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.
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