Essentials in rheumatology: disease management * I34. Metabolic bone diseases

Abstract

The clinical problem: Primary care clinicians such as GPs and physiotherapists are unclear about which patients with common low back pain to select for the provision of extra health resources beyond standard care involving analgesics, advice and education. Although clinical trials have reported the benefits of a wide range of treatments such as exercise, manual therapy and cognitive behavioural approaches compared with standard care, there is a lack of evidence about which patients are likely to benefit from these interventions. This reduces the efficiency of primary care management as it leads to inconsistent and sometimes inappropriate referral decision‐making. The results of this trial specifically sought to address this gap in the existing evidence to better inform commissioners and service providers about how back pain can be better managed in the early stages using a risk stratification approach to help GPs and physiotherapists. Methods ‐ to test risk stratification: A novel approach, gaining interest in other medical specialties, but not previously tested in the management of back pain, is risk stratification, with care provision structured according to an individual's estimated risk of poor prognosis (persistent disability because of back pain). With research funding of academic staff from the NIHR and Arthritis Research UK, we developed a new stratified model of primary care management of back pain, consisting of two complementary components. First, a previously validated, simple‐to‐use prognostic screening method (the Keele STarT Back Screening Tool), to allocate patients into one of three risk‐defined groups‐low, medium, and high risk groups; second, three separate care pathways, were designed with clinical experts, to match treatments to these risk groups. We then conducted a large randomized controlled trial funded by Arthritis Research UK ‐ the STarT Back Trial ‐ to test our main hypothesis that a stratified approach to primary care management for low back pain results in clinical and economic benefits compared with current best practice. With CLRN and PCRN support, 851 patients aged 18 and over who consulted their GP with non‐specific low back pain were recruited to the trial from 10 general practices within the North Staffordshire area of the UK ahead of target. They were randomized to receive either targeted treatment (the STarT Back risk stratification approach), or current best physiotherapy care. Results ‐ a potential solution:The results (Hill et al, 2011 The Lancet) suggest that, when compared to best current care, the STarT Back risk stratification approach improved disability, pain and distress, and, importantly, helped patients take less time off work and improved their treatment satisfaction rates. The reasons for this were in part due to the new approach affecting the pattern of referral to physiotherapy in a way that was more appropriate to individual patient needs, with low risk patients receiving a single session of advice to help them selfmanage, and medium and high risk patients receiving more intensive treatment. Crucially, those patients at highest risk of their back pain becoming long‐term benefited from a more intensive approach that addressed their specific worries. The economic analysis also demonstrated that a risk stratification approach was cheaper than current best practice. Implications for clinical practice: The results of this study have previously been presented at the BSR. This talk will therefore primarily be focussed at the widespread implementation of risk stratification across numerous UK NHS Trust (n20) and the lessons being learnt. GPs are being encouraged to use the Keele STarT Back Screening Tool to assist their early referral decision‐making and physiotherapy services to organize themselves to differentiate their treatment provision according to a patients risk status. This is leading to considerable re‐configuration of services to ensure that low risk patients are not being over treated, and high risk patients are better identified and their individual risk factors addressed in the early stages to prevent long term disabling problems. An independent external audit was recently conducted of the first 8 NHS Trusts who had embedded the approach within their back pain pathways, by a team of clinicians in Scotland, to survey the experiences of early adopter Centres, which revealed strong supportive for the ongoing use of the risk stratification tool (see www.keele.ac.uk/sbt). This is largely because clinical services are finding that substantial efficiency gains can be made by preventing over treatment among low risk patients, and better identifying those at high risk of persistent disabling problems who benefit from early referral to additional services such as physiotherapy. Risk stratification may not help in choosing the best specific treatment for back pain patients. However, it does appear to have an important role in helping to shape the configuration of services in primary care. This talk will, therefore, focus on sharing the lessons being learnt from early adopter Centres, to ensure that across the UK we achieve the best services possible for sufferers of common low back pain.