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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
Copyright © 2016 Northumberland Tyne and Wear NHS Foundation Trust & South Tees Hospitals NHS Foundation Trusts (On behalf of the
North East Quality Observatory Service, (NEQOS)
Ridley House │Henry Street │Newcastle upon Tyne │NE3 1DQ
www.neqos.nhs.uk
Tel: 0191 245 6708
1 Contents
2 Executive Summary ......................................................................................................................... 5
3 Programme Details ......................................................................................................................... 7
3.1 Title or name of intervention .................................................................................................. 7
3.2 Aims and objectives (including primary and secondary outcomes) ....................................... 7
3.3 Rationale for the intervention ................................................................................................ 8
3.4 Contact details ........................................................................................................................ 8
3.5 Commissioners of the intervention and sources of funding................................................... 9
3.6 Description of Interventions and Timescales .......................................................................... 9
3.7 Duration of funding (including dates) ..................................................................................... 9
3.8 Location and setting .............................................................................................................. 10
3.9 Core staff competencies for T&T .......................................................................................... 10
3.10 Incentives for attendance ..................................................................................................... 11
3.11 Detailed breakdown of costs ................................................................................................ 11
3.12 Cost of the intervention per patient ..................................................................................... 11
3.13 Cost to the patient (if possible) ............................................................................................. 11
4 Evaluation Details ......................................................................................................................... 12
4.1 Type of evaluation and evaluation design ............................................................................ 12
4.2 Methods and timings of data collection ............................................................................... 12
5 Demographics of Individual Patients ............................................................................................ 13
5.1 Age ........................................................................................................................................ 13
5.2 Gender .................................................................................................................................. 14
5.3 Ethnicity ................................................................................................................................ 14
5.4 Disability ................................................................................................................................ 14
5.5 Measure of socio-economic status ....................................................................................... 14
5.6 Local Authority / CCG ............................................................................................................ 15
6 Process Evaluation ........................................................................................................................ 17
6.1 Number of referrals to T&T .................................................................................................. 17
6.2 Waiting times for initial appointment .................................................................................. 18
6.3 Number of patients at each pathway point .......................................................................... 19
6.4 Reasons for opt-out and did not attends (DNAs) ................................................................. 20
6.5 Description of what was actually delivered and details of any unexpected outcomes ....... 20
7 Baseline and Discharge Data ......................................................................................................... 21
7.1 STarT Back Scores.................................................................................................................. 21
Page 4 of 38
7.2 Measures of pain & physical activity .................................................................................... 22
7.3 Measures of anxiety and depression .................................................................................... 24
7.4 Generic Health Status outcome measures – EQ-5D ............................................................. 26
7.5 Patient Experience measure - Friends and Family Test ........................................................ 28
8 Summary and recommendations .................................................................................................. 29
8.1 Summary of results (for primary and secondary outcomes) ................................................ 29
8.2 Details of any further analyses and statistical methods used .............................................. 30
8.3 Limitations and generalisability ............................................................................................ 30
8.4 Recommendations to improve data quality and delivery of pathway ................................. 31
8.5 Dissemination of learning and findings ................................................................................ 32
Page 5 of 38
2 Executive Summary
This report is an independent evaluation of the implementation of the South of Tees Back Pain
Triage and Treat Practitioner (T&TP) Service across South Tees and Hambleton, Richmondshire
and Whitby CCG Regions in July 2015. It provides information for the Academic Health Science
Network for the North East and North Cumbria (AHSN NENC)who funded the implementation
of the pathway as well as the CCGs who are now commissioning the ongoing delivery. The
evaluation reports on quantitative process (activity) data from SystmOne and outcomes data
from the Triage and Treat (T&T) database. This data has been combined with qualitative data
collected from staff working across the pathway of care.
This pathway will reduce unnecessary investigations and interventions while providing rapid
access to core therapies and where necessary booked referral slots for MRIs, nerve root blocks,
surgical opinion and pain management. The pathway will improve patient outcomes and
reduce disability and chronicity of back pain. Outcomes are measured using validated patient
reported outcomes and patient experience measures including:
Pain numeric rating score (PNRS)
Oswestry Disability Index (ODI) – back pain outcome score
Measures of anxiety and depression (GAD7 and PHQ9)
EQ-5D – generic health status measure
Friends and Family Test (FFT)
Questionnaires are completed at the initial assessment with a T&TP, on discharge and six
months following the initial assessment.
From July 2015 to April 2016, almost 3,000 have been referred to the T&TP Service with an
average age of 52 years and approximately a 60:40 split between female and male patients.
The majority of patients have come from Middlesbrough and Redcar & Cleveland with growing
numbers coming from the Hambleton, Richmondshire and Scarborough areas. Over 60% of
patients have been seen within 2 weeks of logging on the Choose and Book system but there
have been considerable delays between patients logging on to Choose and Book after referral.
The table below summarises the pathway points for this group of patients and highlights that
the relatively few patients have required onward referral for investigations and/or
management with hospital services and the most common referral is for core therapies.
Pathway Point Total Percentage
Core Therapies 594 21.7% MRI Referrals 372 13.5% Surgical Opinion 119 4.3% Nerve Root Blocks 65 2.4% Pain Management 44 1.6% CPPP 32 1.2%
Total Assessed 2,744
Page 6 of 38
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 below). The greatest improvements have been
noted for the Pain NRS and the ODI and the generic EQ-5D also demonstrated a significant
improvement which on average was 0.22. This improvement in EQ-5D score is considerably
higher than the threshold set by NICE as the minimum improvement required for healthcare
interventions.
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.
Discharge assessments are also collected at varying time points from the initial assessment
depending on their pathway points. Further economic evaluation can be conducted in future
when there is s greater volume of discharge data and change in 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.
The T&TP Service have regular MDT meetings to ensure that the pathway is being delivered to
the standards set in the policies and procedures developed by the Trust and that any issues are
resolved in a timely manner. Results from this evaluation have been fed back via this group and
improvements in data collection and data entry are already in place to provide high quality data
for future evaluations of this service. The MDT is also reviewing where there is variation in
pathway points to ensure that there is not unwarranted variation in patient access to care.
Page 7 of 38
3 Programme Details
This report will evaluate the implementation of the acute low back and radicular pain pathway
across South Tees and Hambleton, Richmondshire and Whitby CCG Regions which commenced
in July 2015. The evaluation will report on quantitative process (activity) data from SystmOne
and outcomes data from the Triage and Treat (T&T) database. This will be combined with
qualitative data collected from staff working across the pathway of care.
3.1 Title or name of intervention
South of Tees Back Pain Triage and Treat Practitioner (T&TP) Service
3.2 Aims and objectives (including primary and secondary outcomes)
The aim of this service is to provide a single point of access for patients aged 16 years or
older with back and/or radicular pain who score 4 or more on the Keele STarT back
screening tool. The pathway encourages primary care to reassure patients who score less
than 4 on the STarT back tool and sign-post them to self-care in this first instance.
The objectives are to reduce the time patients wait for appointments as well as ensure that
they access the right treatment at the right time from the right person.
Referrals predominantly come via primary care and patients access the service via Choose
and Book. After the initial assessment patients may be discharged for self-management or
referred on according to the pathway (see Appendix 1). This pathway will reduce
unnecessary investigations (such as lumbar spine X-rays) and interventions with no evidence
base (such as lumbar facet joint injections) while providing rapid access to core therapies
and where necessary booked referral slots for MRIs, nerve root blocks, surgical opinion and
pain management. The pathway will improve patient outcomes and reduce disability and
chronicity of back pain.
Outcomes are measured using validated patient reported outcomes and patient experience
measures including:
Pain numeric rating score (PNRS)
Oswestry Disability Index (ODI) – back pain outcome score
Measures of anxiety and depression (GAD7 and PHQ9)
EQ-5D – generic health status measure
Global Outcome Score
Friends and Family Test (FFT)
Questionnaires are completed at the initial assessment with a T&TP, on discharge and six
months following the initial assessment.
Page 8 of 38
3.3 Rationale for the intervention
Lower back pain is the largest single cause both of loss of disability adjusted life years and of
years lived with disability in the UK. The condition principally affects people of working age
and those with families, and the burden of disease is increasing.
Patient knowledge of the condition is poor, resulting in unrealistic expectations and high
demands on the health care system. There is variation in back pain management across
professional groups in the NHS and private sector, often resulting in expensive investigations
and ineffective care, leading to poor outcomes and low patient satisfaction.
The report in 2013 of the Spinal Task Force demonstrated that spinal surgery in England is
under pressure. In some areas there are no spinal services available, with patients having to
travel to the next nearest spinal surgeon. Smaller hospitals face pressures in the provision of
adequate audit and governance arrangements. Many spinal centres struggle to achieve
compliance with the 18 week target. Some District General Hospitals have ceased to provide
spinal surgical services.
The volume of spinal surgery is spiralling – the NHS in England spends £200m per annum on
spinal surgery and there are currently approximately 10,000 adult patients each year that
have elective spinal surgery. However there is a large variation in practice with inconsistent
indications. In an addition, there are large numbers of patients being given injections with
low evidence of effectiveness. Reducing ineffective but costly injections alone would save
the NHS £9m a year.
The implementation of the pathway will include a public health programme to promote
“normalisation” of back pain; standardise patient literature/information in conjunction with
retraining of healthcare professionals to “de-medicalise” simple back pain. There is a large
focus on training and educational workshops for all clinicians involved in the pathway which
will also give the opportunity to ensure a consistent message is given to Back Pain and
Radicular Pain patients throughout the pathway.
3.4 Contact details
Charles Greenough, Consultant Orthopaedic Surgeon, South Tees NHS FT
Glynis Peat, Directorate Manager, South Tees NHS FT
Helena Roper, Lead Triage and Treat Practitioner, South Tees NHS FT
Page 9 of 38
3.5 Commissioners of the intervention and sources of funding
Academic Health Science Network for North East and North Cumbria (AHSN NENC) provided
the initial funding to implement the pathway and from July 2015 delivery of the pathway has
been funded by South Tees CCG and Hambleton, Richmondshire and Whitby CCG.
3.6 Description of Interventions and Timescales
Patients referred to the T&TP access this service via Choose and Book and the aim is to
provide an initial appointment within 14 days of referral. The timeliness of seeing patients
for their initial assessment is therefore also dependant on patients logging on to the Choose
and Book system as soon as they are referred.
Following the initial assessment (first attendance) with the T&TP, patients access a range of
treatment and/or further investigation and referral options as per the pathway. This can
include discharge for self-management, referral to core therapies or nerve root blocks,
referral for MRI or referral to surgical opinion or pain management (Appendix 1).
Core therapy appointments are made by the T&TP by electronic referral. Patients are
contacted directly and offered a choice of time and venue for their appointments. Core
therapies follow the ‘Approved Therapy Guidance’ included in Appendix 2. Patients with
a good response can be discharged directly from this service (outcome measures
returned to the T&TP service are required at the time of discharge). If patients make
insufficient improvement, a review with the T&TP is indicated at latest by 12 weeks.
Nerve root block appointments at James Cook University Hospital (JUCH) are made via
direct access slots where patients are given an appointment date and time.
MRI appointments (radicular pain only) are made via direct access slots with two slots
available every day at 7.30pm and patients are provided with a standard information
letter (Appendix 1).
Surgeon appointments (orthopaedics/neurosurgery) are made within 1-2 weeks if
patients are unsuitable for nerve root blocks.
Pain services appointments are made by the T&TP by electronic referral.
On the second assessment with the T&TP the decision is made about the necessity to refer
patients to either a further 6 weeks of core therapy (as per Approved Core Therapies
Guidance), the Combined Physical and Psychological Programme (CPPP) or if unsuitable for
CPPP to refer on to the Pain Services.
3.7 Duration of funding (including dates)
AHSN NENC funding covered the period between November 2014 and July 2015 to set up
the service and provide education and training for a range of stakeholders including GPs,
physiotherapists, nurse practitioners, patients and the public. CCGs funding commenced in
July 2015 for ongoing delivery of the service.
Page 10 of 38
3.8 Location and setting
The Back Pain Triage and Treat service is provided across six locations:
James Cook University Hospital (JCUH)
Resolutions Health Centre (RHC)
Redcar Primary Care Hospital (RPCH)
East Cleveland Hospital (ECH)
Friarage Hospital (FNH)
Whitby Community Hospital (WCH commenced June2016 – data not included in report)
3.9 Core staff competencies for T&T
The current core T&TP staff are either Extended Scope Practitioner Physiotherapists (3.9
WTE) or Specialist Nurse Practitioners (3.5 WTE).
o Specialist Nurse 32 hrs 0.85 WTE (6 x sessions @ JCUH per week)
o Specialist Nurse 30 hrs 0.8 WTE (6 x sessions @ ECH per week)
o Specialist Nurse 1.0 WTE (2 x sessions @ JCUH & 6 x sessions @ RPCH per week)
o Physiotherapist 1.0 WTE (approx. 5 x sessions @ RHC & 3 x sessions @ JCUH)
o Specialist Nurse 1.0 WTE (in training - all sessions @ JCUH)
o Physiotherapist 1.0WTE (8 sessions @ FNH)
o Physiotherapist 0.6 WTE (4 sessions @ FNH)
o Physiotherapist 0.85 WTE (6 sessions @ FNH and 2 sessions @ WCH)
o Physiotherapist 0.55 WTE (Maternity Leave return September 2016)
T&TP are recruited with essential competencies to deliver this service and have an additional
programme of training sessions (Appendix 3) to cover:
o Interpreting MRIs with radiographic report (3 sessions, 2 hours each)
o Pathway and consistent message by all clinicians throughout the pathway (also
attended by community physiotherapists. Session at each site for 2 hours)
o Keele STarT Back Tool – interpreting results (2 days )
Joint educational events (2 sessions, 3 hours) between the T&TP and he community
physiotherapists have also been provided since the implementation of the pathway
(December 2015 and April 2016).
Time out sessions (half-day) with GPs from South Tees CCG and HRW CCG were provided in
2015 prior to the launch of the pathway. These sessions covered the current burden on the
Page 11 of 38
health of the population due to back pain and the burden this places on healthcare services,
rationale for implementing the new pathway, information about the referral process and
using the template (specifically the Keel STarT back tool) to guide GPs through the pathway.
GPs were also provided with an overview of the rationale of the CPPP programme, as well as
experience of delivering this programme from the Royal National Orthopaedic Hospital.
South Tees FT also produces a newsletter that is distributed widely to GPs, community
physiotherapists and other relevant stakeholders across South Tees and HRW CCGs.
3.10 Incentives for attendance
None for attendance but the Trust is working with commissioners to put in place incentives
for completion of patient reported questionnaire data at six months from referral.
3.11 Detailed breakdown of costs
This service was introduced during a financial year (July/August 2015) and replaced an
established service for patients within South Tees and Hambleton, Richmondshire and
Whitby regions. South Tees and HRW CCGs provided the Trust with transitional costs to set
up and run the service for the remainder of the financial year (2015/16).
We would recommend that the CCGs undertake an independent evaluation once the service
has been running for a full financial year to provide a full cost breakdown and enable
analyses of the costs alongside patient reported health gain. As illustrated in section 7 of the
report, on average there have been significant improvements across all outcome measures
collected, and the majority of patients reported a better score at discharge. This will have an
impact on the health economics, the EQ-5D demonstrated a significant improvement which
on average was 0.22 which is considerably higher than the threshold set by NICE as the
minimum improvement required to justify ongoing investment.
3.12 Cost of the intervention per patient
As noted above; this should be included as part of an independent evaluation once the
service has been in place for a full year.
3.13 Cost to the patient (if possible)
Not possible to determine costs to patient in terms of travel and/or costs incurred related to
need to take time off work to attend T&TP. Although traditionally the service was provided
at James Cook University Hospital site and the Friarage Hospital patients now have a choice
of clinics closer to home to help reduce costs of travel to the patient.
Page 12 of 38
4 Evaluation Details
This is an independent evaluation of the acute low back and radicular pathway implanted by
South Tees NHS Foundation Trust for patients registered with South Tees CCG and Hambleton,
Richmondshire and Whitby CCG.
4.1 Type of evaluation and evaluation design
Evaluation of the SystmOne data that collates patient activity once they have registered with
Choose & Book which provides data on attendance, waiting times and onward referrals.
Evaluation of patient questionnaire data entered on the T&T database within the service.
4.2 Methods and timings of data collection
Patient questionnaire data is collected at initial assessment, on discharge and six months
following the initial assessment. Not that at the time of this evaluation only initial and
discharge outcomes data was available.
Page 13 of 38
5 Demographics of Individual Patients
Overall, in SystmOne there are 2,823 patients from South Tees and HRW CCGs who have been
referred to the T&TP between July 2015 and May 2016. The majority of these patients (2,744)
also reside within the five Local Authorities covered by these CCGs.
5.1 Age
The age of patients at the time of referral ranges from 16 to 90 years and overall is normally
distributed with a mean age of 52 years (SD 16 years) which translates to approximately two
thirds of patients being aged between 36 and 68 years (Figure 1).
There is variation in age at the time of referral between the Local Authorities with a higher
proportion of younger patients coming from Middlesbrough (mean 49), Redcar and
Cleveland (mean 52) compared to Hambleton (mean 55), Richmondshire (mean 56) and
Scarborough (mean 55).
0
50
100
150
200
250
300
350
16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90
Figure 1. Number of Referrals by Age Band
0
20
40
60
80
100
120
16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90
Figure 2. Number of Referrals by Age Band & Local Authority
Scarborough
Richmondshire
Hambleton
Redcar and Cleveland
Middlesbrough
Page 14 of 38
5.2 Gender
Overall, there is a about a 60:40 split between females and males being referred to the T&TP
and this is similar across all of the Local Authorities with the exception of Scarborough where
there is a higher proportion of female patients referred.
5.3 Ethnicity
Ethnicity data is only available on approx. 40% of patients on SystmOne and due to the high
proportion of missing data and non-standard use of codes; this data has not been reported.
5.4 Disability
Disability data is not available through the SystmOne.
5.5 Measure of socio-economic status
Socioeconomic status can be calculated using deprivation deciles that are based on the
different lower super output areas (LSOAs) based on where the patient is resident. LSOAs
are similar to wards and have a population of approximately 1,500 people. The deprivation
deciles are 10 categories that range from most deprived to least deprived LSOAs in England.
36 42 41 39 41
64 58 59 61 59
Scarborough(N=123)
Richmondshire(N=275)
Hambleton(N=564)
Redcar andCleveland (N=873)
Middlesbrough(N=909)
Figure 3. Percent of Referrals by Gender & Local Authority
Male Female
0
100
200
300
400
500
600
700
1 - MostDeprived
2 3 4 5 6 7 8 9 10 -Least
Deprived
Figure 4. Number of Referrals by Deprivation Decile
Page 15 of 38
5.6 Local Authority / CCG
Referral rates per 1,000 adult population (age 16+) could be calculated for the different
lower super output areas (LSOAs) based on where the patient is resident. LSOAs are similar
to wards and have a population of approximately 1,500 people. This information can then
be mapped to identify if there is variation across the CCG in referrals, and support targeted
work with GP practices in areas where there are lower referral rates.
Note that it is possible that some patients may be registered with a CCG but not live within
the geographical boundary of the CCG. This can be seen in South Tees CCG (Map 1) where
we see small number of referrals coming from County Durham, Richmondshire and
Scarborough. The majority of referrals for South Tees CCG are for patients who live in
Middlesbrough.
Map 1.
The T&TP clinics are highlighted in red on the maps. South Tees CCG (map above) covers
two Local Authorities: Middlesbrough (James Cook Hospital and Resolutions Health Centre
T&TP clinics) and Redcar & Cleveland (Redcar Primary Care Hospital & East Cleveland
Primary Care T&TP clinic).
Page 16 of 38
Hambleton, Richmondshire & Whitby CCG (Map 2) is over three Local Authorities:
Hambleton (location of Friarage Hospital T&TP clinic), Richmondshire and part of
Scarborough District (new clinic now open in Whitby). The majority of patients referred
from this CCG are for patients who live in Hambleton.
Map 2.
Page 17 of 38
6 Process Evaluation
This section looks at the process of patients moving through the T&TP service since it started on
mid July 2015 with an initial 2-week transition period and full implementation by August 2015.
6.1 Number of referrals to T&T
Referral numbers increased rapidly after the first 2 months and since September 2015 there
have been between 300 and 350 patients booking appointments through Choose and Book
per month. It is possible that some GPs are referring patients who do not go on to register
on the Choose and Book system so this data may underestimate the true volume of referrals
which could only be captured through GP information systems.
Figure 6 presents the number of referrals based on the local authority where the patient
lives and demonstrates that there has been higher uptake of the service in Middlesbrough,
Redcar and Cleveland consistently during this period.
0
20
40
60
80
100
120
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
Figure 6. Number of Referrals per Month by Local Authority
Scarborough
Richmondshire
Hambleton
Redcar & Cleveland
Middlesbrough
Page 18 of 38
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.
Page 19 of 38
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.
Page 20 of 38
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.
Page 21 of 38
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
Page 22 of 38
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)
Approved by Epidemiologist Liz Lingard
Approved by Project Director Michael Walkley
Peer Reviewed by (if appropriate) Not applicable
Originating organisation NEQOS
Website of originating organisation
Contact email address [email protected]
Public file location
Internal file location G:\Project Management\Project Mgt 15-16\AHSN Back Pain Evaluation\Report
VERSION CONTROL
Version Document Type Date Amendments By
1 Draft 8.07.2016 Initial version of report Liz Lingard
2 Draft 25.07.2016 Updated analyses and text with QA of data presented
Liz Lingard
Kayoung Goffe
3 Draft 25.07.2016 Final updates to draft Liz Lingard
Kayoung Goffe
1 Final 1.08.2016 Final edits & corrections to text Liz Lingard
2 Final 02.08.2016 Correction to logos Liz Lingard
PLEASE SEND FINAL REPORT TO NEQOS OFFICE FOR DISTRIBUTION
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If not, the Epidemiologist AND Director must justify why not here, highlight, and agree the need for an NDA
Not applicable
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