Quality "Continuum of Care" for Worst Case Lumbar Patients

Study shows return to work, work retention rates dramatically improve

Measured by such yardsticks as return-to-work, work retention and reoperation rates, the success of lumbar surgeries in the Workers’ Compensation (“WC”) system could be fairly characterized as mixed. This, combined with the reality that lumbar spine surgery rates have been increasing, makes particularly intriguing a recent study suggesting improved outcomes where patients participate in a comprehensive “continuum of care” which includes quality postoperative rehabilitation.

The study, Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes? was financed in part by a National Institutes of Health Grant and published in the February 2014 edition of The Spine Journal. It compared WC lumbar surgery patients who subsequently underwent a “functional restoration” program (medically supervised comprehensive postoperative care) with non-surgical WC lumbar patients who participated in the same program. The results were promising and may provide a blueprint for future treatment.

Background

Guidance on how to improve lumbar surgical outcomes in the WC setting is both timely and welcome. The researchers point to recent studies from Washington State, Utah and Ohio which show return-to-work rates ranging from 26 to 36%, reoperation rates ranging from 22 to 27% and high opioid dependence of up to 85%. Amidst resultant questioning of the efficacy of lumbar surgeries, the suggestion has been made that a “continuum of care” approach could bolster disappointing outcomes. According to the researchers, such an approach is “quite standard” for certain other musculoskeletal injuries. It includes appropriate recommendations for: (1) adequate preoperative care; (2) surgical decision-making; (3) postoperative rehabilitation; and (4) “functional restoration” (for chronic pain.) The study set out to determine whether such a combined approach could be advantageous for a “worst case” group of WC claimants with chronic lower back pain.

Methodology

To do so, the researchers looked at a group comprised of 564 patients, culled from a pool of 3,888 patients admitted to a “functional restoration” program between 1992 and 2003. Each member of the group satisfied the following criteria: (1) it had been 4 or more months since the work injury; (2) non-surgical care did not succeed in allowing a full return to work; (3) surgery either wasn’t an option, or did not succeed in allowing a full return to work; (4) severe pain and “functional limitations” remained even after the usual postoperative rehabilitation. The participants were sub-divided into 3 further groups – those who had undergone at least one lumbar fusion surgery following the injury (“Fusion” group); those who had undergone at least one lumbar surgery, other than fusion, since the injury (“Non-Fusion group”) and a group who had not undergone any spinal surgery (“Un-operated group”.) The total length of disability for this “worst case” study group was 22-32 months, with an average wait of 16-19 months before surgery and a further 11-18 months before entering the “functional restoration” program.

The “functional restoration” program offered to the participants was comprehensive. It included (1) a thorough physical and “psychosocial” evaluation; (2) individual exercise programs overseen by licensed therapists; and (3) a “disability management” program (providing education on pain management and health and fitness issues.)

At both the beginning and the end of the program, the patients were given various “psychosocial” tests to measure such mental health issues such as depression, pain and substance abuse. Additionally, a year after completions of the program, the patients were telephonically interviewed to assess such socioeconomic outcomes as return-to-work and work retention status, and whether there were any new injury claims.

Results

The researchers noted that such factors as depression, pain and substance abuse symptoms could adversely impact return-to-work and work retention success. Monitoring and controlling these factors is therefore key. Upon entry into the program, those in the Fusion and Un-operated groups were more likely to show signs of depression than the Non-Fusion group (59%, 56.5% and 43.4% respectively.) In addition, those in the Fusion group had a “significantly higher” level of post-injury opioid dependence than the Non-Fusion and Un-operated group (31.3%, 19.4% and 17.3% respectively.) By the time each group had completed the program, these psychosocial results were reportedly “comparable” across all groups on all measures.

The study’s socioeconomic findings were similarly positive. For all benchmarks surveyed, the one-year post program completion results showed no “significant” differences between the groups. In other words, each group’s return-to-work, work retention and new surgery rates were about the same. This outcome is noteworthy, since it contrasts sharply with previous studies that measured such benchmarks. Consider the following:

> In the Washington, Utah and Ohio studies, fusion reoperation rates ranged from 22% to 27%. Similarly, in the selected group at issue, 16.7% of the Non-Fusion group and 39.9% of the Fusion group had more than one surgery prior to the rehabilitation program. However, after program completion, reoperation rates across the groups ranged from 1.2% to 3.7%.

> Previous studies indicated recurrent WC injury claims one year post treatment completion ranging from 30-60%. Here, following participation in the postoperative rehabilitation program, these rates dropped precipitously to the 1.4% to 2.4% range.

> Work return and work retention rates for both Fusion and Non-Fusion groups in previous studies ranged from 26% to 36%. Here, following participation in the rehabilitation program, there was a reported work return range of 81% to 85% and work retention range of 75% to 81%.

Takeaway

The study concluded that “a continuum of care produced surgery outcomes that were as positive as those involving un-operated matched patients.” Furthermore, such continuum of care “can dramatically impact outcomes of socioeconomic relevance, not simply patient-reported outcomes.” In other words, this model of care may produce positive outcomes relevant to both the patient (pain, depression, substance abuse) and the WC system (return-to-work, work retention, new surgeries.) Building on this conclusion, the study suggests that surgeons can improve return-to-health and return-to-work outcomes for WC lumbar surgery patients through early referral to a comprehensive “continuum of care”. The study also suggests that there are sufficient quality rehabilitation programs available to further assess the “continuum of care” approach, and to aid in the development of standardized guidelines for the treatment of lumbar patients not only in the WC system, but eventually for a possible wider audience, as federally administered healthcare programs expand.

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