A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back). The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.

1. It’s the Keele difference.
Research Institute for Primary
Care & Health Sciences
Keele University
Delivering high quality multidisciplinary research in primary care.

2. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
‘What is STarT Back’
Stratified care for low Back pain:
Subgrouping and targeting
treatment for LBP in primary care

3. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
• Back pain common, disabling and is costly to society and to the
NHS
• Effective treatments for back pain exist but often management
based on clinical intuition
• Stratified care approaches aim to improve this situation, with a more
systematic approach to management decisions.
• STarT Back is an example of a stratified care approach
• It match patients to treatments based on prognosis or risk of poor
clinical outcome.
• The STarT Back approach uses a simple tool to match patients to
treatment packages appropriate for them. This has been shown to:
– Significantly decrease disability from back pain
– Reduce time off work
– Save money by making better use of health resources
Background

4. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
STarT Back trial

5. Referred leg pain
Comorbid pain elsewhere
Disability x 2
Fear avoidance
Anxiety
Catastrophising
Depression
Overall impact
9 items:
www.keele.ac.uk/sbst
Scoring:
0-3 = low risk
4 or more total score = medium
4 or more sub score = high
The STarT Back Screening Tool

6. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Targeted treatment
matched pathways
1. Low risk group –
Minimal treatment
2. Medium risk -
physiotherapy
3. High risk - Enhanced
physiotherapy
Triage assessment,
Back Book + video -’Get
Back Active’.
One 30 min session:
Assessment, exam,
advice, reassurance,
secondary prevention
and self-management
Low risk triage visit
plus
Up to 6 sessions
Course of
physiotherapy, focused
on evidence based
practice, with regular
supervision
Low risk triage visit
plus
Up to 6 sessions
Course of physiotherapy:
enhanced psychosocial factor
targeting – 6 day training plus
supervision

7. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Results - overall
At 4 and 12 months there were significant improvements in:
- disability (RMDQ) between-group differences
1·8 (95%CI 1·1, 2·6) at 4 months
1·1 (95%CI 0·3, 1·9) at 12 months
- fear avoidance beliefs
- time off work
- global improvement ratings
- patient satisfaction
- quality of life
Targeted treatment was significantly cheaper: saving £34

8. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
STarT Back RCT (n=851)
(Hill et al, 2011)
1. Improved clinical outcomes
2. Improved patient satisfaction
3. Much less time off work
4. Stratified care was cheaper, saving:
 an average £34 per individual
(health costs)
 An average £675 per individual
(societal costs)

9. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Change in referral patterns
• Low risk referral:
– 49% controls
– 7% targeted group
• Medium risk patients:
– 60% controls
– 98% targeted group
• High risk patients:
– 65% controls
– 100% targeted
Overall referral: Control = 58%
Targeted = 75%
Effect on Physio referrals:
 Much less referral
 More referrals early
 More referrals early

10. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Key cost savings
STarT Back trial
• GP consultations
• Visits to NHS consultants
• Investigations
– MRI/x-rays
• Epidural injections
• Other private healthcare
• Medication

11. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Key ‘STarT Back’ message
• This high quality randomised controlled
trial has demonstrated that using the
STarT Back screening tool plus matched
treatments
– Improves patient clinical outcomes
– Improves referral to physiotherapy
– Reduces healthcare costs

12. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
IMPact Back Study

13. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Impact analysis - IMPaCT Back
study
Questions
• Can stratified care for patients with low back
pain be implemented in primary care?
• What is the effect on clinicians behaviour,
patient outcomes and cost-effectiveness
compared with usual care?
• Before and after study design
• 5 GP practices and related physiotherapy services
– 65 GPs and 34 physiotherapists
– 922 patients

14. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Outcomes (Phase 1 v Phase 3)
• Process outcomes
– Decision-making about referral, sick certification
• Health care practitioners outcomes
– Treatment orientations and confidence to assess
and manage patients with LBP
• Patients clinical outcomes
– Recommended set of outcomes including disability
(RMDQ)
• Cost outcomes
– Cost-utility analysis from a health service and
societal perspective

15. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Results – key process outcomes
• Risk appropriate referral to physiotherapy
– 40% before versus 72% after - for patients at
medium/high risk
– OR 2.4
• Reduced sickness certification
– 15% before versus 9% after
– OR 0.6

16. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Results – Health care
practitioners
• GPs
– Significant changes
• Increase in Behavioural Treatment Orientations
• Followed the tools recommendations in 71% of cases
• Physiotherapists
– Significant changes
• Improved confidence to assess and manage LBP
• Increase in Behavioural Treatment Orientations
• Decrease in Biomedical Treatment Orientations

17. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Results – patients clinical
outcomes
At 6 months there were significant improvements
in:
- disability (RMDQ)
0.71 (95%CI 0·06, 1.36), p<0.03
- fear avoidance beliefs
- time off work (it halved!)

18. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Results – per risk group
Low Risk Medium Risk High Risk
Significant differences
- Reduction in NSAIDs
- Greater satisfaction with care
Significant differences
- More accessing physiotherapy
- Reduction in anti-epileptics
- Reduction in sickness certs
- Improved fear avoidance beliefs
- Fewer days lost from work
Significant differences
- More ‘care’
- GP
- Physiotherapy
- Less disability
- Less back pain
- Less depression
- Fewer days lost from work

19. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Health economic analyses
• Overall, stratified care was associated with
– a mean cost saving of GBP £34 per patient
– a small improvement in quality of life (incremental
QALY estimate of 0.03)
• When the indirect costs associated with back pain-
related work absence was included, stratified care was
associated with
– A mean cost saving of GBP £400 per employed
patient

20. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Key cost savings
STarT Back trial
• GP consultations
• Visits to NHS consultants
• Investigations
– MRI/x-rays
• Epidural injections
• Other private healthcare
• Medication
IMPaCT Back study
 GP consultations
 Visits to NHS consultants
 Visits to private consultants
 Other private healthcare
 Medication
Whitehurst et al 2012 Arthritis Rheum

21. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Results of local audit
October 2013
Context
• Locality GP cluster - covers rural and market town population
• 615 referrals of low back pain in 12 months
• Patients referred through GP contact and Physio direct triage service
• Avoided over treating patients
• New to follow up ratios: Low Risk (24%) 1:1.3 Medium Risk (35%) 1:3 High Risk (41%) 1:4
• Reduced waiting times
Pre pilot = 52%; During pilot - 80% seen within target wait time
• Achieved 100% patient satisfaction
• Improved discharge letters back to GP (90% vs 26%)
• Reduced the number of patients being referred on for second opinion (1% to IMPACT
service)
• Ensured patients receive appropriate treatment, delivered by highly trained physiotherapists

22. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Implementation

23. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Our Partners
Impact
Accelerator
Unit
Clinical
networks
Patient
groups
NICE
Pathfinder
project
AHSN /
CLharc
Third
sector

24. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Keele Impact Accelerator Unit
GP Consultation
Referral to
Physiotherapy
generated
automatically
Appropriate
Physiotherapy
treatment
Good quality
patient
information
System
developed
with GPs
Training for
physios
provided

25. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Protocol & Template
• Protocol fires on entry of a
back pain read code
• Red flag screening prompt
• 9 Item tool
• Auto-calculates score
• Treatment
recommendations ‘pop up’
Template
• Bespoke printable patient
information
• Designed with patients
with back pain
• Contains key messages
Information
• Physiotherapy referral
auto completed
• Physiotherapists
received training in
psychosocial factors
Referral

26. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Protocol & Template

27. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Local Clinical Commissioning
Group (CCG) Impact
• E Start back tool embedded in
30 GP Practices in North
Staffordshire and Stoke on
Trent
• All used the tool to some
extent with 866 patients with
low back pain
• GPs completed took in 22% of
cases
• 22% received patient
information
• 51% referred to Physiotherapy
• Local A and E audit underway

28. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Endorsements- NICE 2016
https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#assessment-of-low-back-pain-and-sciatica

29. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
http://www.bmj.com/content/bmj/suppl/2017/01/06/bmj.i6748.DC1/beri151216.w1.pdf

30. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Endorsements
Trauma Programme of Care Pathfinder Project
Low Back Pain and Radicular Pain 2014
http://rcc-uk.org/wp-content/uploads/2015/01/Pathfinder-Low-back-and-Radicular-Pain.pdf

31. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
https://www.keele.ac.uk/sbst/startbacktool

32. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Regional and National Impact
• NICE low back pain guidance
• National Pathfinder project
• Over 200 Physiotherapists trained in matched
treatments
• 5 audits of practice
– Reduce physiotherapy waiting times
– Allows reflection of what services are providing
• Protocol developed and being tested for SysTm
One

33. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.
Patient and Public involvement
• Use of the patient voice in implementation
• Development of the patient champion role
• Use of patient associations and charities
• Bespoke patient information
• Media campaign:
– Articles written through “patient eyes”
– Patient stories
– Communication routes - social media, apps, QR codes, videos

34. It’s the Keele difference.
Acknowledgments
This presentation presents independent research funded by Arthritis Research UK (grant reference: 17741). KS was funded by a National
Institute for Health Research (NIHR) Knowledge Mobilisation fellowship (grant reference: KMF-2012-01-35)
This paper presents implementation activities undertaken as part of:
i) the West Midlands Academic Health Science Network
ii) the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care WestMidlands.
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health
We would like to thank the many contributors to both the research studies and implementation activities including: the Research Users’
Group, the clinical research network, nursing, health informatics and administrative staff at the Arthritis Research UK Primary Care Centre,
the participating general practices, physiotherapists, GP facilitators, North Staffordshire CCG, members of the Primary Care Research
Consortium

35. Thank you
Research Institute for Primary Care and
Health Sciences
David Wetherall Building
Keele University
Newcaslte-under-Lyme
ST5 5BG
Tel: 01782 733905
Fax: 01782 734719
www.keele.ac.uk/pchs
For further information:
• Nicki Evans - n.evans@keele.ac.uk, Project Manager
• Kay Stevenson - Kay.Stevenson@ssotp.nhs.uk, Clinical Lead