The Program for Spine Health: A Novel, Evidence-Based Interdisciplinary Clinic

Session Description: Back pain, neck pain, and radicular pain are common problems that contribute to widespread suffering, disability, and variably appropriate medical care. The dominant paradigms of American spine care, focused on reducing pain, often fall short, especially for patients who have a high degree of biomechanical and/or psychosocial complexity. Physiatrists are uniquely trained to appreciate the complexity of these problems and to facilitate patients' recovery as the leaders of an interdisciplinary, rehabilitation-oriented team. The Program for Spine Health at the University of Pittsburgh Medical Center was designed to help patients, as an alternative to fragmented, low-value care. Working closely with dedicated nurse coordinators, physical therapists, a pain psychologist, a dietician, and a health coach, our physiatrists rigorously seek to understand each patient's challenges and to help them toward a better quality of life, with a focus on promoting each patient's self-efficacy and capabilities. It is a great practice environment, and our patients often get much better.

In this panel discussion, Dr. Christopher Standaert and colleagues will describe how and why the Program for Spine Health was created in collaboration with multiple departments and administrators at UPMC, how to build and lead an interdisciplinary team around a shared vision of providing better patient care, how to train early-career physiatrists to practice in such a model, and how innovative programs of this sort might be created elsewhere. We will consider the opportunities and challenges inherent in providing outpatient spine care through a population health model, analyses of our program's clinical and economic impact, comparisons to other physiatry-led spine/musculoskeletal clinics, parallels with lifestyle medicine, and other lessons learned from the program's first four years. Sharing real-world cases, we will illustrate how the Program for Spine Health functions in practice. Questions and comments from the audience are welcome and encouraged.

Why is this session needed? : Patients with chronic painful spine problems need and deserve better care than they generally receive. Physiatrists need better ways to demonstrate our value. Physiatrists also need practice models in which we can thrive while using our training to its fullest extent to meaningfully benefit patients' lives. Physical therapists need physician teammates who can collaborate with them to help patients who have already tried and "failed" PT. Primary care physicians and surgeons both need a place to send patients whom they aren't sure they can help themselves. Health care plans, for better or worse, are determined to change care patterns in a way that reduces the prevalence of low-value, high-cost interventional care. The Program for Spine Health is designed to address these needs. This descriptive, interactive session is intended to facilitate insight and foster discussion about the best ways for physiatrists to take care of people with complex, painful problems of the spine.

Physiatrists are the experts in the diagnosis and management of disabling conditions, such as spinal cord injury, traumatic brain injury, and amputation, as well as chronic spine/musculoskeletal pain. A commonality among all of these conditions is that some degree of biological recovery is possible, and healing can often be facilitated with modern medical practice, but any sort of true "fix" is rare. Our job as physiatrists is to teach people expertly about their diagnosis and prognosis, to promote patient self-efficacy by giving them the skills to address the barriers that are limiting them, to identify salient and achievable goals, and to help them prevent and manage complications that might arise.

The best available evidence suggests that, for patients in chronic pain, the best treatment paradigm is one that addresses fear of movement, restores the sense of control that pain often takes away, and cultivates a habit of exercise. These goals are difficult to accomplish as a lone physician placing a series of disparate referrals, but often achievable for a highly motivated and closely knit team of specialists. Our team includes nurse coordinators, physical therapists who have undergone postgraduate training to specialize in spine care, a pain psychologist, a dietician, and a health coach. Because patients in chronic pain often have complex medical and personal histories, it is necessary that all of our team members have enough bandwidth to build an accurate diagnostic impression and to treat each individual patient with empathetic, dignified attention. Thus our visit times need to be relatively long, and our nurse-patient ratios need to be high. We refer for axial injections if those seem to be the best option for a specific patient, but in practice we have found that we place such referrals rarely. Referrals to surgical colleagues are also rare.

The biggest drawback of the clinical model described above is that, in a fee-for-service world, it is a money loser. Long visit times, with a low rate of converting patients to surgeries or other procedures, without a large direct impact on system-wide metrics-of-interest such as mortality or readmission rates, would be infeasible in private practice and would be a non-starter for most healthcare systems. We have been able to build such a system at the University of Pittsburgh Medical Center because, like Kaiser Permanente or the VA, it is an Integrated Delivery and Financing System (IDFS): a hospital network partnered with an insurance plan. If our physiatry-led team can help patients in chronic pain to get better, than fewer of those patients will seek spine surgery or other high-cost, low-value forms of care, and the insurance plan will win at the same time our patients do.

We have three main clinical locations in small communities outlying the city of Pittsburgh (Cranberry, PA; Bethel Park, PA; Allison Park, PA). Most of our referrals come either from primary care physicians or spine surgeons; both the PCPs and surgeons seem to see us as a useful place for their patients who have a high degree of medical and/or psychosocial complexity, and who seem unlikely to do well with "usual care." Upon referral into our program, a patient receives a call from one of our nurse coordinators, who explains the program, conducts a triage protocol to screen for red flags, and schedules them either with one of our physical therapists or one of our physiatrists. Roughly 30% of our patients are seen only by physical therapy. However, if the patient starts with PT and is not making progress or if they are more medically complex than anticipated, they are readily referred to the physiatrist for a near-term medical appointment. For the patients who see the physiatrist, the initial appointment is an hour, during which time the physiatrist reviews available medical records, conducts a thorough history and physical exam, and plans next steps. Often we order more diagnostic tests, and often we refer to physical therapy. For roughly one quarter of our patients, we refer to one or more other members of our interdisciplinary program: Charlotte Brown, our pain psychologist; Emily Stasko, our dietician; or Jeff Boyer, our health coach. Our team has weekly meetings to discuss new and difficult cases; during these meetings we benefit not only from coordinating care with the team members who are involved with a specific patient, but also from "curbsiding" our pain psychologist or other team members who might not otherwise be directly involved in the patient's care.

Referrals and scheduling within the program are always facilitated by one of our program's dedicated nurse coordinators or medical assistants, which ensures good patient experience and consistent messaging to reinforce the goals of better health, quality of life, and autonomy rather than pain relief. If needed we will refer outside our program for other specific specialist care: e.g., to neurology if the patient seems to have a movement disorder, to orthopedic surgery if the patient's problem is actually end-stage hip osteoarthritis, or to an interventional colleague for an acute disc herniation without progressive neurologic decline.

Within our program, because we are attempting to improve overall health and quality of life rather than pain severity per se, our main metric is change over time in patient responses to the Patient Reported Outcomes Measurement Information System (PROMIS)-16 questionnaire, which consists of two Likert-style responses in each of eight domains: depression, anxiety, pain interference, fatigue, sleep, cognitive function, social function, and physical function. Patients complete the PROMIS-16 questionnaire at their initial visit in our program, and the survey "fires" again as part of their rooming process at each subsequent clinic visit when 30 or more days have elapsed since the last time they filled out the survey. In an internal analysis, among the approximately 50% of our patients for whom we have follow-up PROMIS-16 scores, when analyzing an aggregate of the PROMIS-16 domains called PROPr, the minimal clinically important difference (MCID) was met by 55% within 90 days, and substantial clinical benefit (defined here as double the MCID) was met by 39% of the patients.

As an alternative way of assessing our program, the UPMC Health Plan has conducted a retrospective review of a subset our patients (n=157) relative to other UPMC Health Plan members (n=477), matched for age, race, sex, insurance, Charleston Comorbidity Index, mental health diagnoses, total cost of care in the preceding six months, and low-back pain diagnosis. In this analysis, total cost of care did not significantly differ between groups. Opiate utilization decreased 23% in the Program for Spine Health cohort relative to a decrease of 5% in the comparator group. Notably, the 12-month incidence of new spine surgery was 2.8% in the Program for Spine Health cohort relative to 12% in the comparator group (p=0.16).

This program seems to work, and it seems to work because it was purposefully designed. If patients have a complex medical history, a complex social history, an unclear diagnosis, and/or past experiences of feeling underappreciated by their clinicians, perhaps they need long visits with a clinician who is subspecialized trained in the diagnosis and advanced management of difficult spine problems -- training that incorporates pathophysiologic knowledge, radiologic interpretation, diagnostic rigor, and a nuanced appreciation of human nature. If they have "failed" one-size-fits-all PT, perhaps they need a better physical-therapy plan that is informed by a better diagnostic impression and shaped around their own specific goals and challenges. If the barriers to their rehabilitation include depression, anxiety, fear-based avoidance, catastrophization, lack of body awareness, or difficulty with pacing, perhaps they need a pain psychologist. If they want to lose adipose tissue, gain lean muscle mass, or learn more about an anti-inflammatory diet, and if making small sustainable changes to their eating habits might increase their sense of self-efficacy and control over their own lives, perhaps they need a dietician. If they know what they "need to do" but struggle with habit change and accountability, perhaps they need a health coach. And, whatever their specific background or challenges, everyone seems to appreciate having their care directed by a knowledgeable, empathetic, and professional nurse coordinator.

This structure will include an overview of our program along the lines of the above, including a specific discussion of the uniquely valuable role of our pain psychologist, Dr. Brown. We will discuss real patient cases to illustrate how the program works in practice, and we will field questions and comments from the audience.

Our speakers will be:
Christopher Standaert, MD, Associate Professor at the University of Pittsburgh, Medical Director of Spine Health at UPMC, and fellowship director for UPMC's novel Value-Based Fellowship in Spine and Musculoskeletal Medicine
Karen Barr, MD, Associate Professor at the University of Pittsburgh and Attending Physician within the UPMC Program for Spine Health
James Eubanks, Jr., MD, DC, MS, Clinical Instructor at the University of Pittsburgh and 2022-2023 Value-Based Fellow in Spine and Musculoskeletal Medicine
Joseph Shivers, MD, Assistant Professor at the University of Pittsburgh and Attending Physician within the UPMC Program for Spine Health
Charlotte Brown*, PhD, Associate Professor of Psychiatry and Health and Community Systems at the University of Pittsburgh, and Pain Psychologist within the UPMC Program for Spine Health

*Dr Brown will be a guest speaker whose participation is contingent on the availability of conference-registration / travel / lodging fees.

We are grateful for your consideration and are open to modifying the design of this presentation in order to best serve the needs of AAPM&R attendees.

Was this session previously presented at the Annual Assembly?: No