Introduction to the Focus Issue on Advocacy

Abstract

Spine care has gone through a very turbulent decade. There has been tremendous innovation in terms of therapeutic and diagnostic technological advancements. While rapid development has tremendous potential in terms of improving the health of patients with back pain, it can also increase cost and add to the need for knowledge dissemination to providers and patients. Advocacy in spinal care embraces a broad spectrum. Advocacy within spinal medicine includes the interests of patients, hospitals, payors, treating professionals, industry, government, and society. In this issue, we have elected to highlight advocacy for the patient. Patient centric care requires an informed physician and an informed patient making cost-effective and efficacious decisions. This information must touch on new developments and how they are ethically brought to market. Surgeons need to have guidelines as to what treatments are truly effective. Hospitals and physicians need to learn how to control costs without compromising care. As advancements escalate in spinal medicine, guidelines regarding the limits and goals of advocacy become ever more important. In patient-centered advocacy, the first dictum is to do no harm. Therefore, patient safety is an appropriate initial topic. Wong and Watters address this topic with an article reviewing the experience and effect of various intervention strategies for improving patient safety. Advocating for patient centric spine care must address issues of cost. No nation can afford to allocate unlimited resources to spine care. Resource allocation must be done in a considered fashion. Strategies to address costs in spine care include cost-effectiveness analysis of the interventions, enhancing physician performance, controlling costs while maintaining quality, and doing technology assessment to determine the value of interventions. The spine field is only beginning to tackle this topic, and it will require significant additional maturation. In addition, all stakeholders, government, industry, hospitals, and physicians, will need to provide resources for developing sufficient data to truly use evidence-based medicine principles. There is a clear need for evidence-based intervention. In order to generate high-quality evidence, measuring the appropriate outcome is crucial. The key question for the outcome of an intervention as stated by Carey and Mielenz is “compared to what.” Clearly, whenever possible, spine surgery decisions should be evidence based. There is a developing body of evidence around some of the scenarios, and this information should be used to guide treatment. Optimizing patient care from the onset of symptoms through final treatment is the focus of true spine centric care and a desired health care system goal. Scientific advances in spine care require close collaboration between clinicians and industry, such as pharmaceutical and device manufacturers. With these collaborations come potential problems with conflict of interest. When unaddressed, such potential conflicts of interest can lead to a lack of trust by patients and the public that physicians are truly acting in patients’ best interest. Several papers in this supplement will discuss ways in which collaboration with industry can occur within the context of appropriate ethical relationships. While this issue of Spine may not answer all of these questions, we hope to focus the discussion so that it can move forward, resulting in the best care for those in need. Hopefully, the readership will be stimulated to refine further the questions and pose even better answers.