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BACKGROUND: Second opinion (SO) on spine surgery was recently implemented as a statutory right in Germany. Prior to this, one health insurer did offer SO to its policy holders including advice on additional conservative treatment options. OBJECTIVES: Which treatment recommendations did 522 patients receive in an interdisciplinary multimodal assessment (IMA) as part of a SO by 4 teams comprising physician, physio- and psychotherapist and what were the long-term consequences? METHODS: Second opinions under a selective contract between insurer and back pain centers were evaluated based on patient-related anamnesis and interdisciplinary multimodal clinical findings including treatment recommendations and patient reports after about 2 years. RESULTS: Initially, spine surgery recommendation was confirmed in 15/522 (2.9%) patients (C-SS) versus 507 recommendations against. CSS patients were older, male, and had current high pain intensity more frequently, their well-being and quality of life were more often considerably impaired and from the perspective of the team morphological findings were stronger. Younger and female patients with higher pain grade and less previous surgery, but more visits to medical specialties received more often a recommendation of an interdisciplinary treatment option (ITO) versus standard care (SC). After 2 years, all 15â¯C-SS patients and 146 randomly selected patients were contacted. Of these 161 patients, 29 (18%) had undergone spine surgery. The long-term outcome was best in ITO patients without surgery, followed by the CSS after surgery and SC patients without surgery. DISCUSSION: Most patients undergoing spine surgery make their decision based on the information that they are provided without requesting a SO. As in comparative studies, most patients with a confirmed surgical indication underwent surgery, while some did not. Some patients underwent surgery inspite of recommendations against-after considering conservative therapy recommendations by the IMA. In retrospect, sound advice and an intensive conservative therapy offer seem necessary and reasonable.
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Tratamiento Conservador , Calidad de Vida , Humanos , Masculino , Femenino , Dolor , Derivación y Consulta , Dimensión del DolorRESUMEN
BACKGROUND: There is no evidence of effectiveness for interdisciplinary second opinion procedures (ISOP) for recommended back surgery (BS). Since 2015, AOK Nordost has been offering the care program RückenSPEZIAL comprising a preliminary examination, ISOP, and optional interdisciplinary multimodal pain therapy (IMPT). The objective of this study is to determine the effectiveness of RückenSPEZIAL to reduce BS and back pain-related costs (BPRC) compared to patients who likewise received a recommendation for back surgery but not RückenSPEZIAL. METHODS: Insured persons in the AOK Nordost consulted the AOK service center, presented a BS hospital admission slip and received advice to participate in RückenSPEZIAL. Following a 1:1 "matched pairs" selection, patients who participated in RückenSPEZIAL (intervention group [IG]) after this consultation (reference date) where compared with patients who did not participate after this consultation (comparison group [CG]). Patient characteristics, BS and BPRC were operationalised from AOK Nordost claims data. RESULTS: Of 108 IG patients and 108 CG patients, 34 (42%) fewer IG patients had one or more BS in 365 following days (relative risk [RR] 0.58; pâ¯< 0.001). The subgroup analysis showed for 21 IG patients with ISOP and IMPT an RR of 0.13 (pâ¯< 0.001), and for 67 IG patients with solely ISOP without IMPT an RR of 0.59 (pâ¯< 0.001). The increase in RBC from the previous year to the following year was 50.2 percentage points lower for IG patients compared to CG patients (pâ¯= 0.088). DISCUSSION: The differences in BS were significant (pâ¯< 0.05) and in favor of RückenSPEZIAL. For the specific population it can be expected that mainly savings on BS can cover the intervention costs of RückenSPEZIAL (approximately significant, small case number). Bias due to self-selection needs to be assumed.
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Dolor de Espalda , Hospitalización , Humanos , Dolor de Espalda/terapia , Derivación y ConsultaRESUMEN
BACKGROUND: A subgroup of patients with acute low back pain (LBP) will develop chronic LBP. Risk factors summarized as yellow flags are fear-avoidance beliefs, depression, catastrophizing, and work-related problems. OBJECTIVE: The aim was to evaluate the effectiveness of screening for yellow flags in general practice followed by a risk-tailored group intervention compared to care as usual. METHODS: This is a cluster-randomized controlled trial in 35 general practices with 354 patients with acute LBP. Information or a standardized group intervention was offered to patients in the intervention group according to the screening algorithm with a short questionnaire for physical and psychosocial risk factors for chronic LBP. Standardized group information contained education concerning back pain and strategies for physical activities and planning of actions. Primary outcome was functional capacity assessed after 6 and 12 months with a questionnaire. Secondary outcomes were pain severity, fear avoidance beliefs, depression score, self-rated health and health service utilization. RESULTS: The intervention had no clinically relevant effect on the primary outcome functional capacity and secondary outcomes, although the course was consistently slightly better. Adherence to the offered intervention was low. Health service utilization was not altered to a relevant extent. A subgroup analysis comparing adherent and non-adherent patients showed a consistently better course of adherent patients. CONCLUSIONS: A risk-tailored short intervention to prevent chronic LBP in general practice had no significant impact on the clinical course compared to care as usual. A subgroup analysis comparing adherent and non-adherent patients suggests that it is possible to have a positive impact on patient-relevant outcomes.
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Medicina General , Dolor de la Región Lumbar , Dolor Crónico , Humanos , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: Although most patients with low back pain (LBP) recover within a few weeks a significant proportion has recurrent episodes or will develop chronic low back pain. Several mainly psychosocial risk factors for developing chronic LBP have been identified. However, effects of preventive interventions aiming at behavioural risk factors and unfavourable cognitions have yielded inconsistent results. Risk tailored interventions may provide a cost efficient and effective means to take systematic account of the individual risk factors but evidence is lacking. METHODS/DESIGN: This study will be a cluster-randomised controlled trial comparing screening and a subsequent risk tailored intervention for patients with low back pain to prevent chronic low back pain compared to treatment as usual in primary care. A total of 600 patients from 20 practices in each study arm will be recruited in Berlin and Goettingen. The intervention comprises the following elements: Patients will be assigned to one of four risk groups based on a screening questionnaire. Subsequently they receive an educational intervention including information and counselling tailored to the risk group. A telephone/email consulting service for back pain related problems are offered independent of risk group assignment. The primary outcomes will be functional capacity and sick leave. DISCUSSION: This trial will evaluate the effectiveness of screening for risk factors for chronic low back pain followed by a risk tailored intervention to prevent chronic low back pain. This trial will contribute new evidence regarding the flexible use of individual physical and psychosocial risk factors in general practice. TRIAL REGISTRATION: ISRCTN 68205910.