Effect of Low Back Pain Risk-Stratification Strategy on Patient Outcomes and Care Processes: the MATCH Randomized Trial in Primary Care
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The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients’ function while reducing costs in England.
This trial evaluated the effect of implementing an adaptation of this approach in a US setting.
The Matching Appropriate Treatments to Consumer Healthcare needs (MATCH) trial was a pragmatic cluster randomized trial with a pre-intervention baseline period. Six primary care clinics were pair randomized, three to training in the STarT Back strategy and three to serve as controls.
Adults receiving primary care for non-specific LBP were invited to provide data 2 weeks after their primary care visit and follow-up data 2 and 6 months (primary endpoint) later.
The STarT Back risk-stratification strategy matches treatments for LBP to physical and psychosocial obstacles to recovery using patient-reported data (the STarT Back Tool) to categorize patients’ risk of persistent disabling pain. Primary care clinicians in the intervention clinics attended six didactic sessions to improve their understanding LBP management and received in-person training in the use of the tool that had been incorporated into the electronic health record (EHR). Physical therapists received 5 days of intensive training. Control clinics received no training.
Primary outcomes were back-related physical function and pain severity. Intervention effects were estimated by comparing mean changes in patient outcomes after 2 and 6 months between intervention and control clinics. Differences in change scores by trial arm and time period were estimated using linear mixed effect models. Secondary outcomes included healthcare utilization.
Although clinicians used the tool for about half of their patients, they did not change the treatments they recommended. The intervention had no significant effect on patient outcomes or healthcare use.
A resource-intensive intervention to support stratified care for LBP in a US healthcare setting had no effect on patient outcomes or healthcare use.
National Clinical Trial Number NCT02286141.
KEY WORDSlow back pain risk-stratification STarT Back primary care patient outcomes
Complementary and alternative medicine
Cognitive behavioral therapy
Digital video disc
Computer-assisted telephone interview
Continuing medical education
Electronic health record
Generalized anxiety disorder
Generalized linear mixed models
Linear mixed models
Matching Appropriate Treatments to Consumer Healthcare needs
National Institutes of Health
Primary care provider
Patient Global Impression of Change
Patient health questionnaire
Pain self-efficacy questionnaire
Physical therapy/physical therapist
Roland-Morris Disability Questionnaire
Subgroups for Targeted Treatment” Risk Stratification
Tampa Scale of Kinesiophobia
Work Productivity and Activity Impairment
We are very grateful to the primary care clinicians, physical therapists, and staff at the Group Health Lynnwood, Northgate, and Renton clinics for their support for and engagement in the intervention. In addition, we would like to thank the following members of the research team; Zoe Bermet, Kristin Delaney, MPH, John Ewing, Kevin Filocamo, Vina Graham, and Margie Wilcox, and Survey Interviewers; Jennifer Brandlin, Donna Luce, and Patricia Scott.
Funding for this trial was provided by the Patient Centered Care Research Institute (“Evaluation of a Patient-Centered Risk Stratification Method for Improving Primary Care for Back Pain”: Contract #398) and by the National Center for Complementary and Integrative Health/NIH (“Implementing Evidence-Based Treatments for Persistent Back Pain into Primary Care”: Grant No. R21AT0007326). Martin Levine, Diane Piekara, and Pam Rock received support to participate in the quality improvement activities from Group Health. Nadine E Foster, an NIHR Senior Investigator, and Jonathan C. Hill were supported through an NIHR Research Professorship (NIHR-RP-011-015) awarded to Nadine Foster. The views expressed are those of the authors and not necessarily those of the Patient Centered Care Research Institute, NIH, NHS, the NIHR, or the Department of Health.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Our research team included four “patient partners” (GB, MJ, AL, JY) with chronic back pain who provided their unique and valuable expert advice on the trial materials and processes.
The views and opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Patient-Centered Outcomes Research Institute, the National Institutes of Health, NIHR, NHS, or the Department of Health. None of the agencies that funded the trial had any input into the trial design, conduct, data collection, analysis or interpretation, reporting, or writing of this article.
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