Comparing the STarT Back Screening Tool's Subgroup Allocation of Individual Patients With That of Independent Clinical Experts
Comparing the STarT Back Screening Tool's Subgroup Allocation of Individual Patients With That of Independent Clinical Experts
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DOI：
10.1097/ajp.0b013e3181f18aac
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发表时间：
2010-11-01
影响因子：
2.9
通讯作者：
Hay, Elaine M.
中科院分区：
文献类型：
--
作者：
Hill, Jonathan C.;Vohora, Kanchan;Hay, Elaine M.
目的：对STarT背部筛查工具（SBST）进行验证，将初级保健背痛患者亚组到与初始决策相关的风险组。然而，目前尚不清楚该工具对个体的分配与主观临床决策的比较。我们评估了临床医生和SBST对风险亚组分配的一致性，并探讨了观察到的差异的原因。方法：对12例初级保健腰痛患者进行录像临床评估。SBST于同日完成。临床专家（3名全科医生、3名物理治疗师和3名疼痛管理专家）单独审查了患者的视频（各4个），对SBST的分配一无所知。他们的任务是将患者分为低、中、高风险组。结果：12例患者中有4例专家之间的分配是一致的，临床医生之间的一致性是“公平的”（kappa = 0.28）。36例中有17例（47%）与SBST一致，Cohen加权kappa为0.22，表明基本一致。出现这种差异的原因有两个。临床医生根据患者的期望和治疗需求来调整他们的决定，临床医生利用可能与背部疼痛无关的困难生活环境的知识。讨论：临床医生单独使用直觉时，对初级保健患者背痛的风险估计不一致，与正式的亚分组工具几乎没有一致。与临床医生不同，SBST不能对患者的偏好、期望和既往治疗史进行复杂的综合。虽然承认背痛亚组工具的局限性，但需要更多的研究来测试它们的使用是否能提高初级保健决策的一致性。
Objectives: The STarT Back Screening Tool (SBST) is validated to subgroup primary care patients with back pain into risk groups relevant to initial decision-making. However, it remains unclear how the tool's allocation of individuals compares with subjective clinical decision-making. We evaluated agreement between clinicians and the SBST's allocation to risk subgroups, and explored reasons for differences observed.Methods: Twelve primary care back pain patients underwent a video-recorded clinical assessment. The SBST was completed on the same day. Clinical experts (3 general practitioners, 3 physiotherapists, and 3 pain management specialists) individually reviewed the patient videos (4 each), blind to SBST allocation. Their task was to subgroup patients into low, medium, or high-risk groups.Results: Interrater agreement between clinicians was "fair" (kappa = 0.28), with consistent allocation between experts in 4 of 12 patients. There was observed agreement with the SBST in 17 of 36 cases (47%) and Cohen's weighted kappa was 0.22, indicating fair agreement. Two reasons for differences emerged. Clinicians tailor their decisions according to patient expectations and demands for treatment and clinicians use knowledge of difficult life circumstances that may be unrelated back pain.Discussion: Clinicians make inconsistent risk estimations for primary care patients with back pain when using intuition alone, with little agreement with a formal subgrouping tool. Unlike clinicians, the SBST could not make a sophisticated synthesis of patient preferences, expectations, and previous treatment history. Although acknowledging the limitations of back pain subgrouping tools, more research is needed to test whether their use improves consistency in primary care decision-making.