Independent Evaluation of Implementation of Acute Low Back and Radicular Pain Pathway in South Tees and Hambleton, Richmondshire and Whitby CCG Regions 1 August 2016 Undertaken by: North East Quality Observatory Service On behalf of: South Tees NHS Foundation Trust and the Academic Health Science Network for the North East & North Cumbria
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Independent Evaluation of Implementation of Acute Low Back and Radicular Pain Pathway in South Tees and
Hambleton, Richmondshire and Whitby CCG Regions
1 August 2016
Undertaken by: North East Quality Observatory Service
On behalf of:
South Tees NHS Foundation Trust and the Academic Health Science Network for the North East & North Cumbria
Figure 6. Number of Referrals per Month by Local Authority
Scarborough
Richmondshire
Hambleton
Redcar & Cleveland
Middlesbrough
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6.2 Waiting times for initial appointment
Overall, 25% of patients were seen within 2 weeks of referral from the GP with a further 40%
within 2-4 weeks, 30% between 4-8 weeks and only 5% greater than 8 weeks. There is wide
variation across the different T&TP clinics for waiting times for initial assessments with
Friarage seeing 60% of patients within 2 weeks compared to James Cook and East Cleveland
seeing a little fewer than 10% of patients within 2 weeks (Figure 7). Additional clinics will
shortly be made available at Redcar Primary Care and James Cook Hospital.
However, it should be noted that the T&TP services are only aware of the referrals once the
Choose & Book system and only then can give patients an appointment. There is wide
variation in the time it takes for patients to log on to Choose & Book. Figure 8 shows the
waiting times between when patients log on to Choose & Book and initial assessment, which
highlights that 66% of patients overall are seen within 14 days and a further 21% within 2-4
weeks. This is relatively consistent across all clinics. GPs need to encourage their patients to
log on to Choose & Book as soon as possible after referral; particularly in South Tees CCG.
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It should be noted that the time from referral to initial assessment depends not only on the
capacity of the T&TP service but also the patient availability for attending the clinic. Further
data about whether delays in being seen are due to service capacity or patient preference
for a later appointment or being seen at a specific clinic is required to help the services
understand these differences and put in place an action plan to reduce these times. It is
recommended that if the patients’ initial appointment is greater than 2 weeks from referral
from the GP that the reason for this delay is captured by the services.
6.3 Number of patients at each pathway point
From a total of 2,744 patients assess by the T&TP service, 594 (22%) were referred to core
therapies, 372(14% were referred for an MRI and 119 (4%) were referred for a surgical
opinion.
Pathway Point Middlesbrough
(N=909)
Redcar & Cleveland (N=873)
Hambleton (N=564)
Richmondshire (N=275)
Scarborough (N=123) Total
Core Therapies 275 217 62 22 18 594
MRI Referrals 121 138 55 29 29 372
Surgical Opinion 60 46 7 <6 <6 119
Nerve Root Blocks 17 29 13 6 0 65
Pain Management 28 12 <6 <6 0 43
CPPP 14 11 <6 <6 <6 32
Total Assessed 909 873 564 275 123 2,744
As can be seen from Figure 9a, when we compare the proportion of referrals accessing the
different pathway points, there is variation based on where the patients live (local authority
where resident) with a higher proportion of patients living in Middlesbrough, Redcar and
Cleveland being referred for core therapies, MRIs and surgical opinions compared to
patients living in Hambleton and Richmondshire. A higher proportion of patients living in
Scarborough compared with Hambleton and Richmondshire are being referred for core
therapies and MRIs. Although there is variation in the proportion of patients having nerve
root blocks by local authority, these numbers are small but should be kept under review.
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Figure 9b demonstrates that only a small proportion of patients being seen by the T&TP go
on to the Pain Management referral and the CPPP pathway points. Similar to the variation
in access to the pathway points reported above, a higher proportion of patients who live in
Middlesbrough and Redcar & Cleveland are accessing these services compared to the other
local authorities. It should be noted that the numbers of patients accessing these services
are small but this variation should be kept under review.
6.4 Reasons for opt-out and did not attends (DNAs)
No data is currently available for evaluating if there are trends in DNA activity by basic
demographics (such as age and gender) or based on where the patient lives or the GP
practice that have referred them. This data would be helpful in future to inform on actions
to reduce DNA and opt-out activity.
6.5 Description of what was actually delivered and details of any
unexpected outcomes
The T&TP and the management team have regular MDT meetings every 2 weeks to discuss any concerns or issues related to the service. The MDT provides a forum for discussion of clinical cases which has proved valuable. Discussing cases in the forum allows clinical education of the whole group. It also promotes convergence of clinical indications for procedures and investigations; and allows consistent explanations and information to be given to patients.
The MDT also has served an important function in resolving teething problems in the service both in the process and in IT support.
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7 Baseline and Discharge Data
Patient questionnaires are completed by the patients on a printed form when they attend the
T&TP clinic for the initial assessment. This data is then entered onto the T&T database that
collates data from each of the T&TP clinics. A standard operating procedure (SOP) for entering
data has been developed to ensure that data is entered consistently and with minimal errors.
7.1 STarT Back Scores
GPs use the Keele STarT Back Screening Tool (SBST) to assist them in deciding which patients
to refer to the T&TP clinics. This is a simple prognostic questionnaire that helps clinicians
identify modifiable risk factors (biomedical, psychological and social) for back pain disability.
The resulting score stratifies patients into low, medium or high risk categories. For each
category there is a matched treatment package. This approach has been shown to reduce
back pain related disability and be cost-effective.
Scores range from 0 to 9 and the threshold for referral is 4 unless on clinical assessment the
referring GP believes the patient would benefit.
Figure 10 demonstrates the distribution of the STarT back scores:
Majority of scores are 4 or higher
250 out of almost 3,000 referrals (approx. 9%) where the STarT back scores <4
STarT Back scores are not available for almost 200 patients (approx. 7%)
Small volume of scores that are 10 which is not possible
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7.2 Measures of pain & physical activity
Pain numeric rating score (PNRS) ask the patients to rate their pain on a numeric scale
from 0 (no pain) to 10 (worst pain). Figure 11 demonstrates that the initial scores are
skewed towards the higher end of the scale with a median score of 7 (Interquartile range,
IQR, 6 to 8). On discharge, the scores are skewed to the lower end of the scale with a
median score of 4 (IQR, 2 to 6. Figure 12)
Figure 13 looks at the change in scores between the initial and discharge assessment and
highlights that the majority of patients (74%) had less pain on discharge. These patients
were more likely to report an improvement in their global outcomes scores compared to
patients who reported similar or greater levels of pain at discharge.
The Oswestry Disability Index (ODI) was developed after interviewing patients with low back pain. A range of drafts of the questionnaire were piloted, and the final version was published in 1980. Since that time the ODI has been widely used as a condition-specific outcome measure for patients with spinal disorders, and was developed for use in secondary care settings.
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The ODI is comprised of ten items with associated statements for the patient to select which reflect the patient’s ability to manage their everyday life while dealing with their pain. The items include:
Pain intensity Standing
Personal care Sleeping
Lifting Sex life
Walking Social life
Sitting Travelling
Each of the ten items in the ODI has six statements from which patients are requested to select one. For example, the pain intensity item the statements and scores are:
0. I have no pain at the moment 1. The pain is very mild at the moment 2. The pain is moderate at the moment 3. The pain is fairly severe at the moment 4. The pain is very severe at the moment 5. The pain is the worst imaginable at the moment
The scores are combined to give a score between 0 and 100 (high score worse) and allowances can be made to the algorithm if 4 or less items are missing to average the completed items and still give a score between 0 and 100. Patients can be categorised based on these scores that give an indication of the level of their disability (Figure 14).
In summary,
Initial assessment mean 43 (95% CI 42, 44) on 2,223 patients
Discharge assessment mean of 26 (95% CI 24, 28) on 330 patients
Average change in score 15 (95% CI 13, 17) on 281 patients
227 patients had a better score, 6 had the same score and 48 a worse score
Please note that the change scores are the most robust measure of impact as these are for patients that had valid initial and discharge scores. Change of 6 or > is clinically perceptible
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7.3 Measures of anxiety and depression
GAD7 is an anxiety scale that asks 7 questions asking patients to reflect on how often over
the last 2 weeks they have been bothered by the following problems:
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Patients respond using the following categories:
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day
If patients check off any problems they are asked an additional question about how difficult these problems have made it for them to do work, take care of things at home, or get along with other people. Responses include not at all, somewhat, very and extremely. Scores for the 7 items are combined to give a score from 0 to 21 (high score worse) interpreted as 0-5 mild, 6-10 moderate, 11-15 moderately severe, 15-21 severe anxiety (Figure 15).
In summary,
Initial assessment mean 8.3 (95% CI 8.0, 8.6 ) on 1,881 patients
Discharge assessment mean 3.8 (95% CI 3.3, 4.4) on 288 patients
Change in score mean of 3.0 (95% CI 2.4, 3.7) on 216 patients
134 patients had a better score, 51 the same score and 31 a worse score
Please note that the change scores are the most robust measure of impact as these are for patients that had valid initial and discharge scores.
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PHQ9 is a depression scale that asks patients over the past 2 weeks how often they have
been bothered by the following problems:
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself
Trouble concentrating on things
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving .around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way
Patients respond using the following categories: 0. Not at all 1. Several days 2. More than half the days 3. Nearly every day
Scores for the 9 items are combined to give a score from 0 to 27 (high score worse) and can be interpreted as 0-4 none, 5-9 mild, 10-14 moderate and 15-19 moderately severe, and 20-27 severe depression (Figure 16).
In summary,
Initial assessment mean 9.7 (95% CI 9.4, 10.1) on 1,878 patients
Discharge assessment mean of 4.8 (95% CI 4.1, 5.5) on 298 patients
Change in score mean of 3.6 (95% CI 2.9, 4.4) on 220 patients
150 patients had a better score, 37 had the same score and 33 a worse score
Please note that the change scores are the most robust measure of impact as these are for patients that had valid initial and discharge scores.
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7.4 Generic Health Status outcome measures – EQ-5D
EQ-5D is a generic health status measure applicable to a wide range of health conditions
and treatments and provides a single index value of health status. EQ-5D is primarily
designed for self-completion by respondents and is ideally suited for use in postal surveys, in
clinics and face-to-face interviews. The respondent is asked to indicate his/her health state
by ticking (or placing a cross) in the box against the most appropriate statement in each of
the 5 dimensions including:
Mobility
Self Care
Usual Activities
Pain / Discomfort
Anxiety / Depression
These individual dimension scores range from 0 to 4 (0 best) and the mean scores for each at initial and discharge assessment are shown in Figure 17. This demonstrates that patients reported significantly better health status across all dimensions with the greatest improvements seen in mobility, usual activities and pain/discomfort.
These responses are combined into a 5-digit number describing the respondents’ health state and this number maps to health status score (range -0.59 and 1.0). Mean scores and 95% CI for the initial and discharge assessment are presented in Figure 18 and demonstrate a significant difference between these two assessment times but it should be noted that discharged scores at the time of this evaluation were only available for 326 patients.
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In summary,
Across all dimensions of the EQ-5D patients report an improvement at discharge
Initial assessment mean 0.42 (95% CI 0.41, 0.44 ) on 2,148 patients
Discharge assessment a mean of 0.66 (95% CI 0.64, 0.68) on 326 patients
Change in scores mean of 0.22 (95% CI 0.19, 0.25) on 274 patients
228 patients had a better score, 9 same score and 37 had a worse score
Please note that the change scores are the most robust measure of impact as these are for patients that had valid initial and discharge scores.
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7.5 Patient Experience measure - Friends and Family Test
Friends and Family Test (FFT) is a measure of patient experience captured by asking the patients on their discharge assessment how likely they would be to recommend this service to friends and family. Responses range across five categories including:
Very Likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
A summary of the responses for 306 patients is presented in Figure 19 and highlights that two thirds of patients were very likely to recommend the service to family or friends, a quarter likely to recommend and only 24 (8%) responding in the other 3 categories.
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8 Summary and recommendations
This independent evaluation of the South Tees Back Pain Pathway provides information for the
AHSN who funded the implementation of the pathway as well as the CCGs who are now
commissioning the ongoing delivery.
8.1 Summary of results (for primary and secondary outcomes)
From the data available at discharge assessment, on average there have been significant
improvements across all outcome measures collected and the majority of patients have
reported better score at discharge (Figure 20). It should be noted that at the time of this
evaluation, discharge data was only available on approximately 300 of almost 3,000 patients
referred to the service up until May 2016.
The discharge assessments also have varying degrees of completion across each of the
outcome measures with some outcome measures not having sufficient data available to
calculate the summary score. Discharge assessments are also collected at varying time
points from the initial assessment depending on their pathway points.
Improvements are greatest for the primary outcome measures of pain (PNRS) and the
back-pain specific measure (ODI) where these improvements are not only statistically
better but would also be considered greater than the minimal clinical change required to
be perceptible at an individual patient level.
Secondary outcome measures related to anxiety (GAD7) and depression (PHQ9) also
demonstrated a significant improvement with a lower proportion of patients reporting
scores indicative of moderate to severe symptoms.
The generic EQ-5D also demonstrated a significant improvement which on average was
0.22 and considerably higher than the threshold set by NICE as the minimum
improvement required to justify ongoing investment. Further economic evaluation can
be conducted in future when there is s greater volume of discharge data and change in
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EQ-5D scores can be reviewed by the treatment groups and the costs related to
providing these interventions.
Patients’ perceptions of the service have been overwhelming positive with 92% of
patients likely or highly likely to recommend the service to friends and family.
These early results should be viewed alongside the six-month data (when available) that will
provided a more robust outcome of the T&TP service as they will be collected at a fixed
time. Given the delays in some patients logging on to the Choose & Book system and other
patient related delays to make an appointment, the six-month questionnaires ideally should
be collected at six months from initial assessment date rather than GP referral date.
8.2 Details of any further analyses and statistical methods used
Statistical differences between initial and discharge assessments provide an indication of the
average difference between these populations of patients but the real improvement is
evaluated by reviewing the change in scores where there is complete data at both time
periods. Change scores reported in this evaluation included 95% confidence intervals to
confirm that these changes are statistically significant (that is, the interval does not cross 0
indicating no difference).
The GAD7, PHQ9 and ODI scores have cut-off points that indicate the severity of anxiety,
depression and disability related to back pain. The proportion of patients in each of these
categories has also been included in this report to provide additional information about how
the population of patients changes between initial assessment and discharge to highlight the
reduction in the proportion of patients in the more severe categories.
8.3 Limitations and generalisability
The data presented in this evaluation is dependent on the quality of data provided to NEQOS
by South Tees FT from SysmOne and the T&T database. NEQOS did not have access to
patient identifiable data so was unable to link data between the two systems.
Additionally, NEQOS did not have access to the questionnaire data so all data quality
assurances for this data being a true reflection of the questionnaire data has been
undertaken by South Tees FT. It is assumed that the questionnaire data collected at both
initial and discharge assessment has been collected using the same method (i.e. self-
completion of the questionnaire) to reduce measurement bias.
NEQOS in the process of undertaking this evaluation has made recommendations to South
Tees about ensuring in future that all data fields can only accept valid entries to reduce the
possibility of entering invalid or erroneous data. It has also been reinforced that
questionnaires must be completed in the same manner at each assessment time and that
collecting this information as either a telephone or face to face interview with patients will
bias the results.
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Outcome findings from this evaluation are limited to fewer than 10% of all patients who
have been referred into the service and although very promising it cannot be assumed at
this time that these findings are generalizable to all patients currently still in the service or
future patients referred to the service.
8.4 Recommendations to improve data quality and delivery of pathway
South Tees FT have put considerable effort into ensuring that the staff recruited to the T&TP
service have essential core competencies and a comprehensive training programme has
been put in place to further develop these staff. There are regular MDT meetings every 2
weeks to discuss any issues and the preliminary analyses from this evaluation have been
shared with staff. Given the variation in some of the processes, further reflection of this
data should be undertaken with the MDT to put in place actions to reduce this variation and
improve both the quality of the data collected and delivery of the pathway.
In terms of data quality, recommendations have been made about the T&TP database to
reduce errors in data entry to make future analyses easier to undertake. Checks of all the
scoring algorithms for the outcome scores have been undertaken and recommendations
about changes required, specifically for the ODI algorithms have been made to the Trust.
From the data available, it is clear that many of the patients have chronic back pain and it is
not clear if this is a new acute episode or a long term condition they are being referred for at
this time. It is recommended that in future, there are two questions that clearly ask when
this episode started as well as when they first had back pain.
Enhanced methods for collecting discharge and six-month questionnaires and the possible
use of incentives are being discussed with the commissioning CCGs. NEQOS has developed
an interactive Word version that may be emailed to patients, completed electronically and
return by email. It is recommended that the six-month questionnaires are collected at a
fixed six-month time period from the initial assessment and not the date of GP referral. All
questionnaire data needs to be collected as a self-completed questionnaire.
In SystmOne data, the T&TP clinic site was not available in the SystmOne extract and had to
be entered manually to the dataset for these analyses. It is recommended that the clinic
sites are added to the SytmOne template to enable easier and more accurate reporting of
waiting times and pathway points by clinics.
It is recommended that further feedback is given to GPs (possibly a patient information
leaflet) to ensure that they encourage patients to log on to Choose and Book as soon as
possible after referral so that they can schedule an appointment with the T&TP Service.
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8.5 Dissemination of learning and findings
The results from this evaluation have been discussed with the South Tees FT T&TP services
and will be disseminated to the commissioning organisations (AHSN NENC and South Tees
and HRW CCGs).
Further presentation of this data to the North of England Regional Back Pain Pathway group
will be undertaken to ensure that the learning from this early implementation project is
shared across the Health Foundation Scaling Up project in the North East as well as the
national Improving Spinal Care project.
Appendix 2
The North of England Regional Back Pain and Radicular Pain Pathway
Approved Core Therapy Guidance
The Triage and Treat Practitioner (T&TP) may refer for appropriate therapy which will be functionally based, goal driven and delivered by a physical practitioner (physiotherapist, osteopath, and chiropractor depending on locally commissioned arrangements).
It is essential for the success of the pathway that all professionals involved ‘sticks to the same script”, giving standard literature and advice, using a biopsychosocial approach and avoiding medicalising the patient. All therapy will be overseen by the T&TP to ensure the pathway’s clinical message is adhered to.
Practitioners should be trained in biopyschosocial approach and be able to incorporate this into clinical practice. This approach includes knowledge of: anatomy, biomechanics, tissue pathology, pain mechanisms (input, processing and output mechanisms), representation, evolutionary biology, psychosocial issues, and fear avoidance.
Patients should be treated with an activity based scientific approach, challenging myths and avoiding medicalising the patient. Patient educational material, formal or informal, should re-enforce the pathway message.
Physical practitioners should provide a package of care tailored to the individual in terms of treatment options and frequency of treatment delivery, taking account of patient expectations and preferences. Low back pain related distress, anxiety, fears, beliefs and expectations should be addressed as an integral part of the package of care.
An exercise based approach to therapy provision using current best evidence should be followed. Patients may be referred to a formal exercise group; if patients are unsuitable for this, individualised exercise therapy with /or without a course of manual therapy or acupuncture may be considered.
It is anticipated that the number of treatment consultations will vary between patients with many only needing short periods of care. Core treatments, if effective, may be used up to the maximum limit indicated below. In practice however, if manual therapy or acupuncture are not demonstrating improvements after 3-4 treatments, then a re-evaluation of approach should be considered.
A structured Exercise programme may be delivered by an appropriate physical practitioner as a group exercise programme (up to 10 people) or a one-to-one tailored exercise programme over 12 weeks for up to 8 sessions using a CBT approach promoting self-efficacy. If appropriate, up to 10 sessions Acupuncture and 9 sessions of Manual therapy (including mobilisation, massage and spinal manipulation) over a period of up to 12 weeks may be considered.
Patients with a good response may be discharged by the physical practitioner; please note outcome measures are required before discharge and returned to the T&TP. If insufficient improvement is obtained then review by the T&T practitioner will be indicated, at the latest by 12/52. Following this review a number of options are available. In some cases a further 6/52 of core therapy may be provided. Referral to Combined Physical and Psychological Programme (CPPP) or other specific services as indicated in the pathway may be discussed in consultation with the patient.
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DOCUMENT GOVERNANCE
Document name Independent Evaluation of Implementation of Acute Low Back and Radicular Pain Pathway in South Tees and Hambleton, Richmondshire and Whitby CCG Regions
Document type Final report
Version Version 1
Date 1/08/2016
Document Classification
Prepared on behalf of NEQOS
Created by Liz Lingard, Terry Phillips (analyst) and Kayoung Goffe (QA)