The Alarming Truth About Low Back Pain Referrals | Podcast Ep. 428

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we have brand new recently released research that is really shocking. This is an episode you're going to want to pay attention to. There's going to be a lot of statistics and a lot of it is directly impactful to your practice and more importantly, to the people that you serve and the people in your community. This is around the appropriateness of specialized care referrals for low back pain. This is a cross sectional analysis took place in Canada and was released just last month. And there were some stats in this that knocked me to the floor. And I think it'll be the same with you as well. We'll get into that in just a moment, but before we do, I want to say a few words about Patient Pilot. If you're looking to ramp up your patient reactivations this year, head over to the smartchiropractor.com, schedule a demo with our team, hop on and see how we can help you. We send weekly email newsletters, big buttons that say click to call and call to schedule. And we track every one of those clicks and deliver them to your team in a reactivation report each day, the following day at 7am when somebody clicks. So you have an easy hot leads list of people who are literally ready to come back in. And these are your most valuable patients because of the people that already know, like and trust you. So if you have hundreds, if not thousands of people in your database and you're not doing anything with them, you're probably losing out and wasting a lot of money other places. So head over to smart chiropractor.com, schedule a demo or ask some questions or get started right off there with our team. So today's episode, we're talking research Frontiers in Medicine. This came out January 2024. Absolutely shocking piece of literature around the referral habits for low back pain. And there's a lot of stats that we're gonna go through, a lot of stuff that's probably gonna make you, as they'd say, mad as a hornet's nest. But it's really important to know, especially if you're like a member of the evidence based chiropractor, you're getting out there building referral relationships using our process to be successful. Understanding what's going on outside of the four walls of your office is, is really, really important to be able to maximize your opportunity as you stretch beyond those four walls. So this was the Canadian study. However, a overwhelming majority of this plays right into what we see here in the United States and really in many places around the world. So in their system, primary healthcare serves as a dual function. It's the first point of contact for healthcare services. No surprise there. And it also provides, or supposed to provide, I should say, continuity of care and coordination with secondary and tertiary care providers when specialized care is needed. Now, why is this a big deal with low back pain? No surprises here. It's the leading cause of years lived with disability around the world. It also accounts for a really thick portion of outpatient physician visits and in turn, spending. Now, there have been clinical guidelines that have come out. We've highlighted pretty much all of them on this, this podcast that are designed to assist primary care providers for taking care of people with low back pain. Prevention, evaluation, management, all of those things, and getting rid of the items that are harmful or wasteful, but also ensuring that all these patients are getting the best care possible. Well, that's not exactly playing out the way. I mean, maybe it will over time, and hopefully it is with you and your community because you're getting out there. But it's very clear that guidelines alone are not going to do it because they've been out for a while. And we'll get to those statistics in just a moment. Big tease there. So, in most healthcare systems, these primary care providers, GPs, general practitioners, however you define them, they're the primary contacts that make the referrals initially. And that's the case many times in the United States. They don't have to be. You can get through to other healthcare providers in many places, including the United States, but. But many people do visit their primary care doctor first. Unfortunately, the advice that they're getting quite often falls far short of what we'd hope or expect. So we've seen also in research that this is true. This isn't myth or conjecture or conspiracy. The evidence suggests that usual care for patients with low back pain does not match guidelines quite often. There's an overuse of advanced imaging, MRI and ct. And opioids are still prescribed way more frequently than they should be. How this is happening is still beyond my understanding. There needs to be far greater accountability. But it hasn't happened yet. So several studies have showed an over reliance on the expertise of medical specialists. And over reliance meaning the primary cares are referring way too early. And how do we know this? Here's one of those stats. 62 to 85% of patients referred to spine surgeons for low back pain are not surgical candidates. So the good news is that many of them aren't just getting still way too many elective surgeries going on spinal surgeries, but many of them are being denied at the spine surgeon most of the time because they haven't met either their financial or their clinical obligations. In terms of the minimums necessary to proceed with that surgery, however, that's a really big deal. Like people are just being dumped straight to surgery. With 60 to 85%, it's not that complex to understand who's a surgical candidate. So I would think it should be the complete opposite where It'd be like 80% are surgical candidates, that would mean they're being appropriately referred. And hey, there might be some red flags or some things that the surgeon picks up on based on their expertise, which makes total sense that 10 to 20% in an ideal world are not candidates for a variety of reasons that might be beyond the knowledge base or scope of the referring doctor. But when 60 to 80% are not candidates, that's telling us people are just being dumped there. And that also is going to, of course, 99% of the time. And it is in this case resulting in elective surgeries that don't need to happen in addition to just waste, confusion, inappropriate referrals, all of those things. So they took a look in this study, moving on, they took a look at about three medical records and they randomly selected about 500 of them to do an analysis. So they found that the pain now in these records, when I talk about documentation, pain status and documentation, excuse me, pain dominance and pain status were reported at 32% and 9%. And back or leg pain intensity was only reported in 2% of the cases. These are incomplete notes. The presence or absence of red flags were not documented for nearly half of the patients. And for about 14% of the patients in this sample, no neurological examination components were described. Chances are it wasn't done. And the progression of symptoms in patients medical history were not documented in 45 and 41%. So this tells us that these patients are quite frankly, I think there's a few inferences we can make from this. They're probably seen in very short order and they're not spending much time with this doctor. The doctor is very clearly not only not gaining a complete case history, but not going through any sort of legitimate examination most of the time. And this is going to of course lead to referrals that are inappropriate and just. Way to go from the primary care doctor to a surgeon without a red flag just doesn't make sense. Yet it's happening all the time. And quite frankly, it's happening in your community today. As you listen to this, this will happen in your community. That's a big problem. That's why I'm so passionate about building referral relationships within the guidance of what we do at the evidence based chiropractor and MD connection is because I just wanna break this cycle and I want you to do everything you can because people should not be having elective surgeries that they don't need to have without exhausting conservative care. We'll get to that in a moment. So conservative treatments were not documented in nearly 40% of these records. That's a big deal. And this is a real big problem. When things are being prescribed, when referrals to advanced modalities are being made, and quite frankly, the basic documentation isn't even there. That's a big problem. The mean age of the person in all of these 500 cases randomly selected was about 60 years old. And 52% were male, 48% were female. So most of the neurosurgery consultation requests came from primary care physicians, nearly 90%. So that means they're going from primary care, let's be clear about this, from primary care to neurosurgeon. 90% of the neurosurgeon's consultations were coming direct from the primary care doctor. Wow, they must have a lot of patients with red flags. Joking. That's not the case. They're not taking a good history and they're not doing any form of an examination and they're basically dumping these people off, which is not ethical, quite frankly. It doesn't live up to the Hippocratic oath and it is just poor patient experience. Would you want that? You know, it's like, I'd love to ask these docs, would you want that for your relative? Would you want that for you? I got a feeling the answer would be no. So nearly 20% of the medical records patients suffered from dominantly back pain as opposed to radicular pain. Red flags were identified in about 8% of patients. That's interesting. Okay, red flags identified, get those patients to where they need to go. No problems with that whatsoever. Most patients, about 85% had chronic pain, meaning pain over 12 weeks. At the time of the neurosurgery consultation, about 30% had had objective sensory deficits. Now these are the information, not necessarily from the primary care doctor, but from the neurosurgery consult. 22% had diminished tendon reflexes, 18% had objective motor deficits. Okay. Great to see this documentation. This makes a lot of sense. This is the stuff that probably should be done in my opinion, on the front end, not at the neurosurgery consult, but it's interesting to see those stats. Over a quarter, over 25% of the patients presented to the neurosurgery service with deteriorating symptoms and interestingly 22% experienced improvement between when they scheduled the neurosurgery consult and when they showed to the neurosurgery consult. So they were already healing, already improving, already getting better. Nearly a quarter of the individuals. So that showcases should many of those people be there? Probably not. A review of patients medical history showed that about 18% had a previous history of lumbar surgery and 50% were using pain medication. 50% using pain medication. So that's a big deal. In terms of comorbidities, 35% were multimorbid, meaning they had more than two or two or more, I should say comorbidities. And here were some of the most frequent ones. Cardiovascular disease, endocrine disease and urogenital disorders were the biggest ones. So for the neurosurgeon's diagnosis, 60% were diagnosed with a radicular syndrome, which included of course radiculopathy and everything associated with neurogenic claudication. So 97%, a lot of stats here, but important to just I want to get these stats out there so we can talk about the impact on them. 97% were referred for diagnostic testing before their consultation. Nearly 80% had an MRI. About 30% had a CT scan. So that is interesting. Now to perform a surgery you need to have a roadmap. So if this is again, these tie directly together when you refer for a neurosurgery consult. Most surgeons won't see somebody or even their team mid level providers won't see somebody without having that imaging. So it goes part and parcel that then you're going to have this imaging. Well, guess what? Of course you're going to find if you're 50, 60 years old, a bunch of what I call not perfects. But which one of those are the problem? That's the real issue at the heart of it here and it's going to scare people. And we know advanced imaging MRIs and CTs early on lead to advanced interventions. Why? Because then everybody's going to see something, quote unquote, where it's like we can work on that. Well, does it need to be worked on is the better question there? So 56% of patients had received conservative care prior to the consultation, 41% had injections, 25% had physical therapy, and a whopping 3% had seen a chiropractor. Now, we've gone through, and here's where I'll start to add some color commentary here. We've gone through on this podcast previous research that basically highlighted the fact nobody should be having, in the absence of red flags, nobody should be having a surgery, spine surgery, without having visited a chiropractor. Why? Because there is a thick percentage of people that will get better and there were no harms or decreased results of the surgery if they didn't get better with the chiropractor. Therefore, it is only potential upside and it's what's right to do and it goes in line with the Hippocratic oath and it's what's in the guidelines. Yet 3% had seen a chiropractor that should literally be 90%. And only half had even received any conservative treatment. And a majority of those, 80% of those that had received a conservative treatment had received injections which are typically off label, expensive and don't really work. They don't solve the structural issue. They provide pain relief at best. And quite frankly, we've also seen in the research that spinal adjustments can outperform nerve root injections quite often. Big deal here. So 44% of patients were discharged from the neurosurgeon, including about 20%. We're talking about relationship building. 20% of the people that were discharged from the neurosurgeon had no recommendation to do anything moving forward. What? Okay, not the surgeons that I want to go to, but that's a story for a different day. 11% were referred for injections, in effect generally off label and short term at best, 5% for conservative and 3% to another healthcare professional. So that's the bad news. It should be embarrassing. However, it also is for those doctors. However, it also is our opportunity as chiropractors looking to get out there. We're doing the right thing, we're helping a lot of people, we're doing it in the right way. The guidelines support what we do. So again, the good news is the bad news. The good news is there is a massive opportunity for you to really pick up with referral relationships, a lot of business in your community. The bad news is, yeah, it's not gonna happen automatically, but that's also the good news because it gives you the opportunity to go out there and tell your story. As I like to say, hey, if everybody were already being referred to a chiropractor, you probably either need to be way better than everybody else in town that's really hard or way cheaper. And that really sucks. So the good news is you don't have to be either of those. You can be you, you can be a great chiropractor doing great things, charging what you deem in your community and receive referrals. But you gotta get out there and have some conversations around it. So 80% of cases and referrals made to the neurosurgery department for low back pain were deemed inappropriate. So 4 out of 5 were inappropriate referrals. Absolutely mind numbing. So 20% of patients were identified as surgical candidates. Now here's what's also interesting. 20% were identified as surgical candidates. 18% were reluctant or refused surgical options. This is just, I mean, I just, I view this as a cup of opportunity that just continues to flow over rightfully. So kudos to those individuals saying, hey, I was referred here fast, I'm not ready for surgery, I don't want structural change because I don't have a red flag. Kudos to them. But now we look back at the what we just referenced, which is 20% walked out without even a single recommendation. And, you know, 40% it was an injection. Absolutely nuts that this is happening in 2024, but I got a feeling that this story is going to continue for years to come. So 40% of the low back pain patients referred to the neurosurgery department were discharged on initial assessment and most of them were advised for conservative care, but again, most of that was for injection. So a lot of statistics on today's episode, but I hope that that frames to you what's going on not only in the Canadian healthcare system, which is where this study was specifically from, but this is what's happening everywhere. So if you're listening to this, if you're a chiropractor and you're listening to this, hey, if you're a patient, a person, a human being out there listening to this, understanding that that's how the system works is really, really important. Because if you don't understand that that's how it works, I can tell you it's really easy to get caught up in it. It's easy to get caught up in it. Once we even know how this works, you with the tenets of who we are as chiropractors, still getting caught up with that. If you or a loved one, if you personally or a loved one have pain going on, and abject pain is no joke. And when somebody goes in it's really easy to kind of flip, so to speak, how you approach your life, to flip how you approach care when pain is present. And that's if you have strong tenants, right, in terms of conservative tenants believing that the body is self healing, that believing that most of the time, in the absence of red flags, time and appropriate care can heal neuromusculoskeletal challenges. But when pain comes into the plate, now imagine if you don't have that foundation of knowledge, man, many of the people in your community just don't stand a chance when they go in and are upscaled, so to speak, from a primary care doctor to a surgeon and then weirdly and ironically back down to basically a pain management doctor to receive an injection. It's costly, it's inappropriate, it's ineffective and it's just not good enough. So my challenge to you, listening to this as a chiropractor, my challenge to you is to get out there and make that change in your community, build those relationships. If you want help doing that, we have proven process. We can guide you through. Head over. Check out the evidencebasedchiropractor.com our MD Connection program. It's super affordable, super easy to implement and it get great results. I always say it's 100% successful when implemented, 0% successful when not implemented. But my passion and my goal is to make a dent in studies like this over time. Are we going to change it over the course of a year? Maybe, maybe not. But I want you to be able to change it in your community and I'd love to be your partner there. So that is today's podcast episode. Before we wrap up, I want to say a few words about Shockwave Therapy. I love the stemwave unit. It's what I use in the practice that I own and you can have special offer and connect with them. They support this podcast, you should support them. If you're thinking it is the best unit that I've come across, I own it. Go stemwave.com the evidencebasedchiropractor head over there, have a conversation. They'll know that you came over from this podcast. They'll hook you up with their best deal, their best offer and they'll take awesome carry and they stand behind their product, which is awesome. Additionally, if you are looking to build your team this year, head over to ChiroMatchmakers. We have virtual chiropractic assistants. They're not AI. They are college educated human beings that can manage your social media feeds, that can answer phones so you never miss a new patient call. 70% less cost than having somebody in the office completely accountable to the standards that you hope and expect and can just free up your time and increase your revenue in the way that many businesses are doing it. And you can too. You can head over to chiromatchmakers.com and schedule a call. Other than that, thank you for tuning into this podcast. Thank you for being a chiropractor. Have a fantastic week in practice and I will talk to you soon. Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit the evidencebasedchiropractor.com and join our MD Marketing membership today.