Becker's Spine Review

39 Executive Briefing: For more information on VCF mortality risk, visit medtronic. com/bkpmortality Developing a clinical care pathway Patients with VCF see a wide variety of practitioners with varying levels of experience regarding the full range of treatment options available. Dr. Hirsch and colleagues — including orthopedic and neurosurgeons, interventional radiologists and pain specialists — wished to develop a clinical care pathway that would be helpful to a broad range of practitioners across that care continuum. This multispecialty group used the RAND/UCLA Appropriateness Method to develop patient-specific recommendations for VCF clinical care pathway. The clinicians reviewed 20 signs and symptoms for VCF and considered relevance of five diagnostic procedures for 576 clinical scenarios; they also considered six aspects of follow-up care. After two rounds of individual ratings and two plenary discussion sessions, the panel developed a recommended clinical care pathway for VCF patients. 8 One challenge the panel specifically wished to address was the number of entry points VCF patients have into the healthcare system. Back pain patients who seek a referral from a primary care provider may be directed to non-surgical treatment options (e.g. physical therapist, an occupational therapist or given an opioid prescription). The provider these patients are seeing may not be familiar with vertebral augmentation or understand treatment options when conservative therapy fails. Other patients who arrive at the emergency room in pain may undergo radiology tests or treatment from non-spine specialists who do not properly identify or diagnose VCFs. "There are so many points where vertebral compression fracture patients intersect with the healthcare system that it's difficult for everyone to know what the optimized care plan might be," Dr. Hirsch said. "There are a great many patients with these fractures that aren't referred to interventional specialists who would benefit from vertebral augmentation. The purpose of our panel was to look at a variety of scenarios and design a system where clinicians that see the patient initially can make an informed decision about the appropriate next steps." Throughout the rating process and discussions, the multidisciplinary panel found areas where there was acceptance and discordance, as well as gray areas where not everyone agreed. In the final article, the panel recommended VCF patients: • Receive a referral to bone density and osteoporosis education. • Participate in a program focused on osteoporosis treatment and prevention. • If symptoms persist at the follow-up visit, undergo additional imaging. The panel also created clinical care pathways based on advanced imaging results and symptom improvement or decline. In addition to recommending patients with severe pain and probability of VCF undergo advanced imaging with MRI, CT scan or bone scan, the panel came to consensus about Reprinted from The Spine Journal 2018, Hirsch J., Beall D., Chambers M., et al. Management of Vertebral Fragility Fractures (VCF): A clinical care pathway developed by a multispecialty panel using the RAND™/ UCLA Appropriateness Method, Copyright 2018 with permission from Elsevier.

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