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Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_2 | Pages 27 - 27
1 Feb 2015
Whitehurst D Bryan S Lewis M Hay E Mullis R Foster N
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Purpose and background

To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within patient risk subgroups (low, medium and high risk of persistent disabling pain determined by the STarT Back tool).

Methods

Adopting a cost-utility framework alongside a prospective, sequential comparison of separate patient cohorts (922 patients in total) with six-month follow-up, the base case analysis estimated the incremental LBP-related healthcare cost per additional quality-adjusted life year (QALY) by risk subgroup. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative approaches (a complete case analysis, the incorporation of non-LBP-related healthcare use and estimation of societal costs relating to work absence).


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_4 | Pages 29 - 29
1 Jan 2013
Foster N Mullis R Lewis M Whitehurst D Hay E
Full Access

Background and purpose

The STarT Back trial demonstrated benefits from a stratified primary care model that targets low back pain (LBP) treatment according to patient prognosis (low-, medium-, or high-risk). The current IMPaCT Back study implemented this approach in everyday primary care to investigate; i) changes in GPs' and physiotherapists' attitudes, confidence and behaviours, ii) patients' clinical outcomes, and iii) cost-effectiveness.

Method

This quality improvement study involved 5 GP practices (65 GPs and 34 physiotherapists) with before and after implementation cohorts of consecutive LBP consulters using an intention to treat analysis to compare patient data. Phase 1: Usual care data collection from clinicians and patients (pre-implementation). Phase 2: Introduction of prognostic screening and targeted treatment including a minimal GP intervention (low-risk group), systematic referral to physiotherapy (medium-risk group) and to psychologically informed physiotherapy (high-risk group). Phase 3: Post-implementation data collection from clinicians and patients.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_4 | Pages 28 - 28
1 Jan 2013
Hill J Whitehurst D Lewis M Bryan S Dunn K Foster N Konstantinou K Main C Mason E Somerville S Sowden G Vohora K Hay E
Full Access

Background

One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes.

Methods

1573 adults with back pain (+/− radiculopathy) consulting at 10 general practices in England responded to invitations to attend an assessment clinic, at which 851 eligible participants were randomised (intervention n=568; control n=283). Primary outcome using intention-to-treat analysis was the difference in change in the Roland-Morris Disability Questionnaire (RMDQ) score at 12 months. Secondary outcomes included 4-month RMDQ change between arms overall, and at risk-group level at both time-points. The economic evaluation estimated incremental quality-adjusted life years (QALYs) and back pain-related health care costs.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 485 - 486
1 Nov 2011
Hider S Whitehurst D Thomas E Foster N
Full Access

Purpose: To evaluate whether the presence of leg pain influences healthcare use and work disability in patients with low back pain (LBP).

Methods: Prospective cohort study of primary care consulters with LBP in North Staffordshire and Cheshire. Patients completed questionnaires at baseline and 12 months, collecting data on back pain, work and healthcare utilisation. At baseline, patients were classified as reporting

LBP only,

LBP + leg pain above knee only or

LBP + leg pain extending below the knee.

Results: 456 patients had complete data and were included in this analysis. At baseline, 191 (42%) reported LBP only, 116 (25%) leg pain above the knee and 149 (33%) leg pain below the knee. In comparison to those with LBP only, patients reporting leg pain below knee were more likely to be referred to secondary care (46% vs 17%, p< 0.01), to re-consult their GP (68% vs 43%, p< 0.01) and to receive physiotherapy (40% vs 21%, p< 0.01) in the 12 months after baseline. At 12 months, those with leg pain below knee were less likely to be employed (67% vs 81%, p=0.01) than patients with LBP alone, more likely to have time off work (55% vs 31%, p< 0.01) or be on reduced work duties.

Conclusions: Self-reported leg pain is common. These patients access significantly more healthcare and are more likely to be off work over 12 months. This highlights the need for early identification of patients with concurrent leg pain and appropriate targeting of interventions to reduce work disability.

Conflicts of Interest: None

Funding source: Arthritis Research Campaign