Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial.

Autor:	Delitto A; School of Health and Rehabilitation Sciences, University of Pittsburgh, 4029 Forbes Tower, Pittsburgh, PA 15260 USA., Patterson CG; School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA., Stevans JM; School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA., Freburger JK; School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA., Khoja SS; School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA., Schneider MJ; School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA., Greco CM; Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA., Freel JA; Physician Network and Quality, St. Clair Hospital, 1000 Bower Hill Road, Pittsburgh, PA 15243 USA., Sowa GA; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA., Wasan AD; Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA., Brennan GP; 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA., Hunter SJ; 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA., Minick KI; 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA., Wegener ST; 600 N. Wolfe Street, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287 USA., Ephraim PL; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA., Beneciuk JM; Department of Physical Therapy, Box 100154, University of Florida College of Public Health and Health Professions, Gainesville, Florida, 32610 USA., George SZ; Duke Clinical Research Institute and Department of Orthopaedic Surgery, 200 Morris Street, Duke University, Durham, North Carolina, 27701 USA., Saper RB; Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118 USA.
Jazyk:	angličtina
Zdroj:	EClinicalMedicine [EClinicalMedicine] 2021 Mar 30; Vol. 34, pp. 100795. Date of Electronic Publication: 2021 Mar 30 (Print Publication: 2021).
DOI:	10.1016/j.eclinm.2021.100795
Abstrakt:	Background: Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability. Methods: We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: ClinicalTrials.gov NCT02647658. Findings: Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n  = 658) versus 51% of patients in the control arm (35 practices, n  = 635; OR=0.83 95% CI 0.64, 1.09; p  = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6; p  = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups. Interpretation: There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines. Funding: Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867. Competing Interests: Dr. Delitto reports grants from PCORI, grants from NIH, grants from DOD, outside the submitted work; Dr. Patterson reports grants from Patient Centered Outcomes Research Institute, during the conduct of the study; Dr. Stevans reports grants from PCORI, during the conduct of the study; Dr. Khoja reports grants from PCORI, during the conduct of the study; Dr. Freel has nothing to disclose; Dr. Schneider reports grants from Patient Centered Outcomes Research Institute, during the conduct of the study; Dr. Greco reports grants from Patient-Centered Outcomes Research Institute, during the conduct of the study; Dr. Sowa reports grants from PCORI, during the conduct of the study; grants from NIH, USAMRMC, VA, The Pittsburgh Foundation, outside the submitted work; Dr. Brennan reports other institutional support from Patient Centered Outcomes Research Institute (PCORI), during the conduct of the study; other institutional support from Patient Centered Outcomes Research Institute (PCORI), outside the submitted work; Stephen J. Hunter has nothing to disclose; Dr. Minick has nothing to disclose; Dr. Wasan has nothing to disclose; Dr. Wegener reports grants from PCORI, during the conduct of the study; Ms. Ephraim has nothing to disclose; Dr. Freburger reports other from American Physical Therapy Association, outside the submitted work; Dr. Beneciuk reports grants from Patient-Centered Outcomes Research Institute, during the conduct of the study; Dr. George reports personal fees from Rehab Essentials, Inc, personal fees from Med Risk, LLC, grants from NIH, other from Duke University, all outside the submitted work; Dr. Saper has nothing to disclose. (© 2021 The Authors.)
Databáze:	MEDLINE
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