Can a back pain screening tool help classify patients with acute pain into risk levels for chronic pain?

BACKGROUND: The 9-item STarT-Back screening tool was developed in primary care patients with low back pain (LBP) to identify those at greatest risk for chronic pain and requiring targeted treatment. We conducted a secondary data analysis study to examine the performance of comparable questionnaire items in a sample of primary care patients with well-defined acute LBP. METHODS: In a prospective cohort study, 605 primary care patients with LBP of less than 30 days answered a questionnaire with 6 items identical and 3 items analogous to the 9-item STarT-Back. Participants were followed up at 6 months and 2 years. STarT-Back rules were applied to classify participant's risk of chronic LBP, and the performance of the screening items in predicting outcomes was assessed using likelihood ratios. RESULTS: The proportion of patients with chronic pain at follow-up was considerably lower (6 months: 22%; 2 years: 25%) than in the STarT-Back validation cohort (40%) of patients with pain of any duration. The probability of developing chronic pain given a high-risk designation by items similar to the STarT-Back increased the pre-test probability to 31% and 35%. Likelihood ratios were close to 1. CONCLUSIONS: A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. The results suggest caution when applying the STarT-Back in patients with acute LBP and a need to consider a modification of its cut-offs.

Association between serum and urine biomarkers and lumbar spine individual radiographic features: the Johnston County Osteoarthritis Project.

OBJECTIVE: (1) To determine associations between radiographic features of lumbosacral (LS) spine disc space narrowing (DSN) and osteophytes (OST) and joint metabolism biomarkers (serum cartilage oligomeric matrix protein (COMP), hyaluronic acid (HA), collagen neoepitope (C2C), C-propeptide of type II procollagen (CP-II), urine C-terminal cross-linking telopeptide (CTX-II) and N-terminal telopeptide (NTX-I)). (2) To explore interactions with race, gender and low back symptoms. DESIGN: Cross-sectional analysis of 547 participants enrolled in the Johnston County (JoCo) Osteoarthritis Project from 2003 to 2004. Mean biomarker levels were estimated with linear regression. Proportional and partial-proportional odds models were used to estimate associations. Interactions were tested with likelihood ratio tests at a P-value < 0.10. Biomarkers were natural log (ln) transformed. RESULTS: Significant differences in mean biomarker levels were found across severity of DSN for lnHA and lnC2C and lnCTX-II across severity of both DSN and OST. Moderate-to-strong associations were found between biomarkers of type II collagen and DSN, whereas associations with OST were weak. An association between lnHA and DSN was seen in women (adjusted odds ratio [aOR] = 1.34 (95% confidence intervals (CI) 1.08, 1.65)) but no association among men (aOR = 0.90 (95% CI 0.63, 1.26)). In Caucasians there was a decreased association with NTX-I and OST (aOR = 0.67 (95% CI 0.49, 0.91)) and no association in African Americans (AAs) (aOR = 1.06 (95% CI 0.76, 1.47)). There was a positive association of lnCOMP with DSN among those with low back symptoms (aOR = 1.82 (95% CI 1.02, 3.27)), but no association in those without low back symptoms (aOR = 0.65 (95% CI 0.35, 1.20)). CONCLUSION: Joint metabolism biomarkers suggest biological differences in the pathologic process involved in DSN and OST that may be gender (HA) and ethnicity (NTX-I) specific.

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

BACKGROUND: Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error. METHODS: A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year. RESULTS: A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06). CONCLUSIONS: Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.

Population-based health principles in medical and public health practice.

Traditionally, medical education, research, and practice have focused on the care of the individual but an increasing emphasis on the care of populations has raised awareness among academic medical centers, integrated delivery systems, and managed care organizations of the value of embracing population-based health principles. Five principles are relevant in this regard: a community perspective, a clinical epidemiology perspective, evidence-based practice, an emphasis on outcomes, and an emphasis on prevention. This article describes these interrelated concepts together with specific strategies to effect implementation. Widespread awareness and adoption of these principles will have a profound impact on medical and public health education, practice, and ultimately the public's health.

Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies.

OBJECTIVE: To compare strategies for diagnosing cancer in primary care patients with low back pain. Strategies differed in their use of clinical findings, erythrocyte sedimentation rate (ESR), and plain x-rays prior to imaging and biopsy. DESIGN: Decision analysis and cost effectiveness analysis with sensitivity analyses. Strategies were compared in terms of sensitivity, specificity, and diagnostic cost effectiveness ratios. SETTING: Hypothetical MEASUREMENTS: Estimates of disease prevalence and test characteristics were taken from the literature. Costs were represented by the Medicare reimbursement for the tests and procedures employed. MAIN RESULTS: In the baseline analysis, using magnetic resonance imaging (MRI) as the imaging procedure prior to a single biopsy, strategies ranged in sensitivity from 0.40 to 0.73, with corresponding diagnostic costs of $14 to $241 per patient and average cost effectiveness ratios of $5,283 to $49,814 per case of cancer found. Incremental cost effectiveness ratios varied from $8,397 to $624,781; 5 strategies were dominant in the baseline analysis. Use of a higher ESR cutoff point (50 mm/hr) improved specificity and cost effectiveness for certain strategies. Imaging with MRI, or bone scan followed in series by MRI, resulted in a fewer unnecessary biopsies than imaging with bone scan alone. Cancer prevalence was an important determinant of cost effectiveness. CONCLUSIONS: We recommend a strategy of imaging patients who have a clinical finding (history of cancer, age > or = 50 years, weight loss, or failure to improve with conservative therapy) in combination with either an elevated ESR (> 50 mm/hr) or a positive x-ray, or using the same approach but imaging directly those patients with a history of cancer.

Training primary care physicians to give limited manual therapy for low back pain: patient outcomes.

STUDY DESIGN: Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice. OBJECTIVES: To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain. SUMMARY OF BACKGROUND DATA: Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training. METHODS: Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care. RESULTS: No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02). CONCLUSION: Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.

Training in back care to improve outcome and patient satisfaction. Teaching old docs new tricks.

BACKGROUND: We examined clinical outcomes and patient perceptions of back care given by physicians before and after an intensive course of training in back care and limited manual therapy techniques. METHODS: From a prospective observational cohort study of low back pain involving 208 physicians (115 primary care) and their patients and a subsequent clinical trial of treatment of low back pain given by 31 physicians specially trained in manual therapy and enhanced back care, outcome data from the patients of 13 physicians participating in both studies were compared. In the observational study, the 13 physicians cared for 120 patients. In the manual therapy trial (191 patients) a control group of 94 patients received enhanced back care and an intervention group of 97 patients received enhanced back care plus manual therapy. Pearson's chi-square comparisons and linear and Cox proportional hazard modeling were used to examine effects of variables and recovery time. RESULTS: Characteristics of the 13 physicians' patients in the cohort group and the manual therapy trial showed some differences in income, workers' compensation, previous employment, and baseline dysfunction. Both control and intervention patients in the manual therapy trial showed more rapid improvement in functional status over time and greater satisfaction with their care than those in the previous cohort study. However, there was no difference between the studies in patient-reported time to return to performing usual daily activities. CONCLUSIONS: A structured clinical approach to low back care may bring modestly improved clinical outcomes and patient satisfaction.

Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain.

STUDY DESIGN: A 22-month prospective cohort study. OBJECTIVES: To describe the course of an inception cohort of patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Chronic low back pain is a debilitating condition with great medical and social cost. METHODS: A cohort of 1246 patients with acute low back pain who sought treatment from 208 North Carolina providers was observed. Patients who developed chronic low back pain were identified. Entry criteria were back pain of less than 10 weeks' duration, no previous care for this episode of low back pain, no previous spine surgery, not pregnant, no nonskin malignancy, and access to a telephone. The providers were of four types: primary care medical doctors, doctors of Chiropractic, orthopedic surgeons, and health maintenance organization-based primary care providers. Patients were contacted by telephone shortly after enrollment and at 2, 4, 8, 12, and 24 weeks, with a final interview at 22 months. Patient functional status, care-seeking, and satisfaction were evaluated. RESULTS: Ninety-six patients had chronic, continuous symptoms for 3 months, forming the inception cohort of chronic low back pain. A valid, reliable measure of back-specific functional disability also was used. Predictors of the development of chronicity were poor baseline functional status and sciatica. A more powerful predictor of chronicity was poor functional status at 4 weeks. Two thirds of patients with chronic low back pain at 3 months had functionally disabling symptoms at 22 months, and a majority of these were employed. Satisfaction with care was low. Forty-six patients (2.6% of the entire cohort) underwent surgery, with no statistically significant difference in surgical rates among initial provider strata. Patients who underwent surgery after 3 months had a Roland disability score at 22 months of 10 (7.7, 12.3). Forty-one percent of patients with chronic low back pain see an orthopedic or neurologic surgeon. Chronic low back pain occurs in 7.7% of patients who seek care for acute low back pain, with unremitting pain for 22 months in 4.7%. CONCLUSION: Once established, chronic low back pain is persistent. Most patients with chronic low back pain seek little care, and a majority are employed. Future research should emphasize maintenance of employment and function.

Assessing "best evidence": issues in grading the quality of studies for systematic reviews.

BACKGROUND: Evidence-based medicine, clinical practice guidelines, quality and value of health services, and science-based decision making are becoming mainstays of the health care sector. As part of the evidence-based movement, systematic reviews of the literature on clinical questions are becoming increasingly common. Part of the structured approach to evaluating the literature involves assessing the quality of individual studies included in systematic reviews. REVIEW QUESTIONS: To clarify issues in this area, in 1998 the Agency for Health Care Policy and Research commissioned a small project to determine how its 12 Evidence-based Practice Centers were carrying out this part of their systematic reviews (called evidence reports). The number of potential checklists, scales, and similar tools for grading the methodology or the clinical relevance of individual reports is large; the reliability, the validity, the feasibility, and the utility of these tools are either unmeasured or quite variable. CONCLUSIONS: Numerous methodologic questions await definitive research and answers, but in the meantime teams developing authoritative systematic reviews can take certain steps to ensure that their approaches to grading the quality of articles meet applicable scientific standards. Clinicians, program administrators, and health policymakers can then be confident in the overall strength of the evidence and study conclusions.

Pharmacological treatment of alcohol dependence: a review of the evidence.

CONTEXT: Alcoholism affects approximately 10% of Americans at some time in their lives. Treatment consists of psychosocial interventions, pharmacological interventions, or both, but which drugs are most effective at enhancing abstinence and preventing relapse has not been systematically reviewed. OBJECTIVE: To evaluate the efficacy of 5 categories of drugs used to treat alcohol dependence--disulfiram, the opioid antagonists naltrexone and nalmefene, acamprosate, various serotonergic agents (including selective serotonergic reuptake inhibitors), and lithium. DATA SOURCES: Reports of randomized controlled trials, nonrandomized trials, and other study designs in English, French, and German identified from multiple searches of MEDLINE, EMBASE, and specialized databases; hand searching bibliographies of review articles; searches for unpublished literature; and discussions with investigators in the field. STUDY SELECTION: We included all studies on alcohol-dependent human subjects aged 18 years or older from all inpatient and outpatient settings between 1966 and December 1997 that met our inclusion criteria. DATA EXTRACTION: We abstracted the following information: study design and blinding, diagnostic instrument and severity assessment, drug interventions and cointerventions, demographic and comorbidity details about patients, compliance, and numerous outcome measures (eg, relapse, return to drinking, drinking or nondrinking days, time to first drink, alcohol consumed per unit of time, craving). We graded quality of the individual articles (scale, 0-100) independently from the strength of evidence for each drug class (A, strong and consistent evidence of efficacy in studies of large size and/or high quality; B, mixed evidence of efficacy; C, evidence of lack of efficacy; and I, insufficient evidence). DATA SYNTHESIS: Of 375 articles evaluated, we abstracted and analyzed data from 41 studies and 11 follow-up or subgroup studies. Naltrexone (grade A) reduces the risk of relapse to heavy drinking and the frequency of drinking compared with placebo but does not substantially enhance abstinence, ie, avoidance of any alcohol consumption. Acamprosate (grade A, from large-scale studies in Europe) reduces drinking frequency, although its effects on enhancing abstinence or reducing time to first drink are less clear. Controlled studies of disulfiram (grade B) reveal a mixed outcome pattern--some evidence that drinking frequency is reduced but minimal evidence to support improved continuous abstinence rates. The limited data on serotonergic agents were not very promising (grade I), although most studies were confounded by high rates of comorbid mood disorders. Lithium lacks efficacy (grade C) in the treatment of primary alcohol dependence. CONCLUSIONS: Recent reports documenting that naltrexone and acamprosate are more effective than placebo in the treatment of alcoholism justify clinical interest in use of these medications for alcohol-dependent patients. Use of disulfiram is widespread but less clearly supported by the clinical trial evidence; however, targeted studies on supervised administration of disulfiram may be warranted. Use of existing serotonergic agents or lithium for patients with primary alcohol dependence does not appear to be supported by the efficacy data available at this time; these medications may still have a positive effect in patients with coexisting psychiatric disorders.

Recurrence and care seeking after acute back pain: results of a long-term follow-up study. North Carolina Back Pain Project.

OBJECTIVE: To explore the relationship between type of initial care as well as the likelihood of recurrence and consequent care seeking behavior. RESEARCH DESIGN: Prospective observational cohort recruited from 208 randomly selected North Carolina practices. Cohort study examined the recurrence of low back pain among patients free of back pain 3 months after their index visit to a practitioner for that problem. The following four practitioner strata were examined: primary care providers, chiropractors, orthopedic surgeons, and practitioners in a group model HMO. Patients were interviewed by telephone at 6 and 22 months after the initial visit. MAIN OUTCOME MEASURES: Rates of disabling and non-disabling low back pain; functional status using the Roland back disability scale; and care seeking. RESULTS: Rates of recurrence were substantial; functionally disabling recurrence rates varied between 8% and 14% between 3 to 6 months, and 20% to 35% between 6 to 22 months. Differences in rates among practitioner strata were statistically significant only between 6 to 22 months with higher recurrence rates for HMO patients. Functional status, number of bed days, and time off work were very similar among the practitioner strata. Care seeking, however, was greater among those patients who had initially seen a chiropractor for their back pain. Patients with recurrence saw the same practitioner type they had seen for the index episode 88% of the time. Satisfaction was slightly greater for patients who saw chiropractors when compared with patients seeing allopathic physicians. CONCLUSIONS: The recurrence of low back pain is common. Severe disability is rare. Patients who had sought care from chiropractors are more likely to return for recurrences than patients who had initially sought care from MDs.

Disability: how successful are we in determining disability?

Individuals who have severe back pain have trouble bending, may not be able to put on their shoes, have difficulty in ambulation, and may not be able to clean their own houses. What distinguishes these individuals with low back pain from those afflicted with other conditions (i.e., congestive heart failure, metastatic cancer, symptomatic acquired immune deficiency syndrome) is prognosis. Back pain essentially never shortens life. Acute back pain has a very benign prognosis, with more than 90% of the individuals returning to functional status equivalent to their baseline status within 3 months of the onset of pain. Patients who have chronic back pain have a significantly worse prognosis, but most cohort studies show that substantial numbers of chronic back pain patients improve over time with supportive therapy.

Practitioner self-confidence and patient outcomes in acute low back pain.

OBJECTIVE: To compare outcomes for patients with acute low back pain who received care from practitioners with different self-confidence scores on a 4-item scale. DESIGN: Cross-sectional survey of practitioners. Prospective cohort study of patient outcomes. SETTING: Private practices and a group model health maintenance organization. PARTICIPANTS: One hundred eighty-nine practitioners, including private practice traditionally trained medical physicians, chiropractors, and physicians in a group model health maintenance organization, who were randomly chosen from practices across the state of North Carolina. These practitioners enrolled 1633 patients with acute low back pain into a prospective cohort study. METHODS: The practitioner survey contained 10 questionnaire items that measured aspects of practitioner confidence and attitudes in assessing and treating patients with low back pain. Patients were interviewed by telephone after the initial office visit and at 2, 4, 8, 12, and 24 weeks, or until complete recovery, whichever came first. RESULTS: Of 189 study practitioners, 95% responded to the survey. A 4-item scale, shown by factor analysis to describe practitioners' self-confidence, demonstrated good internal consistency among physicians and chiropractors. Chiropractors had significantly stronger self-confidence scores than physicians. Among patients of primary care physicians and chiropractors, those who received care from practitioners with stronger self-confidence scores did not differ in the time to functional improvement, overall patient satisfaction, or their perception of the completeness of care. CONCLUSION: The level of practitioner self-confidence, as measured by a 4-item scale, did not predict patient outcomes in the treatment of acute low back pain.

Physical therapy utilization by patients with acute low back pain.

BACKGROUND AND PURPOSE: The purposes of this study were (1) to describe the demographic and clinical characteristics of a group of patients with acute low back pain (LBP), (2) to describe those patients who were being treated by physical therapists, and (3) to analyze their use of physical therapy services. SUBJECTS: The study sample consisted of 1,580 patients with acute LBP who were treated by 208 practitioners in North Carolina. The initial providers were primary care physicians, chiropractors, orthopedic surgeons, and primary care providers at a health maintenance organization. METHODS: A telephone interview was conducted after the initial office visit to assess demographics and medical history, health care services utilization, and functional status. Follow-up telephone interviews were also conducted 2, 4, 8, 12, and 24 weeks later. RESULTS: One hundred ninety-nine (12.6%) of the subjects reported that they saw a physical therapist either by any provider referral or by direct access. Therapeutic exercise was the most commonly reported treatment procedure. Post-high-school education, receipt of Workers' Compensation, prior physical therapy for LBP, LBP and pain below the knee in one or both legs, and a higher baseline Roland-Morris Questionnaire score were associated with being treated by physical therapists. CONCLUSION AND DISCUSSION: In this study, physical therapists were utilized in the treatment of patients with greater severity of LBP. The findings demonstrate the importance of controlling for baseline characteristics when comparing outcomes of LBP when treated by different types of providers.