Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison
Nadine E Foster, Ricky Mullis, Jonathan C Hill, Martyn Lewis, David G T Whitehurst, Carol Doyle, Kika Konstantinou, Chris Main, Simon Somerville, Gail Sowden, Simon Wathall, Julie Young, Elaine M Hay, IMPaCT Back Study team, Nadine E Foster, Ricky Mullis, Jonathan C Hill, Martyn Lewis, David G T Whitehurst, Carol Doyle, Kika Konstantinou, Chris Main, Simon Somerville, Gail Sowden, Simon Wathall, Julie Young, Elaine M Hay, IMPaCT Back Study team
Abstract
Purpose: We aimed to determine the effects of implementing risk-stratified care for low back pain in family practice on physician's clinical behavior, patient outcomes, and costs.
Methods: The IMPaCT Back Study (IMplementation to improve Patient Care through Targeted treatment) prospectively compared separate patient cohorts in a preintervention phase (6 months of usual care) and a postintervention phase (12 months of stratified care) in family practice, involving 64 family physicians and linked physical therapy services. A total of 1,647 adults with low back pain were invited to participate. Stratified care entailed use of a risk stratification tool to classify patients into groups at low, medium, or high risk for persistent disability and provision of risk-matched treatment. The primary outcome was 6-month change in disability as assessed with the Roland-Morris Disability Questionnaire. Process outcomes captured physician behavior change in risk-appropriate referral to physical therapy, diagnostic tests, medication prescriptions, and sickness certifications. A cost-utility analysis estimated incremental quality-adjusted life-years and back-related health care costs. Analysis was by intention to treat.
Results: The 922 patients studied (368 in the preintervention phase and 554 in the postintervention phase) had comparable baseline characteristics. At 6 months follow-up, stratified care had a small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, 0.1-1.4), with a large, clinically important difference in the high risk group of 2.3 (95% CI, 0.8-3.9). Mean time off work was 50% shorter (4 vs 8 days, P = .03) and the proportion of patients given sickness certifications was 30% lower (9% vs 15%, P = .03) in the postintervention cohort. Health care cost savings were also observed.
Conclusions: Stratified care for back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs. Wider implementation is recommended.
Keywords: family practice; low back pain; practice-based research; primary care; quality improvement; screening; stratified care; subgroups.
Source: PubMed