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DM program targets low back pain
Goal: Save costs, improve patient quality of life
Low back pain is the second most frequent reason for physician visits, the fifth most frequent reason for hospitalization, and the third most frequent reason for surgical procedures.
That’s one reason CIGNA Health Care, based in Bloomfield, CT, has developed a low back pain disease management program
The program includes education, telephonic intervention by disease management nurses, depression screening, tips on how members can decrease their pain and stay active, and working with the physician’s plan of treatment.
"Low back pain is one of the most common health problems in the United States, affecting as many as 45% of Americans each year. Having a history of low back pain is one of the most reliable predictors of having subsequent problems," says Mary Jane Osmick, MD, senior medical executive for the disease management program and health facilitation for Intracorp, a subsidiary of CIGNA HealthCare.
About 70% to 80% of all Americans experience muscular low back pain at some point in their lives. According to the American Academy of Orthopaedic Surgeons, about 90% recover within six to 12 months, but 75% relapse within a year.
"There is a huge population of people who experience low back pain on a regular basis. It tends to recur and can lead to disability and potentially even surgery if it’s not handled properly," she says.
The insurer revamped its low back pain program in October 2000. About 108,000 members are enrolled in the program. Osmick is anticipating a 7% cost savings from the program based on research, although it’s too early to have any firm figures at this point, she says.
Until a few years ago, practitioners believed that bed rest was the best way to treat muscular low back pain.
"Treatment of muscular low back pain has now been studied, and our beliefs have changed. The reality is that literature suggests that staying moderately active with muscular low back pain has no worse outcomes than bed rest, and if people with back pain keep moving, they might avoid other problems related to being sedentary during their acute pain phase," Osmick says.
The program helps members understand that they will not hurt themselves by remaining active with muscular low back pain, she adds.
Here’s how the program works:
CIGNA examines its monthly claims review, looking for members with several episodes of low back pain in a 12-month period of time. Members with more serious causes of low back pain, such as those with spinal tumors, are excluded.
Members also may be enrolled in the program by self-referral or referrals from physicians, case managers, or nurses in other disease management programs.
"It frequently happens that a member is being treated for diabetes or another condition and their problem with back pain comes to light in conversations with the disease management nurse," Osmick says.
When members are identified as eligible for the program, a disease management nurse conducts a telephone assessment, looking for red flags that indicate more serious low back problems.
For instance, if someone with chronic low back pain has loss of bladder control, numbness, loss of feeling, loss of muscle strength, or fever, he or she isn’t appropriate for the low back program. Instead, they should see a physician immediately, since these symptoms might mean a more serious problem is occurring, Osmick adds.
"Patients with these symptoms in addition to low back pain are directed to see a physician immediately to define the cause of what may be a potentially serious problem," she says.
The nurses ask questions about how severely back pain limits their activity, how much time they have missed from work, and factors such as smoking, being overweight, and a history of back surgery.
"We put together a snapshot of the member. We are looking for someone who has a type of low back pain that is amenable to self-management and prevention," she says.
The initial nurse assessment stratifies members into severity levels. The severity level dictates a minimum number of calls the nurse makes to the patient.
The nurses find out how much knowledge the members have about low back pain, whether they know how to work ergonomically, and help them try to discover what they may do in the course of everyday life to exacerbate the problem, she adds.
"This program helps them understand the physical mechanics of why they got into trouble," Osmick says.
If the patient does not seem to be progressing well or has problems with reinjury, the nurse may increase the frequency of calls with the member. If the member develops any of the "red-flag" symptoms, the nurse directs him or her to the physician. In some cases, with member approval, the nurse contacts the physician directly.
"We use nurses because of their ability to use their clinical acumen and pay attention to signs that the patient may need more attention," Osmick says.
The nurses schedule a convenient time of day for the member to receive telephone calls.
"It may be at 9 p.m., if that’s what the member wants. We want to talk to people at a time when they are most likely to absorb the information," she says.
Because people who have chronic pain have a high incidence of depression, the back pain program nurses use a simple screening tool to find out if the member is likely to have depression.
"Data suggest that it costs three times as much to treat people with low back pain who are also depressed," Osmick says.
If the screening tool indicates a potential for depression, the nurse asks the member if they may share the information with their physician.
"This is a very important step in order to protect patient confidentiality," Osmick says.
In most cases, the members are willing to share the information with their physician.
As a follow-up to a positive depression screen, each time a nurse calls, she asks patients how they are doing from a psychosocial standpoint, and determines whether they are worse and if they still screen positive for depression.
"Tracking a member’s depression and working with them to address these issues with their health care provider is a very important part of caring for all chronic disease problems, including muscular low back pain," she adds.
The low back pain program includes supportive material such as ergonomic guides, a diary that allows patients to track their back pain, and educational materials.
The nurses instruct members on issues such as smoking cessation, strengthening exercises, positioning exercises, and how the way they sleep at night can affect their backs.
"There are many things that increase back pain that people don’t think about. We help them understand what may be causing their problems and how to correct it," she says.
When members have been in the program for 12 months and are stable at the lowest level of severity, they can graduate from the program. If problems recur, they can re-enroll in the program.