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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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By identifying and developing shared goals, all stakeholders can,
collectively, properly align efforts that will improve system-wide
performance and properly assign accountability.24 Value in health care
cannot be measured only by assessing the patient outcome divided by the
monetary expense of care. A medical system devoted to achieving value in
this manner will ultimately degrade benefits for the providers, suppliers,
payers, and society.
Often, the patient does not play the role of a customer. Rather, through a
third-party payer arrangement, the customer role is subordinated to a health
insurance company that, in turn, negotiates reimbursement with the providers
and suppliers on behalf of their patients and their own third-party payer
organizations. Patients simply become the consumers of healthcare services
and products and relinquish their authority to control the cost of their care; in
addition, they are not incentivized to critically evaluate the need for services.
Often, patients attempt to access the maximum amount of available resources
permitted by the third-party payer; this strategy potentially increases
associated costs and negatively affects the value equation. Until the consumer
and customer are synchronized and aligned, providers and suppliers will
struggle to enhance the value equation. Clearly, optimizing care quality and
cost-efficiency will enhance value; however, the formula for value
determination must consider the proposition of a favorable return on
investment for all stakeholders, including the US taxpayer.
With respect to multidisciplinary integration, the derived value of care
should be referenced against the collective effort rather than one particular
service provider or intervention.24 The team should get the credit, not just one
player. The need for focused factories is disputed, and integrated systems
where accountability can only be attributed to the whole process is
championed. Although this perspective has been widely praised and
supported, the prospect of creating an interdisciplinary system must deliver
more than just the best care at the lowest cost. Rather, the needs and
expectations of providers and suppliers also must be considered. In doing so,
all stakeholders will be incentivized to create interdisciplinary systems of
care integration that are balanced with respect to shared value.
A 2014 article offers an important perspective regarding value and costeffectiveness.25 Most healthcare institutions and providers consider
individual patient preferences and available resources as the guiding factors
in determining the appropriateness of medical interventions. However,
societal preferences supported by the general public are more suitable. If the
taxpayer is considered a customer stakeholder, the value proposition of an
interdisciplinary model should favor the needs and expectations of those who
are making provisions to fund health care. From this standpoint, the value
proposition would best be calculated in a manner that considers the needs and
contributions attributable to all stakeholders, not just individual patients,
providers, or payers.
Assuming successful implementation of an interdisciplinary system of
care for lumbar disorders, Table 3 outlines the expected value proposition for
each stakeholder previously identified in this chapter. This list and the
associated deliverables may not be exhaustive. Many factors, including
unique geographic, occupational, economic, social, and cultural
idiosyncrasies, will influence the particular characteristics of each group. The
diversity and variability among stakeholders necessitates special
interdisciplinary consideration and attention.
Evidence for Interdisciplinary Care for Spine Disorders
Ascertaining the presence of red flags such as severe or rapidly progressing
neurologic compromise, a history of major trauma, or atypical symptoms has
been one of the primary justifications for early intervention. On the one hand,
these red flag issues are relatively rare and, in most instances, patients seek
urgent care when these problems occur. On the other hand, patients who are
at a high risk for the development of a chronic or disabling disorder because
of poor coping strategies, unreasonable recovery expectations, anxiety,
depression, occupational stress, or social factors may require early
intervention. Patients in whom chronic low back pain (LBP) develops have a
greater frequency of comorbid psychological conditions such as depression
and anxiety.26 The cost burden for these patients also is much higher because
resource utilization is much greater than that of control patients. Given the
fact that 7.6 million adults in the United States report having a chronic and
disabling low back issue, the influence and management of nonmedical
factors make early access to care a priority for this patient population. Early
intervention can mitigate the effect of psychosocial factors, prevent
inappropriate coping strategies caused by hopelessness and fear, and expedite
return to work.
27
Early intervention combined with risk stratification implemented by
either primary care physicians or a frontline patient navigator is an expanding
model throughout the United States.28 A risk stratified tool called the Keele
STarT Back Screening Tool is a simple prognostic questionnaire that helps
clinicians identify modifiable risk factors (biomedical, psychological, and
social) for back pain disability. This tool was used in a multipractice study.
The resulting questionnaire score was used to stratify patients into low-,
medium-, or high-risk categories. A 2014 study compared usual medical
management to stratified care of patients with LBP.29 A total of 1,647 adults
with LBP participated in the study. Results showed that, compared with
traditional care, patients who received stratified care had substantially less
disability, 50% less time off from work, and used fewer healthcare services.
Other studies on stratified primary care management support these
findings.
30,31
If initial single provider care is unsuccessful in patients with nonradicular
low back symptoms, consensus exists that these patients can benefit
considerably from an interdisciplinary approach.
32,33
Patients who might
traditionally be considered surgical candidates because of the failure of
typical single-provider care often decline surgery when provided functionally
based interdisciplinary rehabilitation.34 Stronger support of risk stratification,
triage, and early interdisciplinary care has been reported in studies that have
shown that a structured clinical pathway can lead to a reduction in
inappropriate referrals to spine surgeons while maintaining surgical candidate
volume.
35,36
Proper vetting of a patient before consultation with a surgeon is
a meaningful and valuable process outcome because the surgeon’s time is
better spent with a patient who is an appropriate surgical candidate.
In a 2015 study, 41 trials consisting of 6,858 subjects were analyzed to
determine the efficacy of an integrated biopsychosocial rehabilitation
program for patients with chronic LBP.37 Participants had a mean duration of
LBP of more than 1 year, and nonsurgical treatment had been unsuccessful.
The authors found moderate-quality evidence in support of an integrated
model of care with respect to improvements in pain and daily function when
compared with usual care. In addition, moderate evidence showed that the
collaborative approach doubled the likelihood that a patient would return to
work within 6 to 12 months compared with the comparison group.
Evidence Against Interdisciplinary Care for Spine Disorders
Despite the various advantages and benefits previously described in this
chapter, some notable caveats exist. When evaluating the value proposition
for all stakeholders as opposed to the patient only, the return on an
investment may not be as favorable for all the stakeholders. For example, in
medical surgical progressive care units, patient navigators have contributed to
improvements in patient safety, fewer complications, and reduced
readmission rates; however, patient satisfaction ratings were shown to be
reduced in programs that leverage midlevel support as first responders.
28
Table 3
In a 2016 study, 58 patients were randomly assigned to two groups. One
group was examined within 2 weeks of the onset of LBP and were deemed to
have received early intervention.38 The comparison group remained on a
waiting list for 12 weeks before consultation. Both groups received the same
intervention, which consisted of an outpatient, intensive back school.
Although the study authors acknowledged that this preliminary study was
underpowered, they reported that both groups had an equitable amount of lost
work days. Despite this finding, study limitations include the small number of
patients, the author’s definition of “early” with respect to waiting time, and
the homogenous method of intervention.
In a study of 351 employees that were listed as sick because of LBP, a
brief intervention with reassuring advice was compared with a
multidisciplinary intervention involving a team of spine specialists and a case
manager.39 The treatment costs, volume of healthcare utilization, and amount
of sick leave were calculated to determine the cost-effectiveness of the two
approaches. Results showed that the brief intervention with reassurance led to
fewer sick leave weeks and considerably less cost. The only subgroup that
seemed to benefit from the multidisciplinary approach were sick-listed
employees who had a self-perceived risk of job loss and feelings of little
influence over their work situation. It is possible that this program may have
had greater success with an upfront triage and stratification process, or it may
show that many patients do well with reassurance and self-care.
Despite the general acceptance and support among spine specialists for
incorporating a biopsychosocial approach, there remains a paucity of
integrated programs throughout the United States. Barriers to incorporation
may include fear of autonomy loss by providers, lack of understanding with
respect to interdisciplinary roles, limited professional resources, inadequate
leadership, difficulty staying up-to-date on the latest advances, implementing
electronic medical record solutions, and capitalizing anticipated upfront costs.
In a constantly changing and complex medical system with evolving
regulations, the need to care for an increasing number of patients, and the
increasing documentation required for each patient, the prospect of adopting
a new, integrated system may be too daunting for many practitioners to
consider.
40
Discussion: Evidence for and Against Interdisciplinary Care
Considering the evidence both for and against interdisciplinary care for
lumbar disorders, the preponderance of data suggests that an integrated model
can better meet the needs of all stakeholders in several expectation domains.
Extra effort is required to ensure that patients are fully satisfied with the level
of attention they are receiving in an early interventional triaged process.
Some reported deficiencies might reflect unsettled emotional attachment to
the traditional model of seeing a doctor as the frontline care provider versus
being treated using a nontraditional triage process in which a midlevel
clinician or ancillary specialist serves as the first point of contact.
Using the literature, the status of achieving the previously proposed value
proposition for each stakeholder can be evaluated. Clearly, more research is
required to examine the expectations of each stakeholder in an integrated
model and to verify that all aspects of the value proposition are being
achieved.
Consensus Guidelines
It is interesting to consider the needs of all stakeholder groups as those needs
pertain to clinical guidelines. If providers and suppliers are aware of their
consumer and customer assumptions, the clinical guidelines used to meet
those needs will be more meaningful, relevant, and impactful. One study
examined the understanding of patients and the public regarding clinical
guidelines, what patients and the public expected to be included in a clinical
guideline to help support the health care they receive, and the decisions they
make about diagnostic and treatment choices.41 The awareness of clinical
guidelines was found to be low. Participants expected clinical guidelines to
include the presentation and clarification of treatment options, with a
provision for some level of expected outcome for each option. In addition,
the study participants expressed the need for provider guidance, especially
from general practitioners.
In 2007, the American College of Physicians (ACP) collaborated with the
American Pain Society (APS) to publish clinical guidelines for the diagnosis
and treatment of LBP. Interestingly, these guidelines recommended a triage
process, stratification, and identification of symptom severity and neurologic
compromise as a means of establishing thresholds to trigger various treatment
pathways, along with patient education, evidence-informed decision making,
and interdisciplinary care for conditions that are recalcitrant to early
nonsurgical treatment.
42
In 2009, the National Institute for Health and Care Excellence published a
guideline on LBP in adults.43 This guideline references nonspecific LBP of
no less than 6 weeks’ duration and no more than 12 months’ duration. An
intent of this guideline is to effectively reduce the effect of nonspecific LBP
as it relates to disability and the socioeconomic status of affected individuals.
Self-management and education are key recommendations. Having uniform
educational messages across the continuum of care is of critical importance.
Particular mention is made of an interdisciplinary process whereby
communication between the clinicians and patients is uniform, robust, and
relevant. Detailed attention to tailoring an approach to the needs of multiple
stakeholders, including those of the patient’s family, are encouraged. The
patient’s family is invited to participate in the shared decision-making
process.
A systematic review performed to identify international guidelines on the
management of nonspecific LBP found that 15 such guidelines were
published between 2000 and 2008.44 The content of those guidelines was
noted to be very similar with respect to the use of diagnostic and therapeutic
procedures. A common theme of early intervention, optimistic assurance,
discouragement of bed rest, consideration of psychosocial factors,
multidisciplinary care, and gradual reactivation was reported.
A literature search of articles from 2002 to 2010 identified 13 relevant
clinical guidelines on the management of LBP.45 A universal consensus
regarding the use of a triage and stratification process was noted. Generally
accepted recommendations were noted for patient education, consideration of
psychosocial factors, exercise, and multidisciplinary care management.
In 2016, the Agency for Healthcare Research and Quality published a
guideline regarding the medical treatment of LBP.46 A strong emphasis was
placed on early return to work, cessation of ineffective treatments, and
provision and documentation of education so that a patient can be an active
participant in the decision to pursue a treatment pathway and articulate the
purpose of diagnostic and treatment procedures. Most importantly, this
guideline encourages an interdisciplinary approach, including psychological
or psychosocial evaluations and treatments in patients meeting specific
criteria. The guideline specifically states that care management should be
driven by interdisciplinary programs that emphasize collective and
coordinated evaluations, goal setting, planning, and execution. These
programs are designed for patients with complex multifactorial disorders.
Practical Clinical Applications
The goals of any spine care management paradigm are coordination,
efficiency, and adequate quality that ensures the most optimal outcome in a
cost-effective manner. Some patients need only simple reassurance and
encouragement during the natural recovery process and require the attention
of a single provider. Others, although more rarely, demand a complex array
of medical, pain management, rehabilitation, and psychosocial support
services to secure the most desirable outcome. The challenge is determining
the proper level of care for each patient, the timing of care, the extent of care,
and how to pay for the associated expenses.
Observations and recommendations from a 2008 article about
interdisciplinary care at an academic spine center can be adopted by private
and group practices, nonacademic hospitals, and within medical communities
where providers conduct their business independently but have the resources
to collaborate via any number of communication strategies.47 The keys to
success include having a common mission that resonates with the entire
interdisciplinary team; integrated scheduling and triage; and leveraging spine
specialist physiatrists to screen, classify, and manage a coordinated process
of care. In addition, the need to attend to patient expectations and care
pathway preferences tempered by evidence-based guidance and cost-effective
resources is emphasized. At the spine center described in the study, the
members of the interdisciplinary team worked in close proximity to each
other and weekly group meetings were held.
A 2013 study used a systematic review of the literature on
interdisciplinary teamwork and the perceptions of 253 staff members working
in interdisciplinary systems within 11 rehabilitation systems to determine the
10 key factors that characterize a good interdisciplinary system48 (Table 4).
Three well-known organizations, the Texas Back Institute (TBI), the
Virginia Mason Medical Center (VMMC), and Dartmouth-Hitchcock
Medical Center (DHMC) have successfully implemented integrated
interdisciplinary models for the management of lumbar spine disorders.
The TBI model was inspired by a specialty program at Rancho Los
Amigos Hospital in California. The founders of the TBI program envisioned
an integrated multidisciplinary team in which patients with spine disorders
benefit from systematic care coordination and an institutional focus on
combining high-quality care with research and public education. By 1982,
TBI was garnering national attention that, with time, vaulted the organization
to international acclaim. Commonly referred to as the world’s best and most
impactful “pracademic” (referencing the combination of active clinical
practice with research and scientific inquiry) spine center of excellence, the
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