Introduction: The 2018 Lancet series on LBP provides a compelling “call for action”, advocating for system-wide transformation of how patients, providers, payers, and society approach the management of chronic low back pain (CLBP). The primary objective of this study was to compare outcomes of an interprofessional CLPB program, which utilizes multidimensional risk assessment to provide individualized, low-cost, shared-care management strategies (evidence-based education, self-management exercises and, as required, referral recommendations) from a 5-year pilot (2012-2017) to 5 years post full-scale implementation (2018-2023).
Methods: The program is a shared-care model aimed at enabling patients to better understand and manage their CLPB. A networked provider approach is used to enable primary to tertiary care guideline concordant education and support for patients and their primary care providers (PCPs) over diverse geographies and socioeconomic populations. Adults experiencing unmanageable persistent LBP related symptoms lasting from 6 weeks to 12 months are eligible for a standardized assessment (1-hour) using validated and evidence-based risk assessment tools and receive consistent best-practice management recommendations by geographically proximate Advanced Practice Providers (Physiotherapists/Chiropractors) who undergo continuous interprofessional training/education. We performed a descriptive evaluation using multiple program data sources for a variety of patient and program metrices and outcomes to assess program fidelity from pilot to post full-scale implementation.
Results: The pilot program was conducted in a metropolitan, urban and rural/northern population to represent the geographic and socioeconomic diversity of Ontario. The pilot supported 540 PCPs and assessed 6,500 referrals (50% had follow visits and 25% underwent additional specialty assessments); demonstrated unprecedented access of less then 4 weeks from referral (virtually enabled as required); and >90% of patients (n= > 3.000 surveys) reported high patient experience and satisfaction across all multidimensional questions including the ability to better manage their CLPB. As a result of reduced diagnostic imaging, annual estimated per physician cost avoidance was $4175 in year 2. Surgical referral appropriateness increased to 96% compared to 20-30% prior to the program. 97% of PCPs reported satisfaction with the program and felt the program would be useful to all PCPs.
Consistent annual pilot results across geographies/economies led to ministry of health funding for full-scale implementation across Ontario (population 14 million). Since April of 2018, the number of PCPs enrolled in the program has grown to 8,782 (1,205 nurse practitioners) and counting. As of October 2023, over 71,000 patients have been assessed (53% had follow-ups and 20% underwent additional specialty assessment). The biopsychosocial profile of patients remained the same as the pilot, as did assessment access times (less than 4 weeks), multidimensional patient experience and satisfaction >90% (n= >12,000 surveys) and specialty referral appropriateness (> 90%). 33,729 referrals requested “recommend appropriate imaging” (12% proceeded to imaging) and 47,526 requested “indicate need for specialist intervention” (16% had specialist assessment).
Discussion: An integrated primary-to-tertiary care, shared-care, interprofessional assessment and education CLBP program-maintained program fidelity from pilot to full-scale implementation. The Ontario RAC-LBP program provides significant positive multidimensional impact on CLBP patients, providers and the healthcare system (public, single-payer, fee for service).