The North of England Back Pain and Radicular Pain Pathway

Transcription

1 The North of England Back Pain and Radicular Pain Pathway First Site Implementation Charles Greenough 15 th September 2015

2 Costs In CG88 NICE estimated that the cost of Back Pain to the NHS in 2008 was 2.1 billion

3 Years Lived with Disability %

4 Low Back Pain Never in the field of human healthcare has so much been spent by so many for such disastrous results

5 Secondary Care Activity Secondary care for patients with back and/or radicular pain Includes all activity for adults 16+ Private providers are included Includes mix of NHS-funded and private-funded care Overview of activity by CCG and Trust National comparisons with North East & North Cumbria CCGs and Providers highlighted GP Practice level data for emergency v. elective admissions Activity and costs (national tariff) are shown

6 Number of Admissions per 100,000 Number of Admissions per 100,000 Elective v. Emergency Admissions by CCG 1,400 1,200 Number of Admissions per 100,000 Population 01/04/ /03/2015 Elective Admissions only North East CCGs South Tees CCG National Average North East CCGs Average 1, CCGs Number of Admissions per 100,000 Population 01/04/ /03/2015 Emergency Admissions only North East CCGs South Tees CCG National Average North East CCGs Average CCGs

7 GP Practice Variation Emergency Admissions

8 GP Practice Variation Elective Admissions

9 Injection Types by Trust North East & North Cumbria

10 Surgery Types by Trust North East & North Cumbria

11 GETTING IT RIGHT FIRST TIME Improving the Quality of Orthopaedic Care within the National Health Service in England Selected Spinal Procedures Cumbria and NE England FCEs per 100,000 population Provider Primary lumbar discectomy Primary lumbar fusion Back pain Radicular pain Discectomy Total Back pain Radicular pain Fusion Total City Hospitals Sunderland (FT) Gateshead Health (FT) Newcastle on Tyne Hospitals (FT) Northumbria Healthcare (FT) S Tees Hospitals (FT) Univ Hosp of Morecambe Bay (FT) N Tees and Hartlepool (FT) Average

12 Back Pain - Diagnosis Specific diagnosis was associated with a FIVE FOLD increased risk of chronicity

13 Diagnosis Labelling Shifts goal from recovery to cure Degenerative changes work related Specific investigations delay treatment Patient expectations hard to change Abenhaim et al 1995

14 MRI

15 You ve got a BLACK DISC!

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17 Imaging The British Pain Society Noted difficulties with communication and interpretation of MRI scans that resulted in patients being made unnecessarily anxious and frightened. Believe that poorly managed increased access to MRI scans might lead to an increased demand on secondary services Price and Hester

18 Consensus on Low Back Pain NICE CG 88 Low back pain May 2009 European Guidelines June 14th 2005 Cochrane Reviews Clinical Practice Guideline American Pain Society 2009 UK Spinal Taskforce February 2013

19 The North of England Regional Back Pain and Radicular Pain Pathway

20 What is the Pathway for? Identify Serious Pathology Red Flags Fast Track Treatable Pathology e.g. Prolapsed Disc Provide Effective and Expeditious Treatment of Low Back Pain

21 Introduction The Northern CCG Forum agreed to test a potential framework for wider pathway development, with the support of the Clinical Networks and benefits of regional Commissioning Support Service.

22 Introduction The network held a back pain scoping event on 21 st March 2013 at Newcastle Racecourse, which was attended by approximately GPs, physios, pain management specialists, orthopaedic surgeons and neurosurgeons.

23 Aims and Objectives of the Pathway The Pathway will have a benefit to patients, carers and health professionals by providing improved quality of care, safety, choice, access, service user experience

24 Key features of the pathway In scope - Simple mechanical low back pain and acute radiculopathy Out of scope - chronic back pain management interventions and non- mechanical back pain. Preventative public health programme an important element of back pain strategy and normalisation of simple mechanical back pain

25 Key features of the pathway Re-training of health professionals to demedicalise simple back pain Agreed standardisation of patient literature. Use of Keele University STarT Back screening tool to stratify risk and determine management, fast-tracking individuals most likely to become chronic. Treatment should be prioritised to moderate/severe group.

26 Key features of the pathway As up to 80 % of simple mechanical back pain episodes resolve in 6 weeks, defer simple therapies to after 6 weeks. Assessment by a specialist spinal Triage and Treat Practitioner to identify red flags, identify radicular pain and mange patients on CBT principles. The pathway will be managed in primary care by this practitioner.

27 Key features of the pathway Offer one (occasionally more) of three approved core therapies (Manual therapy, group exercise therapy, acupuncture). Review by the T&T practitioner who will maintain overall direction of the management plan. Offering a Combined Physical and Psychological Programme (CPPP, 100 hours over 3-8 week period) to those patients failing to improve sufficiently.

28 Key features of the pathway No direct referral to a spinal surgeon for chronic mechanical back pain without passage through a CPPP. For acute radiculopathy, improve management and rapidity of access to epidural injection or nerve root block as an option for conservative management of and rapid access to a spinal surgeon if surgery required.

29 Key features of the pathway No x-rays of backs by GPs or other professionals and no direct access to MRIs by GPs unless red flags present. Urgent assessment by Spinal Triage and Treat practitioner should be 1 st line. Agree intended outcomes and KPIs on the various elements of the pathway including patient feedback.

30 Pathway Benefits Triage and treat practitioners will provide safe, consistent advice to the patient, and provide continuity of care throughout the pathway. A single point of contact for the patient, providing an improved patient experience by replacing the current pinball management pathway.

31 Pathway Benefits It will eliminate the delays between therapies, reducing the development of chronicity. The use of Keele University STarT Back will stratify risk and fast-track individuals in the moderate/severe group most likely to become chronic. Clinics will be closer to home in easily accessible locations throughout the community.

32 Pathway Benefits Offering a service that is attractive and convenient for all patients Continuity of care is not only what patients' want and value but that it is also the most efficient way of delivering care. Engaging with hard to reach groups through Clinic Settings within the regions, listening to what they have to say and developing services to meet their needs.

33 Patient Benefits Access to highly specialised advice and treatment Expert knowledge and skills in the management of Back Pain and Radicular Pain A range of evidenced based core therapies tailored to individual needs

34 Patient Benefits A smooth transition between primary and secondary care interface ensuring timely intervention / referrals and rapid access to emergency diagnostics or treatment

35 Health Economy Benefits Eliminate ineffective but costly investigations and therapies which are still widely offered, with cost savings Reduction in referral for fusion surgery by mandating participation in a Combined Physical and Physiological Programme prior to surgical consultation

36 The North of England Regional Back Pain and Radicular Pain Pathway Ver Feb Community Education Arrival at Services Consultation Therapy Information/Decision Discharge First Presentation Rheumatology Start Back - Low risk of Low Back Pain /52 Initial Review Suspected Red Flag Appointment Suspected Radiculopathy 16 Cauda Equina Start Back Med/High 9 risk 8 Discharge Self Management Local Pathway/ECU 28 T&T 6/52 Review Appointment 13 Radiculopathy - Non Concordant Imaging 19 Confirmed Red Flag 17 Radiculopathy - Core Therapies Concordant Imaging Specialist Secondary Care 29 Staged RTW/OCC 25 Health Unsuitable for CPPP 23 Pain Services 24 Further Rx 6/52 max 15 T&T 12/52 Review Appointment 21 High Intensity CPPP 22 T&T 4th review 27 Surgical Opinion 31 Nerve Root Block 30 Discharge Self Management Operation

37 The North of England Regional Back Pain and Radicular Pain Pathway GP Pathway Ver Feb Community Education Arrival at Services Consultation Therapy Information/Decision Discharge 10 Rheumatology First Presentation of Start Back - Low risk Low Back Pain 3 7 GP 2/52 Initial Review Suspected Red Flag Appointment GP Cauda Equina Start Back Med/High 9 risk 16 Suspected Radiculopathy 8 Discharge Self Management Local Pathway/ECU T&T 6/52 Review Appointment

38 The North of England Regional Back Pain and Radicular Pain Pathway Triage and Treat Practitioner Ver Feb 2015 Radiculopathy - Non T&T 6/52 Review Concordant Imaging Appointment Confirmed Red Flag 17 Radiculopathy - Core Therapies Concordant Imaging Specialist Secondary Care 29 Further Rx 6/52 max Nerve Root Block Staged RTW/OCC 25 Health T&T 12/52 Review Appointment Discharge Self Management Unsuitable for CPPP 23 High Intensity CPPP Pain Services 27 T&T 4th review Surgical Opinion Operation

39 Triage and Treat Practitioner They will normally have a specialist nurse or extended scope physiotherapist background.

40 Triage and Treat Practitioner The individual with this functionality will be highly trained, with complex skills History and examination Diagnostic triage (red flags, Radicular pain, Mechanical back pain, Inflammatory disorders etc) Psychosocial assessment Assessment of medication

41 Combined Physical and Psychological Program (CPP) (Functional Restoration) A major service gap at present (NICE, Taskforce Review) Located in community centres Evidence based Proven Effectiveness Referral from Triage and Treat Practitioner

42 CPPP or Functional Restoration Variable content in research papers. Typically - Intensive full time over 2/3 weeks Group Setting Self Reliance, Coping Strategies, Problem Solving Aerobic Training, Gym, Pool Some occupational training, lifting, pulling CBT, counselling, pain management skills

43 Commencement Timeline - South Tees 20 th July 2015 PATHWAY COMMENCED

44 Commencement Timeline - South Tees 20 th July to 3 rd August 2015 Transitional period for the Spinal Assessment Clinics to move to Triage and Treat Practitioner Service

45 Commencement Timeline - South Tees 3 rd August 2015 Triage and Treat Practitioners commenced Clinics at James Cook University Hospital Clinics appointments available on Choose and Book under BACK PAIN SERVICES

46 Commencement Timeline - South Tees 17 th August 2015 Triage and Treat Practitioners commenced Clinics within the community East Cleveland Community Hospital North Ormesby Redcar Community Hospital James Cook University Hospital

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52 Acknowledgements Liz Lingard, Deputy Director, NEQOS Andrea Brown, Epidemiological Analyst, NEQOS Valerie Corris, Senior Analyst, NEQOS Adam Fearing, Analyst, NEQOS

53 THANK YOU

54 Discussion