Improvements Are Needed in the Adherence to the TRIPOD Statement for Clinical Prediction Models for Patients With Spinal Pain or Osteoarthritis: A Metaresearch Study.

This metaresearch study aimed to evaluate the completeness of reporting of prediction model studies in patients with spinal pain or osteoarthritis (OA) in terms of adherence to the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) statement. We searched for prognostic and diagnostic prediction models in patients with spinal pain or OA in MEDLINE, Embase, Web of Science, and CINAHL. Using a standardized assessment form, we assessed the adherence to the TRIPOD of the included studies. Two independent reviewers performed the study selection and data extraction phases. We included 66 studies. Approximately 35% of the studies declared to have used the TRIPOD. The median adherence to the TRIPOD was 59% overall (interquartile range (IQR): 21.8), with the items of the methods and results sections having the worst reporting. Studies on neck pain had better adherence to the TRIPOD than studies on back pain and OA (medians of 76.5%, 59%, and 53%, respectively). External validation studies had the highest total adherence (median: 79.5%, IQR: 12.8) of all the study types. The median overall adherence was 4 points higher in studies that declared TRIPOD use than those that did not. Finally, we did not observe any improvement in adherence over the years. The adherence to the TRIPOD of prediction models in the spinal and OA fields is low, with the methods and results sections being the most poorly reported. Future studies on prediction models in spinal pain and OA should follow the TRIPOD to improve their reporting completeness. PERSPECTIVE: This article provides data about adherence to the TRIPOD statement in 66 prediction model studies for spinal pain or OA. The adherence to the TRIPOD statement was found to be low (median adherence of 59%). This inadequate reporting may negatively impact the effective use of the models in clinical practice.

Predictive validity of the STarT Back screening tool among older adults with back pain.

BACKGROUND: The predictive validity of the STarT Back screening tool among older adults is uncertain. This study aimed to assess the predictive validity of the SBT among older adults in primary care. METHODS: This prospective cohort study included 452 patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain. A poor outcome (persistent disabling back pain) was defined as a score of ≥7/24 on the Roland-Morris Disability Questionnaire (RMDQ) at 3, 6 or 12 months of follow-up. The ability of the SBT risk groups to identify persistent disabling back pain was assessed with multivariable logistic regression, area under receiver operating characteristics curve (AUC), and with the accuracy measures sensitivity, specificity, predictive values and likelihood ratios. RESULTS: The adjusted odds ratios (95% CI) for persistent disabling back pain were 2.40 (1.34-4.30) at 3 months, 3.42 (1.76-6.67) at 6 months and 2.81 (1.47-5.38) at 12 months for the medium-risk group (n = 118), and 8.90 (1.83-43.24), 2.66 (0.81-8.67) and 4.53 (1.24-16.46) for the high-risk group (n = 27), compared to the low-risk group (n = 282). There were no statistically significant differences in odds between the medium- and high-risk groups at any time point. AUC values (95% CI) were 0.65 (0.59-0.71), 0.67 (0.60-0.73) and 0.65 (0.58-0.71) at 3, 6 and 12 months. Accuracy measures were poor at all time points, with particularly poor sensitivity and negative likelihood ratio values. CONCLUSION: The predictive validity of the SBT risk groups in predicting persistent disabling back pain in older adults was poor. SIGNIFICANCE STATEMENT: This study found that the STarT Back screening tool had poor predictive validity among older adults and that it may need recalibration or extension before widespread implementation among older adults. Having valid tools for this population may aid clinicians with allocating scarce healthcare resources, which is especially important considering the rapidly ageing population and its expected challenge to the healthcare systems.

Identifying latent subgroups in the older population seeking primary health care for a new episode of back pain - findings from the BACE-N cohort.

BACKGROUND: Back pain is the number one condition contributing to years lived with disability worldwide, and one of the most common reasons for seeking primary care. Research on this condition in the ageing population is sparse. Further, the heterogeneity of patients with back pain complicates the management in clinical care. It is possible that subgrouping people with similar characteristics would improve management. This paper aimed to identify latent classes based on demographics, pain characteristics, psychosocial behavior, and beliefs and attitudes about back pain, among older patients seeking primary care with a new episode of back pain, and to examine if there were differences regarding the classes' first point-of-contact. METHODS: The study was part of the international BACE (Back complaints in elders) consortium and included 435 patients aged ≥ 55 years seeking primary care (general practitioners, physiotherapists, and chiropractors) in Norway from April 2015 to March 2020. A latent class analysis was performed to identify latent classes. The classes were described in terms of baseline characteristics and first point-of-contact in primary care. RESULTS: Four latent classes were identified. The mean age was similar across groups, as were high expectations towards improvement. Class 1 (n = 169, 39%), the "positive" class, had more positive attitudes and beliefs, less pain catastrophizing and shorter duration of current pain episode. Class 2 (n = 31, 7%), the "fearful" class, exhibited the most fear avoidance behavior, and had higher mean pain intensity. Class 3 (n = 33, 8%), the "distressed" class, had the highest scores on depression, disability, and catastrophizing. Finally, class 4 (n = 202, 46%), the "hopeful" class, showed the highest expectations for recovery, although having high pain intensity. The identified four classes showed high internal homogeneity, sufficient between-group heterogeneity and were considered clinically meaningful. The distribution of first point-of-contact was similar across classes, except for the positive class where significantly more patients visited chiropractors compared to general practitioners and physiotherapists. CONCLUSIONS: The identified classes may contribute to targeting clinical management of these patients. Longitudinal research on these latent classes is needed to explore whether the latent classes have prognostic value. Validation studies are needed to evaluate external validity. TRIAL REGISTRATION: Clinicaltrials.gov NCT04261309.

External validation and updating of prognostic prediction models for nonrecovery among older adults seeking primary care for back pain.

ABSTRACT: Prognostic prediction models for 3 different definitions of nonrecovery were developed in the Back Complaints in the Elders study in the Netherlands. The models' performance was good (optimism-adjusted area under receiver operating characteristics [AUC] curve ≥0.77, R2 ≥0.3). This study aimed to assess the external validity of the 3 prognostic prediction models in the Norwegian Back Complaints in the Elders study. We conducted a prospective cohort study, including 452 patients aged ≥55 years, seeking primary care for a new episode of back pain. Nonrecovery was defined for 2 outcomes, combining 6- and 12-month follow-up data: Persistent back pain (≥3/10 on numeric rating scale) and persistent disability (≥4/24 on Roland-Morris Disability Questionnaire). We could not assess the third model (self-reported nonrecovery) because of substantial missing data (>50%). The models consisted of biopsychosocial prognostic factors. First, we assessed Nagelkerke R2 , discrimination (AUC) and calibration (calibration-in-the-large [CITL], slope, and calibration plot). Step 2 was to recalibrate the models based on CITL and slope. Step 3 was to reestimate the model coefficients and assess if this improved performance. The back pain model demonstrated acceptable discrimination (AUC 0.74, 95% confidence interval: 0.69-0.79), and R2 was 0.23. The disability model demonstrated excellent discrimination (AUC 0.81, 95% confidence interval: 0.76-0.85), and R2 was 0.35. Both models had poor calibration (CITL <0, slope <1). Recalibration yielded acceptable calibration for both models, according to the calibration plots. Step 3 did not improve performance substantially. The recalibrated models may need further external validation, and the models' clinical impact should be assessed.

The one-year clinical course of back-related disability and the prognostic value of comorbidity among older adults with back pain in primary care.

ABSTRACT: Back pain and comorbidity are common in older adults. Comorbidity is a promising prognostic factor for the clinical course of back-related disability, but confirmatory studies assessing its prognostic value are needed. Thus, the aims of this study were to describe the clinical course of back-related disability during 1-year follow-up in patients aged ≥55 years visiting primary care (general practitioner, physiotherapist, or chiropractor) with a new episode of back pain and assess the prognostic value of comorbidity on back-related disability during 1-year follow-up. A prospective cohort study was conducted, including 452 patients. The outcome measure was Roland-Morris Disability Questionnaire (RMDQ, range 0-24) measured at baseline and at 3-, 6-, and 12-month follow-up. The Self-Administered Comorbidity Questionnaire was used to assess comorbidity count (CC, range 0-15) and comorbidity burden (CB, range 0-45). The RMDQ scores improved from median (interquartile range) 9 (4-13) at baseline to 4 (1-9), 4 (0-9), and 3 (0-9) at 3, 6, and 12 months, respectively. Using linear mixed-effects models, we found that CC and CB were independently associated with RMDQ scores. A 1-point increase in CC was associated with an increase in RMDQ score of 0.76 points (95% confidence interval [0.48-1.04]) over the follow-up year, adjusted for known prognostic factors. A 1-point increase in CB was associated with an increased RMDQ score of 0.47 points (95% confidence interval [0.33-0.61]). In conclusion, the clinical course of back-related disability for older adults presenting in primary care was favorable, and increased comorbidity was an independent prognostic factor for increased disability levels.

Healthcare utilization and related costs among older people seeking primary care due to back pain: findings from the BACE-N cohort study.

OBJECTIVES: To describe healthcare utilization and estimate associated costs during 1 year of follow-up among older people seeking primary care due to a new episode back pain and to describe healthcare utilization across patients with different risk profiles stratified using the StarT Back Screening Tool (SBST). DESIGN: Prospective cohort study. PARTICIPANTS AND SETTING: A total of 452 people aged ≥55 years seeking Norwegian primary care with a new episode of back pain were included. OUTCOME MEASURES: The primary outcome of this study was total cost of healthcare utilization aggregated for 1 year of follow-up. Secondary outcomes included components of healthcare utilization aggregated for 1 year of follow-up. Healthcare utilization was self-reported and included: primary care consultations, medications, examinations, hospitalisation, rehabilitation stay, and operations. Costs were estimated based on unit costs collected from national pricelists. Healthcare utilization across patients with different SBST risk profiles was compared using Kruskal-Wallis test, post hoc Mann-Whitney U tests and Bonferroni adjustment. RESULTS: In total, 438 patients were included in the analysis. Mean (BCa 95% CI) total cost per patient over 1 year was €825 (682-976). Median (BCa 95% CI) total cost was €364 (307-440). The largest cost category was primary care consultations, accounting for 56% of total costs. Imaging rate was 34%. The most commonly used medication was paracetamol (27%-35% of patients). Medium- and high-risk patients had a significantly higher degree of healthcare utilization compared with low-risk patients (p<0.030). CONCLUSION: This study estimated a 1 year mean and median cost of healthcare utilization of €825 and €364, respectively. Patients within the top 25th percentile accounted for 77% of all costs. Patients classified as medium risk and high risk had a significantly higher degree of healthcare utilization compared with patients classified as low risk. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04261309, results.

Assessing physical workload among people with musculoskeletal disorders: validity and reliability of the physical workload questionnaire.

BACKGROUND: Demands of physical work are related to musculoskeletal disorders, and hence, important to assess. The Physical Workload Questionnaire (PWQ) is based on 26 items related to physical workload. The PWQ has been translated into Norwegian, but its psychometric properties have not yet been tested. The aim of this study was to assess the validity and reliability of the PWQ among patients with musculoskeletal disorders. METHODS: A cross-sectional study with a test-retest design was conducted to assess construct validity (structural validity and hypothesis testing) and reliability (internal consistency and test-retest reliability) among employed patients with musculoskeletal disorders. Exploratory factor analysis was performed to assess the structural validity and number of items to be included in the Norwegian version of the PWQ. Hypothesis testing was assessed by 14 a priori hypotheses ("known" group, convergent and discriminant validity). Internal consistency was evaluated using Cronbach's alpha and test-retest reliability by Intraclass Correlation Coefficient (ICC2.1), Standard Error of Measurement (SEMagreement) and Smallest Detectable Change (SDC95%ind). RESULTS: In total, 115 patients with a mean age (SD) of 46 (9) years were included, of which 48 were included in the reliability analyses. Exploratory factor analysis resulted in two subscales: "Heavy physical work" (15 items, range 0-100) and "Long-lasting postures and repetitive movements" (7 items, range 0-100). No floor or ceiling effects were seen in the subscales. Twelve of the 14 (85%) predefined hypotheses were confirmed. The internal consistency with Cronbach's alpha was 0.94 and 0.85 on subscales 1 and 2, respectively. Test-retest reliability analyses demonstrated an ICC2.1 of 0.96 (95% CI 0.88, 0.98) and 0.92 (95% CI 0.81, 0.96), SEM of 6.9 and 10.0 and SDC95%ind of 19.2 and 27.7 of subscales 1 and 2, respectively. CONCLUSIONS: The Norwegian version of the PWQ demonstrated good validity and reliability and can be used to evaluate physical workload in patients with musculoskeletal disorders.

Characteristics of older adults with back pain associated with choice of first primary care provider: a cross-sectional analysis from the BACE-N cohort study.

OBJECTIVES: To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor). DESIGN: Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study. SETTING: Norwegian GP, PT and chiropractic primary care centres. PARTICIPANTS: Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor. PRIMARY AND SECONDARY OUTCOME MEASURES: For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses. RESULTS: Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05). CONCLUSION: Older back pain patients in primary care had moderate to severe levels of back-related disability, and most had recurring episodes. Our results suggest that older adult's choice of first primary care provider was associated with important patient characteristics, which highlights the need for caution with generalisations of study results across primary care populations. TRIAL REGISTRATION NUMBER: NCT04261309.