Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

Rhon, Daniel I.; Greenlee, Tina A.; Poehlein, Emily; Beneciuk, Jason M.; Green, Cynthia L.; Hando, Ben R; Childs, John D.; George, Steven Z.

doi:10.1001/jamanetworkopen.2023.21929

Cited by 10 publications

(11 citation statements)

References 34 publications

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“…Our results suggest a superior benefit of the SPLIT program vs UC compared to previous studies testing a similar stratified approach in primary care in different countries. 12,14,[16][17][18][19][20] Interestingly, our findings occurred even considering the predominant proportion of patients with low risk of poor disability within our sample.…”

Section: Discussioncontrasting

confidence: 50%

“…14,15 Considering that health systems are context specific and might vary substantially between countries, several studies sought to adapt and test the stratified approach in primary care. [16][17][18][19][20] A country that might benefit from such a comprehensive approach is Portugal. In addition to being the major cause of disability-adjusted life-years, 1 LBP management in Portuguese primary care is described as fragmented and not aligned with clinical recommendations.…”

Section: Introductionmentioning

confidence: 99%

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A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study

Gomes,

Fernandes,

Caeiro

et al. 2024

Ann Fam Med

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PURPOSETo determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care. METHODSWe conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, −5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points). RESULTSWe enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, −2.94; 95% CI, −3.63 to −2.24; P ≤ .001), pain (ß, −0.88; 95% CI, −1.18 to −0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC.CONCLUSIONS Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.

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Section: Discussioncontrasting

confidence: 50%

Section: Introductionmentioning

confidence: 99%

A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study

Gomes,

Fernandes,

Caeiro

et al. 2024

Ann Fam Med

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“…Though evidence-based care pathways may be applicable in a given setting, improved outcomes do not necessarily follow. Three recent clinical trials compared risk-stratified care using the STarT Back tool with usual care for participants with LBP [ 39 – 41 ]. Each trial reported similar outcomes for both groups, suggesting referral pathways informed by risk stratification added no clinical benefit.…”

Section: Discussionmentioning

confidence: 99%

Development of a low back pain care pathway in an academic hospital system: results of a consensus process

Bejarano,

Vining,

Desai

et al. 2024

J Orthop Surg Res

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Background Low back pain (LBP) is the leading cause of disability worldwide and a significant component of healthcare expenditures. Clinical practice guidelines (CPGs) have been highlighted as a key resource to improve the quality of care. This study aimed to develop a clinical pathway for LBP based on CPGs in an academic health system. Methods We conducted a modified Delphi study of clinicians caring for patients with LBP who were asked to rate 21 CPG-informed seed statements through an online survey. The goal was to identify statements that achieved a minimum of 80% consensus among panelists. Results Thirty-five healthcare providers participated as panelists. The majority of participants were male (68.6%), had MD or DO (62.9%) degrees, and were clinicians (73.8%) working in neurosurgery (36.1%), orthopedics (25.7%), emergency medicine (14.3%), or physical therapy (11.4%). Initially, consensus was reached on 20 of 21 seed statements. One statement did not reach consensus in the initial round and was revised into two separate statements based on feedback from panelists. One of these statements achieved consensus in the second review round. All statements reaching consensus were incorporated into a care pathway consisting of diagnosis, evaluation, and treatment for LBP. Conclusion Healthcare providers across various disciplines supported statements interpreting current CPGs related to care for LBP. This study represents a step toward supporting guideline-concordant care for LBP. Additional research is needed to assess how such pathways impact actual clinical care.

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“…Stratified care has been proved to possess tremendous potential to tailor a more appropriate and effective approach to treatment and improve outcomes in many complex diseases (41)(42)(43). In this study, we firstly identified 1,273 SRGs using univariate Cox analysis and successfully stratified OC patients into three subgroups based on the different molecular patterns of these SRGs.…”

Section: Discussionmentioning

confidence: 99%

Multifactor assessment of ovarian cancer reveals immunologically interpretable molecular subtypes with distinct prognoses

Guo,

Li,

et al. 2023

Front. Immunol.

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BackgroundOvarian cancer (OC) is a highly heterogeneous and malignant gynecological cancer, thereby leading to poor clinical outcomes. The study aims to identify and characterize clinically relevant subtypes in OC and develop a diagnostic model that can precisely stratify OC patients, providing more diagnostic clues for OC patients to access focused therapeutic and preventative strategies.MethodsGene expression datasets of OC were retrieved from TCGA and GEO databases. To evaluate immune cell infiltration, the ESTIMATE algorithm was applied. A univariate Cox analysis and the two-sided log-rank test were used to screen OC risk factors. We adopted the ConsensusClusterPlus algorithm to determine OC subtypes. Enrichment analysis based on KEGG and GO was performed to determine enriched pathways of signature genes for each subtype. The machine learning algorithm, support vector machine (SVM) was used to select the feature gene and develop a diagnostic model. A ROC curve was depicted to evaluate the model performance.ResultsA total of 1,273 survival-related genes (SRGs) were firstly determined and used to clarify OC samples into different subtypes based on their different molecular pattern. SRGs were successfully stratified in OC patients into three robust subtypes, designated S-I (Immunoreactive and DNA Damage repair), S-II (Mixed), and S-III (Proliferative and Invasive). S-I had more favorable OS and DFS, whereas S-III had the worst prognosis and was enriched with OC patients at advanced stages. Meanwhile, comprehensive functional analysis highlighted differences in biological pathways: genes associated with immune function and DNA damage repair including CXCL9, CXCL10, CXCL11, APEX, APEX2, and RBX1 were enriched in S-I; S-II combined multiple gene signatures including genes associated with metabolism and transcription; and the gene signature of S-III was extensively involved in pathways reflecting malignancies, including many core kinases and transcription factors involved in cancer such as CDK6, ERBB2, JAK1, DAPK1, FOXO1, and RXRA. The SVM model showed superior diagnostic performance with AUC values of 0.922 and 0.901, respectively. Furthermore, a new dataset of the independent cohort could be automatically analyzed by this innovative pipeline and yield similar results.ConclusionThis study exploited an innovative approach to construct previously unexplored robust subtypes significantly related to different clinical and molecular features for OC and a diagnostic model using SVM to aid in clinical diagnosis and treatment. This investigation also illustrated the importance of targeting innate immune suppression together with DNA damage in OC, offering novel insights for further experimental exploration and clinical trial.

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Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

Cited by 10 publications

References 34 publications

A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study

A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study

Development of a low back pain care pathway in an academic hospital system: results of a consensus process

Multifactor assessment of ovarian cancer reveals immunologically interpretable molecular subtypes with distinct prognoses

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