Comparative Effectiveness of Management Strategies for Acute Low Back Pain

描述(由申请人提供)：下腰痛(LBP)是一种常见且代价高昂的疾病。大多数急性LBP患者通过初级保健提供者进入医疗系统。初级保健管理目前的特点是高度多样化。初级保健实践中记录了各种临床决定的不明和不合理的变异性，包括转诊到物理治疗等专科。鉴于医疗保健的差异，初级保健管理的结果也有很大的变数也就不足为奇了。大多数患者病情有所改善，但有相当一部分患者会复发和慢性化。与这些患者相关的直接医疗成本可能很高，而与丧失工作效率相关的间接成本也很高。急性LBP患者的物理治疗管理在使用的干预措施和取得的结果方面也有很大的变数。为急性下腰痛患者制定更有效的管理策略，这些策略适合广泛的临床采用，为标准化和改善对一种非常常见和昂贵的疾病的护理提供了机会。目前急性LBP患者初级护理的临床实践指南建议采用分级护理方法，包括最初的建议和保证管理，并转介给专家，如对未能康复的患者仅在几周后进行物理治疗。最近的研究已经制定了一种决策规则，确定了一组可能通过特定物理治疗干预获得快速、持续改善的LBP患者，这表明通过转介这种特定治疗来始终如一地管理这一亚组可能更具成本效益。使用这一决定规则标准化初级保健和理疗管理的影响尚未评估。这项拟议的研究试图比较通常的分步护理方法与早期实施物理治疗的替代方法对这组急性LBP患者的有效性。具体目的是比较两种不同管理方法的临床有效性、成本(直接和间接)和成本效益。这项研究是一项随机试验，考察了急性LBP患者亚组的初级保健管理。其中一组将根据决策规则接受标准化护理，并及早实施物理治疗。另一名患者将按照通常的分步护理方法进行管理，即延迟转介。结果将包括一年内对残疾、疼痛、满意度和费用的测量。这项研究将允许检查两种不同方法对一组急性下腰痛患者进行初级保健管理的有效性和成本。这项研究的结果将有助于确定关于哪些护理应该标准化的最有效的管理策略。 与公共卫生相关：下腰痛是一种常见的疾病，导致社会和受影响个人的高成本和残疾。大多数指南建议对初级保健管理采取分阶段护理方法，转诊至监督治疗的转诊推迟到最初几周，以允许自发康复。该项目的目标是检查与使用标准化物理治疗计划的早期转诊的替代管理方法相关的临床有效性和成本。

DESCRIPTION (provided by applicant): Low back pain (LBP) is a common and costly condition. Most patients with acute LBP enter the healthcare system through primary care providers. Primary care management is currently characterized by a high degree of variation. Unexplained and unwarranted variability has been documented in primary care practice for variety of clinical decisions including referral to specialties such as physical therapy. Given the variations in care, it is not surprising that the outcomes of primary care management are also highly variable. Most patients improve, yet a considerable proportion goes on to recurrence and chronicity. Direct healthcare costs associated with these patients can be substantial, and indirect costs related to lost work productivity are high. Physical therapy management of patients with acute LBP is also highly variable in terms of interventions used and outcomes achieved. Developing more effective management strategies for patients with acute LBP that are feasible for wide-spread clinical adoption presents an opportunity to standardize and improve care for a very common and expensive condition. Current clinical practice guidelines for primary care management of patients with acute LBP recommend a stepped care approach, involving initial management of advice and reassurance, with referral to specialists such as physical therapy used only after several weeks for patient who fail to recover. Recent research has developed a decision rule identifying a sub-group of patients with LBP likely to experience rapid, sustained improvement with a specific physical therapy intervention, suggesting it may be more cost-effective to consistently manage this sub-group with referral for this specific treatment. The impact of standardizing primary care and physical therapy management using this decision rule has not been assessed. The proposed study seeks to compare the effectiveness of the usual, stepped care approach to the alternative approach of early implementation of physical therapy for this group of patients with acute LBP. Specific aims are to compare the clinical effectiveness, costs (direct and indirect), and cost-effectiveness of the two different management approaches. This study is a randomized trial examining primary care management of a sub-group of patients with acute LBP. One group will receive care standardized around the decision rule with early implementation of physical therapy. The other will be managed with the usual stepped care approach of delayed referral. Outcomes will include measures of disability, pain, satisfaction, and costs over 1 year. This study will permit an examination of the effectiveness and costs associated with two different approaches to primary care management of a group of patients with acute LBP. The results of this study will help to determine the most effective management strategies about which care should be standardized. PUBLIC HEALTH RELEVANCE: Low back pain is a common condition resulting in high costs and disability for society and affected individuals. Most guidelines recommend a stepped care approach for primary care management, with referral for supervised therapy delayed for the first few weeks to permit spontaneous recovery. The goal of this project is to examine the clinical effectiveness and costs associated with an alternative management approach using early referral for a standardized physical therapy program.