It should come as no surprise to any health professional or patient in Southwestern Ontario that when it comes to low back pain, our region is a chaotic mess. Patients struggling to access adequate care, languishing on wait lists, with physicians powerless to provide them any help. The situation is a combination of many factors, including the aging demographics of the region, a disorganized primary care and specialist system, and underfunding of physiotherapy and spine surgery operating time. Where it has left us is with surgical wait lists approaching 3 years, with patients falling into severe disability while they await appropriate care.
The South West LHIN has begun work on initiating the Inter-professional Spine Assessment and Education Clinics (ISAEC) program in the region as a means to begin to address the local crisis. The program has been implemented with success at the University Health Network in the GTA, improving surgical wait times and improving patient satisfaction. The model includes an initial assessment by an Advanced Practice Clinician (physiotherapist or chiropractor) in the program assessing and educating the patient, and returning a consultation note with recommendations. Some patients are given self-management education, while some patients will be referred on to a Practice Lead (physiotherapist or chiropractor) at LHSC who would make recommendations for more complex patients (imaging, injections, or surgical consultation). It is being proposed as a pilot project in the South West LHIN, starting with a small group of physicians in 2017-18, and expanding to the entire region for 2018-19.
I agree with the principles in theory, but given the current complexity of the problem in the South West LHIN, there are a number of added issues that must be considered.
We need to be very careful not to create multiple competing referral streams that all inevitably compete for the same surgical resources. CBI Westmount has already initiated a referral program in conjunction with a couple of the spine surgeons, where physicians can refer their patients to be seen within a short period of time. An ISAEC program working alongside the CBI program would end up at a bottleneck of the same scarce surgical and injection resources.
Here’s what I would propose:
- A LHIN-led analysis of the current referral burden to all spine surgeons in the South West LHIN. This may include a complete re-design of the existing referral forms, which are currently inadequate for conveying relevant information from the referring physician to the surgeon. The referral form could include an area for the referring physician to designate why they believe the patient is a surgical case, with an educational component to the form that would dictate what constitutes a surgical referral and appropriate management/evaluation of back pain. Once an appropriate referral form is agreed upon, it may be necessary to ask referring physicians to re-refer patients using the appropriate form to be able to properly work through the existing glut of patients. This would also allow for the LHIN and surgeons to determine the exact magnitude of the surgical backlog and what surgical resources will be required to reduce surgical wait times expeditiously.
- An analysis of the capacity in the South West LHIN for back injection services and existing wait times for epidural and facet injections. A majority of potential surgical cases are being sent for diagnostic injection by the surgeon, which ends up causing a frustrating delay for the patient because of the inadequate local resources. The LHIN needs to work with local interventional radiologists to ensure stable capacity.
- Offer educational sessions for local family physicians on the CORE Back Tool, similar to the sessions presented by Dr. Hamilton Hall. I personally found this program to be transformative in how I diagnose and treat mechanical back pain, decreasing the number of unnecessary referrals. Identify physicians who refer a disproportionally high number of patients to spine surgeons, and encourage those physicians to attend the educational sessions.
- I would suggest that the ISAEC model be revised for the South West LHIN whereby referrals are made by physicians directly to the Practice Lead, and that all interested local physiotherapists and chiropractors are provided complimentary education in the ISAEC model.
- Work towards having ONE spinal surgery stream in the South West LHIN that flows through the Practice Lead, rather than allowing multiple competing streams to develop.
- Ensure that patients with acute back pain, who do not have private benefits, have adequate access to a brief course of physiotherapy with a focus on transition to self-management and home exercise programs.
- Focus on increasing the ability of family physicians to competently diagnose, triage, and manage acute and chronic mechanical back pain, rather than pushing resources towards creating more chronic pain clinics.
- Develop a free local Spinal Stenosis Boot Camp, similar to the program offered at Mount Sinai, to support the increasing prevalence of spinal stenosis among the elderly. Participate in this program should be mandatory (with appropriate exceptions) for those seeking either surgery or ongoing epidural injections for pain relief.
- Opening up FHT-led chronic pain self management programs to non-FHT patients, and advertising these widely.
- Ensure that our local libraries have an abundance of copies of “A Consultation with the Back Doctor” by Dr. Hamilton Hall. This book has been invaluable for my patients with chronic back pain to understand the nature of mechanical back pain, and gives many patients the confidence to self-manage their pain.
Just a few ideas for now, but we need to have open discussions about our current local challenges before we move forward with an ISAEC pilot program.