorbidities and psychosocial factors) and assists in team
coordination. By evaluating a patient in a holistic manner—considering all
potential contributing domains such as his or her medical, physical,
biomechanical, psychosocial, economic, occupational, ergonomic, and goalrelated expectations—a targeted and properly planned management program
can be developed with all disciplines included, considered, and leveraged, as
needed. Using this approach, gaps can be filled before they degrade the care
process and the potential outcome.
21
Table 1
Stakeholders and Associated Needs
Historically, the primary stakeholders afforded the greatest consideration in
the US medical system have included the patients, clinicians, hospitals,
medical companies (pharmaceutical and devices), and third-party payers.
Given the preponderance of reimbursement arrangements between clinicians
and health insurance companies, many business-minded healthcare
economists have likened the patient to a “consumer,” the third-party payer to
a “customer,” the clinician to a “service provider,” and hospital/medical
company to “supplier.” These relationships and assumed roles have caused
incentives to become misaligned and asynchrony has ensued.
The playing field in medicine has expanded dramatically as patient care
has become more holistic. Greater consideration is now given to
nontraditional stakeholders, including the patient’s family, the primary care
physicians, ancillary clinicians, employers, disability insurers, and taxpayers.
A closer perspective on the various stakeholders, their potential challenges as
they relate to an episode of spine care, and their anticipated needs in an
interdisciplinary system is presented in Table 2.
Value Proposition
Two important articles published in 2010 described the concept of the value
equation, which is some quantifiable measure of outcome quality divided by
associated cost (value = outcomes/cost).
23,24
In this formula, an increase in
outcome quality and a correlative decrease in cost will increase value. At face
value, if the denominator is driven down to just $1 and the numerator is
raised as high as possible, then value optimization would be achieved.
Unfortunately, depending on who the individual is and the factors that affect
his or her perception of value, the metrics input into this equation may not
accurately measure applicable value for that individual. In fact, the equation
may not reach an equitable level across all potential stakeholder groups.
Without a clear understanding of the needs and expectations of all
stakeholders considered in balance, an interdisciplinary system might meet
the expectations of some stakeholders and underperform for others within a
single episode of care.
Table 2
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