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Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice.

ABSTRACT: BACKGROUND:Low back pain (LBP) is a common cause of contact with the primary healthcare sector. In some patients, symptoms quickly resolve, but others develop long-lasting pain and disability. To improve the care pathway for patients with LBP, the STarT Back Tool (STarT) questionnaire has been developed. It helps initial decision-making by subgrouping patients on the basis of their prognosis and helps to target treatment according to prognosis. An assumption behind the use of STarT is the ability to predict functional improvement. This assumption has never been tested in a population that consists exclusively of patients enrolled when consulting a Danish general practitioner for LBP. The aim of this study was to investigate STarT's ability to predict a 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score. METHODS:This was an ancillary analysis using data from a Danish guideline implementation study (registered at ClinicalTrials.gov NCT01699256). An inclusion criterion was age 18 to 65 years of age. Exclusion criteria were pregnancy, fractures, and signs of underlying pathology. Patient-reported STarT score and the Roland Morris Disability Questionnaire were administered at baseline and again after 4, 8, and 52 weeks. RESULTS:Between January 2013 and July 2014, 475 patients from the original trial participated with questionnaires. From this subpopulation, 441 (92.8%) patients provided information regarding STarT. Baseline and eight-week RMDQ data were available for 304 (64.0%) patients. After 8 weeks, 61 (65.6%) in the low-risk group, 67 (54.9%) in the medium-risk group, and 33 (37.1%) in the high-risk group had achieved a 30% improvement in the RMDQ score. After 8 weeks, high-risk patients were at 61% (95% CI: 20-125%, P < 0.001) higher risk of not achieving a 30% improvement in the RMDQ score compared with patients in either the low-risk group or the medium-risk group. CONCLUSION:STarT was predictive for functional improvement in patients from general practice with LBP. TRIAL REGISTRATION:ClinicalTrials.gov NCT01699256 , Nov 29, 2016 (registered retrospectively).

SUBMITTER: Riis A

PROVIDER: S-EPMC5569517 | biostudies-literature | 2017 Aug

REPOSITORIES: biostudies-literature

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Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice.

Riis Allan A Rathleff Michael Skovdal MS Jensen Cathrine Elgaard CE Jensen Martin Bach MB

BMC musculoskeletal disorders 20170823 1

<h4>Background</h4>Low back pain (LBP) is a common cause of contact with the primary healthcare sector. In some patients, symptoms quickly resolve, but others develop long-lasting pain and disability. To improve the care pathway for patients with LBP, the STarT Back Tool (STarT) questionnaire has been developed. It helps initial decision-making by subgrouping patients on the basis of their prognosis and helps to target treatment according to prognosis. An assumption behind the use of STarT is th ...[more]

PMID: 28835238

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Project description:ObjectiveTo examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.DesignSecondary analysis of data from participants receiving usual care in a randomized clinical trial.SettingPrimary care clinics.ParticipantsAdults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.InterventionsNot applicable.Main outcome measuresThe original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.ResultsThe STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.ConclusionsThe STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.

Project description:Background contextThe STarT Back Screening Tool (SBST) categorizes risk of future disability in patients with low back pain (LBP). Previous studies evaluating the use of SBST in physical therapy (PT) populations do not reflect the ethnic and socioeconomic diversity occurring in clinical practice and lack statistical power to evaluate factors associated with outcomes within each SBST risk category.PurposeThe purpose of this study is to further refine SBST risk categorization for predicting improvements in functional disability with attention toward patient level factors that might guide SBST use in routine outpatient physical therapy practice.Study design/settingThis was a retrospective cohort study that took place within a large academic, tertiary-care health system.Patient sampleThe study cohort consisted of 1,169 patients with LBP who completed a course of outpatient physical therapy from June 1, 2014 to May 31, 2015 and who completed the patient-reported SBST and modified low back pain disability questionnaire (MDQ) questionnaires as part of standard of care.Outcome measuresImprovement in functional disability defined as decrease in 10 or more points in the MDQ.MethodsMultivariable logistic regression was performed to evaluate independent predictors of improvement after PT, which included SBST risk category, baseline MDQ, a two-way interaction term between SBST category and baseline MDQ, prior level of function (independent vs. required assistance), demographic characteristics, number of completed PT visits, and duration of PT episode of care. In exploratory analyses, additional two-way interaction terms between SBST category and the significant predictors were added to the regression model.ResultsMean age of patients in the study cohort was 55.1 years (SD 16.1); 657 (56.2%) were female, 117 (10.0%) were black race, 127 (10.9%) had Medicaid insurance, and 353 (30.2%) had previously received PT for back pain. In all, 35.8% (n=419) patients categorized as low risk SBST category, 40.7% (n=476) medium risk SBST category, and 23.4% (n=274) high risk SBST category. There was an interaction between baseline MDQ and SBST risk category and improvement with PT. For all three SBST categories, higher baseline MDQ was associated with higher probability of improvement, but the effect was less pronounced as SBST risk category increased. Additional factors independently associated with reduced odds of improvement after PT included black race (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.28-0.72), Medicaid insurance (OR=0.58, 95% CI 0.36-0.95), and prior PT (OR=0.48, 95% CI 0.34-0.67). In exploratory analyses, there was a significant interaction between insurance type and SBST risk category in predicting functional improvement after PT. Patients with Medicare and Medicaid insurance had similar rates of improvement in low and high risk SBST categories but different rates of improvement in the medium risk categories.ConclusionsThe SBST tool predicts outcomes of PT in a cohort of patients receiving outpatient PT for LBP. The odds of improvement varied according to baseline disability and SBST risk status. Race, insurance type, and history of previous PT influenced prediction independent of SBST risk status. Incorporating these variables and the interaction between SBST and baseline disability in outcome models has the potential to refine prediction of outcomes after PT.

Dataset Information

Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice.

Publications

Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice.

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