Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals.
BACKGROUND
Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program.


METHODS
Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999.


RESULTS
A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%.


CONCLUSIONS
Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.
Harrington
J T
JT
Rheumatology Section, Department of Medicine, University of Wisconsin (UW) Medical School, Madison, Wisconsin, USA. tim.harrington@uwmf.wisc.edu
Dopf
C A
CA
Chalgren
C S
CS
D000208:Acute Disease / Q000145:classification; D000465:Algorithms; D001071:Appointments and Schedules; D002908:Chronic Disease / Q000145:classification; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D017116:Low Back Pain / Q000145:classification / Q000628:therapy*; D009985:Orthopedics / Q000458:organization & administration*; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D012017:Referral and Consultation / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D012219:Rheumatology / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration*; D014922:Wisconsin