Primary Care Management of LBP: Pilot Project
By Andrea Endicott, LLB, MPPAL; OCA Senior Health Policy Analyst
Recently, the Ontario government established the Excellent Care for All Strategy to build and enforce a culture of evidence-based care today to ensure health system sustainability for future generations. As part of the strategy, provincial initiatives were sought out to enhance patient care, improve wait times and reduce inappropriate diagnostic utilization. One of the initiatives funded by the Ministry of Health and Long Term Care (MOHLTC) is a pilot project for a consulting chiropractor role in the primary-care setting to assist physicians in the management of lower back pain (LBP).
Developed in conjunction with the Ontario Chiropractic Association (OCA), this innovative project aims to advance greater integration within collaborative, primary health care settings. The pilot project began in September 2011 and involves four chiropractors working with four medical clinics in a consulting capacity to support LBP management at the primary care level before, rather than after, a referral to advanced imaging and medical specialists.
In the model, patients with back pain are referred to the chiropractor consultant at the discretion of the physician. After completing a thorough patient assessment, the chiropractor then provides a recommendation to the physician on whether the patient could benefit from a course of conservative therapies, is a potential surgical candidate, or if advanced diagnostic tests should be ordered. The final patient care decision is determined by the physician, with the chiropractor consultant providing assessment, rather than treatment. If required, patients are then referred to a selected list of relevant community care providers including chiropractors, physiotherapists, registered massage therapists and mental health professionals.
"The objective of this pilot project is to test the feasibility, acceptability and value of this model of care, specifically, physician decision support and knowledge transfer," said Dr. Bob Haig, OCA chief executive officer. "All MOHLTC initiatives to date on the issue of diagnostic tool costs have focused on the ‘supply side' of delivery. This initiative impacts the demand side by focusing on guidelines and quality of care."
The OCA believes that this model of care can demonstrate provider and patient satisfaction and have a positive health system impact related to the management of LBP.
LBP is a major cause of disability and health care expenditure, and accounts for a significant portion of primary care physician workload. In Ontario alone, it is estimated that 8-11 percent of primary care patient visits are related to LBP.1 Most LBP patients eventually recover, but some do not and recurrence is common. Recurrent, chronic LBP patients who do not respond to usual physician care represent a unique challenge for the health care system and are cited as the most common reason for referrals to orthopedic surgeons and neurosurgeons.2
Compounding the issue is the fact that wait times to see a spine surgeon are among the highest in Canada, with an average wait time of more than seven months,3 and many of these patients may not derive benefit from surgical care.
Initial response to the project from physicians and clinical staff has been overwhelmingly positive, with reports that the assessment clinics are running very efficiently.
Andrea Endicott joined the Ontario Chiropractic Association in 2010, filling the newly created position of senior health policy analyst. She is responsible for providing broad and specialist policy analysis and stakeholder engagement on issues key to the health care sector. She leads research and policy analysis projects in several areas including financial health modeling and innovative models of care. Following completion of her law degree (LLB), she completed her master's degree in public policy, administration and law.