Becker's Spine Review, "How spine patient treatment care pathways are changing - for the better?"

Published December 8, 2014

How spine patient treatment care pathways are changing - for the better? 

By: Laura Dyrda

Spine treatment plans and protocols are changing as healthcare reform puts more emphasis on high quality, cost-effective care encouraging physicians and healthcare professionals to work together on providing the continuum of care for patients while eliminating waste and improving patient satisfaction.

Outpatient surgery
One of the biggest ways to save is performing outpatient procedures in ambulatory surgery centers. ASCs typically have higher quality — because they treat elective surgery specifically for otherwise healthy patients — and more personalized care.

"We are seeing a lot of trying to shift care out of the hospitals and more into the ambulatory surgery centers because it's much more inexpensive to deliver care there," says Michael E. Goldsmith, MD, of The Centers for Advanced Orthopaedics, Summit Orthopaedic Surgery division in Chevy Chase, Md. "It's going to be affordable for the community and country at large. Even compared to five or 10 years ago, I'm doing much more in the ASC."

The ingrained hospital mentality is to keep patients for two or three days after spine surgery, but there are several benefits for mobilizing patients the same day and allowing them to recover from home:

  • Early mobilization is associated with an easier recovery
  • Patients are more comfortable at home
  • There is a lower risk for infection when patients cut their hospital stay short
  • Costs are lower in the ASC

The minimally invasive procedures performed in ASCs also typically have less muscle disruption and blood loss. Technology has been modified to provide less invasive procedures, and even though the implants are more expensive, the overall cost of care is lower because patients go home. "I can do the same two-level spine surgery at both the hospital and ASC, but at the ASC I can do it for half the price," says Dr. Goldsmith.

But not everyone is a good candidate for outpatient spine surgery. Patient selection is key to achieving good outcomes, and if there are additional comorbidities and risks, the patient is better served in the hospital where there are more resources for potential complications.

Physician extenders
A second area changing in spine care delivery is the use of physician extenders. Surgeons can see more patients when their physician assistants are seeing and triaging patients first. Patients have better access to care and physicians can focus on surgical patients.

"The PA vets the patients we need to see," says Dr. Goldsmith. "My time is better spent seeing patients who need surgery and getting them to those procedures. In the past, every single patient saw the doctor, and that's not a good use of the healthcare system."

Most patients presenting with back pain don't need surgery and the PA can direct them to appropriate nonoperative treatment. The visit with the PA is also cheaper than a consultation with the surgeon, and the patients will see the right spine care specialist sooner. But some patients demand to see the surgeon regardless of the PA's diagnosis.

"It takes a lot of work to educate the community about PAs and physician extenders," says Dr. Goldsmith. "Younger patients tend to be more receptive to PAs and nurse practitioners providing care. You might not convince some of your older patients until they are able to see the doctor. We have also noticed this trend runs along the monetary demographic; the more money someone makes, the more entitled they feel to see a physician, even when they have the same insurance plan as people in a lower economic bracket."

To put patients at ease with physician extenders, ensure them each patient is discussed between the physician and PA, and they'll still be able to see the physician if they need surgical care. "In our country, that's still an uphill struggle because most people feel they need to see a physician," says Dr. Goldsmith.

Younger physicians are also more comfortable working with PAs and nurse practitioners because they interacted with them during residency and fellowships. The same is true for referring and primary care physicians.

"When the middle aged and older aged physicians were trained, they didn't use PAs or extenders, so they are often not comfortable sending their patients to groups that use PAs," says Dr. Goldsmith. "But if they see good outcomes with the PA, then they'll get more comfortable sending you patients."

The physician extenders and other professionals assisting the physician also serve as an extra set of eyes when treating patients. "You're getting the benefit of two high-level individuals who are seeing the patient and picking apart the nuances and diagnoses," says Dr. Goldsmith. "There is also synergy working with the same person every day and you can develop a good flow in the office and OR to provide even better care."

Patient involvement in decision-making
Once the patient has seen the physician or another medical professional, they're put down a treatment pathway, which is changing. Previously, physicians often ordered imaging studies for all their patients. More recently, professional society guidelines show X-rays and MRI may be wasteful in some cases.

"MRIs are a huge cost to society, and we are ordering too many," says Dr. Goldsmith. "Many of the MRI studies are unnecessary. But patients still want them even when we don't recommend them. It's an education process to tell them why they don't need an MRI."

In other cases, the patient is onboard for following the physician's advice. High deductibles are forcing patients to really pay attention to the doctor's orders and make decisions about how they want to spend their healthcare dollars.

"Patients should be involved in the consumption of what is going on in their body," says Dr. Goldsmith. "Employers are also starting to control healthcare decisions. We are seeing instances where certain implant companies have relationships with large employers and patients are directed to providers who use the implant company's devices," says Dr. Goldsmith. "They'll say they only want to spend a certain amount on fusion, and then they'll direct all their patients to you. You'll get a certain implant and the choice of five surgeons who use it. Employers will dictate that care in the future."

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