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LBP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的变化。在初级保健实践中，对于各种临床决策（包括转诊到物理治疗等专科），已记录了无法解释和无根据的变异性。考虑到护理的变化，初级保健管理的结果也是高度可变的，这并不奇怪。大多数患者病情好转，但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，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存在很大差异。为急性LBP患者制定更有效的管理策略，使其在临床上广泛采用，这为标准化和改善非常常见和昂贵的疾病提供了机会。目前急性LBP患者初级护理管理的临床实践指南建议采用分步护理方法，包括建议和保证的初始管理，并将其转介给专家，例如对于未能康复的患者，仅在几周后进行物理治疗。最近的研究开发了一种决策规则，确定了LBP患者的一个亚组可能会经历快速，持续的改善与特定的物理治疗干预，这表明它可能是更符合成本效益的一致管理这个亚组与转诊这种特定的治疗。尚未评估使用此决策规则标准化初级保健和物理治疗管理的影响。拟议的研究旨在比较通常的有效性，分步护理方法的替代方法，早期实施物理治疗的急性腰痛患者组。具体目标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。本研究是一项随机试验，检查急性LBP患者亚组的初级保健管理。一组将接受围绕决策规则的标准化护理，并尽早实施物理治疗。另一种则会采用延迟转介的一般阶梯式护理方法。结果将包括残疾、疼痛、满意度和1年内的费用。这项研究将允许检查的有效性和成本与两种不同的方法来初级保健管理的一组急性腰痛患者。这项研究的结果将有助于确定最有效的管理策略，护理应标准化。 公共卫生相关性：腰痛是一种常见的疾病，导致社会和受影响的个人的高成本和残疾。大多数指南建议采用阶梯式护理方法进行初级保健管理，在最初几周内推迟转诊接受监督治疗，以允许自发恢复。本项目的目标是检查临床有效性和成本相关的替代管理方法，使用早期转诊的标准化物理治疗计划。

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.