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  • New in the Literature: Low Back Pain (Lancet. 2011;378:1560-1571.)

    Authors of a study that compared the clinical effectiveness and cost effectiveness of stratified primary care (intervention) with non-stratified current best practice (control) report that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care.

    For this study, 1,573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at 10 general practices in England responded to invitations to attend an assessment clinic. The 851 eligible participants were randomly assigned to the intervention group (n=568) and control group (n=283) by use of computer-generated stratified blocks with a 2:1 ratio. Participants in both groups were screened using the Keele STarT Back Screening Tool to stratify their prognostic risk. Treatment, including physical therapy, was standardized for the participants in the intervention group and matched according to their risk; whereas the participants in the control group received current best practice including referral for physical therapy. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, the authors focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. (This study is registered, number ISRCTN37113406).

    Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4.7 vs 3.0, between-group difference 1.81 [95% CI 1.06-2.57]) and at 12 months (4.3 vs 3.3, 1.06 [0.25-1.86]), equating to effect sizes of 0.32 (0.19-0.45) and 0.19 (0.04-0.33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0.039 additional QALYs) and cost savings (£240.01 vs £274.40) compared with the control group.

    "For many years, the potential for targeting treatment has been emphasized as a research priority for back pain," the authors said in a press release. "The results of this trial provide the first evidence that a stratified management approach to target the provision of primary care significantly improves patient outcomes and is associated with substantial economic benefits compared with current best practice."

    This study was published October 29 in Lancet.


    • These kinds of studies are going to drive me crazy! First--there is this study "helping" primary care figure out what to do with back pain and then in another article from APTA on a study on patient self referral to PT as being more cost effective (rather dramatically) than seeing an MD first. The study on the screening tool is comparable to how someone would feel/react/behave if they were given a diagnosis of "consumption" 100 or 2000 years ago--you would be miserable, pessimistic, etc because there wasn't a treatment. When patients see a doctor who does a poorly applicable exam and then gives them a psychological tool to figure out what to do, the patient knows they are in big trouble. That is why massage therapists, chiropractics, PTs and acupuncturists all get better patient satisfaction and outcomes from all of these other practitioners--unless your back pain is coming from kidney disease, the primary care and internal medicine doctor can't help. That is all this study on this screening tool says. The tool is only helping them to figure out that they really can't help people who score more than 6--unfortunately, the "easy" folks that score less than 6 who are just being given "recommendations" are the folks PTs should most certainly see. We should be the ones giving recommendations based on OUR screening tools that screen for treatment (this tool screens for morbidity in an untreated or poorly treated population--think about it). I guess I should applaud that this at least is making an effort on subjective information to screen patients. I wonder what would happen if I screen patients and determined their treatment based on a thorough physical therapy exam. That is what is being tested when we look at the outcomes when patients self refer to PT first. We need more studies looking at how PTs stratify their patients (not to say this hasn't been done but there are more strategies out there that PTs are using that have not been evaluated--there are probably some excellent answers to how to stratify patients that need to be tested).

      Posted by Herb Silver on 11/11/2011 8:41 AM

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