Hello, my name's Josh Benden. I'll be discussing a multidisciplinary spine clinic model and how it significantly reduces lead times for appropriate specialist visits and interventions in an underserved population. I have no disclosures. As many of you know, back pain and spinal disorders are among the most common disabling conditions in healthcare today. The estimated economic cost associated with back pain and spinal disorders is in the billions of dollars annually, and much of these costs is due to indirect costs such as lost wages or reduced productivity for patients secondary to the debilitating symptoms they experience from these pathologies. Previous research has demonstrated that multidisciplinary methods can positively impact spine care. For instance, one study has looked at the utility of a multidisciplinary team evaluating the use of lumbar spine fusion in patients who are initially recommended for these procedures. This multidisciplinary group included numerous stakeholders who are both physicians and non-physicians involved in spine care. After reviewing these patients initially recommended for lumbar fusion, they determined a significant number of them did not need the surgical procedures they were recommended for and instead only required more conservative therapies. And there was no adverse impact on the outcomes of these patients. Similarly, studies of other multidisciplinary standardized protocols have demonstrated improvement in patient outcomes after spine surgery, including reductions in complication rates and blood transfusion utilization, among other outcomes. So given the success that multidisciplinary methods have shown in different aspects of spine care, stakeholders must continue to explore strategies to implement multidisciplinary methods to improve the spine care process, and they may be helpful in streamlining access to spine specialists and treatment recommendations. Traditionally, patients have had to interact with a single surgeon model for spine care. In this model, patients are at the center of coordinating their own care and have to juggle these referrals between a number of spine specialists from disparate backgrounds, including surgeons, physiatrists, and interventionalists. This can often lead to delays in patients connecting with the appropriate spine specialist to receive a definitive diagnosis as well as a treatment recommendation. On the other hand, a more integrated model would focus on patients at the center of the care, and they could be simultaneously seen by specialists during one clinic visit as appropriate. And this integrated model would bring together interventional surgeons and physiatrists from all these different spine backgrounds to help streamline. So at our own institution, we have both of these clinic models present. In the unidisciplinary spine clinics, we have one spine specialist present, such as a surgeon. So in our spine surgeons' unidisciplinary clinics, they'll just include the attending surgeon and nurse practitioner present there to see patients. However, no other spine specialists, such as physiatrists or pain specialists, are present in the clinic. On the other hand, we have a multidisciplinary clinic model that we've implemented and it's staffed with a spine surgeon, a physiatrist, and a pain specialist, all available for consultation during a visit. Providers from each specialty are running their own simultaneous co-located clinics within this building that shares the same exam rooms and computer workstations to facilitate easier communication between specialists. And patients are scheduled to see one provider, who then involves the other providers at their own discretion for a combined patient visit and treatment planning and decision making as needed. The purpose of the study is to compare the times to specialist visits and spine interventions between an integrated multidisciplinary spine clinic and a traditional surgical unidisciplinary spine clinic. To study this question, we included patients who initially sought spine care at our institution from a spine specialized neurosurgeon. The study period was from April through June of 2018. Patients were excluded if they had no follow up with any spine providers, had a non-degenerative spine disease, had previous instrumentation of their spine, had cranial pathology that they're seeing a neurosurgeon for rather than spine pathology, had a lack of imaging, or initially sought care from another spine specialist at our institution such as a physiatrist, pain specialist, or orthopedic surgeon prior to neurosurgery. Variables that were collected for patients in the study included whether they attended the unidisciplinary single surgeon clinic versus the multidisciplinary integrated clinic, their baseline patient demographic and medical characteristics, as well as the days from their index visit with that initial neurosurgeon to a specialist visit with another spine specialist such as a physiatrist or pain specialist, and also the number of days from that index visit to them receiving an intervention, be it an epidural steroid injection or spine surgery. To analyze our data, we used univariate analysis initially to identify baseline differences between the two clinic cohorts, and subsequently multivariate linear regression was used to discern relationships of initial visit location with the time to the specialist visit and intervention outcomes. So overall, we identified 150 consecutive patients who met inclusion criteria. 101 of them had attended the multidisciplinary clinic initially, while 49 of them attended the unidisciplinary clinic initially. Looking here at this table, we have a breakdown for the univariate analysis between our two clinic cohorts. At the bottom, I've highlighted our outcomes of interest. First, we have our median days from IV, our initial visit, to SV, the specialist visit. For the multidisciplinary integrated clinic, we see a 20-day lead time between these two time points, whereas for the unidisciplinary single surgeon clinic, there was a 49-day lead time, which is more than double this amount of time, and was statistically significant on a univariate analysis. Similarly, looking at the bottom row for time from the initial visit to the actual intervention, again, patients experienced significantly shorter lead times when they were going up to the integrated multidisciplinary clinic versus the unidisciplinary clinic. This is on the order of 43 days from the multidisciplinary clinic between these two time points versus 63 days, or 20 extra days, between these two time points for the unidisciplinary clinic. This was, again, statistically significant on multivariate analysis. To better visualize these differences, we have some bar plots here. This one's looking at our first outcome of time from the initial index visit to seeing a subsequent spine specialist between the two clinic models. Here the single surgeon unidisciplinary clinic is in purple, while the integrated multidisciplinary clinic is the blue bars. This figure shows that consistently throughout the one-month follow-up period after an initial visit, patients were far more likely to have a visit with another specialist that they were initially seeing at the integrated clinic. Similarly, this figure is now looking at our other outcome, and it's a comparison of time intervention between the two clinic models. And here, again, a similar story. We see that consistently throughout the two-month follow-up period after the initial visit, patients were far more likely to receive an appropriate and timely intervention if they were initially seen in the integrated clinic. Again, the blue lines on this figure. Now looking at our multivariate analysis, this is trying to isolate the effect of what clinic type the patient attended initially. So first we're looking at our outcome of time to specialist visit. And here we see on the order of roughly a 56-day decrease in the time to a specialist visit between the unidisciplinary clinic versus the multidisciplinary clinic model. And this was statistically significant. Again, for the outcome of receiving an intervention, we also see a significant decrease in the amount of time patients have to wait from that initial index visit to receiving an intervention. This was on the order of 55 days, or roughly two months, when they attended the multidisciplinary clinic versus the unidisciplinary clinic. This was also statistically significant. The study has several limitations that are worth noting. Although we believe that the triage of the appointments for both sites was relatively random, patients were not truly randomized between the two clinic models. Also there is an issue of selection bias. Our institution serves a medically underserved population with among the worst health outcomes in New York State. So their demographics and comorbidities almost certainly differ from those patient populations seen at other institutions. As far as next steps for this type of work, it would be worth evaluating the impact of a multidisciplinary clinic on the leads times to specialist visits and interventions for patients who initially sought spine care but from a non-spine surgeon. So if they initially sought care from a physiatrist at a unidisciplinary versus a multidisciplinary clinic model, as well as a pain interventionalist. Another avenue for future research into this issue is to prospectively rather than retrospectively assess this data, and to do a randomized assignment prospectively of patients to the two clinic models to better control for potential confounding variables. So in conclusion, multivariable analysis showed that patients seen in an integrated clinic received specialist consultation and intervention on a scale of one and a half to two months earlier on average, respectively. These findings were achieved in an underserved population, so they may be generalizable to other patient populations and other institutions. We believe that this is an appropriate strategy to streamlining patient care and potentially mitigating the indirect costs of caring for degenerative spine disease in our country, particularly as we face ever increasing costs in spine care. Thank you for your time.

multidisciplinary spine clinic model

lead times

specialist visits

interventions

underserved population