What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project).

STUDY DESIGN: Multiround wiki-based Delphi expert panel survey. OBJECTIVE: To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care." METHODS: Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators. RESULTS: From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided. CONCLUSION: These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

Health-related quality of life 24 months after sustaining a minor musculoskeletal injury in a road traffic crash: A prospective cohort study.

OBJECTIVES: A better understanding of the long-term factors that independently predict poorer quality of life following mild to moderate musculoskeletal injuries is needed. We aimed to establish the predictors of quality of life (including sociodemographic, health, psychosocial, and pre-injury factors) 24 months after a noncatastrophic road traffic injury. METHODS: In a prospective cohort study of 252 participants with mild/moderate injury sustained in a road traffic crash, quality of life was measured 24 months following the baseline survey. A telephone-administered questionnaire obtained information on various potential explanatory variables. Health-related quality of life was measured using the European Quality of Life-5 Dimensions (EQ-5D) and Medical Outcomes Survey Short Form-12 (SF-12). Multivariable linear regression analyses determined the associations between explanatory variables and quality of life measures. RESULTS: Mean SF-12 physical component summary (PCS) and mental component summary (MCS) scores increased by 7.3 and 2.5 units, respectively, from baseline to 24-month follow-up. Each 10-year increase in baseline age was independently associated with 3.1-unit (P < .001) and 1.5-unit (P = .001) decrease in EQ Visual Analogue Scale (VAS) and SF-12 PCS scores at follow-up, respectively. Poor/fair compared to excellent pre-injury health was associated with a 0.16-, 21.3-, and 11.5-unit decrease in EQ-5D summary (P = .03), VAS scores (P = .001), and SF-12 PCS scores (P < .001), respectively. Baseline pain severity ratings and pain catastrophizing scores were inversely associated with 24-month EQ VAS scores (both P < .001). Each unit increase in baseline pain score (P = .001) and pain catastrophizing score (P = .02) was associated with a 1.0- and 4.6-unit decrease in SF-12 MCS scores at 24 months, respectively. Other observed predictors of quality of life measures (EQ-5D summary and/or VAS scores and/ or SF-12 MCS) included marital status, smoking, hospital admission, pre-injury health (anxiety/depression and chronic illness), and whiplash injury. CONCLUSION: Sociodemographic indicators, pre-injury health, and biopsychosocial correlates were independently associated with health-related quality of life 24 months following a noncatastrophic road traffic crash injury.

Predictors of time to claim closure following a non-catastrophic injury sustained in a motor vehicle crash: a prospective cohort study.

BACKGROUND: Research suggests that exposure to the compensation system (including time to case closure) could adversely influence a persons' recovery following injury. However, the long-term predictors of time to claim closure following minor road traffic injuries remain unclear. We aimed to assess a wide spectrum of factors that could influence time to claim closure (socio-demographic, compensation-related, health, psychosocial and pre-injury factors) over 24 months following a non-catastrophic injury. METHODS: Prospective cohort study of 364 participants involved in a compensation scheme following a motor vehicle crash. We used a telephone-administered questionnaire to obtain information on potential explanatory variables. Information on time to claim closure was obtained from an insurance regulatory authority maintained database, and was classified as the duration between the crash date and claim settlement date, and categorized into < 12 (early), > 12-24 (medium) and > 24 months (late). RESULTS: Just over half of claimants (54 %) had settled their claim by 12 months, while 17 % and 30 % took > 12-24 months and > 24 months for claim closure, respectively. Whiplash at baseline was associated with claim closure time of > 12-24 months versus < 12 months: multivariable-adjusted OR 2.38 (95 % CI 1.06-5.39). Claimants who were overweight/obese versus normal/underweight at the time of injury were ~3.0-fold more likely to settle their claim at > 12-24 months than < 12 months. Consulting a lawyer was associated with a 10.4- and 21.0-fold increased likelihood of settling a claim at > 12-24 months and > 24 months, respectively. Each 1-unit increase in Orebro Musculoskeletal Pain Screening Questionnaire scores at baseline was associated with greater odds of both medium (> 12-24 months) and delayed claim settlement date (> 24 months): multivariable-adjusted OR 1.04 (95 % CU 1.01-1.07) and 1.02 (95 % CI 1.00-1.05), respectively. CONCLUSIONS: Around a third of claimants with a minor injury had not settled by 24 months. Health-related factors and lawyer involvement independently influenced time to claim closure.

Comparison of health outcomes between hospitalised and non-hospitalised persons with minor injuries sustained in a road traffic crash in Australia: a prospective cohort study.

OBJECTIVES: This prospective cohort study aimed to investigate whether there are differences in health outcomes among persons with mild or moderate injuries who were hospitalised compared with those not hospitalised following a road traffic crash. SETTING: Sydney Metropolitan, New South Wales, Australia. PARTICIPANTS: Persons aged ≥18 years involved in a motor vehicle crash were surveyed at baseline (n=364), and at 12 (n=284) and 24 months (n=252). A telephone-administered questionnaire obtained information on a range of socioeconomic, and preinjury and postinjury psychological and heath characteristics of all participants. PRIMARY OUTCOME MEASURE: Participants who reported admission to hospital for 24 h or more (but less than 7 days) after the crash were classified as being hospitalised; those admitted for less than 24 h were classified as non-hospitalised. RESULTS: Around 1 in 5 participants (19.0%) were hospitalised for ≥24 h after the crash. After adjusting for age and sex, hospitalised participants compared with those not hospitalised had approximately 2.6 units (p=0.01) lower Short Form-12 Physical Component Summary (SF-12 PCS) scores (poorer physical well-being) and approximately 4.9 units lower European Quality of Life visual analogue scale (EQ-VAS) scores (p=0.05), 12 months later. After further adjusting for education level, whiplash, fracture and injury severity score, participants who were hospitalised had approximately 3.3 units lower SF-12 PCS (p=0.04), 12 months later. The association with EQ-VAS did not persist after multivariable adjustment. No significant differences were observed between the 2 groups in health outcomes at 24-month follow-up. CONCLUSIONS: These findings indicate that long-term health status is unlikely to be influenced by hospitalisation status after sustaining a mild/moderate injury in a vehicle-related crash.

Course of recovery for whiplash associated disorders in a compensation setting.

CONTEXT: The detailed course of recovery following compensable whiplash associated disorders (WAD) is not well understood. Some people recover within months and others report symptoms for extended periods. Recent research identified distinct recovery pathways. Identifying recovery pathways for people with this condition in compensable settings could assist clinical and claim management. STUDY OBJECTIVE: This study aimed to identify recovery trajectories based on disability, pain catastrophising and mental health and, secondly, to examine developmental linkages between the trajectories. STUDY DESIGN: A cohort of 246 people with compensable WAD were followed for 24 months after a motor vehicle related injury. OUTCOME MEASURES: Functional Rating Index (FRI), Pain Catastrophising Scale (PCS) and the SF36 Mental Component Score (SF 36 MCS). METHOD: Group-based trajectory analytical techniques were used to identify distinct post-injury profiles. Multinominal logistic regression modelling identified factors associated with membership of different trajectories. RESULTS: 246 people were enrolled a median of 72 days after injury. Three trajectories were identified for the measures used and their prevalences, respectively, were: for disability (FRI) they were mild (47%), moderate (31%), and severe (22%); for pain catastrophising (PCS) they were non-catastrophisers (55%), moderate-low catastrophisers (32%) and clinically significant catastrophisers (13%); and, for mental health (SF36 MCS) they were good mental health (40%), moderately low mental health (42%) and severely low mental health (18%). All groups showed no further recovery beyond 12 months after injury. The significant baseline predictors of the severe disability trajectory were: lower (that means worse) bodily pain scores (SF 36 BPS) (p≤0.01); high pain catastrophising (p≤0.01); and, self-reported fair or poor general health (p=0.03). Conditional probabilities for group membership showed that the three trajectories for both PCS and FRI were linked. Dual membership was high for the mild disability and mild pain catastrophising trajectories and, for the severe disability and clinically significant pain catastrophising trajectories. CONCLUSIONS: There is a strong and plausible association between severe disability, clinical levels of pain catastrophising and low mental health. Claimants can be identified at claim notification based on three estimated recovery trajectories. Claim and clinical interventions can be targeted to the profile within each recovery trajectory.

Associations with duration of compensation following whiplash sustained in a motor vehicle crash.

CONTEXT: Continued exposure to compensation systems has been reported as deleterious to the health of participants. Understanding the associations with time to claim closure could allow for targeted interventions aimed at minimising the time participants are exposed to the compensation system. STUDY OBJECTIVE: To identify the associations of extended time receiving compensation benefits with the aim of developing a prognostic model that predicts time to claim closure. STUDY DESIGN: Prospective cohort study in people with whiplash associated disorder. OUTCOME MEASURES: Time to claim closure, in a privately underwritten fault based third party traffic crash insurance scheme in New South Wales, Australia. METHOD: Cox proportional hazard regression modelling. RESULTS: Of the 246 participants, 25% remained in the compensation system longer than 24 months with 15% remaining longer than three years. Higher initial disability (Functional Rating Index≥25 at baseline) (HRR: 95% CI, 1.916: 1.324-2.774, p<0.001); and lower initial mental health as measured by SF-36 Mental Component Score (HRR: 95% CI, 0.973: 0.960-0.987, p<0.001) were significantly and independently associated with an increased time-to-claim closure. Shorter time to claim closure was associated with having no legal involvement (HRR: 95% CI, 1.911: 1.169-3.123, p=0.009); and, not having a prior claim for compensation (HRR: 95% CI, 1.523: 1.062-2.198, p=0.022). CONCLUSIONS: Health and insurance related factors are independently associated with time to claim closure. Both factors need to be considered by insurers in their assessment of complexity of claims. Interventions aimed at minimising the impact of these factors could reduce claimants' exposure to the compensation system. In turn insurers can potentially reduce claims duration and cost, while improving the health outcomes of claimants.

A comparison of health outcomes in older versus younger adults following a road traffic crash injury: a cohort study.

BACKGROUND: Given the aging demographics of most developed countries, understanding the public health impact of mild/moderate road traffic crash injuries in older adults is important. We aimed to determine whether health outcomes (pain severity and quality of life measures) over 24 months differ significantly between older (65+) and younger adults (18-64). METHODS: Prospective cohort study of 364, 284 and 252 participants with mild/moderate injury following a vehicle collision at baseline, 12 and 24 months, respectively. A telephone-administered questionnaire obtained information on socio-economic, pre- and post-injury psychological and heath characteristics. RESULTS: At baseline, there were 55 (15.1%) and 309 (84.9%) participants aged ≥65 and 18-64 years, respectively. At 12- and 24-month follow-up, older compared to younger participants who had sustained a mild/moderate musculoskeletal injury had lower physical functioning (3.9-units lower Short Form-12 Physical Composite Score, multivariable-adjusted p = 0.03 at both examinations). After multivariable adjustment, older (n = 45) versus younger (n = 207) participants had lower self-perceived health status (8.1-units lower European Quality of Life-5 Dimensions Visual Acuity Scale scores at 24 months, p = 0.03), 24 months later. CONCLUSIONS: Older compared to younger participants who sustained a mild/moderate injury following a road-traffic crash demonstrated poorer physical functioning and general health at 24 months.

The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review.

The effect of financial compensation on health outcomes following musculoskeletal injury requires further exploration because results to date are varied and controversial. This systematic review identifies compensation related factors associated with poorer health outcomes following musculoskeletal injury. Searches were conducted using electronic medical journal databases (Medline, CINAHL, Embase, Informit, Web of Science) for prospective studies published up to October 2012. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Studies solely measuring return to work outcomes were excluded. Twenty nine articles were synthesised and then assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to determine evidence levels. The results were mixed. There was strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There was moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There was limited evidence of an association between compensation status and increased pain. In seven studies the association depended on the outcome measured. No studies reported an association between compensation related factors and improved health outcomes. Further research is needed to find plausible reasons why compensation related factors are associated with poorer health following musculoskeletal injury.

Prognostic indicators of social outcomes in persons who sustained an injury in a road traffic crash.

INTRODUCTION: There is a lack of longitudinal studies with adequate sample size and follow-up period which have objectively assessed social outcomes among those with mild or moderate musculoskeletal injury or that are not limited to hospital inpatients. We aimed to address this gap by prospectively assessing the potential predictors of return to pre-injury work and daily activities. METHODS: Persons with mild/moderate musculoskeletal injuries from a vehicle-related crash were surveyed within the first 3 months after the crash (baseline; n=364), and at 12 (n=284) and 24 months (n=252). Participants self-reported return to work, and whether it was return to full or modified duties at work. Analyses were restricted to 170 participants who reported being in pre-injury paid work and had provided information at either 12 months only or at both 12 and 24 months. Return to usual activities was assessed using the European Quality of Life-5 Dimensions (EQ-5D) scale 'Usual Activities' dimension. RESULTS: Twenty-four months after injury 82% (n=121) had returned to work. After multivariable adjustment, not being admitted to hospital was associated with 44% higher likelihood of returning to work at 24 months. Not having any pre-injury chronic illness was associated with returning to work after 24 months, multivariable-adjusted risk ratio (RR), 1.21 (95% confidence intervals, CI: 1.02-1.45). Each 1-SD increase in Medical Outcomes Survey Short Form-12 Mental Component Summary (SF-12 MCS) score at baseline was associated with returning to work at 24 months RR 1.13 (95% CI: 1.02-1.25). Younger age, higher SF-12 physical component summary (PCS), and EQ-5D visual analogue scale (VAS) scores were mutually independent predictors of returning to usual activities 24 months later. CONCLUSION: A range of bio-psychosocial factors, particularly quality of life measures, independently predicted social outcomes including return to work and return to usual daily activities. These determinants could be measured early in the recovery process and be potentially amenable to intervention.

Associations with legal representation in a compensation setting 12 months after injury.

CONTEXT: Many people with Whiplash Associated Disorder (WAD) seek treatment though a compensation system where factors such as legal involvement have been reported as having a negative impact on recovery outcomes. OBJECTIVE: To compare those with and without legal involvement in their compensation claim, and identify associations with legal involvement at 12 months post injury; and longer term disability. STUDY DESIGN: Inception cohort study. PARTICIPANTS: 246 people with WAD compensation claim. OUTCOME MEASURES: Legal involvement and Functional Rating Index at 12 months post injury. METHODS: Participants were recruited from an insurance database. Baseline health (Functional Rating Index, Pain Catastrophising Scale and SF-36), socio-economic, work capacity, and claims data were collected within three months of injury and 12 months. Logistic regression models were used to identify associations with legal involvement at 12 months; and disability (FRI) at 12 months. RESULTS: At baseline 246 participants were enrolled into the study in a median 72 days post injury. At 12 months post injury 52 (25%) had engaged a lawyer. The significant independent associations with legal involvement at 12 months were higher levels of initial disability, work disability, speaking a language other than English at home and lower levels of mental health. Specifically, the odds of lawyer involvement at 12 months post injury was 4.9 times greater for those with work disability; 2.3 times greater for those who spoke a language other than English at home. In terms of health, they had poorer mental health and for every 10 unit increase in the baseline FRI score the odds of having lawyer involvement increased by 38%. DISABILITY: at 12 months (FRI) was significantly independently associated with, PCS-helplessness (p<0.001), age (p<0.001) and prior claim (p=0.001). CONCLUSION: This study suggests the people with lawyer involvement in their claim 12 months after injury have socio-economic disadvantage, have had a prior claim and a worse baseline health profile compared to those without a lawyer. Understanding this profile could allow for improved claims processes and targeted interventions to assist this group through any perceived complexities in the system and address the underlying reasons for lawyer participation within compensation schemes.

Restriction in functioning and quality of life is common in people 2 months after compensable motor vehicle crashes: prospective cohort study.

BACKGROUND: We sought to identify the role of pre-injury socio-demographic and health characteristics, and injury severity in determining health-related quality-of-life outcomes for mild to moderate injuries 2 months after a motor vehicle crash in a compensable setting. METHODS: People aged 17 years and older, injured with a New Injury Severity Score of 8 or less, in a motor vehicle crash in New South Wales and who had registered a claim with the Compulsory Third Party Insurance scheme from March to December 2010 were contacted to participate in the study. Information for 364 eligible participants was primarily collected through telephone interview, approximately 2 months after injury. RESULTS: Substantial proportions of participants continued to have adverse outcomes approximately 2 months after their injury with mean Short Form Health Survey (SF-12) physical component score of 36.7 (SD ±10.3), SF-12 mental component score of 46.6 (SD ±11), Euro Qol (EQ) analogue scale score of 65.8 (SD ±18) and Euro Qol five dimension (EQ-5D) summary score of 0.70 (SD ±10). Key factors predicting adverse outcomes were prior chronic illness, obesity, hospitalisation and self-perceived threat to life due to injury. CONCLUSIONS: This study highlights the substantial impact of apparently "minor" motor vehicle crash injuries in a compensable setting and suggests targets for studies of tertiary prevention to improve health-related quality-of-life outcomes.

Determining return to work in a compensation setting: a review of New South Wales workplace rehabilitation service provider referrals over 5 years.

BACKGROUND: Australian workers' compensation data reports a reduction in injury rates and claim incidence but no improvement in Return to Work (RTW) rates. OBJECTIVE: To identify factors associated with a positive RTW outcome and describe those referred to Workplace Rehabilitation Providers (WRPs) in the New South Wales (NSW) Australian workers' compensation scheme. METHODS: A retrospective review of 65,762 de-identified WRP case records over a 5 year period. 9,262 cases specifically referred for RTW assistance were analysed to identify factors associated with a positive RTW outcome RESULTS: Overall 47% of those referred for RTW services were able to upgrade their work status whilst 30% maintained their Stay at Work or pre-referral work status. The significant independent predictors associated with a positive RTW outcome were a shorter duration of disability (p< 0.001) (0R, 0.971; 95% CI, 0.964-0.977) and a higher socio economic index score (p=0.002) (OR, 1.131; 95% CI, 1.045-1.223). CONCLUSIONS: The study suggests that WRPs are seeing an increased focus on management of workers with increasing disability, with socio-economic disadvantage, increasing age, from blue collar backgrounds. The duration of disability is a significant determinant in achieving positive RTW outcomes suggesting that injured workers should be referred earlier for RTW services.

Identifying predictors of early non-recovery in a compensation setting: The Whiplash Outcome Study.

CONTEXT: People with Whiplash Associated Disorder (WAD) often experience pain and disability for extended periods of time. A large proportion of these people will seek treatment through a compensation process. Rarely is data related to people's health collected within the compensation process making it difficult to identify those that are at risk of delayed recovery and appropriately direct interventions. STUDY OBJECTIVE: To compare people with WAD who have recovered with those that have not, within 3 months of injury and identify potential predictors of poorer health and non-recovery to inform claim screening processes. STUDY DESIGN: Cross-sectional analysis of a cohort study. PARTICIPANTS: People who sustained a WAD and claimed compensation within an Australian Motor Accidents Compensation Scheme between November 2007 and June 2009. MEASURE OF RECOVERY: Functional Rating Index (FRI) score (25). HEALTH OUTCOME MEASURES: Short Form 36 (SF36), FRI, and the Pain Catastrophising Scale (PCS). METHODS: 246 people who had lodged a claim for compensation were enrolled in the Whiplash Outcome Study within 3 months of sustaining a WAD injury. Participants were assigned to a recovered or non recovered group and analysed for differences between the two groups. Multiple linear regression models were used to identify potential predictors of poorer health and non-recovery. RESULTS: Overall 23% of the study population had recovered within 3 months of sustaining a WAD, whilst only 9% had finalised their insurance claim. The recovered group had significantly better scores on all health outcome measures; SF36 Physical Component Score, SF36 Mental Component Score and the PCS(p < 0.001). The significant independent predictors of poorer health and non-recovery were helplessness(p < 0.001), older age (p < 0.001) and pre-injury work status being affected (p < 0.001) (r(2) = .624).Regardless of the health outcome measure used, helplessness was significantly associated with poorer reported health. CONCLUSION: Including additional information at claim notification, specifically the PCS and information on the effect the injury has on the working population could significantly improve claim screening processes, identifying those with poorer health and risk of non-recovery.