Primary Care Physicians Unable to Form Early Diagnosis of Cervical Spondylotic Myelopathy

This is an important finding, because previous studies have shown that early diagnosis and treatment of CSM lead to better outcomes. The majority of patients initially sought a diagnosis for their symptoms from family physicians, who arrived at a correct diagnosis in only 4.8% of cases and never at the first clinic visit. Many other patients initially consulted community-based orthopedic surgeons, only one of whom suspected CSM at the first visit. Detailed findings of this study are reported and discussed in the article "Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians," by Eyal Behrbalk, M.D., Khalil Salame, M.D., Gilad J. Regev, M.D., Ory Keynan, M.D., Bronek Boszczyk, Dr. Med., and Zvi Lidar, M.D., published today, in the July 2013 issue of Neurosurgical Focus.

Cervical spondylotic myelopathy (CSM) has been called the most common form of spinal cord dysfunction in older adults, although it can occur in younger people due to injury. As we age, vertebral joints in our necks begin to show wear (cervical spondylosis) and cervical spine ligaments thicken. These changes cause the spinal canal to narrow, which can lead to compression of the spinal cord. As spinal cord compression increases, nerve cells die, resulting in symptoms of cervical myelopathy that range from mild neck pain to motor weakness, sensory loss, impaired walking, and, in cases of advanced disease, loss of bladder and bowel control. CSM is a progressive disease. Surgery is indicated when there is neurological impairment. Studies have shown that outcomes of surgery are best when the operation is performed during the early stages of the disease, when neurological impairment is minimal.

Between January 2009 and December 2010, 146 patients underwent surgery for CSM at The Spine Unit of Tel-Aviv Medical Center, a tertiary care center. All cases of degenerative pathological conditions of the cervical spine were included. Complete medical records (from both the Center and community-based physicians' offices) were available for 42 patients, and these patients comprised the study population. The researchers collected data from the time the first signs or symptoms of CSM were documented until the date of surgery. The diagnosis of CSM was based on the following: 1) symptoms consistent with CSM; 2) neurological findings suggestive of myelopathy; and 3) MRIs showing compression of the cervical spinal cord. In addition to the review of medical records, phone interviews with patients were conducted to obtain any missing clinical data.

Behrbalk and colleagues found that 69% of patients initially sought a diagnosis for their symptoms from family physicians and 21.4% from community-based orthopedic surgeons. The remaining patients consulted other physicians, none of whom was a neurologist or neurosurgeon, the most likely to recognize the disease. The researchers state that this follows the normal pattern of physician visits in Israel, where patients can directly schedule appointments with family physicians and orthopedic surgeons but require referrals to see neurologists or neurosurgeons. During the first physician visit, only one doctor?an orthopedic surgeon?suspected that CSM could be the underlying cause of the patient's symptoms.

At the second physician visits, most patients went to orthopedic surgeons (48.8%) and family physicians (26.8%); far fewer saw neurologists (9.8%) or neurosurgeons (2.4%). At the third physician visit, patients continued to consult orthopedic surgeons most frequently (38.5%), but more patients sought out neurologists (25.6%) and neurosurgeons (18%) than before; 12.8% of patients returned to family physicians.

In this study, Behrbalk and colleagues found that it took a mean of 5.2 ? 3.6 physician visits to obtain the correct diagnosis of CSM. In the end, the diagnosis was made most often by neurosurgeons (38.1%) and neurologists (28.6%), and less frequently by orthopedic surgeons (19%), family physicians (4.8%), and a variety of other specialists (9.5%). The delays in diagnosis in this study, according to the researchers, rest primarily on a lack of awareness of CSM on the part of family practitioners and community-based orthopedic surgeons, who did not conduct full neurological examinations that could indicate myelopathy.

Given that CSM is a progressive disease, the researchers point out that delays in diagnosis can mean that "patients are referred to surgery at an advanced stage of the disease, at which point they are suffering from severe, often irreversible neurological damage."

Behrbalk and colleagues call for continued education of family practitioners and community-based orthopedic surgeons to make them more aware of CSM and promote early referrals for surgery when patients present with CSM symptoms.

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Disagreement Found on the Role of Primary Care Nurse Practitioners

In 2010 an Institute of Medicine (IOM) committee recommended that "advance practice registered nurses should be able to practice to the full extent of their education and training" and that nurse practitioners should be able to admit patients to hospitals and hospices, lead medical teams and medical homes, and receive reimbursements similar to what physicians receive for providing the same services.

A study published in the May 16 New England Journal of Medicine finds, however, that while primary care physicians and nurse practitioners for the most part agreed with the first recommendation, they significantly disagreed about some proposed changes to the scope of nurse practitioners' responsibilities. Specific points of disagreement revealed in the survey - led by investigators from Massachusetts General Hospital (MGH) and the Institute for Medicine and Public Health at Vanderbilt University Medical Center - include appropriate leadership roles for nurse practitioners, reimbursement levels and the overall quality of services they provide.

"We were surprised by the level of disagreement reported between these two groups of professionals," says Karen Donelan, ScD, EdM, of the Mongan Institute for Health Policy at MGH, lead author of the report. "We had hypothesized that, since primary care physicians and nurse practitioners had been working together for many years, that collaboration would lead to more common views about their roles in clinical practice. The data reveal disagreements about fundamental questions of professional roles that need to be resolved for teams to function effectively."

Adds Peter Buerhaus, RN, PhD, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt and a co-author of the paper, "It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other's contributions. I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce." Additional co-authors of the paper are Catherine DesRoches, DrPh, Mathematica Policy Research, Cambridge, Mass.; and Robert Dittus MD, MPH, Veterans Administration Tennessee Valley Geriatric Research, Education and Clinical Center and Vanderbilt Institute for Medicine and Public Health.

Although debates on the appropriate roles of health professionals are nothing new, the authors note, little data has been available on the roles played by nurse practitioners in primary care and how they differ from those of primary care physicians. The current study was designed to assess those roles and how expanding them might affect the health care system. The survey was mailed to a national random sample of nearly 2,000 primary care clinicians - evenly divided between physicians and nurse practitioners - and responses were received from 467 nurse practitioners and 505 physicians.

The majority of both groups - 96 percent of nurse practitioners and 76 percent of physicians - agreed with the IOM recommendation that nurse practitioners "be able to practice to the full extent of their education and training," and 76 percent of nurse practitioners reported they were doing so. Majorities also agreed that increasing the supply of primary care nurse practitioners would improve the timeliness of and access to care, and respondents working in collaborative practices indicated that both professions provide a wide range of services in their practices.

But the survey revealed significant disagreements on specific recommendations: 82 percent of nurse practitioners believed they should be able to lead medical homes - practices using a team-based model to deliver coordinated patient care - but only 17 percent of physicians agreed; 64 percent of nurse practitioners agreed they should be paid equally for providing the same services, compared with only 4 percent of physicians; 60 percent of nurse practitioners in collaborative practices indicated they provided services to complex patients with multiple conditions, but 23 percent of physician in such practices responded that those services were provided by nurse practitioners, the two groups disagreed significantly regarding whether an increase in the supply of nurse practitioners would improve patient safety, the effectiveness of care and health costs, with one third of physicians responding that such an increase might have a negative effect on safety and effectiveness.

The investigators note the need for more analysis of the economic implications of expanding nurse practitioner roles and responsibilities, as well as the contribution of nurse practitioners to the care of complex patients. Buerhaus stresses, "At this stage, discussion is critical to finding points of agreement. Several states have workforce commissions that might serve as a forum for primary care physicians, nurse practitioners, payors and even patients to discuss these issues. Our study did not find major differences by states and did not include physician assistants or other allied health professionals, but including everyone in this dialogue will be important."

Adds Donelan, "Patients need health care teams that work in concert. We need to look at models of successful collaboration and understand how good teams function effectively and efficiently. We also need to consider how to structure nursing, medical and interprofessional education to enhance understanding and appreciation of each others' professional cultures."

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