Implementing Stratified Primary Care Management for Low Back Pain: Cost-Utility Analysis Alongside a Prospective, Population-Based, Sequential Comparison Study
Whitehurst, David G. T. PhD; Bryan, Stirling PhD; Lewis, Martyn PhD; Hay, Elaine M. MD; Mullis, Ricky PhD; Foster, Nadine E. DPhil
Spine
15 March 2015
Vol. 40 – Issue 6: p 405–414
Abstract
A wealth of empirical evidence reported in the biomedical and health services literature identifies the global burden of low back pain (LBP) and the challenges regarding the provision of effective primary care.1–3 In the United Kingdom, LBP accounts for approximately 14% of all primary care consultations4; 60% to 80% of primary care LBP consulters continue to report pain and disability 12 months on, despite the fact that many stop seeing their general practitioner (GP) in the first 3 months.5,6 A study published in 2000, using 1998 prices, estimated the societal impact of LBP-related health service resource use and periods of work absence to be £7 to £12 billion, with National Health Service (NHS) and community costs alone in excess of £1 billion.7
Clinical guidelines recommend first line treatments such as exercise and manual therapy for LBP, although optimal approaches for use in primary care remain elusive.8 Although active intervention is preferred over no treatment,9,10 many existing active treatments tend to show, at best, small benefits when tested in heterogeneous samples of patients.11 Identifying ways to better match treatments to patient subgroups, in ways that enhance patient outcomes, is an international research priority.12 A recent randomized controlled trial (the STarT Back trial) demonstrated the clinical and cost-effectiveness of stratified care for nonspecific LBP in a primary care physiotherapy setting.13,14 A prognostic risk stratification tool (the STarT Back tool) was used to identify patients at low, medium, and high risk of persistent disabling LBP that were subsequently matched to targeted treatments. In that trial, the GP was not involved in delivering stratified care; all potentially eligible study participants were referred to a physiotherapy-led community-based clinic. Consequently, the trial did not reflect usual practice internationally, where the minority of patients with LBP are referred to physiotherapy services.15
The question as to whether stratified care implemented in primary care, with GPs as the first contact practitioner, provides the same clinical and societal benefits has been explored in a recent population-based, sequential comparison study (the IMPaCT Back study).16,17 The IMPaCT Back study design permitted analyses of process, clinical and economic outcomes for the overall comparison of stratified care with usual care, as well as prespecified analyses within each patient subgroup. The study demonstrated modest improvements in patients’ outcomes overall, more targeted use of health care resources and reduced sick certification, without any associated increase in health care costs. This article reports new data from the prespecified subgroup analyses, exploring cost-utility considerations within each patient subgroup to help inform decision making by clinicians, service managers, and policy makers.