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| Denver Pain Management Forges New Frontiers in Treatment of Chronic Spinal Pain
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Since its founding in 1995, Denver Pain Management (DPM) has led the way in the treatment and relief of patients with chronic spinal pain, an agonizing reality for millions of Americans. DPM stands at the forefront of an exciting new approach: interventional pain management (IPM). Differing from traditional treatments involving drugs, physical therapy, chiropractic adjustments or surgery, IPM provides a set of therapies that are minimally invasive. DPM is one of the few centers worldwide that regularly performs the full range of advanced IPM procedures.
Clinic founder Robert Wright, MD, a leader in the field of IPM, heads a team of highly experienced IPM practitioners. The group includes pain management physicians Scott Brandt, MD, Eric Kalhoefer, MD, and Bradley Vilims, MD, and research coordinator Mr. David Bailey.
Ongoing research explores more effective techniques
In complement to its clinical practice, DPM conducts research on promising new treatments for the reduction and relief of chronic spinal pain. One of DPM’s current clinical trials centers on comparing systems for the advanced treatment of lumbar disc pain, a condition that affects five million people in the U.S. and is the number one cause of health care expenditure. Traditional surgical approaches (e.g., discectomy and fusion) involve open dissection of soft tissue and bone. In the interest of improving patient outcomes and decreasing recovery time, DPM is investigating the use of minimally invasive techniques that can safely and effectively remove disc material and decrease pain.
Specifically, DPM is testing two methods for long-term effectiveness at improving the patient’s quality of life: radio frequency energy applied with a variety of advanced treatment tools and techniques as well as a new, minimally invasive means of mechanical decompression of the disc. Clinic patients are enrolled in these studies based on their failure to respond to traditional and conservative therapy.
Another clinical trial underway at DPM focuses on testing the effectiveness of different early intervention techniques with spinal cord stimulation for the treatment of Complex Regional Pain Syndrome (CRPS). This physically and psychologically incapacitating syndrome is characterized by sensory, motor and autonomic disturbances. With CRPS, pain occurs in a regional distribution that does not correlate to a single peripheral nerve. Often, the degree of pain experienced by the sufferer is disproportionate to the event that caused the original injury.
There appears to be little doubt that early intervention results in favorable outcomes for CRPS patients. However, the question of which interventions are most effective is still open to debate. To address this issue, the DPM study is comparing the effectiveness of more traditional treatments (i.e., sympathetic nerve blocks, physical therapy, medication) to treatment using a percutaneous spinal cord stimulator. Patients with CRPS are randomly divided into two groups, each group receiving one of the two methods of treatment.
In yet another clinical trial, DPM is following a group of patients from evaluation through a series of diagnostic / therapeutic injections to gain a better understanding of the effectiveness of this form of treatment. This non-randomized study will track patients to determine if they have experienced a reduction in pain without having received further interventional treatment.
BBHI™ 2 test provides multi-purpose tool
In all three of these clinical trials, patients will be assessed regularly for a minimum of one year to track patient outcomes. DPM selected the BBHI™ 2 (Brief Battery for Health Improvement 2) test as its principal evaluation tool and is serving as a beta site for the test.
Derived from the well-researched, widely used BHI™ (Battery for Health Improvement) test, the shorter BBHI 2 instrument helps practitioners to quickly screen for a number of psychomedical factors commonly seen in medical patients, such as pain, somatic, and functional complaints—as well as traditional psychological concerns such as depression, anxiety and patient defensiveness.
“We chose the BBHI 2 test because it is specifically designed to track patient progress,” says Mr. Bailey. “I don't believe there is any other diagnostic test that’s structured for this purpose—certainly not one that captures the same broad range of information.”
Dr. Brandt concurs. “We've been wanting a tool like this for quite a while. With the BBHI 2 test, we can see the patient’s results over time, as well as how the individual’s results compare to those of the average patient with a similar diagnosis. If a test doesn’t give you this kind of information, where’s the value? All you have is numbers on a chart.”
Although the clinic started using the BBHI 2 test to track specific patient groups, the staff quickly realized other ways the test would be beneficial to them. “Most other diagnostic tests are designed primarily for research, which makes them less helpful for clinical purposes,” says Dr. Brandt. “The BBHI 2 test, by contrast, is short and easy to administer—and we receive results quickly, which is invaluable in assessing patients effectively.”
Recognizing the BBHI 2 test’s usefulness for clinical applications as well as for research, DPM administers the test to all new patients, not just those enrolled in its clinical trails.
“With the BBHI 2 test, the physician has the test results in hand as he meets with the patient for the first time,” says Mr. Bailey. “He can use the information then and there to confirm or disaffirm his own ‘gut reactions’ about the patient’s psychological profile.”
At two of DPM’s five clinic facilities, patients use an innovative hand-held electronic device to take the BBHI 2 test. “I was the biggest naysayer on using the device,” Mr. Bailey says. “But in fact, we’ve found that patients really like it. It’s a very easy-to-use testing method and typically takes less time than the paper-and-pencil format. And since the data is entered directly into the computer as the patient takes the test, there’s no administrative time needed to key in the responses—so we have results instantly.” In fact, the device has proven so popular with both patients and staff that the other three DPM facilities are requesting that it be introduced at their sites.
Gaining a global perspective of patients
The staff at DPM convey their strong dedication to improving quality of life for their patients. “We pride ourselves on trying to provide the best possible diagnostic treatment of spinal pain possible—and on conducting research that’s geared toward providing relief for our patients,” says Dr. Brandt. “In this work, the more global a view we have of our patients, the better. The BBHI 2 test is proving to be of enormous value to us in fleshing out important elements of that picture.”
Bios:
Prior to founding Denver Pain Management, Robert Wright, MD, served as the staff anesthesiologist for the USAF Academy Hospital in Colorado Springs, Colorado. A graduate of Baylor College of Medicine, Texas Medical Center, Houston, Dr. Wright sits on the instructor panels of a number of medical organizations, including the Interventional Spinal Injection Society, the Advanced Neuromodulation Society, and the North American Spine Society.
With a broad range of medical experience, Scott Brandt, MD, has devoted his practice to IPM full time since 1997. He is actively involved in research and publication, teaching instructional workshops for other physicians, and presenting on a variety of subjects in advanced IPM. Dr. Brandt is a graduate of the University of Michigan-Ann Arbor, and the Bowman Gray School of Medicine.
Bradley Vilims, MD, joined DPM after establishing and serving in directorships of IPM practices in Aberdeen, South Dakota, and Madison, Wisconsin. A graduate of the University of Iowa, Dr. Vilims has more than ten years’ experience using state-of-the-art pain management therapies. His current work includes helping to develop new pain treatment therapies and protocols and conducting physician training on IPM skills.
David Bailey has served as a research assistant or coordinator for most of his professional career. His background includes overseeing clinical evaluations of minimally responsive brain-injured patients and helping develop protocols to assist in communication and “breakthrough” techniques. A graduate of Drexel University, Mr. Bailey was hired by DPM as its fulltime research coordinator in 2001.
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The MBMD™ Test in Practice:
MBMD Test Facilitates Bariatric Evaluations
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Psychological factors play an important role in contributing to or impeding bariatric post-surgical success. The MBMD (Millon™ Behavioral Medicine Diagnostic) test is a self-report tool that helps identify those factors in bariatric surgery candidates.
Jeffrey Wilbert, PhD, is a consulting psychologist in private practice in Dayton, Ohio, specializing in emotional eaters and bariatrics. Area surgeons require a presurgical psychological evaluation for their bariatric surgery candidates and refer them to Dr. Wilbert. The surgeons use the information from the evaluations to help them with patient selection.
Dr. Wilbert added the MBMD test to his battery of tests last fall, replacing a lengthy test that he believes isn't particularly well suited for the bariatric population.
He selected the MBMD test because of its:
- norms on medical patients, making it an appropriate test for this population
- brevity – with 165 true/false items, patients need only 20-25 minutes to complete the test
- ease of administration
- face validity for this population
Patient data obtained from the MBMD test results that Dr. Wilbert and the surgeons he works with find especially useful include: level of depression, emotional distress, anxiety, description of personality functioning, and non-compliance with medical instructions.
With this data, along with data from other tests in his battery and patient interviews, Dr. Wilbert helps the surgeons identify suitable candidates for surgery, as well as patients who potentially may have a difficulty with post-operative emotional adjustment. For those latter patients, Dr. Wilbert may recommend psychological treatment and advises the surgeon on how to handle the patient to help enable a positive outcome.
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It’s Not Just the Pain
Authors to present research results at IASP conference
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Results of a recent exploratory study, conducted at the Texas Pain Clinic in Dallas, indicate certain areas in a chronic pain patient’s life relate to important indicators of treatment outcome. Study authors believe that medical practitioners can use this information to help them become more aware of areas that may need further investigation and treatment to help the pain patient’s recovery.
The purpose of the exploratory study was to look at the ability of the BHI™ (Battery for Health Improvement) test to predict treatment outcome and barriers to rehabilitation. Eighty one chronic pain patients at the clinic comprised the subject pool. From August 1999 through August 2001 all subjects participated eight hours per day, five days per week in a rehabilitation program that lasted from four to eight weeks. Subjects took the BHI test at the first visit. The MPI (Multidimensional Pain Inventory) was administered during the first week and again at discharge. The patients also participated in a telephone interview six months after discharge.
The BHI test helps measure factors such as depression, anxiety, hostility, symptom dependency, substance abuse, family dysfunction, job dissatisfaction, doctor dissatisfaction, and others. The MPI test helps measure whether the patient is functional or dysfunctional in various areas of their pain experience.
The results of the study indicate significant relationships in five areas:
- Patients who did not show improvement on the MPI scored higher on the “Depression” scale of the BHI test.
- Patients who did not show improvement on the MPI reported a higher number of body areas with pain on the BHI test.
- Patients who continued to have surgeries for pain at six months following treatment had higher “Job Dissatisfaction” scores on the BHI test.
- Patients who were unemployed at six months had significantly higher “Symptom Dependency” scores on the BHI test.
- Patients who were unemployed at six months had significantly lower “Substance Abuse” scores on the BHI test than those who were employed.
The authors note that, due to the limited number of patients examined, the results of the study cannot predict outcome. However, they can conclude that these five relation ships exist and that the relationships point to areas doctors should consider during diagnosis and treatment. “Doctors need to be aware that there are multiple reasons for people to be disabled, and multiple reasons there could be barriers to progress in rehabilitation,” says Robert Freedenfeld, PhD, Director of Clinical Research and Training at the Texas Pain Medicine Clinic. “It’s not just the pain,” he says.
The authors will present their data and its implications at a poster session at the International Association for the Study of Pain (IASP) conference in San Diego on Tuesday afternoon, August 20.
The study was conducted by: Freedenfeld; Berit E. Bailey, PhD, Clinical Psychology Fellow, Texas Pain Medicine Clinic; Daniel Bruns, PsyD, Health Psychology Associates, Greeley, CO; Perry N. Fuchs, PhD, Assistant Professor of Research Statistics and Design, University of Texas, Arlington; and R. Sanford Kiser, MD. Medical Director, Texas Pain Medicine Clinic.
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| Psychological Tests Can Help Medical Professionals Meet New Industry Recommendations
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Recently, the U.S. Preventive Services Task Force issued a recommendation that all adult patients be screened for depression as part of their regular clinic visits. The task force—an independent panel of experts in prevention and primary care convened by the federal government—reports that:
- 5% to 9% of adults in the U.S. have depression
- 50% of these patients go undiagnosed and untreated in primary care
- Depression costs $43 billion per year, of which $17 billion are in lost workdays
As part of its recommendation, the task force also advises clinics that screen for depression to have systems in place to ensure accurate diagnosis, effective treatment and follow-up.1
The science behind screeners
Standardized psychological tests can help primary care physicians comply with the task force’s recommendations effectively. However, medical professionals may have concerns about using psychological screeners, believing that they are not as empirically based as medical tests.
In fact, standardized psychological tests are developed using the science of psychometrics, which dictates that the test be:
- Valid (The test should measure what it is supposed to measure.)
- Reliable (The test should give the same results every time.)
- Normed (The test should provide norms that serve as clinical benchmarks to which a patient can be compared.)2
The efficacy of psychological assessments is supported by the findings of the APA’s Psychological Assessment Work Group. In a study based on 125 meta-analyses, the work group determined that many psychological tests have comparable validity to medical tests.
As reported in Monitor on Psychology, the APA study found that:
- Psychological tests such as the Millon™ Clinical Multiaxial Inventory, the Thematic Apperception Test, the Hare Psychopathy Checklist and other neurological and cognitive tests produce medium to large effect sizes, as do medical tests such as Pap smears, mammography, magnetic resonance imaging (MRI) and electrocardiograms.
- The MMPI® scale scores and average ability to detect depressive or psychotic disorder generates an effect size of 0.37 while the use of a Pap test to detect cervical abnormalities produces an effect size of 0.36. The effectiveness of these very different tests used to detect very different outcomes is much the same.3
1. U.S. Preventive Services Task Force. (2002) Screening for depression: Recommendations and Rationale. Annals of Internal Medicine, 136(10), 760-764.
2. Bruns, D., & Disorbio, J.M. (2002). BBHI 2 (Brief Battery for Health Improvement 2) manual. Minneapolis, MN: NCS Pearson.
3. Daw, Jennifer. (2001) Psychological assessments shown to be as valid as medical tests. Monitor on Psychology, 32(7), 46-47.
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| New Health & Behavior CPT Billing Codes—An Update
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In the previous issue of Bridging the Gap, we introduced new Current Procedural Terminology (CPT) health and behavior assessment and intervention codes and printed highlights from the American Psychological Association (APA) Practice Directorate’s Action Alert about the codes.
The codes are listed in the 2002 Physician Fee Schedule published in the November 1, 2001 Federal Register and were designated as “active” beginning January 1, 2002. Psychologists, nurses, licensed clinical social workers and other healthcare clinicians whose scope of practice permits, can bill using the codes.
The codes are for health and behavior assessment and intervention services and can only be used for patients with a diagnosed physical health problem.
Some healthcare professionals who submitted claims under the new codes have had their claims inappropriately denied. The APA Practice Directorate has worked with the Centers for Medicare and Medicaid Services (CMS) from the outset to address implementation problems, and continue to do so. Now the organizations are also approaching private insurance carriers directly to challenge inappropriate denials.
According to the APA Practice Directorate, as a result of APA/CMS interventions, Trailblazer, the Medicare carrier in Texas, Maryland, Delaware and Virginia; Wisconsin Physician Services, the Medicare carrier in Wisconsin, Illinois, Michigan and Minnesota; and Empire Medicare, serving lower New York State, have all notified the APA that they will pay for services billed under the codes.
Private third-party insurance plans may have different payment policies and should be contacted directly to find out about their reimbursement rates under the codes.
The APA Practice Directorate asks psychologists to notify the APA Government Relations office at 202-336-5889 with any problems experienced when billing under the codes.
To learn more about the codes, FAQs and Medicare coding standards, log on to the APA Practice Directorate’s web site, www.apa.org/practice/cpt_2002.html. You may also contact your local Medicare carrier or your regional CMS office for information. APA conference attendees might want to attend the symposium on implementation and reimbursement for the new CPT codes. It will be held August 25, 8:00 a.m.–9:50 a.m. in Meeting Room S504bc of McCormick Place.
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Visit Our Website!
http://www.pearsonassessments.com/medical/index.htm
Tradeshows
Visit with us! Be sure to stop by our booth at these upcoming conferences:
International Spine Injection Society (ISIS)
September 6–8, 2002
Austin, TX
www.spinalinjection.com
American Society of Interventional Pain Physicians (ASIPP)
September 21–23, 2002
Washington, DC
www.asipp.org
American Academy for Pain Management (AAPM)
September 26–29, 2002
Reno, NV
www.aapainmanage.org
American Academy of Disability Evaluating Physicians (AADEP)
November 7–9, 2002
Asheville, NC
www.aadep.org
American Society of Reg. Anesthesia and Pain Medicine (ASRA)
November 7–10, 2002
Phoenix, AZ
www.asra.com
American Academy of Physical Medicine & Rehabilitation (AAPM&R)
November 21–24, 2002
Orlando, FL
www.aapmr.org
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Fall 2002
