Comparative Effectiveness of Management Strategies for Acute Low Back Pain

描述（由申请人提供）：腰痛（LBP）是一种常见且昂贵的疾病。大多数急性腰痛患者通过初级保健提供者进入医疗保健系统。初级保健管理目前的特点是高度变异。在初级保健实践中，对于各种临床决策，包括转诊到专科，如物理治疗，已经记录了无法解释和没有根据的变异性。鉴于护理的差异，初级保健管理的结果也高度可变也就不足为奇了。大多数患者病情好转，但相当大比例的患者会复发并成为慢性疾病。与这些患者相关的直接医疗成本可能非常高，与工作效率损失相关的间接成本也很高。急性腰痛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是高度可变的。为急性腰痛患者制定更有效的管理策略，并广泛应用于临床，这为标准化和改善这种非常常见且昂贵的疾病提供了机会。目前的临床实践指南对急性腰痛患者的初级保健管理建议采取阶梯式护理方法，包括初始管理的建议和保证，转诊给专家，如物理治疗，只有在几周后，患者恢复不了。最近的研究开发了一种决策规则，确定了一个亚组的LBP患者，通过特定的物理治疗干预可能会经历快速、持续的改善，这表明通过转诊进行这种特定治疗来持续管理这个亚组可能更具成本效益。使用这一决策规则规范初级保健和物理治疗管理的影响尚未得到评估。本研究旨在比较常规的、阶梯式护理方法与早期实施物理治疗的替代方法对这组急性腰痛患者的有效性。具体目的是比较两种不同管理方法的临床效果、成本（直接和间接）和成本效益。本研究是一项随机试验，检查急性腰痛患者亚组的初级保健管理。一组患者将根据决策规则进行规范化护理，早期实施物理治疗。另一种将采用延迟转诊的常规阶梯式护理方法进行管理。结果将包括残疾、疼痛、满意度和1年内的费用。本研究将对一组急性腰痛患者的两种不同初级保健管理方法的有效性和成本进行检查。这项研究的结果将有助于确定最有效的管理策略，哪些护理应该标准化。

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.