provider should be seen for LBP, but what level of provider
expertise should be seen for LBP.
question asked was how many patients
will get to the surgical consultation level
compared to parallel or historical data
without the pyramid? Ten thousand
patients entered the study. None went to
surgical consultation before resolution
of their back pain. Comparing this to
conventional referral rates, the cost savings were not insignificant: £829,000.3
Good news for the Fleet Street types to
be sure, and probably for the surgeons.
Was this finding having any impact
on the practicing surgeon? Unhesitatingly, I turned to level of evidence
favored by surgeons, anecdotal. My
colleague and I turned over our napkins,
retrieved our most recent clinic data
via cell and had at it. N = 1 day, patients
reviewed by our infallible recollections,
no data pre-NICE. Results . . .
n 44 visits of 52 booked
n 15 new patient visits of 18 booked
n 9 new PCLBP patients
n BASS colleague:
n 32 visits of 33 booked
n 14 new patient visits of 14 booked
n 4 PCLBP patients
As I had over twice as many “primary
care LBP” referrals as my colleague, it
became clear to us that NICE works.
How would (does) such a pyramid impact value? The quality of the criteria is
high, evidence-based and thorough, and
the obvious cost savings would shrink
the value denominator substantially.
The result? Higher value. Theoretically.
Perhaps the thorniest issue here is
the specter of care rationing. I realize
that the term “rationing” is to be avoided
and, as the Choosing Wisely Initiative4
stated clearly, we as providers need
to acquire the skills to be responsible
stewards of limited resources. I could
not agree more. On the one side, fee for
service with attendant excessive utili-
zation and on the other, a regimented
algorithm with specified services of-
fered—sensitive versus specific. We have
a great deal of frustration as providers
dealing with never ending regulatory
These are difficult issues, most notably for the patient. Who is supposed to
benefit from the quality, the numerator of value? The patient has a right to
care that is as close to 100% sensitive
and specific as we can deliver. There
is no question that evidenced-based
medicine (EBM) has revolutionized
health care. EBM recommendations are
overwhelmingly of benefit to all parties
in health care.
Back to the issue of PCLBP—one that
I think cannot be handled by top-down
regulation (eg, NICE) or bottom-up fee-for service. For starters, we are not able
to construct a pyramid of care until we
agree exactly what problem we are trying to solve. What is PCLBP? None other
than the dreaded “nonspecific” LBP. If
the disease entity to be studied is broad
and nonspecific, the pyramid will be
built on a faulty foundation. Most LBP
is amenable to more specific subgroup
5 Subgroup diagnosis
should consign the term “nonspecific”
LBP to the dust bin of history.
The issue for the patient then be-
comes not what level provider should be
seen for LBP, but what level of provider
expertise should be seen for LBP. My
personal approach to this need has been
to lean toward a form of physical therapy
and assessment based on the response
of the LBP to repeated end range move-
ment. Our group has also attempted to
educate primary care physicians on the
importance of active physical therapy
in the first six weeks of symptoms, prior
to specialty referral. Even after many
years, this has not been successful. Most
primary care physicians are reluctant to
order the six weeks of “physical therapy”
What can we do to increase the in-
terest level of primary care providers in
LBP? Education is certainly a start, but
the ultimate solution will require a great
deal more than that. We constantly refer
to LBP as an epidemic, for which we
need all the help available. Personally, I
would hate to have a pyramid dropped
1. The NHS in England. Available at: www.
2. National Institute for Health and Care
Excellence. Available at: www.nice.org.
3. Annual Meeting of the British Association
of Spine Surgeons. Manchester, UK; 14-17
5. Long A, Donelson R, Fung T. Does it
matter which exercise? A randomized
controlled trial of exercise for low back
pain. Spine. 2004; 29( 23): 2593-602.
6. Wetzel FT. Precisely! SpineLine.
2016; 17( 6): 8-10.
7. Kerr DJ, Scott M. British lessons on
health care reform. New Eng J Med.
Board of Directors, McKenzie Institute