Low Back Pain Improved With Stratified Management in Primary Care

Hill JC, Whitehurst DG, Lewis M, et al, Keele University, Stoke-on-Trent, United Kingdom, and other centers. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.

Outcomes in patients with low back pain (LBP) improve significantly with a stratified management approach in primary care that combines prognostic screening and treatment targeting. Such an approach is associated with substantial economic benefits compared with current best practice.

Hill and associates compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with nonstratified current best practice (control) in 1573 adults with LBP. The effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months was the primary outcome. The analysis of cost-effectiveness focused on estimation of mean incremental quality-adjusted life years and LBP-related health care costs.

Overall, a larger reduction in RMDQ score was seen in the intervention group than in the control group. The between-group adjusted mean differences in change in RMDQ scores were significant at 4 months and 12 months. Significant improvements also were noted in secondary outcomes, such as catastrophizing, fear, and depression. Stratified care was associated with improved health-related quality of life, a reduction in health care use, and fewer days off work related to LBP.

The authors suggested that their findings represent an important advance in primary care management of LBP and have important implications for providers of LBP services.

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