Can primary care for back and/or neck pain in the Netherlands benefit from stratification for risk groups according to the STarT Back Tool-classification?

OBJECTIVE: To evaluate whether current Dutch primary-care clinicians offer tailored treatment to patients with lower-back pain (LBP) or neck pain (NP) according to their risk stratification, based on the Keele STarT (Subgroup Targeted Treatment) Back-Screening Tool (SBT).

DESIGN: Prospective cohort study with 3 month follow-up SETTING: Primary care PARTICIPANTS: General practitioners (GPs) and physiotherapists (PTs) included patients with non-specific LBP and/or NP.

INTERVENTIONS: Patients completed a baseline questionnaire, including the Dutch SBT, for either LBP or NP. A follow-up measurement was conducted after 3 months to determine recovery (using the Global Perceived Effect (GPE) scale), pain (using the Numeric Pain-Rating Scale (NPRS)) and function (using the Roland Disability Questionnaire (RDQ) or the Neck Disability Index (NDI)). A questionnaire was sent to the GPs and PTs to evaluate the provided treatment.

MAIN OUTCOME MEASURES: Prevalence of patients' risk profile and clinicians' applied care, and the percentage of patients with persisting disability at follow-up. A distinction was made between patients receiving the advised treatment and those receiving the non-advised treatment.

RESULTS: In total, 12 GPs and 33 PTs included patients. After 3 months, we analyzed 184 patients with LBP and 100 patients with NP. In the LBP group, 52.2% of the patients were at low risk for persisting disability, 38.0% were at medium risk and 9.8% were at high risk. Overall, 24.5% of the LBP patients received a low-risk treatment approach, 73.5% a medium-risk and 2.0% a high-risk treatment approach. The specific agreement between the risk profile and the received treatment for patients with LBP was poor for the low-risk and high-risk patients (respectively 21.1% and 10.0%), and fair for medium-risk patients (51.4%). In the NP group, 58.0% of the patients were at low risk for persisting disability, 37.0% were at medium risk and 5.0% were at high-risk. Only 6.1% of the patients with NP received the low-risk treatment approach. The medium-risk treatment approach was offered the most (90.8%) and the high-risk approach was applied in only 3.1% of the patients. The specific agreement between the risk profile and received treatment for NP patients was poor for low-risk and medium-risk patients (resp. 6.3% and 48.0%); agreement for high-risk patients could not be calculated.

CONCLUSION: Current Dutch primary care for patients with non-specific LBP and/or NP does not correspond to the advised stratified-care approach based on the SBT as the majority of patients receive medium risk treatment. The majority of "low-risk" patients are over-treated and the majority of "high-risk" patients are undertreated. Although the stratified-care approach has not yet been validated in Dutch primary care, these results indicate that there may be substantial room for improvement.