Stratified or targeted care of back pain implemented by family doctors leads to ‘significant’ improvements for patients and a 50% reduction in work absence – without an increase in healthcare costs – according to new research.
A team at the Arthritis Research UK Primary Care Centre at Keele University also found that the proportion of people receiving stratified care given sickness certificates was 30% lower than those patients receiving usual care.
Researchers analysed data on 922 patients with low back pain from five GP practices in Cheshire. They found those who received stratified care in which a prognostic screening tool was used to classify patients into groups at low, medium or high risk for persistent disability and then matched with risk-appropriate treatment, had modest improvements in physical function, fear avoidance beliefs, satisfaction with care and time off work.
Patients were also prescribed fewer non-steroidal anti-inflammatory drugs and reported greater satisfaction with the results of their care. Benefits from stratified care also included a concurrent small overall reduction in health care resource use and large societal cost savings due to fewer periods of pain-related work absence. Their research is published in the journal Annals of Family Medicine.
The prognostic screening tool, called STarT Back, is a recently developed nine-item questionnaire given to patients during their GP consultation. Patients are ‘stratified’ to different treatments according to their needs. Those in the low risk group receive good advice about how to manage their back pain, reassurance about their good prognosis and help with pain relief, while patients in the medium and high risk groups receive more intensive treatments led by physiotherapists.
Stratified care for back pain has already been shown to be effective in a randomised trial (published in 2011 in The Lancet; Hill et al 2011). The results of the IMPaCT Back study now show that stratified care can be implemented in everyday clinical practice with GPs and physiotherapists, and that it leads to a higher proportion of appropriate patients being referred from their GP to physiotherapists. Patients who have the most complex back pain problems in primary care benefit the most from stratified care.
The study was funded by the Health Foundation and led by NIHR Professor Nadine Foster at Keele University, who said: “We have shown that this approach to stratifying care can be implemented in general practice, leading to better outcomes for patients, reductions in work absence and more targeted use of health care resource without increasing health care costs. As a result we believe that stratification should be implemented more widely across primary care in the UK. This research is particularly timely given that the National Institute for Health and Care Excellence (NICE) is currently reviewing national guidance for the management of back pain patients.”
Professor Alan Silman, medical director of Arthritis Research UK added: “This exciting research shows that stratified or targeted approach to managing back pain in primary care is effective, and challenges the ‘one-size fits all’ strategy that is currently recommended by national guidelines in which everyone with nonspecific back is offered the same treatment, irrespective of their risk of persistent problems”.
“Back pain is one of the leading causes of work place absence, and to be able to reduce this burden on society by getting more people back to work, as well as giving benefit to individuals is a fantastic outcome.”
Back pain is the sixth highest contributor to the global burden of disease. Between 6% and 9% of adults consult a GP for back pain each year, accounting for 14% of consultations.
Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison, Nadine E. Foster, DPhil, Ricky Mullis, PhD, Jonathan C. Hill, PhD, Martyn Lewis, PhD, David G. T. Whitehurst, PhD, Carol Doyle, MSc, Kika Konstantinou, PhD, Chris Main, PhD, Simon Somerville, MSc, Gail Sowden, MSc, Simon Wathall, HND, Julie Young, HND and Elaine M. Hay, MD on behalf of the IMPaCT Back Study team, Ann Fam Med, doi: 10.1370/afm.1625, March/April 2014 vol. 12 no. 2 102-111.