Journal of General Internal Medicine

, Volume 33, Issue 8, pp 1324–1336 | Cite as

Effect of Low Back Pain Risk-Stratification Strategy on Patient Outcomes and Care Processes: the MATCH Randomized Trial in Primary Care

  • Dan CherkinEmail author
  • Benjamin Balderson
  • Rob Wellman
  • Clarissa Hsu
  • Karen J. Sherman
  • Sarah C. Evers
  • Rene Hawkes
  • Andrea Cook
  • Martin D. Levine
  • Diane Piekara
  • Pam Rock
  • Katherine Talbert Estlin
  • Georgie Brewer
  • Mark Jensen
  • Anne-Marie LaPorte
  • John Yeoman
  • Gail Sowden
  • Jonathan C. Hill
  • Nadine E. Foster
Original Research



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.

Main measures

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.

Key Results

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.

Trial Registration

National Clinical Trial Number NCT02286141.


low 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


Group Health


Generalized linear mixed models


Linear mixed models


Matching Appropriate Treatments to Consumer Healthcare needs


National Institutes of Health


Primary care


Patient-Centered Outcomes


Primary care provider


Patient Global Impression of Change


Patient health questionnaire


Pain self-efficacy questionnaire


Physical therapy/physical therapist


Roland-Morris Disability Questionnaire


Risk stratification


Subgroups for Targeted Treatment” Risk Stratification


Tampa Scale of Kinesiophobia


Usual care


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 Support

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.

Authors’ Information

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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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Dan Cherkin
    • 1
    Email author
  • Benjamin Balderson
    • 1
  • Rob Wellman
    • 1
  • Clarissa Hsu
    • 1
    • 2
  • Karen J. Sherman
    • 1
  • Sarah C. Evers
    • 1
  • Rene Hawkes
    • 1
  • Andrea Cook
    • 1
  • Martin D. Levine
    • 3
  • Diane Piekara
    • 1
  • Pam Rock
    • 1
  • Katherine Talbert Estlin
    • 4
  • Georgie Brewer
    • 5
  • Mark Jensen
    • 5
  • Anne-Marie LaPorte
    • 5
  • John Yeoman
    • 5
  • Gail Sowden
    • 6
  • Jonathan C. Hill
    • 6
  • Nadine E. Foster
    • 6
  1. 1.Kaiser Permanente Washington Health Research InstituteSeattleUSA
  2. 2.Center for Community Health and EvaluationSeattleUSA
  3. 3.Iora HealthLynwoodUSA
  4. 4.FortunaUSA
  5. 5.SeattleUSA
  6. 6.Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health SciencesKeele UniversityKeeleUK

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