Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial
Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial
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DOI：
10.1016/s0140-6736(11)60937-9
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发表时间：
2011-10-29
期刊：
影响因子：
168.9
通讯作者：
Hay, Elaine M.
中科院分区：
文献类型：
--
作者：
Hill, Jonathan C.;Whitehurst, David G. T.;Hay, Elaine M.
背景背痛仍然是国际初级保健的一个挑战。一种尚未测试的模式是根据患者的预后(低、中或高风险)进行分层管理。我们比较了分层初级保健(干预)和非分层当前最佳实践(对照)的临床效果和成本效益。方法1573名有背痛(有或不有神经根病)的成年人(年龄=18岁)在英格兰10个全科诊所接受邀请参加评估诊所的咨询。符合条件的参与者被随机分配，采用计算机生成的分层块，与干预组或对照组的比例为2：1。主要结果是治疗对12个月时罗兰·莫里斯残疾问卷(RMDQ)评分的影响。在经济评估中，我们重点估计与背痛相关的增量质量调整寿命年(QALY)和医疗保健成本。分析采用意向治疗。本研究注册编号为ISRCTN37113406，共发现851例患者，其中干预组568例，对照组283例。总体而言，干预组RMDQ评分的调整后平均变化在4个月时显著高于对照组(4.7[SD 5.9]vs 3.0[5.9]，组间差异1.81[95%CI 1.06-2.57])和12个月时(4.3[6.4]vs 3.3[6.2]，1.06[0.25-1.86])，相当于效果大小为0.32(0.19-0.45)和0.19(0.04-0.33)，分别进行了分析。在12个月时，与对照组相比，分层护理平均增加了一般健康收益(0.039个额外的QALY)和成本节约(240.01英镑对274.40英镑)。解释结果表明，通过使用配对路径的预后筛查的分层方法，将对未来初级保健中腰痛的管理具有重要意义。
Background Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control).Methods 1573 adults (aged >= 18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406.Findings 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4.7 [SD 5.9] vs 3.0 [5.9], between-group difference 1.81 [95% CI 1.06-2.57]) and at 12 months (4.3 [6.4] vs 3.3 [6.2], 1.06 [0.25-1.86]), equating to effect sizes of 0.32 (0.19-0.45) and 0.19 (0.04-0.33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0.039 additional QALYs) and cost savings (240.01 pound vs 274.40) pound compared with the control group.Interpretation The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care.