Improving Adherence to Back Pain Guidelines in a Resident Run Outpatient Clinic

From the 2019 HVPAA National Conference

Dr. Essam Nagori (Greenwich Hospital Yale New Haven Health), Dr. Stephanie DeLuca (Greenwich Hospital Yale New Haven Health), Dr. Annette Lukose (Greenwich Hospital Yale New Haven Health), Dr. Nicole Tyer (Greenwich Hospital Yale New Haven Health)

Back pain is one of the most common presenting complaints in the primary care setting, accounting for approximately 3% of all outpatient diagnoses (1). Most nonspecific back pain resolves spontaneously without the need for costly interventions. Despite clear guidelines, direct and indirect costs due to back pain are tremendous, often because of unnecessary imaging, medications, and physical therapy referrals (2).

This quality improvement project aimed to improve adherence to evidence based, high value guidelines for back pain in a resident run free clinic at an academically affiliated community hospital.

We retrospectively reviewed all outpatient charts with a primary or secondary diagnosis of “back pain” from September 1, 2017 through December 31, 2017 in our resident run clinic. We reviewed charts for appropriate documentation of pain, red flag symptoms (as identified by the AAFP guidelines (3) which include motor or sensory loss, incontinence of bladder/bowel, malignancy, or infection), prior imaging, and prior treatments, as well as treatment recommended during the visit, specifically medications, imaging, and physical therapy referrals. Didactic sessions were then provided to all residents which included a combination of small group discussions and education of an EMR-embedded smart phrase to standardize all back pain visits to address the pain, red flag symptoms, prior imaging, prior treatment, and treatment recommendations. We then performed a second retrospective review of all outpatient charts with a primary or secondary diagnosis of “back pain” from September 1, 2018 through December 31, 2018 to see if our educational measures and EMR-embedded smart phrase improved both clinical care and documentation.

Guideline based high value care improved in the post-intervention group compared to the pre-intervention group. After educating the residents and embedding an EMR smart phrase into the clinic notes, residents were significantly less likely to order imaging, prescribe medications, or refer to physical therapy (see Table 1). Interestingly, although there was an overall decrease in the percentage of patients who received a medication prescription, there was a slight relative increase in the amount of non-recommended medications prescribed in the post-education group. The secondary outcome (improvement in documentation) was also met as there was a significant improvement in documentation and coding in the post-intervention period. The increased volume of patients captured during the post-intervention group has been attributed to better documentation and coding of back pain as a primary or secondary diagnosis.

Education of the appropriate guidelines to residents and implementation of an EMR-embedded smart phrase significantly improved adherence to guideline-based recommended treatment plans and appropriate documentation in our resident run outpatient clinic. In addition to enhancing care and documentation, a standardized EMR template appears to help residents perform required, but sometimes missed, aspects of the history and physical exam, which may also be an indirect medicolegal benefit.

There were a limited number of “pre-intervention” charts reviewed from 2017. Most of this can be explained because, prior to the intervention, there was a lack vigilance to uniformly code “back pain” as a primary or secondary diagnosis. Opportunities for future investigation include: evaluation of costs pre and post-intervention, and evaluation of further follow-up visits for persistent or chronic back pain following initial review. We also believe we can use this same model to extrapolate to other common outpatient complaints, especially ones that have clear guidelines.


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