Implementing the Keele stratified care model for patients with low back pain: an observational impact study

Six Externally Validated Prognostic Models Have Potential Clinical Value to Predict Patient Health Outcomes in the Rehabilitation of Musculoskeletal Conditions: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to identify and appraise externally validated prognostic models to predict a patient's health outcomes relevant to physical rehabilitation of musculoskeletal (MSK) conditions.

METHODS

We systematically reviewed 8 databases and reported our findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. An information specialist designed a search strategy to identify externally validated prognostic models for MSK conditions. Paired reviewers independently screened the title, abstract, and full text and conducted data extraction. We extracted characteristics of included studies (eg, country and study design), prognostic models (eg, performance measures and type of model) and predicted clinical outcomes (eg, pain and disability). We assessed the risk of bias and concerns of applicability using the prediction model risk of bias assessment tool. We proposed and used a 5-step method to determine which prognostic models were clinically valuable.

RESULTS

We found 4896 citations, read 300 full-text articles, and included 46 papers (37 distinct models). Prognostic models were externally validated for the spine, upper limb, lower limb conditions, and MSK trauma, injuries, and pain. All studies presented a high risk of bias. Half of the models showed low concerns for applicability. Reporting of calibration and discrimination performance measures was often lacking. We found 6 externally validated models with adequate measures, which could be deemed clinically valuable [ie, (1) STart Back Screening Tool, (2) Wallis Occupational Rehabilitation RisK model, (3) Da Silva model, (4) PICKUP model, (5) Schellingerhout rule, and (6) Keene model]. Despite having a high risk of bias, which is mostly explained by the very conservative properties of the PROBAST tool, the 6 models remain clinically relevant.

CONCLUSION

We found 6 externally validated prognostic models developed to predict patients' health outcomes that were clinically relevant to the physical rehabilitation of MSK conditions.

IMPACT

Our results provide clinicians with externally validated prognostic models to help them better predict patients' clinical outcomes and facilitate personalized treatment plans. Incorporating clinically valuable prognostic models could inherently improve the value of care provided by physical therapists.

Perspectives and experiences of physiotherapists and general practitioners in the use of the STarT Back Tool: a review and meta-synthesis

Introduction The STarT Back Tool (SBT) is used to triage people with acute low back pain (LBP) into treatment groups, matched to their risk of chronicity. It was developed in the UK where it has been shown to improve clinical outcomes, patient satisfaction, and reduce time off work. Successful implementation of the SBT outside the UK is dependent on health practitioner's attitudes and the healthcare system in which they work. Gaining health practitioners' perspectives on the SBT is an important step in implementation. Methods A computerised search of qualitative literature was conducted across seven databases in March 2021 using keywords to identify studies investigating the perspectives of physiotherapists and general practitioners on the use of the SBT in primary health care. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tool. Data were coded and analysed using reflexive thematic analysis. Results Eight articles met inclusion criteria and included the views of 76 physiotherapists and 65 general practitioners, working in primary health care in four countries. Three themes were created from the data: 'Making it work', identifies factors that influence implementation and continued use of the SBT. The second 'will I do it?', captured potential consequences of adopting the SBT, and the third, 'it's all about the patient' emphasised how the SBT may  affect patients. Discussion Physiotherapists and general practitioners found using the SBT frequently enhanced practice. General practitioners expressed concerns about time constraints and the SBT's potential to undermine clinical experience. Findings from this study will inform modifications to contextualise the tool to each healthcare environment.

Patients' Views on the Implementation Potential of a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study

Stratified care for low back pain (LBP) has been shown to be clinically- and cost-effective in the UK, but its transferability to the German healthcare system is unknown. This study explores LBP patients’ perspectives regarding future implementation of stratified care, through in-depth interviews (n = 12). The STarT-Back-Tool was completed by participants prior to interviews. Interview data were analysed using Grounded Theory. The overarching theme identified from the data was ‘treatment-success’, with subthemes of ‘assessment and treatment planning’, ‘acceptance of the questionnaire’ and ‘contextual factors’. Patients identified the underlying cause of pain as being of great importance (whereas STarT-Back allocates treatment based on prognosis). The integration of the STarT-Back-Tool in consultations was considered helpful as long as it does not disrupt the therapeutic relationship, and was acceptable if tool results are handled confidentially. Results indicate that for patients to find STarT-Back acceptable, the shift from a focus on identifying a cause of pain and subsequent diagnosis, to prediction-orientated treatment planning, must be made clear. Patient ‘buy in’ is important for successful uptake of clinical interventions, and findings can help to inform future strategies for implementing STarT-Back in the Germany, as well as having potential implications for transferability to other similar healthcare systems.

PRISM: a brief screening tool to identify risk in parents of youth with chronic pain

Having a child with chronic pain impacts a parent's life. Reciprocally, parent cognitive, affective, and behavioral responses to the child's chronic pain can influence the child's pain experience. The purpose of this study is to develop a brief self-report screening tool (Parent Risk and Impact Screening Measure [PRISM]) of parent psychosocial functioning and behavioral responses to child pain. This measure assesses parents' reports of their own stress, health, psychosocial functioning, and disruption in activities due to their child's pain and related disability. In an effort to preliminarily validate this screening tool, we examined the PRISM in relation to existing measures of parent distress, parent behavior, and child functioning. An initial 30-item PRISM was administered to 229 parents of children with persistent pain. Parents also reported on distress, protectiveness, pain catastrophizing and family impact, and youth completed measures of pain, pain-related disability, and quality of life. Item refinement resulted in a final 12-item PRISM tool. The PRISM demonstrates strong internal consistency, and initial support for construct validity was shown by associations with parent distress, protectiveness, and catastrophizing. Results also revealed higher PRISM scores are associated with higher child pain intensity, greater functional disability, and poorer quality of life. Cutoff scores were determined to identify parents at differing levels of risk. The PRISM is a brief and clinically important means of screening parent distress and behaviors associated with child pain-related dysfunction. Further validation will use PRISM in longitudinal studies, particularly testing PRISM scores as a predictor of parent and child outcomes over time.

The effectiveness of a simplified core stabilization program (TRICCS-Trivandrum Community-based Core Stabilisation) for community-based intervention in chronic non-specific low back pain

BACKGROUND

Chronic low back pain is a common public health problem all over the world. Conservative therapy is prescribed as the initial treatment strategy in chronic low back pain. The cornerstone of conservatism in back care is core muscle strengthening. However, exercises prescribed for the purpose are manifold and some are not easily done by patients in Asian countries. We developed an easy to adhere exercise protocol for core stabilization and tested its effectiveness in south Indian population.

METHODS

Prospective study of 73 patients with chronic low back pain (CLBP) who were subjected to Trivandrum Community-based Core Stabilisation protocol of treatment. The enrolled patients underwent initial Oswestry Disability Index (ODI) evaluation and Keele Start Back (KSB) questionnaire before starting the protocol. Back education was given, and the patient started on stratified exercise protocol. ODI assessment was done weekly. The trend in ODI changes and the factors determining them were assessed using ANOVA. The correlation of quantitative variables like age, initial ODI score, and KSB score with the rate of reduction of ODI was assessed using Pearson's correlation. Cross-tabulations were done using the chi-square test. Parametric tests were used throughout the analysis as the quantitative study variables found to be linear. Multiple linear regression (for the quantitative outcome) and binary logistic regression (for the dichotomous outcome) were performed.

RESULTS

Mean (SD) of ODI score has reduced significantly from 43.4 (16.6) to 24.6 (17.1) over the period of 6 weeks (p value < 0.001). The trend in reduction of ODI scores was significantly more in KSB score less than or equal to 3 compared to KSB more than 3 even after adjusting for the general trend of decreasing ODI score over time. The reduction in ODI scores appeared to be low for advancing age (p = 0.468) and higher KSB scores (p = 0.001).

CONCLUSION

The TRICCS protocol is effective in a community-based approach in achieving satisfactory outcomes in CLBP in a period of 6 weeks. Patients with high KSB scores may require cognitive intervention also.

Advancing practice for back pain through stratified care (STarT Back)

BACKGROUND

Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care.

RESULTS

The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care.

CONCLUSIONS

The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.

Population-based contracting (population health): part II

Modern healthcare contracting is shifting the responsibility for improving quality, enhancing community health and controlling the total cost of care for patient populations from payers to providers. Population-based contracting involves capitated risk taken across an entire population, such that any included services within the contract are paid for by the risk-bearing entity throughout the term of the agreement. Under such contracts, a risk-bearing entity, which may be a provider group, a hospital or another payer, administers the contract and assumes risk for contractually defined services. These contracts can be structured in various ways, from professional fee capitation to full global per member per month diagnosis-based risk. The entity contracting with the payer must have downstream network contracts to provide the care and facilities that it has agreed to provide. Population health is a very powerful model to reduce waste and costs. It requires a deep understanding of the nuances of such contracting and the appropriate infrastructure to manage both networks and risk. Cite this article: Bone Joint J 2017;99-B:1431-4.