Scoliosis Collaborative Initiative

A Comprehensive Educational Approach to Enhance the Value of Subspecialty Referrals

PPOC-affiliated pediatrician Dr. Wanessa Risko, and Dr. Tim Hresko, an orthopedic surgeon at Boston’s Children’s Hospital, collaborated to enhance the ability of primary care providers to manage and triage adolescent idiopathic scoliosis (AIS) in their setting.

Their collaboration, supported by their organizations, has led to the development and implementation of a comprehensive longitudinal educational initiative for the PCPs in the PPOC network.

AIS, defined as a spinal curvature with a Cobb angle of 10 degrees or greater, is a common disorder affecting approximately two to four percent of all youngsters. For most patients, AIS can be managed with observation alone, with about 90 percent of all patients requiring no intervention (braces or surgery).

Nevertheless, AIS is one of the most common diagnoses leading to a referral to an orthopedic specialist in the PPOC network. Often, the referral will lead to multiple visits specialist visits over time. Clearly, there are times when a specialist consultation is necessary for optimum management of these patients. However, there are circumstances when the severity of AIS is mild and primary care management is appropriate and specialist referral is an unnecessary cost for families.

Dr. Risko, Dr. Hresko and Boston pediatrician Dr. Louis Vernacchio conducted a retrospective study of youngsters referred to an orthopedic surgeon for further evaluation. The Scoliosis Collaborative Initiative, informed by this initial research, consisted of the development and dissemination of education, EHR decision support tools, and clinician specific data from 2009 to present. Components of the program included:

  • A short video sharing with PCPs the findings of the retrospective study of the PPOC referrals for AIS.
  • A decision support algorithm to guide general pediatricians about the appropriate steps when diagnosing and managing (AIS) and Information handouts for parents and patients with AIS.
  • A series of didactic sessions attended by PPOC pediatricians and NPs to review the definition, etiology, epidemiology, and management guidelines in the algorithm. These sessions were highly rated as a way to enhance knowledge acquisition and recall, a mini- curriculum was delivered via-biweekly emails for about 10 weeks following the didactic.
  • Integration of an Order Set into the EHR of all PPOC practices with a copy of decision support algorithm, handouts and orders for imaging studies. This greatly facilitates clinicians’ access to the algorithm and the handouts in real time, as they interact with families.
  • Dissemination of individual physician’s AIS referral data (comparing them to network) at multiple points in time.

Using the tools provided by the Scoliosis Collaborative Initiative, PPOC practices were able to decrease their AIS referrals by 24 percent.

Click here to read a report about the project that was presented to Harvard Pilgrim Health Care.