Software-assisted spine registered nurse care coordination and patient triage--one organization's approach.

Back disorders encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The use of a traditional spine center model of patient flow, in which the patient is scheduled the first available appointment without an initial assessment of spine-related symptoms at West Virginia University Spine Center, Morgantown, West Virginia, resulted in frustration and delays for the spine patient and referring physician dissatisfaction. Today, the use of a software-assisted spine patient triage and registered nurse care coordinator patient navigation system in this multidiscipline, multimodality comprehensive spine program provides quick and efficient patient triage to the appropriate level of spine care (surgeon vs. nonsurgeon). The model consists of five major steps, which are explored in this article: medical history intake; films or studies retrieval; rapid review of the patient's medical condition and diagnostics by a spine specialist preappointment and subsequent triage to the appropriate level of spine care; registered nurse care coordinator patient education and guided navigation through the patient's preferred treatment plan; and last, diagnostic study, pain injection, and provider scheduling. Patient satisfaction scores, referring physician satisfaction scores, and resultant impact on referral volumes, ancillary utilization, workload productivity, and surgical yield demonstrate that this new approach to patient triage has made significant improvements in efficiency, productivity, and service.

Testing strategies for diagnosing lupus anticoagulant: decision analysis.

Clinicians commonly evaluate patients with thrombosis or a prolonged activated partial thromboplastin time (aPTT) for the presence of a lupus anticoagulant (LA). We evaluated strategies for detecting LA, in three clinical settings, with decision-modeling techniques. A decision tree was constructed with 12 strategies, using a combination of aPTT and dilute Russell viper venom times (dRVVT) with confirmatory tests, tissue thromboplastin time (TTI), platelet neutralization procedures, and mixing studies. Probabilities and costs of adverse events and test costs were obtained from the literature. Patient preference for each strategy was evaluated by assigning utilities to each outcome. On the basis of assay results in 90 healthy people and 77 patients, we calculated sensitivities and specificities for each strategy, with true positives defined as suggested by the International Society on Thrombosis and Haemostasis. The least costly strategy for evaluation of patients with a prolonged aPTT, or with thrombosis, is not to test and to assume that LA is absent. For patients with systemic lupus erythematosus (SLE), it is least expensive not to test, although testing with TTI alone can also be considered an efficient strategy. The strategy of highest utility to patients with SLE is testing with TTI, followed by dRVVT. On the basis of these cost and utility results, clinicians' strategies for detecting LA may need modification. These strategies would then optimally be tested in clinical trials.