New research that compares a more tailored or stratified management of back pain by general practitioners (GPs) in primary care with the current “one size fits all” standard approach finds it could be more effective for patients and also cost less. You can read how the UK-based trial came to this conclusion in the 29 September online issue of The Lancet.
In the UK, about 9% of adults goes to see their GP every year because of back pain.
Under the current primary care strategy, which promotes a standard approach regardless of the level of severity of the condition, as many as 80% of these patients are still reporting pain or disability 12 months later.
Lots of studies have reported the benefits of various treatments, including cognitive behavioural therapy and exercise-based approaches, but none has looked at them in terms of which therapies benefit which patients, suggesting there may be room for efficiency improvements in the primary care management of back pain.
In this study, Dr Jonathan C Hill from the Arthritis Research UK Primary Care Centre at Keele University in Stoke-on-Trent, UK, and colleagues report how they carried out the STarT Back trial designed to compare the clinical and cost effectiveness of stratified management to current best practice.
In the stratified approach, patients fill in a simple screening questionnaire that allows their low back pain to be assessed according to estimated risk of persistent disability: low, medium or high risk. Treatment is then tailored to each of these groups.
In this study, a low risk patient was given a minimum of one consultation session where they received advice on activity, exercise and returning to work.
The medium risk patient received the standardized physiotherapy that is included in the one size fits all approach, while the high risk patient received physiotherapy enhanced with psychological advice.
The participants were 851 adults with back pain whom the researchers recruited between June 2007 and November 2008. They had been to see their GPs at ten different surgeries in England.
They were randomly assigned to receive either stratified care (568 patients), or to be in a control group (283) that received the current best practice comprising advice, exercise and manual therapy given by qualified physiotherapists.
To measure outcomes, the researchers asked the participants to fill in the Roland and Morris Disability Questionnaire. This assesses the extent to which treatment relieves pain and improves ability to function.
The researchers also calculated the costs of the two approaches, both in terms of estimated healthcare moneys spent, and quality adjusted life years (QALYS).
The results showed that at 4 months and also at 12 months, the patients who received stratified care showed a significant improvement on the disability scores compared to the controls.
Also, at 12 months, the stratified care group reported lower levels of fear, depression and higher levels of general health. They were also significanlty more likely to be satisfied with the treatment they received at the 4 month point, and they had lower absence rates from work due to back pain over the 12 month period than the controls.
For the costs, the researchers found stratified management was more beneficial and cost less than the average health care cost, with an average saving of £34.39 per patient compared to the best practice received by the controls.
“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,” they write.
They conclude:
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.”
“The findings of this study represent an important advance in primary care management of back pain, and have important implications for commissioners and providers of services for back pain,” they add.
In an accompanying comment, Bart Koes from Erasmus University Medical Centre, Rotterdam, The Netherlands, describes the results as “very promising”. He says they show the stratified approach is cost-effective and sees no financial reason why it should not be adopted:
“Clinicians and researchers now face the challenge of implementing and further optimising the new approach,” he adds.
Arthritis Research UK funded the trial, which was was carried out from the Primary Care Centre at Keele.
Written by Catharine Paddock