Adaptation and Implementation of the STarT Back Risk Stratification Strategy in a US Health Care Organization: A Process Evaluation.

OBJECTIVE: To support implementation of effective treatments for back pain that can be delivered to a range of people, we summarize learnings from our process evaluation of the MATCH trial's implementation of an adaptation of the STarT Back risk-stratified care model. DESIGN: Our logic model-driven evaluation focused primarily on qualitative data sources. SETTING: This study took place in a US-based health care delivery system that had adapted and implemented the STarT Back stratified care approach. This was the first formal test of the strategy in a US setting. METHODS: Data collection included observation of implementation activities, staff/provider interviews, and post-training evaluation questionnaires. Data were analyzed using thematic analysis of qualitative data and descriptive statistics for questionnaire data. RESULTS: We found that both primary care teams and physical therapists at intervention clinics gave the training high scores on evaluation questionnaires and reported in the interviews that they found the training engaging and useful. However, there was significant variation in the extent to which the risk stratification strategy was incorporated into care. Some primary care providers reported that the intervention changed their conversations with patients and increased their confidence in working with patients with back pain. Providers using the STarT Back tool did not change referral rates for recommended matched treatments. CONCLUSIONS: These insights provide guidance for future efforts to adapt and implement the STarT Back strategy and other complex practice change interventions. They emphasize the need for primary care-based interventions to minimize complexity and the need for ongoing monitoring and feedback.

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

BACKGROUND: The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients' function while reducing costs in England. OBJECTIVE: This trial evaluated the effect of implementing an adaptation of this approach in a US setting. DESIGN: 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. PARTICIPANTS: 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. INTERVENTIONS: 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. CONCLUSIONS: 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.

Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative.

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older. DESIGN: Randomized, controlled trial. SETTING: Two primary care clinics in the Seattle, Washington, area. PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older. INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care. MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2-Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed. RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P=.03). CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.

Bringing geriatricians to the front lines: evaluation of a quality improvement intervention in primary care.

BACKGROUND: Frail elders often receive low-quality primary care, yet the optimal role of geriatricians in primary care settings remains uncertain. We evaluated the health utilization impacts of an innovative intervention emphasizing chronic disease self-management and physical activity promotion among frail elders in primary care. METHODS: The intervention was implemented within two primary care practices at a single clinic serving a large population of frail elders enrolled in a western Washington health plan. Subjects included older patients (age >or=65 years) with disproportionate baseline outpatient service use who attended two on-site visits with a geriatrician during which each received comprehensive assessment and a problem-solving intervention to enhance chronic disease self-management and promote physical activity (N = 146). Our evaluation had a retrospective matched cohort design. Controls receiving primary care at other health plan clinics were matched 3:1 to intervention subjects by sex and a propensity score (N = 437), which was computed using demographic, clinical, and health care utilization factors that were predictive of attending the intervention. Among intervention subjects and controls following the intervention, we compared relative rates of hospitalization, outpatient and specialty visits, nursing home admission, mortality, and prescription of selected high-risk medications, as well as total health care costs. RESULTS: From March 2002 to November 2003, the geriatrician evaluated 146 of 725 elderly subjects (20%) in the two primary care practices. During a mean follow-up of 1.3 years, intervention subjects had a reduced rate of hospitalization relative to matched controls (incidence rate ratio 0.57; 95% CI: 0.37 to 0.86; P < .01). Intervention and control subjects did not have significantly different rates of specialty visits, outpatient visits, nursing home admission, mortality, or high-risk prescriptions. Relative to matched controls during follow-up, total health care costs were 26.3% lower among intervention subjects (95% CI: 1.3%, 44.9%; P = .04). CONCLUSIONS: Outpatient geriatric interventions emphasizing collaboration between geriatricians and primary care physicians, chronic disease self-management, and physical activity may reduce hospitalization risk and total health care costs among vulnerable elders.