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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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outcomes at the lowest expense can be realized.
Customization of an interdisciplinary lumbar spine care model is required
for different practice settings, geographic nuances, and cultural distinctions.
Proven models of success can serve as a road map in all types of settings,
including academic, pracademic, and private practice.
The role of medication in managing both acute and chronic LBP should
be considered and used in the proper circumstances and in appropriately
selected patients. Medication can aid in reducing pain and restoring function.
With proper leadership, all spine service lines can take part in a system
that delivers the highest quality care at the most reasonable costs, with
enhanced efficiency and expediency to adequately meet the needs of all
stakeholders.
Key Study Points
A systematic and consistent interdisciplinary process for lumbar spine care
that is laden with objective metrics, meaningful data collection, and
actionable analytics can optimize efficiencies, enhance patient outcomes,
and save money.
Efficient and cost-effective interdisciplinary lumbar spine care models
incorporate a navigator and uniform thresholds at which spine specialist
providers become engaged within the coordinated team.
Staying up to date on the latest advances, caring for an increasing volume
of patients, documenting each case, implementing electronic medical
record solutions, and maintaining compliance with the ever-changing
regulatory mandates make it difficult for spine specialists to effectively
participate in an interdisciplinary lumbar spine care model.
Customization of an interdisciplinary lumbar spine care model is required
for different practice settings and geographic nuances.
In patients with acute LBP, medications can play a meaningful role in
reducing pain and restoring function.
For patients with acute LBP, the choice of medication must be
individualized and can include a skeletal muscle relaxant, an NSAID, and
an opioid for patients with severe pain.
For patients with chronic LBP, medications should be part of a program
that also includes rehabilitation and possible spinal injections and/or
psychological treatment.
Opioids should be reserved for well-selected patients with severe and
refractory LBP; careful follow-up is essential.
Annotated References
1. Survey of Income and Program Participation 2008 Panel Wave 6 Topical Module
Microdata File. US Census Bureau. Washington, DC, 2014. Available at:
https://www.census.gov/content/dam/Census/programs-surveys/sipp/techdocumentation/completedocuments/2008/SIPP%202008%20Panel%20Wave%2006%20%20Topical%20Module.pdf. Accessed February 21, 2017.
2. Brault MW: Americans with Disabilities: 2010. Household Economic Studies: Current
Population Reports. US Department of Commerce Economics and Statistics
Administration, US Census Bureau, 2012, pp 70-131. Available at:
https://www.census.gov/prod/2012pubs/p70-131.pdf. Accessed February 21, 2017.
This highly regarded resource provides specific data from the 2008 Survey of Income
and Program Participation as it relates to the number of individuals with disability and
severity prevalence by age, race, type, region, employment, and income level.
3. Ma VY, Chan L, Carruthers KJ: Incidence, prevalence, costs, and impact on disability
of common conditions requiring rehabilitation in the United States: Stroke, spinal cord
injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis,
limb loss, and back pain. Arch Phys Med Rehabil 2014;95(5):986-995.e1.
This literature review of 82 articles reported data regarding the incidence, prevalence,
costs, and effect of various medical conditions, including back pain. Results showed
that back pain and arthritis are the most common conditions and the costliest.
4. Vos T, Flaxman AD, Naghavi M, et al: Years lived with disability (YLDs) for 1160
sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the Global
Burden of Disease Study 2010. Lancet 2012;380(9859):2163-2196.
This article examines the renowned Global Burden of Disease study of 2010 and,
specifically, the effect of 291 diseases on years lived with disability. The analysis
revealed that back pain and neck pain are among the leading worldwide causes of
disability.
5. Rizzo JA, Abbott TA III, Berger ML: The labor productivity effects of chronic
backache in the United States. Med Care 1998;36(10):1471-1488.
6. Andersson G: The Burden of Musculoskeletal Diseases in the United States:
Prevalence, Societal and Economic Cost. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2008.
7. Katz JN: Lumbar disc disorders and low-back pain: Socioeconomic factors and
consequences. J Bone Joint Surg Am 2006;88(suppl 2):21-24.
8. DeHaven T: The Rising Cost of Social Security Disability Insurance. Cato Institute
Policy Analysis No. 733. August 6, 2013. Available at:
https://object.cato.org/sites/cato.org/files/pubs/pdf/pa733_web.pdf. Accessed February
21, 2017.
9. US Social Security Administration: Office of Retirement and Disability Policy, Office
of Research, Evaluation, and Statistics Annual Statistical Report on the Social Security
Disability Insurance Program, 2013. Available at:
http://www.socialsecurity.gov/policy/docs/statcomps/di_asr/2013/ Accessed February
21, 2017.
Adult Acute and Subacute Low Back Pain. Updated November 2012. Available at:
https://www.icsi.org/_asset/bjvqrj/lbp.pdf. Accessed February 17, 2017.
This article provides a healthcare guideline with algorithmic presentation of the
recommended care process for nonspecific LBP, radicular pain, and the identification of
red flags. Full referencing, evidence-based grading, and recommendations are provided.
Health Interview Survey, 2008. Vital Health Stat 10 2009;242:1-157.
US Army: The Operation Enduring Freedom and Operation Iraqi Freedom effect. J Am
Acad Orthop Surg 2012;20(suppl 1):S23-S30.
In this retrospective review of the entire US Army Physical Evaluation database,
medically discharged individuals were identified to determine and compare disabling
conditions. Back pain and osteoarthritis were the two most common causes of medical
discharge during peacetime and war.
Medical Surveillance Monthly Report 2010;17(7):2-7. Available at
https://www.health.mil/Reference-Center/Reports/2010/01/01/Medical-SurveillanceMonthly-Report-Volume-17-Number-7. Accessed February 21, 2017.
(STReC): Are spine injuries sustained in battle truly different? Spine J 2012;12(9):824-
829.
The authors examine the severity and prognosis of battlefield and nonbattlefield spinerelated injuries from October 2001 to December 2009. Results showed comparatively
disparate spine disorders in both populations, with vastly different long-term prognoses.
Arch Dis Child 2005;90(3):312-316.
Occurrence and characteristics. Pain 2002;97(1-2):87-92.
Available at:
https://www.disabilitycanhappen.org/chances_disability/disability_stats.asp. Accessed
April 11, 2017.
Available at:
https://www.disabilitycanhappen.org/research/CDA_LTD_Claims_Survey_2013.pdf.
Accessed April 11, 2017.
complexity are often worse in the United States compared to 10 other countries. Health
Affairs Web First. November 14, 2013. Available at:
https://www.commonwealthfund.org/publications/in-the-literature/2013/nov/accessaffordability-and-insurance. Accessed February 20, 2017.
This article summarizes the results of a 2013 survey of 11 industrialized countries,
including the United States, to determine adult perspectives on healthcare access, costs,
and the utility of the insurance system. Adults in the United States are substantially
more likely to complain about all of these factors as they relate to the current medical
system and are much more likely to endorse sweeping healthcare reform.
surgery under national health reform: An analysis of power, process, adaptation, and
leadership. AOA critical issues. J Bone Joint Surg Am 2014;96(13):e111.
The authors present a general review of evolving healthcare reforms, barriers to
success, and the driving factors that will force modifications to ensure affordability and
appropriate use of available resources.
Rao RD, Smuck M, eds: Orthopaedic Knowledge Update: Spine 4. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2012, pp 169-180.
A comprehensive framework is described for managing patients with chronic pain by
leveraging multiple disciplines in a process of care coordination that is objective and
goal directed. Emphasis is placed on interprofessional communication and cooperation
rather than care prescribed in a stepwise and fragmented manner.
program on work-related musculoskeletal compensation outcomes at a poultry meat
processing plant. J Occup Rehabil 2017;27(1):24-34.
An 18% reduction in claims and an $831 average cost reduction per claim was achieved
by implementing a program of early intervention, triage, reassurance, and onsite
physiotherapy at an Australian poultry plant.
https://www.academia.edu/2917824/Measuring_health_outcomes_the_outcomes_hierarchy
Accessed April 10, 2017.
Establishing value in spine care. Spine (Phila Pa 1976) 2014;39(22 suppl 1):S43-S50.
Determining value in spine care is complex and burdensome. Simplistic equations that
consider a limited dataset related to individual patient outcomes are inadequate when
the effect of medical management considers all stakeholders. Legislative actions that
lead to meaningful and cost-effective reform must factor in the economic, occupational,
and social effects on society.
pain: Clinical comorbidities, treatment patterns, and health care costs in usual care
settings. Spine (Phila Pa 1976) 2012;37(11):E668-E677.
This claim-based review of 101,294 patients with chronic LBP compared levels of
comorbidity, treatment patterns, healthcare utilization, and direct medical cost with
those of a control group. A substantial burden of comorbidity and a relatively higher
rate of healthcare utilization and associated cost was found in the patients with chronic
LBP compared with the control group.
work after sickness absence: A systematic literature review. J Occup Rehabil
2012;22(4):462-477.
This systematic review examined evidence-based interventions that facilitate return to
work after an injury or the onset of symptoms. Early intervention and multidisciplinary
care had a positive effect on return to work.
and Patient Satisfaction. Jacksonville, Florida, University of North Florida,
2013.Thesis.
The effects of leveraging masters-level–educated nurses to offset the effects of higher
patient-to-nurse ratios in a hospital setting are examined. Results showed a positive
effect on readmissions and other indicators; however, patient satisfaction was not
preserved with relatively lower patient-to-nurse ratios.
for low back pain in family practice (IMPaCT Back): A prospective population-based
sequential comparison. Ann Fam Med 2014;12(2):102-111.
This prospective study compared usual medical management with risk-stratified care
using a stratification tool that classified patients based on relative risk for disability. In
the 922 patients reviewed, the risk-stratified cohort had less disability, less time off
work, and lower costs at the 6-month follow-up compared with the patients who
received usual medical management.
stratified primary care management for low back pain: Cost-utility analysis alongside a
prospective, population-based, sequential comparison study. Spine (Phila Pa 1976)
2015;40(6):405-414.
A cost-utility analysis was used to compare usual medical management with stratified
care of patients with LBP. Results showed cost savings and earlier return to work in the
stratified care subgroup. Level of evidence: II.
care with health care quality, utilization, and cost. JAMA 2016;316(8):826-834.
This retrospective cohort study examined patient outcomes, healthcare utilization, and
costs associated with integrated primary care versus the usual care of 113,452 unique
patients over a 3-year period. Results demonstrated higher levels of quality of some
measures and lower rates of care utilization and costs in patients managed with an
integrated primary care process.
low back pain: Can a continuum of care enhance outcomes? Spine J 2014;14(2):263-
273.
This prospective cohort study compared socioeconomic and patient-reported outcomes
in a workers’ compensation patient population. Patients with chronic LBP were divided
into two groups—those who had a lumbar fusion procedure and those who had
nonfusion lumbar surgery prior to admission to a functional restoration program. Both
groups received medically supervised functional restoration. Both groups had similar
return-to-work rates and few differences relative to socioeconomic measures.
pain management program for chronic back pain: A pilot study. J Pain Res 2012;5:209-
216.
This retrospective pilot study reported on 160 patients with chronic LBP who
underwent a program of comprehensive interdisciplinary care. Results showed
significant improvements in pain and self-perceived disability after only 3 weeks of
care.
interdisciplinary functional restoration in occupational injuries. Arch Phys Med Rehabil
2012;93(2):268-274.
The authors report on a prospective study of 1,850 patients with a chronic disabling
occupational musculoskeletal disorder who underwent interdisciplinary functional
restoration treatment. Predictive factors related to posttreatment work retention are
identified.
multidisciplinary care pathway: A value-based comparison with conventional referral
processes. Spine (Phila Pa 1976) 2014;39(22 suppl 1):S129-S135.
This retrospective review of the medical records of patients with LBP examined the
likelihood of surgical recommendation in a cohort managed through a multidisciplinary
care pathway versus a conventional referral process. The clinical differences between
the groups and wait times for diagnostic and surgical considerations also were
reviewed. Results showed that the multidisciplinary pathway delivered a greater
proportion of surgical candidates and reduced wait times for MRI and surgical
assessment. Level of evidence: III.
multidisciplinary care pathway: Effects of nonsurgeon triage including MRI utilization.
J Neurosurg Spine 2014;20(1):87-92.
The authors report on 87 consecutive patients managed through a process of triage to
determine appropriate imaging, surgeon referrals, and cost savings. Results showed
reduced rate of MRI use, less inappropriate surgeon referrals, and lower costs.
rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis.
BMJ 2015;350:h444.
This systematic review and meta-analysis of randomized control trials evaluated the
effects of multidisciplinary biopsychosocial rehabilitation in patients with chronic LBP.
Results showed that this treatment paradigm was more effective than usual care and
other therapies.
with chronic low back pain benefit from early intervention regarding absence from
work? A randomized, controlled, single-center pilot study. Spine (Phila Pa 1976)
2016;41(21):E1257-E1264.
A single-center, randomized controlled trial that examined the effects of an early
intervention for 58 patients with LBP reported that early intervention did not affect
return to work and sick leave at a follow-up of 12 months. The authors advocate for a
larger sample size of at least 382 patients in future studies.
analyses of a multidisciplinary intervention compared with a brief intervention to
facilitate return to work in sick-listed patients with low back pain. Spine (Phila Pa
1976) 2013;38(13):1059-1067.
Multidisciplinary care versus a brief intervention for patients with LBP were compared
in this randomized control trial. Outcome measures included costs, utilization of
healthcare services, and sick leave benefits used. Results showed higher costs in the
multidisciplinary patient group because of greater use of healthcare services by most
patients; however, cost savings were observed in a high-risk subgroup of patients. Level
of evidence: II.
implementation of integrated care pathways in orthopaedics. J Bone Joint Surg Am
2013;95(14):e100-e106.
The authors present a general review of evolving healthcare reforms, barriers to
success, and forces that will encourage modifications to ensure affordability and
appropriate use of available resources. An emphasis is placed on integrated care
pathways as a means of mitigating quality degradation and achieving fiscal stability.
clinical practice guidelines and what do they want from them? A qualitative study.
BMC Health Serv Res 2016;16(1):74.
A survey study of 62 individuals from the general public showed low awareness and
understanding of clinical guidelines. However, participants expressed strong interest in
any process that would afford them a better understanding of treatment options and
potential side effects.
American College of Physicians; American College of Physicians; American Pain
Society Low Back Pain Guidelines Panel: Diagnosis and treatment of low back pain: A
joint clinical practice guideline from the American College of Physicians and the
American Pain Society. Ann Intern Med 2007;147(7):478-491.
ACP and APS guidelines for managing acute and chronic LBP included early testing
and imaging and early treatment with exercise, advice, and the administration of
medications.
management of persistent non-specific low back pain: Summary of NICE guidance.
BMJ 2009;338:b1805.
overview of clinical guidelines for the management of non-specific low back pain in
primary care. Eur Spine J 2010;19(12):2075-2094.
for chronic low back pain management in primary care. Joint Bone Spine
2012;79(2):176-185.
This systematic review of clinical guidelines published between 2002 and 2010
compared and contrasted recommendations related to the treatment of patients with
chronic nonspecific LBP in a primary care setting. Results showed acceptable quality
guidelines with patterns of diagnostic and treatment recommendations distinct from
those related to acute LBP.
Comparative Effectiveness Review No. 169. AHRQ Publication No. 16-EHC004-EF.
Rockville, MD, Agency for Healthcare Research and Quality, 2016. Available at:
https://effectivehealthcare.ahrq.gov/ehc/products/553/2192/back-pain-treatmentexecutive-160922.pdf Accessed February 17, 2017.
This systematic review looked at the evidence for pharmacologic and other nonsurgical
treatments of LBP. It is currently the most up-to-date systematic review.
medical center. Iowa Orthop J 2008;28:98-101.
interdisciplinary team work. Hum Resour Health 2013;11:19.
This integrated report combined the results of a systematic review of the literature
regarding interdisciplinary teamwork and feedback from 253 healthcare providers.
Results of this study produced 10 distinct characteristics that can be attributed to highly
effective interdisciplinary teams.
providers, employers, and health plans to transform care cut costs and improved quality.
Health Aff (Millwood) 2011;30(9):1680-1687.
This article describes the integrated process of care developed and used at VMMC. This
system resulted in enhanced quality as well as a reduction in unnecessary treatments
and costs.
Team approach to adult deformity surgery: A systems-based approach to perioperative
care and subsequent reduction in perioperative complication rates. Spine Deform
2014;2(2):95-103.
This retrospective review reports on complication rates associated with adult spine
deformity surgery in two groups of patients. One group received care via an
interdisciplinary process, dual-attending surgeons, and an intraoperative protocol. The
other group was managed in a traditional manner with the systematic approach just
described. Complication rates were substantially lower in the systematically managed
group.
clinical practice for outcomes improvement: From vision to reality—the Spine Center at
Dartmouth-Hitchcock, year one. Qual Manag Health Care 2000;8(2):1-20.
exploratory cluster analysis approach for early detection of unfavorable recovery.
Disabil Rehabil 2016;19:1-7.
In a cohort of 158 patients with acute LBP followed for 1 year, one-third of the patients
did not fully recover. High pain intensity and high disability, particularly when there
was minimal pain reduction in the first week tended to predict a poor outcome.
Ambassador Program: The development of a contextually relevant, multidisciplinary
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