The predictive ability of the STarT Back Screening Tool in a Danish secondary care setting

Abstract

Introduction The predictive ability of the STarT Back Tool (SBT) in secondary care settings has not been investigated. The aim of this study was to determine the SBT's predictive ability in a Danish secondary care setting and compare this to a Danish primary care setting. Methods Poor clinical outcome at 6 months ([30 points on a 0-100 Roland Morris Disability Scale) was calculated in secondary care (n = 960) and primary care (n = 172) cohorts. The cohorts were stratified into SBT subgroups and estimates of additional risk for poor outcome were calculated [relative risk (RR), unadjusted and adjusted odds ratios]. The discriminative ability was determined using the area under the curve statistic. Results In secondary care 69.0 % and in primary care 40.2 % had poor outcome on activity limitation. Although significant, the predictive ability of the SBT in secondary care (medium-risk RR 1.5, high-risk RR 1.7) was not as strong as in primary care (medium-risk RR 2.3, high-risk RR 3.5). Adjusting for episode duration and pain intensity only changed the predictive ability marginally in secondary care. The discriminative ability of the SBT was similar in both cohorts despite differences in the predictive ability. Conclusion The SBT had less predictive ability in a Danish secondary care setting compared to a Danish primary care setting for persistent activity limitation at 6 months follow-up. SBT-targeted treatment implications in secondary care were not investigated in this study.

Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting

“…We note that several studies finding less impressive outcomes when replicating the STarT Back method of risk stratification have modified the tool or risk categories in some way 13, 24 , used an alternative outcome, 9, 10, 12 and/or been conducted in settings other than primary care physicians’ clinics. 9,11 It may not be fair to expect the STarT Back tool to perform for risk stratification in such a scenario, given the deliberate development of the tool as a simple-to-complete yet relatively crude predictor of outcomes, rather than an elaborate measure meant to capture all subtleties of risk prediction even while using a range of continuous outcome measures.…”

“…The STarT Back tool has also not performed as well in secondary settings such as physical therapy or chiropractic clinics. 9–11 To our knowledge, no prior study has examined the external predictive validity of the original 9-item STarT Back tool among people with back pain in US primary care.…”

Long-term effectiveness of an educational and physical intervention for preventing low-back pain recurrence: a randomized controlled trial

“…Based on our results, we can recommend a careful case definition of workers with previous history of LBP (33) and a better characterization of this subgroup (34) allowing a stepped secondary prevention similar to the primary care stratification developed in LBP (35)(36)(37). Another recommendation is to investigate the value of a workplace component to address the physical and psychosocial factors of LBP among workers still at work, as this component has proven its value in other LBP populations (10,11).…”

Descriptive analysis of a 1:1 physiotherapy outpatient intervention post primary lumbar discectomy: one arm of a small-scale parallel randomised controlled trial across two UK sites

“…This is the first time the STarT Back tool has been used in secondary care with post operative patients, as previous secondary care studies excluded post operative patients23 or included a broad range of conditions 2426 The STarT Back tool has less predictive ability in secondary care but its performance equals alternative measures 26. Overall, STarT Back may therefore be useful in combination with other factors to inform decisions regarding patients that require more than minimal physiotherapy intervention.…”

“…The tool possesses high reliability,21 and validity compared to the Örebro Musculoskeletal Pain Screening Questionnaire 22. Researchers have investigated the predictive value of STarT Back in secondary care, in physical therapy clinics in USA23 24 and Danish specialist care;25 26 finding it less effective than in primary care, but equivalent to other measures such as pain intensity or activity limitation. The six-item tool was used for consideration of participant questionnaire burden (referred leg pain, disability, catastrophising, depression and overall impact items) that stratifies patients into low risk/not at low risk of poor outcome.…”