Dr Ventura has over 30 years of clinical practice experience & now serves on the Center for Medicare/Medicaid Services technical expert panel, on the board of the United States Bone and Joint Initiative and is on the musculoskeletal committee of the National Quality Forum. Read more
In our last post we discussed a recent review that outlines how doctors are now more likely to recommend non-pharmacological treatment for most forms of back pain. We look at recent changes to guidelines that dictate this new approach.
The American College of Physicians recently (2017) published their clinical practice guideline for non-invasive treatments of acute, sub-acute and chronic lower back pain. The guideline discussed the evidence base and the strength of each of their recommendations. Their conclusions led them to 3 general recommendations:
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).
Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).
This certainly represents a step in the right direction as we all work together towards developing new models of care
Image: Credit- American College of Physicians
This article was originally published in the Spine Journal: Spine J. 2016 Jul;16(7):801-4
BACKGROUND CONTEXT: Back and neck problems are among the most common medical symptoms in the general US population, they generate substantial direct and indirect costs, and there is substantial variation in care provided to treat such conditions.
PURPOSE: To brainstorm methods to improve the value of healthcare services provided to patients with spine-related disorders.
SETTING: The 2015 North American Spine Society Annual Meeting in Chicago where a group of providers, insurers, employers, advocates, and researchers convened to discuss ways to improve the value of healthcare services provided to patients with spine-related disorders.
METHODS: Guided by the Institute of Medicine’s six aims of care (safe, effective, patient-centered, timely, efficient, and equitable care), the group surfaced several evidence-based opportunities for improving value.
RESULTS: The opportunities centered on four themes: the need to develop commonly-defined groupings of spine pain patients to ensure fair comparisons of healthcare value; ways to address current misuse of care providers through improved protocols; the need to avoid patient harms including unnecessary risk exposure, disability labeling, and overuse of opioid drug prescriptions; and the need to establish and use, on a broad scale, methods to learn from actual patient care experiences.
CONCLUSIONS: These themes lend themselves to several obvious long-term interventions – identification and establishment of better-specified treatment guidelines targeting specific groups of patients, integration of primary spine care providers who do not prescribe addictive medications as a first-line treatment, and the establishment of registries. The convergence of accelerating and divergent resource consumption for its treatment, widespread use of new delivery and payment methods designed to improve outcomes and curtail the rise in healthcare costs, and availability of technologies that can facilitate data collection, analysis, and learning provide a rich opportunity to improve the value of healthcare delivery for spine pain.
This is an open-access recording of our first webinar, which reviews the problem of spine and the future of spine care in a value-based, evidence-based healthcare environment. We review the role of the Primary Spine Provider in the future world of spine.
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John M Ventura, DC, DABCO
American Chiropractic Association, committee on quality assurance and accountability
National Quality Forum, musculoskeletal committee
United States Bone and Joint Initiative, board member representing ACA
Center for Medicare/Medicaid Services, technical expert panel
The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine
(ABIM) Foundation, “seeks to advance a national dialogue on wasteful or unnecessary
tests.” This initiative is in partnership with Consumer Reports, one of the premier
purveyors of public education in our country.
Both Choosing Wisely and Consumer Reports utilize best available evidence in formulating their recommendations. Even long held beliefs and ‘sacred cows’ must be abandoned if best evidence suggests otherwise. It is about the evidence and being ‘consumer driven’ in the case of Consumer Reports and evidence and ‘patient centered’ in the case of Choosing Wisely.
This initiative hopes to spark dialogue between patients and health care providers about
some common services and procedures that current research evidence has called into
question. For example, best available research evidence demonstrates that clinical
outcomes for acute lower back pain in the absence of red flags are not improved, no matter
the provider, by the addition of plain film X-Rays taken in the first 6 weeks. Additionally,
there is no evidence to suggest that the acute low back pain patient is at greater risk by not
having plain film X-Rays within the first 6 weeks, no matter the provider. So if the clinical
outcome is not improved, and there is no added risk, then why take an X-Ray within the
first 6 weeks? This is the type of dialogue that Choosing Wisely hopes to spark between the
patient and the provider.
If the provider believes that clinical outcomes are improved by having those X-Rays, then
the onus of responsibility is upon that provider to show the evidence. If the provider
believes that there is added risk by not having the X-Rays, then the onus of responsibility is
upon that provider to show the evidence. However, as previously stated, this evidence
does not exist, otherwise, the Choosing Wisely items would not have included the plain film
X-Ray recommendation. A sign of a mature profession is one that adopts new practices that
are supported by new research evidence, and holds a willingness to abandon those
practices which evidence shows to be wasteful or unnecessary. An example in the medical
profession is in the use of antibiotics for acute otitis media, a decades long practice that
many physicians still cling to in spite of very strong evidence to the contrary. An example in
the chiropractic profession is in the use of plain film imaging for acute low back pain in the
absence of red flags. While a long held practice in the chiropractic profession, the best
current evidence shows that plain film imaging in the first 6 weeks of acute low back pain
in the absence of red flags is simply not necessary – it will not improve outcomes, it will not
reduce risk. Just as we would expect the informed patient to question a physician who
prescribes antibiotics for acute otitis media, we would expect a patient to question any
provider who orders an X-Ray for acute low back pain.
The participation of the American Chiropractic Association in the Choosing Wisely
campaign is a sign of professional maturity, a sign that the ACA supports evidence based
practice and a clear demonstration that the American Chiropractic Association puts the
patient first and foremost in decision making. One of the concerns expressed by the
participating Choosing Wisely groups queried about the possible participation of the
chiropractic profession was that the chiropractic profession might select non-evidence
based recommendations, which could then be contrary to evidence based
recommendations chosen by other health professions. We reassured the ABIM Foundation
and Consumer Reports that the American Chiropractic Association supports evidence
based, patient centered care and would utilize best available research evidence in making
The inclusion of the chiropractic profession, via the American Chiropractic Association, in
the Choosing Wisely campaign is a huge step forward for chiropractors and the patients we
serve. In essence, the Choosing Wisely campaign is a public health initiative, and the
American Chiropractic Association has reason to be very proud to be participating.
Written by John M. Ventura, DC, Spine Care Partners, LLC, and Michael Allgeier, DC, medical director, Mercy Spine and Back Care, Mercy Hospital Chicago, IL | Wednesday, 02 July 2014, originally published in Becker’s Spine Review.
When it comes to new technology, Christensen’s model of disruptive innovation can be fairly well understood.
New markets with added value are created by the introduction of a new business model (not just a new technology), which disrupts the existing market. The transistor radio is a classic example of a disruptive innovation. (1) However, when we discuss a system built upon process, like healthcare, the notion of defining disruptive innovation becomes more challenging. Perhaps O’Ryan’s description of constructive disruptive innovation becomes more relevant. In this construct the goal is to create a model that is less expensive but more creative, more useful, more impactful while still being scalable. Constructive disruptive innovation combines ‘off the shelf’ technology/ideas with the novel and original to improve the process. (2)
It goes without saying that the field of spine care is replete with variation, waste and misuse. Direct costs for spine care have risen almost exponentially over the past three decades, while indirect costs (those typically associated with lost productivity) have followed suit. (3) In spite of these exorbitant expenditures on spine care, our outcomes as measured by disability are worsening. Many investigators have identified spine-related disorders as one of the costliest health conditions society faces. The need for change is obvious, but what change and how do we get there?Read more
By Michael Schneider, DC, PhD, Donald Murphy, DC, DACAN, David Seaman, DC, MS, DABCN, John Ventura, DC, DABCO, Ian Paskowski, DC, Richard E. Vincent, DC and Stephen M. Perle, DC, MS. Originally published in Dynamic Chiropractic 2012.
The American health care system is in crisis. We have an unsustainable growth in health care expenditures that will consume 20 percent of our gross domestic product within the next five years.
Last year, this crisis culminated in passage of the Patient Protection and Affordable Care Act by Congress. Although parts of this act are currently being legally challenged, the health care reform train has left the station. The question is whether chiropractors are going to board this train, watch it pass by, or be run over by it.
There is a specific “subcrisis” within the broader health care crisis; the medical mismanagement of spine problems. Back and neck pain, as well as related disorders such as radiculopathy and cervicogenic headache, continue to be the most common reason for disability in American adults and the second most common condition for which patients seek medical care. Patients are faced with an environment in which a wide variety of practitioners offer a disparate array of diagnostic tests and treatments, many of which are completely unnecessary.
In addition, there is little or no coordination of services and no central resource to which patients can turn for guidance through the spine care maze. Spine surgery rates are higher in the U.S. than in any other nation in the world, inappropriate use of imaging and injections is rampant, and the number of Americans addicted to prescription pain medications is at an all-time high.Read more
Written by Laura Dyrda & originally published in Becker’s Spine Review, 2013.
Excellus Blue Cross Blue Shield has started an innovative program working with providers in New York to develop a community model of spine care for patients suffering from spine-related disorders.
“Right now the patient as a consumer has dozens of choices related to spine care and we see tremendous variation in the manner in which that care is delivered,” says Brian Justice, DC, Associate Medical Director, Pathway Development and Spine Care, Excellus Blue Cross Blue Shield in Rochester, N.Y. “It’s hard from the payer’s perspective to measure quality with all this variation. We are working to find a cadre of practitioners who can agree on common pathways and then measure value-driven data.”
Dr. Justice discusses the program and his vision for developing new models for spine care.
By John Ventura, DC, DABCO & originally published on Dynamic Chiropractic, 2013.
A large New York Blue Cross / Blue Shield plan hosted the formal inaugural training program for primary spine practitioners (PSP) on Sept. 28-29, 2013. Ninety-five health care providers participated in the program, which included DCs (70 percent of attendees), as well as DPTs (20 percent), PTs (8 percent) and MDs (2 percent). The program was taught by Donald R. Murphy, DC.
An understanding of the role of the primary spine practitioner is best understood from the following:
“This individual, the primary spine practitioner (PSP), is provided specific training, tools and support to augment existing attributes regardless of the provider’s specific discipline. The PSP role allows for the existing professional workforce to be re-purposed and fill the need for first contact, best evidence, low cost management of all spine related disorders regardless of severity.”1
Spine-related disorders are among the most debilitating and costliest health conditions our society faces. Over the past three decades, we have witnessed exponential growth of costs related to spine disorders, with current estimates approaching $90 billion a year. These direct costs of diagnosing and managing spine disorders include a 400 percent increase in opiate use, 200 percent increase in spine fusion surgery and 600 percent increase in use of epidural steroid injections. We have seen the indirect costs, those evidenced by disability / impairment / lost productivity, as also rising at an exponential rate, and currently may be 1-5 times as high as the direct costs.2-5
To solve this problem, a patient-centered, evidence-influenced model of care was developed that includes the PSP as the “quarterback” of spine care. Murphy, et al., have written about the specific skill set of the PSP.6 Fortunately for our profession, DCs require the least amount of additional training to meet these requirements compared to other professions involved in spine care.Read more