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Low Back Injury - Expert Panel Summary

AUGUST 30, 2001 - 1:00 - 3:00 pm

Location: West Virginia Health Care Authority, Charleston West Virginia

Present: Marsha Bailey, M.D., James Becker, M.D., Derrick Billups, Cathy Chadwell, Cindy Dellinger, Ed Doyle, M.D., Alan Ducatman, M.D., Mary Emmett, PhD, John Grey, Sallie Hunt, Sandra Joseph, M.D., Art Lilly, Linda Sovine, and Scott Spradlin, M.D.

Unable to Attend: Joyce Bachman, M.D., John Brehm, M.D., Lou Holloway, Todd Hudnall, and Roland Parsley.

The meeting was opened by Sallie Hunt from the WV Health Care Authority who welcomed participants and introduced Mary Emmett from the Center for Health Services and Outcomes Research at Camcare Health Education and Research Institute. Dr. Emmett described the objective for this work group as identifying and developing population-based indicators for work related low back injury. The indicators should be sensitive to changes in either health status or quality of life. Additionally, measurement may effect changes such as reduced workers compensation costs or have implications for policy or practice. Samples of outcome and process measures noted in the literature provided discussion points. Multiple themes emerged in discussion including areas such as treatment (diagnosis, documentation, & interventions), education, care access and coordination, and patient factors, all reflecting the complexity of the topic. A summary of discussion points by topic area follows.

Treatment (diagnosis, documentation & interventions)
Lack of standardized algorithm for treatment that crosses settings, providers and payers.
Impact of medical/legal issues on decision-making.
Difficulty in establishing appropriateness of imaging use across providers.
Importance of physical exam in initial evaluation and good documentation of findings.
Importance of detailed/documented patient history in understanding individual patient behaviors/response.
Importance of early return to function and use of appropriate type of Physical Therapy.
Difficulty in determining use of alternative treatment options such as acupuncture, chiropractic or massage treatments.
Need exists for a standard scale that supports practitioner decision making and increases their comfort level in dealing with low back pain patients.
Reimbursement difficulties present when a very precise, incorrect initial diagnosis is made.
Patient and families need education on importance of early return to work and maintaining physical activities (avoid bed rest).
Employers need education on the importance of early return to work (new state initiative may support this).
Employers need education to consider modified work options.
Employers and employees benefit from workplace back prevention education programs.
An educational tool targeting family and general practitioners would be valuable.
Patients need education on use of an emergency room versus a primary care provider regarding back injury.
Care Access and Coordination
ยท Importance of early evaluation and return to work to prevent long term pattern of disability.
Waiting for initial appointment (4-5 days or more) results in lost work time before being seen.
Repeat injury may be followed by a different provider and result in repeated tests/ costs.
Need to establish some long-term follow-up to determine impact of initial treatment and avoid repetition.
Patients with ongoing complaints of pain need care coordination - often may be referred to multiple specialists including neurosurgery, pain management, physiatrics and so on.
Patient Factors
Determining quality of life is an important factor and may be obtained from a variety of instruments such as the SF36, SF12.
Instrument should be appropriate to the functional level of the patient.
One approach to collecting quality of life data would be to target a stratified sample of providers. Form could be provided to patients who are going to be returning for another appointment. Patient could complete form at home between appointments.
Patient frame of reference regarding work and health is very important in their response (e.g., beliefs regarding work attendance, illness and use of medical services).
Disconnection from work causes employee to face greater challenge in return (longer time off = more difficult to return). Need to encourage employer to stay in contact with employee and keep them connected.
Health care providers and disconnection from work may unintentionally transition patient into "sick role".

In advance of discussing specific indicators, it was suggested that consideration be given to the type and availability of data. Using the indicators listed below that were obtained through the literature search process ( also found in SEARCH SUMMARY) as examples, data availability through the Worker's Compensation database was explored.

Four indicators presented in materials from the Institute for Healthcare Improvement (IHI) Breakthrough series:

1) For all patients under age 50 with a new visit for low back pain (no low back pain visits in past year), what fraction received a plain x-ray within 1 month of the visit?
2) For all patients with a new visit for low back pain, what fraction had a CT or MR scan within 1 month of the visit?
3) For all patients with a new visit for low back pain, what fraction had a surgical procedure within 6 weeks of the visit?
4) For all patients with a new visit for low back pain, what fraction had a visit for physical therapy within 1 month of the visit?
Other general process and outcome measures were frequently described in the literature. Outcomes of interest include:
1) Calendar time to first return to work (length of disability- LOD);
2) Cumulative time on temporary disability;
3) Point prevalence studies of work status post injury;
4) Costs (medical, lost work etc.); and
5) Recovery measures (changes in symptoms, impairment, functional status, ADL).
Processes of interest include:
1) Use of imaging (x-ray, CT, MRI);
2) Specialty referrals;
3) Medication prescriptions (extended use of opioids, NSAIDs, muscle relaxants);
4) Physical Therapy (bed rest); and
5) Surgery.
Some general considerations in using data were discussed including:
1) Data alone does not equal information or yield quality judgments;
2) Need to analyze and compare results against outside reference point;
3) Retrospective data can be used to make some determinations about data and care problems; and
4) Permission must be obtained from appropriate authority to access the Bureau of Employment Programs and Worker's Compensation (WC) databases.
Some specific issues related to data needed for calculating listed low back injury indicators include:
1) "First return to work" is a data element that has multiple and varied definitions (an alternative approach would be access the Bureau of Employment database and obtain work status post injury on a sample of patients - could also provide information about wages pre and post injury);
2) Worker's Compensation system promotes use of the most general diagnostic code and the system does not update codes;
3) How will one episode of low back injury be defined versus a recurrence?;
4) Will not be able to capture "bed rest" as a data element in WC data;
5) There is no identification system (i.e., universal pin number) that captures specialty of physician for determining specialty referrals; and
6) Data regarding medication use may be more difficult to obtain since it is collected by an outside agency.

In general, the data is available to calculate most of the remaining indicators if they were selected for use. It was also noted that the available data can be used to determine guideline adherence and can be further explored for cost and other specifics such as site of initial visit. The possibility of accessing both WC and employment databases presents opportunities that may be of interest to a wide audience, including the Federal government. These data appear to support the development of indicators that would capture patterns of good and poor quality care.

Next Steps:
1) Permission to access the Worker's Compensation and Bureau of Employment databases will be pursued by project staff;
2) Guidelines from the West Virginia Worker's Compensation Division addressing HERNIATED LUMBAR DISK , Physical Medicine and Chiropractic Care will be obtained and distributed to all panel members along with the guidelines from the American Physical Therapy Association;
3) An initial analysis (pending approval) of the data will be designed to obtain a baseline picture of the status of occupational low back injury care in West Virginia and to help define the pertinent indicators for ongoing quality assessment; and
4) A second meeting of the panel will be convened upon completion of the analysis and is targeted for late fall 2001.

Meeting was adjourned at 3:00 p.m.