Assessment of general practitioners’ interests in expediting wait lists for spine surgical consultation with use of allied health professionals—results of a pilot study

Introduction

Spine surgeon consultation for patients with non-urgent low back pain (LBP) is among the longest wait-times for any medical service in Canada (1). Braybrooke et al. have estimated a 1–2 year waiting period between one’s primary care visit and subsequent spine surgical consultation for non-urgent LBP in Canada (2). Given that many individuals with non-urgent LBP do not need surgical intervention (3), prolonged physical and emotional stress as a consequence of excessive wait times can be avoided. Beyond the individual level, there is evidence that LBP also manifests as an immense economic burden in the United States and in Canada (4-6). This fact, compounded with an ever-increasing mean population age, underscores the importance of anticipating the forthcoming obstacles faced by all parties involved in the management of LBP (1,4).

It is clear that the Canadian research community is largely aware and concerned about the inaccessibility of spine surgeon consultations for cases of LBP (2,3,7). General Practitioners (GPs) are consistently regarded as a source of insight, since these professionals are often entrusted by patients with LBP to make initial decisions on one’s course of treatment (3,8,9). Oftentimes, however, these decisions lead to inappropriate surgical referrals, as Deis and Findlay have previously estimated the rate of inappropriate LBP referrals for surgical consultation to exceed 40% (9). Findings from a survey administered by Busse et al. to fifty-five spine surgeons adds to the complexity of this process, as 78% of respondents require imaging to accompany all referrals (10). This is in contrast to evidence which discourages GPs from routine, immediate lumbar imaging (11), therefore placing GPs in a state of limbo and uncertainty. Such a discrepancy is likely to augment the already excessive wait times for spine surgeon consultation in Canada, which has been shown to predict worse post-operative outcomes for those needing surgical intervention (2,12).

Spine triage programs in which allied health professionals are trained by surgeons to assess patients with LBP has been widely accepted by the academic community (1,10,13-17). Triage would, in theory, improve the quality and accessibility of care for patients with LBP by offering evidenced-based screening and non-operative treatment prior to surgery (18). The Saskatchewan Spine Pathway is a testament to this notion, as researchers demonstrated that a unified and multidisciplinary approach to LBP management can reduce unnecessary MRI utilization and surgical referrals (13,14). Non-physician clinicians (NPCs), such as physiotherapists (PTs), nurse practitioners, and physician assistants, who train alongside spine surgeons have a proven ability to spearhead such an initiative (15,16,19-21).

Thus, our primary objective was to assess general practitioner’s (GPs) experiences with referral to a single-centre, large-scale spine surgery service at the Hamilton General Hospital. Additionally, we sought to assess GPs’ receptiveness to the triaging of their LBP referrals by NPCs. Our secondary objective was to determine the criteria that GPs use when referring their LBP cases to the aforementioned spine surgery service.

Methods

Survey development

The previously outlined parameters for successful surveying of healthcare professionals was used as a guideline throughout the survey development process (22). We developed a web-based cross-sectional survey to evaluate which criteria are important for GPs to consider when referring their LBP patients for a spine surgeon consultation, and to elucidate their feelings towards triaging of such referrals by NPCs. A 21 closed-ended question English language survey with a host of multiple choice and Likert Scale-style questions was piloted for face and content-validity across a selected cohort of GPs referring to the Hamilton General Hospital spine surgery service. These pilot respondents were not given the final copy of the survey to avoid any potential bias. Revisions included the removal of any sense of personal bias, complex jargon, judgmental tone, cultural insensitivity, and convolution from each question stem (23). The final 21-question survey assessed pertinent demographic information from respondents, their current referral practices, overall experiences with the spine surgery service at the Hamilton General Hospital, and receptiveness to an NPC-run triaging program. Prior to survey dissemination, the study received ethics approval through the Hamilton Integrated Research Ethics Board (HIREB 14-335).

Survey administration

We targeted all GPs who were currently in practice and members of the Hamilton Academy of Medicine (HAM), amounting to 281 potential respondents which represented over half of the entire Hamilton-area GP population referring to the Hamilton General Hospital spine surgery service. A brief personalized e-mail that included a cover letter to communicate the study objective, study implications, confidentiality, a defined time frame for completion, and relevant contact information was disseminated to these individuals on three separate occasions (each four-weeks apart) over the course of a 12-week period. Also included in this email was a secure link where respondents could anonymously access our survey via SurveyMonkey^® (www.surveymonkey.com, Palo Alto, CA, USA), a password-protected online software. For those who did not respond to the initial request, a total of three separate reminder e-mails were administered to the HAM communications department.

Statistical analysis

Descriptive data was obtained from all completed surveys. Categorical, ordinal, and interval variables, which comprised the entire data set, were reported as counts and percentages. Most percentages were calculated with a denominator of 57 total respondents, except for ‘Referral criteria’ (den =56), ‘Referral practices’ (den =52), and ‘Receptiveness to Triage program’ (den =52). All statistical analyses were completed in consultation with a faculty biostatistician, using Microsoft Excel (Microsoft, Santa Rosa, CA, USA, 2008).

Results

Respondent demographics

Of a possible 281 GPs who were members of the HAM, 57 (20%) completed the survey. Gender was nearly equal among the respondents [30 (53%) were male], and most were over 50 years of age [39 (68%)] (Table 1). Of respondents, 42 (74%) were working in a community setting and 51 (89%) reported having more than ten years of clinical experience.

Most respondents [37 (65%)] saw at least 5 patients with a primary complaint of LBP per week. Physicians were less likely to encounter a case with both LBP and associated radicular leg symptoms, as only 16 (28%) respondents reported seeing more than three of these patients per week.

Experience with access to spine surgeons

Overall, there was dissatisfaction among respondents regarding the course of treatment for non-urgent LBP patients. Specifically, 48 (84%) of GPs admitted to experiencing personal frustration with the current referral process to spine surgeons. A large majority of respondents [52 (91%)] admitted personal frustration with long wait-times for spine surgeon assessment of their patients, with 55 (96%) stating their patients had expressed similar annoyance with the long waiting period (Table 2).

Referral criteria

Participants were asked a series of Likert-scale questions (responses ranging from ‘Strongly Agree’ to ‘Strongly Disagree’) with a total of 56 respondents completing this component of the survey. Fifty respondents (89%) were in disagreement that persistent LBP even after a minimum 6 weeks of analgesics warranted referral. A similar majority of GPs [46 (82%)] also denied the necessity of a surgical consultation if LBP continued after a reasonable trial of physiotherapy. However, 50 (89%) of respondents were in strong agreement that LBP with concurrent bowel and/or bladder incontinence was sufficient cause for spine surgeon referral. A similar trend for LBP with possible neoplastic cause was observed, as 46 (82%) of GPs at least somewhat agreed in the need to send these patients for a specialist’s opinion. Conversely, three quarters [42 (75%) of participants did not feel that cases with LBP and multiple episodic flare-ups were worthy of a consultation. A surprising minority of GPs (22 (39%)] referred for LBP that prevented a patient from returning to work, and a similar proportion [23 (41%)] admitted to referring LBP cases based on uncertainty of etiology (Table 3).

Referral practices

Among 52 respondents’ pre-spine surgeon referral practices, 30 (58%) indicated they never ordered a CT of the lumbar spine prior to referral (Table 4). With regards to clinical indicators of CT and/or MRI investigation of the lumbar spine, ‘Bowel/bladder incontinence’ unsurprisingly obtained a 100% response. Thirty-four (65%) respondents indicated they “Usually, but not always” referred to a physiatrist for consultation and an electromyography/nerve conduction velocity (EMG/NCV) study assessment prior to referral.

To ensure patient-centered care, 49 (94%) participants attempted to educate their patients with LBP on the rationale for referral and explained what interventions might be proposed upon consultation. Similarly, 50 (96%) respondents routinely addressed their patient’s thoughts on having surgery, should it be necessary for their LBP. Among respondents, all (100%) agreed that all CT and/or MRI reports should be reviewed with their patient prior to referral.

Receptiveness to a Triage program

From a total of 52 respondents, referring patients with LBP to an NPC-run triage program was supported by 46 (88%) GPs (Table 5). A similar proportion [44 (85%) of GPs supported surgical screening assessment and subsequent referral recommendations by nurse practitioners, especially in cases where a patient’s CT and/or MRI was inconclusive. Most participants (50 (96%)] would feel comfortable with a Physiotherapist-led spine triage program, with support of Nurse Practitioner or Physician Assistant-run triage programs less favoured at 28 (54%) votes. Thirty-two (62%) respondents indicated they had prior experience in referring cases to an NPC pre-screening LBP clinic.

The survey also assessed if GPs would be interested in spearheading their own triage initiatives. Forty-two (81%) respondents were receptive to courses that teach GPs about LBP-specific physical examination and triaging techniques that are directed by spine surgeons with continuing medical education (CME) credits. Fewer [33 (66%)] participants, however, were open to courses offered through an online, web-based curriculum.

Discussion

Our survey revealed an overwhelming dissatisfaction among GPs regarding wait times for spine surgery consultation for patients with LBP. Most primary care physicians pursue surgical referral in cases of persistent LBP with concurrent bowel and/or bladder incontinence and separately with concurrent radicular leg pain, or possible neoplastic origin. Respondents were quite conservative in their identification of the clinical indices that warrant subsequent diagnostic imaging, with MRI of the lumbar spine often accompanying referral to a spine surgeon. Once a decision was made regarding consultation, an overwhelming majority of GPs empowered their patients by ensuring transparency and addressing any apprehensiveness about the management process going forward. To streamline referrals, GPs expressed a strong support for LBP triage programs run by NPCs, particularly advanced practice physiotherapists, who would conduct surgical screening assessments and subsequent surgical and non-surgical referral recommendations for their patients. Although the majority of respondents had previous experience in utilizing such a service, many GPs demonstrated an interest in learning more about how they can better integrate spine triaging initiatives into their decision-making process.

The implementation of triaging programs to expedite wait lists for patients with LBP seeking spine surgeon consultation has garnered international attention. However, with various research teams assessing the feasibility and impact of such an initiative, the culmination of evidence to date is heterogeneous (24). Though the exact nature of how such programs should come to fruition has not yet been established, there is clear interest among many key stakeholders to streamline this process from a resource management and patient-flow perspective (17,25). In particular, Busse et al. (17) administered a survey to Canadian spine surgeons and found that 77.6% of respondents were interested in an allied-health professional pre-screening led model of care. More recently, Rempel et al. (25) used a very similar approach to assess patients’ attitudes toward non-physician screening of their condition and observed that a large majority of respondents (88.8%) would support a program of this nature, with nearly half considering neither distance nor out-of-pocket payment to be a potential barrier. Thus, it appears to be clear that patients, primary care physicians, and Canadian spine surgeons involved in the managing LBP appear to be overwhelmingly in favour of implementing allied health professional-led LBP triaging programs.

With a “patient-centered” model of care being emphasized throughout the medical community, streamlining the management of patients with LBP through triaging is inherently warranted. NPCs with an appropriate scope of practice to serve such an initiative include nurse practitioners, chiropractors, occupational therapists, athletic therapists, and physiotherapists (26). Due to their musculoskeletal expertise and autonomy for referral, the latter subgroup is consistently at the forefront of discussion (15,21,24,26-30). In particular, advance practice physiotherapists (APPs) whom are trained alongside orthopedic surgeons have high clinical diagnostic accuracy, thus increasing the efficiency of the referral process (16,27-29). Recently, Robarts et al. (27) demonstrated an observed agreement of 86.3% on decision for surgical consultation for LBP patients between an orthopedic surgeon and an APP. Furthermore, the present survey highlights primary care physicians’ current practice of accompanying referrals with costly diagnostic imaging (10). Through spine triage programs spearheaded by NPCs, there is a potential to minimize seemingly futile CT and MRI scanning and maximize holistic evaluation and management strategies (27,30,31).

Although Boakye et al. appropriate a GP’s scope of practice within the initial assessment phase prior to NPC-led triaging of LBP patients (26), the referral criteria identified by respondents included in the present study are in line with established guidelines (24,27,30,31). In particular, GPs identified concurrent LBP and radicular leg pain, leg numbness/paraesthesias, bowel and/or urinary incontinence, and possible neoplastic cause as clinical indices that warrant consultation with a spine surgeon. Furthermore, GPs reportedly educate their patients on evidence surrounding LBP as well as what they should expect going forward, which is an inherently patient-centered approach. This finding might suggest that GPs are equipped with the tools to triage their patients alongside NPCs—however, a major component of this type of program is implementing management strategies for those deemed ineligible for surgery (30,31). Though these recommendations require an expertise of the musculoskeletal system, which might be outside the scope of practice for GPs, future studies aimed at uncovering GPs’ approach to care are warranted.

Limitations

We were only able to accrue 57 responses from 281 total GPs that the survey was initially disseminated to. Given that our response rate of 20% falls below the 54% benchmark proposed by Asch et al. (32), which was based on mailed-in surveys rather than online administration, our results face inherent limitations. However, recent qualitative studies targeting Canadian (33-35) and foreign (36-38) GPs have reported a similarly low response rate, suggesting that survey administration is difficult to conduct among this physician population. Indeed, our results are in line with the expected sub-40% response rate for online questionnaires with physician respondents (39). Response bias must also not be discounted from the present study, as GPs who have had more positive experiences with accessing spine surgery care for their patients may have been more apt to respond. It is also likely that GP frustrations with the Hamilton-area spine surgery service was exceedingly high at the time of survey administration, as non-urgent referral wait times exceeded 18 months on average. Furthermore, targeting only those GPs who were members of the HAM retracts from the national and international applicability of the present findings. However, physician frustration with long-wait times and access to spine surgeon consultations for their patients is a well-known frustration across Canada (40). This notion is especially relevant for private health care systems, as patients in this setting might not experience wait times that are extreme enough to warrant triaging by NPCs.

Conclusions

Current experiences for patients and primary care physician referrers of individuals with LBP is poor with respect to accessing spine surgeon consultation services. Using NPCs and in particular physiotherapists to lead triaging programs for patients with LBP is well-received by GPs. The utilization of such referral programs has the potential to expedite appropriate care pathways for patients with LBP and better utilize diagnostic imaging resources and spine surgeon consultation. Future research endeavors need to assess the cost-effectiveness and feasibility of such government run NPC LBP screening programs to better assess patient experiences, outcomes and resource utilization if such a shift from the current spine surgical consultation model is to occur.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jhmhp.2018.09.01). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Informed consent was waived due to the nature of the study. Prior to survey dissemination, the study received ethics approval through the Hamilton Integrated Research Ethics Board (HIREB 14-335).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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