independent evaluation of implementation of acute low … 4 of 38 7.2 measures of pain &...

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

http://www.neqos.nhs.uk/

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

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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

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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

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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.

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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.

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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

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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.

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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

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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.

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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.

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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

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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

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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).

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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.

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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

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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.

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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.

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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.

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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

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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


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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


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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.

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

mailto:[email protected]

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

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