Practical steps and solutions towards making MSDs a health and work priority at the national and Prof

Oliver FitzGerald EU levels National QCCD Programme Lead for Rheumatology,

Ireland

4/29/12

Musculoskeletal Bottlenecks (Pre-2010)

Big problem is access to services Considerable service deficits (ISR 2003/ Comhairle 2005/ HSE Working group 2009) While service deficits need to be addressed, new model of care also required which would highlight the development of combined primary care/secondary care rheumatology networks Development of care pathways, early

4/29/12

DB, Male 37 yrs

Electrician, married with 2 children. Acute-onset low back pain 2 years ago; Treated by GP with a non-steroidal anti-inflammatory drug (NSAID) and pain killers (analgesia). Chiropractor involved Pain got worse despite medication/chiropractor. 4/29/12

What Do We Know About Back Pain?

Life time prevalence of low back pain is up to 84%

In 85% of people, low back pain is not attributable to a specific pathology Epidemiologic studies have shown that the longer the sick leave related to chronic low back pain, the more difficult it is to return to work and the greater the economic cost Sick leave has a negative IS EARLY INTERVENTION psychological impact CRITICAL

4/29/12

Orthopaedic Spinal clinic

Average wait for orthopaedic spinal clinic: 82 weeks in Jan 09 Average: 16 new back pain referrals per month (11GP, 5 Consultant) 77 back pain patients were still awaiting offers of appointments beyond April 2010.

4/29/12

Evidence From Literature

33% of orthopaedic referrals were referred on to the orthopaedic surgeon when screened by a physiotherapist. 24 % of back pain patients seen by a physiotherapist in an orthopaedic outpatient setting were subsequently seen by the orthopaedic surgeon. 85% of patients referred to a spinal orthopaedic surgeon could be triaged by a physiotherapist. 4/29/12

Back Pain Screening Clinic (BPSC) structure

All routine GP / A&E spine referrals identified European Guidelines Red Flags Yellow Flags Patients classified into:

Non-specific low back pain Nerve root pain Serious pathology

4/29/12

Treatment Pathways

Non specific low back pain (55%)

Rehabilitation (1-1 or group exercise rehab.)

Nerve Root Pain (35%)

Investigation and review in BPSC Rehabilitation if appropriate Post investigation, if confirmed nerve root compression, referral to Orthopaedic Team If not surgical option, referral for rehabilitation or to Pain Team

Serious pathology (10%)

Investigation and review in Ortho Clinic or Rheumatology Clinic 4/29/12

BPSC outcome

Discharged Rehabilitation

12.5% 55%

Investigation & review BPSC 15% Ortho team referral Pain team referral 15 % 2.5%

5 week waiting time by end July 09

4/29/12

Benefits

Hospital waiting times:

Greatly reduced waiting time for back pain referrals to access appropriate treatment ( 82wks to 26 wks)

Complying with HSE targets for 12/52 waiting time this year Increased access for orthopaedic referrals ( non-spine refs); improved conversion time Long term: screen out non-surgical back pain PATIENT OUTCOMES BETTER patients from the IMPROVED WORK RETENTION Orthopaedic clinic. ECONOMIC SAVINGS SUBSTANTIAL

4/29/12

National QCCD Rheumatology Progress

Appointment of 24 MSK physiotherapists; 6 per region Role in assessment/triage initially of orthopaedic and rheumatology referrals; aim for each to see 1000/cases/year leading to significant waiting list reduction More medium term development of interface clinics
4/29/12

RMcG, Male 34 yrs

1989: acute-onset, multiple joint pain and swelling Diagnosis: Rheumatoid Arthritis (after 2 year waiting list) Treatment side-effects; treatment resistance Severe progressive disease: joint damage, disability surgical replacements hip/elbow, fusion of ankles 4/29/12

What Do We Know About Rheumatoid Arthritis?

Estimated 28,000 people with RA in Ireland Severe, progressive and disabling in many Uncontrolled RA shortens life expectancy by 6-10yrs 22% stopped work due to RA within 5 yrs In a recent study in Ireland, 41% were work disabled Newer approaches to treatment can lead to disease remission in 50% of patients if treated early EARLY INTERVENTION IS
4/29/12

CRITICAL

Early Arthritis Clinics

Fast-track service to identify, diagnose and treat patients with recent onset inflammatory arthritis Control of joint inflammation leads to improved patient outcomes including possibility of sustained, drug-free remission Requires careful liaison between primary and secondary care Prevention of work disability and economicindependence achievable in most patients
4/29/12

National QCCD Rheumatology Progress

26.5 WTE Rheumatologist in Ireland (population of ~4million) in 2010. Agreement to proceed with an additional 7 posts (plus 1 additional paediatric post; plus2 Chairs of Rheumatology) Early Arthritis Referral Pathway agreed by all consultants with commitment to see patients within a 6 week period

4/29/12

Medical Profession and Work Retention

Think beyond the physical symptoms Encourage early intervention Promote self-management Support managers with job design interventions Focus on capacity not incapacity Emphasising to rheumatologists the importance of communicating with other all stakeholders including patients/ employees, GPs, physiotherapists, employers and WORK IS GOOD policymakers

4/29/12

FOR YOU!