A new retrospective analysis of prospectively collected data is shedding light on the triage process when it comes to patients with low back pain. This topic was a project undertaken by first author Lauren M. Boden, M.D. as a fourth-year medical student. Boden is now a first-year orthopedic surgery resident at University of Pennsylvania hospital.
Data-Driven Triage Algorithm for Back Pain Patients
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The study, “Predicting Likelihood of Surgery Before First Visit in Patients With Back and Lower Extremity Symptoms: A Simple Mathematical Model Based on More Than 8,000 Patients,” was published in the September 15, 2018 edition of Spine.
The goal? Create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within one year of presentation.
The authors wrote, “Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained before the initial physician-patient encounter to direct patients to the optimal physician type.”
“We analyzed patient-reported data from 8,006 patients with a chief complaint of low back pain and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within 1 year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort and validated on the remaining 20%.”
Scott Boden, M.D., a co-author on the study, told OTW, “So many patients with spine problems present for evaluation. It can be a challenge to have non-clinical staff assign patients accurately to surgeons or non-surgeon spine specialists for their first appointment. Correct assignment makes things more efficient for the patient and physician.”
“This large database derived model offers some specific triage questions to improve accuracy. Interestingly, these questions proved more discriminating than many of the clinical questions we had in our long-standing triage protocol. Surgeons are more effectively used if they are seeing patients that potentially need and are ready for surgery.” — EH
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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