BACK PAIN OUTCOME ASSESSMENT TEAM

An Assessment Team will be developed to study the medical care outcomes of
persons with low back pain. Back pain is proposed as a focus because it is
extremely common in the populations served by Medicare. Back problems
result in frequent hospitalization, surgery, and use of expensive
diagnostic tests, and wide geographic variations in the use of these
services are well documented. We hypothesize that these variations are
largely related to differing physician practice styles, and that overall
utilization can be reduced with no adverse effect on patient outcomes. The
Assessment Team will be based in the Department of Health Services at the
University of Washington, with extensive involvement by the relevant
clinical departments of the School of Medicine, by the Group Health
Cooperative (HMO) of Puget Sound, and by the Maine Medical Assessment
Foundation. An Advisory Board is comprised of community physicians; major
hospital, medical, and health care payer associations; and international
experts. The specific aims of the Team are to (1) characterize geographic
variation and outcomes of lumbar spine surgery; (2) characterize the
content and outcome of non-surgical hospitalizations for back problems; (3)
examine the value and optimal sequence of expensive diagnostic tests for
spine conditions; and (4) disseminate relevant findings to modify clinical
practice styles. Initial studies will focus on spinal stenosis, which is
the leading diagnosis associated with both surgical and medical
hospitalizations for back pain in persons over age 65. Because herniated
intervertebral disc is also a common condition in this age group, as well
as in the younger population served under SSDI, outcomes of care for this
condition will also be investigated. The study of lumbar spine surgery will
include a methodologic review and synthesis of existing literature on the
outcomes of laminectomy, discectomy, and fusion. It will further
characterize geographic variations in these procedures by use of hospital
claims data. The frequency of mortality, readmission, reoperation and
nursing home placement will assessed with Medicare data. Symptomatic,
functional, and cost outcomes will assessed in a clinical cohort study of
surgical patients. These diverse data will provide probabilities,
utilities, and costa for a formal decision analysis of the surgical
decision. Similarly, variability in medical admissions for back pain will be assessed
with Medicare and other claims data. These data will also identify the most
commonly used diagnostic and therapeutic procedures. Through literature
review, physician interviews, and patient interviews, the potential for
shifting these activities to the outpatient setting will be assessed.
Literature synthesis will also be used to examine the sensitivity,
specificity, side effects, and costs of expensive technologies used to
diagnose herniated discs and spinal stenosis (e.G., myelography, MRI,
discography). These data will be used to construct a decision analysis to
clarify the role and optimal sequence of these tests. Finally, the Team
will provide targeted feedback of data on hospitalization and surgery rates
to physicians and hospitals. Guidelines for use of these services will ge
disseminated by professional and payer organizations and innovative CME
efforts. New decision aids for both physicians and patients will
incorporate data from all the assessment activities.