Summary Background Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, ...medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control). Methods 1573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we 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. Findings 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4·7 SD 5·9 vs 3·0 5·9, between-group difference 1·81 95% CI 1·06–2·57) and at 12 months (4·3 6·4 vs 3·3 6·2, 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. Interpretation The results show 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. Funding Arthritis Research UK.
Identification of patient characteristics influencing treatment outcomes is a top low back pain (LBP) research priority. Results from the STarT Back trial support the effectiveness of prognostic ...stratified care for LBP compared with current best care, however, patient characteristics associated with treatment response have not yet been explored. The purpose of this secondary analysis was to identify treatment effect modifiers within the STarT Back trial at 4-month follow-up (n = 688). Treatment response was dichotomized using back-specific physical disability measured using the Roland-Morris Disability Questionnaire (≥7). Candidate modifiers were identified using previous literature and evaluated using logistic regression with statistical interaction terms to provide preliminary evidence of treatment effect modification. Socioeconomic status (SES) was identified as an effect modifier for disability outcomes (odds ratio OR = 1.71, P = .028). High SES patients receiving prognostic stratified care were 2.5 times less likely to have a poor outcome compared with low SES patients receiving best current care (OR = .40, P = .006). Education level (OR = 1.33, P = .109) and number of pain medications (OR = .64, P = .140) met our criteria for effect modification with weaker evidence (.20 > P ≥ .05). These findings provide preliminary evidence for SES, education, and number of pain medications as treatment effect modifiers of prognostic stratified care delivered in the STarT Back Trial.
This analysis provides preliminary exploratory findings about the characteristics of patients who might least likely benefit from targeted treatment using prognostic stratified care for LBP.
Low back pain research – Future directions van der Windt, Danielle A., PhD; Dunn, Kate M., PhD
Best practice & research. Clinical rheumatology,
10/2013, Letnik:
27, Številka:
5
Journal Article
Recenzirano
Abstract Low back pain is a challenge for clinicians and researchers, due to the large variability in clinical presentation, lack of consensus regarding diagnostic criteria or clinical ...classification; wide variation in course and prognosis, and limited success in identifying effective treatments. However, increasing research efforts has generated an expanding body of evidence on the epidemiology, prognosis and treatment of back pain. This paper presents four key developments in research and clinical practice, and describes how these can influence the future direction of back pain research: (1) the increasing awareness of the impact of low back pain on population health; (2) new approaches to describing and investigating course and prognosis of back pain; (3) the need to better understand the bio-psycho-social mechanisms or pathways that explain impact and long-term outcomes in order to inform intervention research; and (4) the potential for stratified models of care to improve patient outcomes and efficiency of care for back pain.
Abstract Background A colposcopy examination is the main management option for women with an abnormal cervical screening test result. Although some women experience adverse psychological effects ...after colposcopy, those at greatest risk are unknown. We investigated predictors of worries about cervical cancer, sex, future fertility and general health during 12 to 30 months after colposcopy. Methods We invited 1,515 women, aged 20 to 59 years with low-grade cervical cytology who attended colposcopy to complete questionnaires at recruitment (∼8 weeks after cytology result) and after 12, 18, 24, and 30 months of follow up. Outcomes were worries about having cervical cancer, having sex, future fertility, and general health at any time during follow-up. Factors significantly associated with each outcome were identified using multiple logistic regression. Results At one or more time points during follow-up, 40% of women reported worries about having cervical cancer, 26% about having sex, 24% about future fertility, and 60% about general health. For all outcomes except sex, worries reported at recruitment were associated with significantly increased risk of worries during follow-up. Significant anxiety at recruitment was associated with all worries during follow-up. Women diagnosed with CIN2+ had significantly higher risks of worries about cervical cancer and future fertility. Management received was associated significantly with worries about cervical cancer and having sex. Younger women significantly more often reported worries about future fertility, whereas women who had children had reduced risk of future fertility worries but increased risk of cervical cancer worries. Conclusion Clinical, sociodemographic, lifestyle, and psychological factors predicted risk of reporting worries after colposcopy.
WITHDRAWN: Low back pain across the lifecourse Dunn, Kate M., PhD; Hestbaek, Lise, PhD; Cassidy, J David, PhD, DrMedSci
Best practice & research. Clinical rheumatology,
10/2013
Journal Article
Recenzirano
The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.berh.2013.10.006 The duplicate article has therefore ...been withdrawn.
Abstract Objective When designing prediction models by complete case analysis (CCA), missing information in either baseline (predictors) or outcomes may lead to biased results. Multiple imputation ...(MI) has been shown to be suitable for obtaining unbiased results. This study provides researchers with an empirical illustration of the use of MI in a data set on low back pain, by comparing MI with the more commonly used CCA. Effects will be shown of imputing missing information on the composition and performance of prognostic models, distinguishing imputation of missing values in baseline characteristics and outcome data. Methods Data came from the Beliefs about Backpain cohort, a study of psychologic obstacles to recovery in primary care back pain patients in the United Kingdom. Candidate predictors included demographics, back pain characteristics, and psychologic variables. Complete case analysis was compared with MI within patients with complete outcome but missing baseline data (n = 809) and patients with missing baseline or outcome data (n = 1591). Multiple imputation was performed by a Multiple Imputation by Chained Equations procedure. Results Cases with missing outcome data (n = 782, 49.1%) or with missing baseline data (n = 116, 8%) both differed from complete cases regarding the distribution of some predictors and more often had a poor outcome. When comparing CCA with MI, model composition showed to be affected. Conclusions Complete case analysis can give biased results, even when only small amounts of data are missing. Now that MI is available in standard statistical software, we recommend that it be used to handle missing data.
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