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Better Ways to Treat Back Pain

THE INFORMED PATIENT

By LAURA LANDRO

 

Insurers, Employers Target

Excessive Scans and Surgeries

To Improve Patient Outcomes

Wall Street Journal

May 16, 2007
 
After recovering from injuries suffered in an all-terrain-vehicle accident a few years ago, 57-year-old Tony Georges, manager of a wetland conservation bank in Marin County, Calif., had persistent back pain that started to worsen last December and was only temporarily relieved by stretching, yoga, physical therapy and painkillers.
 
Diagnosed with lumbar arthritis aggravated by injury, Mr. Georges might be
considered a prime candidate for lumbar fusion, in which a surgeon fuses vertebrae on the spine together with a bone graft and, sometimes, metal screws. Wary of the surgery, which can take up to a year to fully heal, he was relieved when Brian Andrews, chairman of the neurosurgery department at Sutter Health's California Pacific Medical Center, recommended a more conservative course: continued strengthening and flexibility exercises, a consultation with a pain expert and, if needed, a pain-relieving injection that combines local anesthetic and steroids.

Dr. Andrews and several colleagues at California Pacific are among a number of physicians around the country participating in an ambitious program to improve care for 30 million Americans suffering from back pain. That number is expected to grow as aging baby boomers who lead active lifestyles face the limitations of age and degenerative diseases like osteoarthritis. Back pain sends more patients to physicians than any ailment except for the common cold and accounts for a quarter of all workers' compensation claims. It costs the health-care system more than $90 billion annually -- much of that for X-rays, CT scans, injections and surgeries that studies show are often premature or unnecessary.

The new Back Pain Recognition Program aims to reduce the number of superfluous tests and procedures and increase the adoption of treatments that are proven to work. The program is sponsored by the National Committee for Quality Assurance, an organization that monitors health-care quality and accredits health plans. Doctors and chiropractors will apply to the program and those who adhere to its treatment guidelines will be listed in the NCQA's searchable online directory and cited on consumer Web sites and provider directories offered by health plans to their members.
 
Studies show that as many as four in 10 imaging studies associated with lower-back pain are unnecessary, and as many as two in three epidural steroid injections are avoidable. While the rates of back surgery vary greatly across the country, the NCQA says patients often undergo aggressive treatments when less-costly and less-complicated therapy may yield similar or better results.

" 'Do no harm' is a bedrock principle of medicine, but needless tests and procedures that provide no real benefit to the patient can't do anything but harm," says NCQA President Margaret E. O'Kane.

For many patients, the most effective treatment for back pain is much less invasive. Studies show that most acute back pain usually is resolved in four to six weeks with pain management, minimal bed rest and a return to physical activity. Prolonged bed rest and limiting physical activity, which some doctors prescribe, is often not helpful and can even lead to harm, such as bed sores.

Bridges to Excellence, a group of large corporations, including General Electric Co., Procter & Gamble Co. and Ford Motor Co., will use the NCQA quality measures for its own Spine Care Link program for MDs and osteopaths; top performers in the program can earn as much as $50 a year for each patient covered by a participating employer, and will be listed on the HealthGrades Physician Quality Ratings Web site for consumers (healthgrades.com). "Overtreatment of back pain often leads to expensive and sometimes dangerous care that leaves them in worse health," says François de Brantes, coordinator of the Bridges to Excellence program.

There are currently more than 115 "early adopters" participating in the NCQA program which is open to physicians and chiropractors, who must pay fees of about $500 for the application and data-collection program the NCQA will use to assess performance.

The back-pain program is modeled on earlier recognition programs to improve care of diabetes and heart-disease patients, which employers and health plans use to pay doctors a per-patient bonus for adherence to guidelines for care -- such as making sure diabetics get regular eye exams. The NCQA is accepting applications for the back-pain program and hopes it will reach the scale of its other recognition programs, which have more than 5,500 doctors nationwide.

Large health plans including Aetna Inc. and Cigna Corp. are also participating in the program, and will steer health-plan members to doctors who win recognition from the NCQA. According to an analysis by consulting firm Towers Perrin, health plans could reduce costs by $205 per back-pain patient per year by reducing inappropriate epidural use, X-rays and CT scans, and surgical complications. Consumers will get incentives as well: Dick Salmon, senior national medical director of Cigna HealthCare, says members of its Cigna Care Network will receive a modest reduction in their co-payments for choosing NCQA-recognized doctors.

The program also seeks to ensure that patients whose back pain is a sign of something more serious or who do undergo surgery get appropriate care and are followed after surgery for complications such as infection that often lead to new problems and a diminished quality of life. There are number of widely recognized red flags that can signify that the back pain is a symptom of a more serious disorder. Those red flags include a previous cancer diagnosis, numbness or weakness in a limb, loss of bladder or bowel control, or neurological symptoms. Also, nerve roots can be compressed and paralyzed by a ruptured disk, tumor, infection, fracture or narrowing of the spinal canal, which may require emergency surgery.

"If we are going to be good spine-care providers, we have to hold each other accountable for adequate, reasonable care, without being too restrictive but without being so wide open that we waste time and effort," says Charles Branch, chairman of the neurosurgery department at Wake Forest Baptist Medical Center, who served on the advisory committee to set the standards for the program.

The NCQA will rate doctors on whether they advised patients to maintain normal activities and avoid more than four days of bed rest, and will measure the percentage of patients with back pain who received an epidural steroid injection without radiating pain. Evidence shows such injections are most effective for the treatment of pain that radiates along nerves caused by more serious conditions such as a herniated disk.

Doctors are already steering patients away from surgeries like lumbar fusion more often. "A lot of patients are worse off for having had these surgeries," says Dr. Andrews of California Pacific. "There is a movement towards less invasive, motion-sparing procedures" such as microdiscectomy, which uses a small incision to remove bone and disc material, relieving pressure on the nerve root and speeding healing from a herniated disc.

That's the procedure Dr. Andrews recommended for another patient, Dominic Swinn, a 37-year-old sales and marketing director of an online balloting site. In his case, a herniated disc was pushing against a nerve that made his leg and foot numb, prevented him from picking up his daughter and forced him to work on his laptop lying down. While the procedure required an overnight stay, "compared to normal surgery where they cut you open and you stay in the hospital for days, it was a lot less intrusive," Mr. Swinn says.

Participants in the program say one of its advantages is requiring doctors to document every step of patient care, including whether they performed a mental-health assessment, counseled smokers on quitting, educated patients about their options and provided follow-up care after surgery. Studies show that patients with back pain often are depressed or have other psychological barriers to treatment, and that cigarette smoking may increase the risk of lower-back pain.

The program may also help insulate doctors from patient demands for unnecessary drugs and tests, and from malpractice claims. "Doctors face patient pressure and the fear of litigation to go quickly to imaging and move patients to specialists," says Thomas Knight, vice president of quality at California Pacific Medical Center. "Once you get on that train, it is hard to get off."