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Jt Comm J Qual Improv. 2001 Dec;27(12):651-63.

Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals.

Author information

  • 1Rheumatology Section, Department of Medicine, University of Wisconsin (UW) Medical School, Madison, Wisconsin, USA. tim.harrington@uwmf.wisc.edu



Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program.


Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999.


A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%.


Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.

[PubMed - indexed for MEDLINE]
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