Back pain: Research on new Group Health guidelines will shine light on changing systems of care

Few health conditions are as common and confounding as back pain, the second leading cause of all doctor visits.

“Primary care providers can usually help patients whose back pain is due to specific identifiable causes,” said Group Health Research Institute (GHRI) Senior Investigator Dan Cherkin, PhD. “But research shows only 15 percent of back pain patients have this kind of pain.” The pain of the other 85 percent is due to “non-specific causes”—making it difficult for doctors to match patients to effective treatments, he explains.

Later this month, Group Health will publish new guidelines to help providers select the most effective interventions for their patients and avoid potential harm from overtreatment. Dr. Cherkin and GHRI Senior Investigator Michael Von Korff, ScD worked with Group Health Medical Director of Clinical Improvement David McCulloch, MD, and others to develop the guidelines—all part of a system-wide effort to improve care for chronic pain.

GHRI researchers will also compare different approaches to rolling out the guidelines, determining how more intensive provider training affects health outcomes, utilization, costs, and clinician satisfaction. The research is federally funded by a $2 million grant from the Patient-Centered Outcomes Research Institute (PCORI) and a $300,000 grant from the National Center for Complementary and Alternative Medicine.

In the past, Group Health’s back care guidelines focused primarily on assessing patients’ physical pain and recommended care based on duration of their condition. The new guideline is holistic, recognizing that back pain may be more than just a mechanical problem of the spine, explained Group Health Assistant Medical Director Marty Levine, MD, who is leading the rollout. Because evidence shows that psychosocial factors such as anxiety, depression, and attitude about improvement can predict how patients fare, the new guideline recommends considering these factors when discussing treatment options.

Patients will be assessed using a simple nine-item questionnaire called the Keele STarT Back Screening Tool, which rates patients by “complexity.” For a patient with minimal pain and dysfunction and no psychosocial distress (“low complexity”), for example, providers might advise acetaminophen and help the patient enroll in a yoga class. A patient with psychosocial distress (“high complexity”) might be offered more intensive interventions, such as referral to physical therapy and behavioral health, and be encouraged to enroll in chronic disease self-management classes. The guidelines advise clinicians to engage all back pain patients in a shared decision-making process.

Dr. Levine predicted patients will benefit: “In traditional back care, there’s a poor match between patients’ underlying needs and the type and intensity of the treatments they receive. Our new guideline helps us to identify people who need a more personalized intervention fast—so it’s a much better approach.”

Because the new guideline is a big shift, Dr. Cherkin saw its rollout as a rich opportunity for research. Working with Dr. Levine, he designed a study comparing two approaches. One is standard practice, including tactics such as offering continuing medical education (CME) lectures for providers. Another more intense approach will be tried at three pilot clinics—Northgate, Lynnwood, and Renton—where physicians will get extra training to use the STarT Back tool and shared decision-making. Plus, physical therapists at the pilot locations will be trained to tailor treatment to patients’ level of complexity.

Cherkin said prior research shows CME alone doesn’t usually change providers’ habits, so he wants to discover whether a more elaborate approach makes a difference. “One of PCORI’s hallmarks is to find out what actually changes practice in the real world,” he added. “If it doesn’t work, then it shouldn’t be used.”

The team will also learn more about the STarT Back tool. Developed and used in the U.K., it has guided treatment to improve function, increase quality of life, and lower cost. “This tool is one of the first hopeful advances in primary care for back pain in decades,” said Dr. Cherkin. This study will be the first to test it in a U.S. primary care setting.

“With our model of collaboration between researchers and those in clinical improvement—and with external funding from places like PCORI—we can do research that’s valuable to Group Health patients and others around the world,” Dr. Cherkin said.

In addition to Drs. Cherkin and Levine, the current research team includes Kate Estlin, MD; Clarissa Hsu, PhD; Andrea Cook, PhD; Karen Sherman, PhD, MPH; and Ben Balderson, PhD. Other contributors are Keele University researchers; four patients, including two from Group Health and two volunteers from the American Chronic Pain Association; and Richard Deyo, MD, MPH, and Roger Chou, MD, MPH, both of Oregon Health & Science University.

by Joan DeClaire