Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison

Abstract

PURPOSE We aimed to determine the effects of implementing risk-stratified care for low back pain in family practice on physician's clinical behavior, patient outcomes, and costs. METHODSThe IMPaCT Back Study (IMplementation to improve Patient Care through Targeted treatment) prospectively compared separate patient cohorts in a preintervention phase (6 months of usual care) and a postintervention phase (12 months of stratified care) in family practice, involving 64 family physicians and linked physical therapy services. A total of 1,647 adults with low back pain were invited to participate. Stratified care entailed use of a risk stratification tool to classify patients into groups at low, medium, or high risk for persistent disability and provision of risk-matched treatment. The primary outcome was 6-month change in disability as assessed with the Roland-Morris Disability Questionnaire. Process outcomes captured physician behavior change in risk-appropriate referral to physical therapy, diagnostic tests, medication prescriptions, and sickness certifications. A cost-utility analysis estimated incremental quality-adjusted life-years and back-related health care costs. Analysis was by intention to treat. RESULTSThe 922 patients studied (368 in the preintervention phase and 554 in the postintervention phase) had comparable baseline characteristics. At 6 months follow-up, stratified care had a small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, 0.1-1.4), with a large, clinically important difference in the high risk group of 2.3 (95% CI, 0.8-3.9). Mean time off work was 50% shorter (4 vs 8 days, P = .03) and the proportion of patients given sickness certifications was 30% lower (9% vs 15%, P = .03) in the postintervention cohort. Health care cost savings were also observed.CONCLUSIONS Stratified care for back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs. Wider implementation is recommended. INTRODUCTIONI t has been stated that "most cases of back pain resolve regardless of the course of therapy, and some do not get better no matter what is done. Therein lies the problem for practitioners, patients, and policy makers."1 Health care systems universally face the challenge of providing effective primary care for low back pain within constrained resources, in the face of increased demands for treatment and investigations.2,3 Back pain is now the 6th highest contributor to the global burden of disease. 4 In the United Kingdom, 6% to 9% of adults consult a family physician for back pain each year, 5 accounting for 14% of consultations. 6 More than 60% still report pain and disability a year later, 7,8 and 2% to 7% will develop severe persistent symptoms 9 leading to high levels of reconsultation, work loss, and sickness certification. 10 evidence-based treatments, but the optimal approaches to tar...

‘I think positivity breeds positivity’: a qualitative exploration of the role of family members in supporting those with chronic musculoskeletal pain to stay at work

“…Data analysis and assimilation were subject to recommended procedures to ensure consistency and credibility, but combining un-related data from participants with different musculoskeletal pain conditions inevitably means that a certain degree of flexibility was required to reconcile features of both studies. Thus, it is recognised that findings could be vulnerable to redefinition with implications for the validity of our results, but there is no support in the literature to suggest sub-grouping by pain site is helpful when continued work participation is the aim, while there is evidence that non-specific chronic pain can be classified based on psychosocial complexity [39,40].…”

Intégrer l’éducation thérapeutique en pratique quotidienne : une médecine centrée sur le patient

“…Les études en rhumatologie sont actuellement peu nombreuses. Dans le cas des lombalgies, la stratification de la prise en charge en soin primaire selon le niveau de risque de handicap des patients s'est montrée efficace du point de vue de la santé des patients et des coûts de santé [11]. Des démarches éducatives plus légères ont également été testées dans l'arthrose [12].…”

Comparison of a Stratified Group Intervention (STarT Back) With Usual Group Care in Patients With Low Back Pain

“…[5][6][7] Emerging evidence demonstrates that stratifying patients into more homogenous groups and offering targeted treatment leads to better patient outcomes. [8][9][10] The STarT Back Trial has demonstrated efficacy with respect to prognostic risk stratification on an individual basis within the controlled environment of a randomized controlled trial (RCT). 8 The translation of this model of care to everyday clinical practice is the next phase in the implementation of this system of care.…”