Can patient-reported profiles avoid unnecessary referral to a spine surgeon? An observational study to further develop the Nijmegen Decision Tool for Chronic Low Back Pain
Chronic Low Back Pain (CLBP) is a heterogeneous condition with lack of diagnostic clarity. Therapeutic interventions show small effects. To improve outcomes by targeting interventions it is recommended to develop a triage system to surgical and non-surgical treatments based on treatment outcomes. Th...
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| Veröffentlicht in: | PloS one 2018-09, Vol.13 (9), p.e0203518-e0203518 |
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| creator | van Hooff, Miranda L van Dongen, Johanna M Coupé, Veerle M Spruit, Maarten Ostelo, Raymond W J G de Kleuver, Marinus |
| description | Chronic Low Back Pain (CLBP) is a heterogeneous condition with lack of diagnostic clarity. Therapeutic interventions show small effects. To improve outcomes by targeting interventions it is recommended to develop a triage system to surgical and non-surgical treatments based on treatment outcomes. The objective of the current study was to develop and internally validate prognostic models based on pre-treatment patient-reported profiles that identify patients who either respond or do not respond to two frequently performed treatments (lumbar spine surgery and multidisciplinary pain management program).
A consecutive cohort study in a secondary referral spine center was performed. The study followed the recommendations of the PROGRESS framework and was registered in the Dutch Trial Register (NTR5946). Data of forty-seven potential pre-consultation (baseline) indicators predicting 'response' or 'non-response' at one-year follow-up for the two treatments were obtained to develop and validate four multivariable logistic regression models. The source population consisted of 3,410 referred CLBP-patients. Two treatment cohorts were defined: elective 'spine surgery' (n = 217 [6.4%]) and multidisciplinary bio-psychosocial 'pain management program' (n = 171 [5.0%]). Main inclusion criteria were age ≥18, CLBP (≥6 months), and not responding to primary care treatment. The primary outcome was functional ability: 'response' (Oswestry Disability Index [ODI] ≤22) and 'non-response' (ODI ≥41).
Baseline indicators predictive of treatment outcome were: degree of disability (all models), ≥2 previous spine surgeries, psychosocial complaints, age (onset 50), and patient expectations of treatment outcomes. The explained variances were low for the models predicting response and non-response to pain management program (R2 respectively 23% and 26%) and modest for surgery (R2 30% and 39%). The overall performance was acceptable (c-index; 0.72-0.83), the model predicting non-response to surgery performed best (R2 = 39%; c-index = 0.83).
This study was the first to identify different patient-reported profiles that predict response to different treatments for CLBP. The model predicting 'non-response' to elective lumbar spine surgery performed remarkably well, suggesting that referrals of these patients to a spine surgeon could be avoided. After external validation, the patient-reported profiles could potentially enhance timely patient triage to the right secondary care specialist |
| doi_str_mv | 10.1371/journal.pone.0203518 |
| format | Article |
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A consecutive cohort study in a secondary referral spine center was performed. The study followed the recommendations of the PROGRESS framework and was registered in the Dutch Trial Register (NTR5946). Data of forty-seven potential pre-consultation (baseline) indicators predicting 'response' or 'non-response' at one-year follow-up for the two treatments were obtained to develop and validate four multivariable logistic regression models. The source population consisted of 3,410 referred CLBP-patients. Two treatment cohorts were defined: elective 'spine surgery' (n = 217 [6.4%]) and multidisciplinary bio-psychosocial 'pain management program' (n = 171 [5.0%]). Main inclusion criteria were age ≥18, CLBP (≥6 months), and not responding to primary care treatment. The primary outcome was functional ability: 'response' (Oswestry Disability Index [ODI] ≤22) and 'non-response' (ODI ≥41).
Baseline indicators predictive of treatment outcome were: degree of disability (all models), ≥2 previous spine surgeries, psychosocial complaints, age (onset <20 or >50), and patient expectations of treatment outcomes. The explained variances were low for the models predicting response and non-response to pain management program (R2 respectively 23% and 26%) and modest for surgery (R2 30% and 39%). The overall performance was acceptable (c-index; 0.72-0.83), the model predicting non-response to surgery performed best (R2 = 39%; c-index = 0.83).
This study was the first to identify different patient-reported profiles that predict response to different treatments for CLBP. The model predicting 'non-response' to elective lumbar spine surgery performed remarkably well, suggesting that referrals of these patients to a spine surgeon could be avoided. After external validation, the patient-reported profiles could potentially enhance timely patient triage to the right secondary care specialist and improve decision-making between clinican and patient. This could lead to improved treatment outcomes, which results in a more efficient use of healthcare resources.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0203518</identifier><identifier>PMID: 30231051</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adolescent ; Adult ; Aged ; Aged, 80 and over ; Back pain ; Biology and Life Sciences ; Bone surgery ; Care and treatment ; Chronic Pain - physiopathology ; Chronic Pain - therapy ; Consultation ; Decision Making ; Diagnostic systems ; Epidemiology ; Female ; Health aspects ; Health care ; Health sciences ; Humans ; Indicators ; Low back pain ; Low Back Pain - physiopathology ; Low Back Pain - therapy ; Male ; Management ; Medical diagnosis ; Medical research ; Medicine and Health Sciences ; Methods ; Middle Aged ; Models, Biological ; Observational studies ; Orthopedic Procedures ; Orthopedic Surgeons ; Pain ; Patient outcomes ; Patients ; People and Places ; Performance prediction ; Primary care ; Public health ; Questionnaires ; Registries ; Regression analysis ; Regression models ; Research and Analysis Methods ; Smoking ; Social Sciences ; Spinal surgery ; Spine ; Spine (lumbar) ; Studies ; Surgeons ; Surgery ; Surgical instruments ; Systematic review ; Therapeutic applications</subject><ispartof>PloS one, 2018-09, Vol.13 (9), p.e0203518-e0203518</ispartof><rights>COPYRIGHT 2018 Public Library of Science</rights><rights>2018 van Hooff et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2018 van Hooff et al 2018 van Hooff et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c692t-de53fa6125ddda5b662962f399379c70e70520419cb75b7222cdfd009e16666d3</citedby><cites>FETCH-LOGICAL-c692t-de53fa6125ddda5b662962f399379c70e70520419cb75b7222cdfd009e16666d3</cites><orcidid>0000-0001-5313-6436</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145570/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145570/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,27901,27902,53766,53768,79342,79343</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30231051$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>van Hooff, Miranda L</creatorcontrib><creatorcontrib>van Dongen, Johanna M</creatorcontrib><creatorcontrib>Coupé, Veerle M</creatorcontrib><creatorcontrib>Spruit, Maarten</creatorcontrib><creatorcontrib>Ostelo, Raymond W J G</creatorcontrib><creatorcontrib>de Kleuver, Marinus</creatorcontrib><title>Can patient-reported profiles avoid unnecessary referral to a spine surgeon? An observational study to further develop the Nijmegen Decision Tool for Chronic Low Back Pain</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>Chronic Low Back Pain (CLBP) is a heterogeneous condition with lack of diagnostic clarity. Therapeutic interventions show small effects. To improve outcomes by targeting interventions it is recommended to develop a triage system to surgical and non-surgical treatments based on treatment outcomes. The objective of the current study was to develop and internally validate prognostic models based on pre-treatment patient-reported profiles that identify patients who either respond or do not respond to two frequently performed treatments (lumbar spine surgery and multidisciplinary pain management program).
A consecutive cohort study in a secondary referral spine center was performed. The study followed the recommendations of the PROGRESS framework and was registered in the Dutch Trial Register (NTR5946). Data of forty-seven potential pre-consultation (baseline) indicators predicting 'response' or 'non-response' at one-year follow-up for the two treatments were obtained to develop and validate four multivariable logistic regression models. The source population consisted of 3,410 referred CLBP-patients. Two treatment cohorts were defined: elective 'spine surgery' (n = 217 [6.4%]) and multidisciplinary bio-psychosocial 'pain management program' (n = 171 [5.0%]). Main inclusion criteria were age ≥18, CLBP (≥6 months), and not responding to primary care treatment. The primary outcome was functional ability: 'response' (Oswestry Disability Index [ODI] ≤22) and 'non-response' (ODI ≥41).
Baseline indicators predictive of treatment outcome were: degree of disability (all models), ≥2 previous spine surgeries, psychosocial complaints, age (onset <20 or >50), and patient expectations of treatment outcomes. The explained variances were low for the models predicting response and non-response to pain management program (R2 respectively 23% and 26%) and modest for surgery (R2 30% and 39%). The overall performance was acceptable (c-index; 0.72-0.83), the model predicting non-response to surgery performed best (R2 = 39%; c-index = 0.83).
This study was the first to identify different patient-reported profiles that predict response to different treatments for CLBP. The model predicting 'non-response' to elective lumbar spine surgery performed remarkably well, suggesting that referrals of these patients to a spine surgeon could be avoided. After external validation, the patient-reported profiles could potentially enhance timely patient triage to the right secondary care specialist and improve decision-making between clinican and patient. This could lead to improved treatment outcomes, which results in a more efficient use of healthcare resources.</description><subject>Adolescent</subject><subject>Adult</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Back pain</subject><subject>Biology and Life Sciences</subject><subject>Bone surgery</subject><subject>Care and treatment</subject><subject>Chronic Pain - physiopathology</subject><subject>Chronic Pain - therapy</subject><subject>Consultation</subject><subject>Decision Making</subject><subject>Diagnostic systems</subject><subject>Epidemiology</subject><subject>Female</subject><subject>Health aspects</subject><subject>Health care</subject><subject>Health sciences</subject><subject>Humans</subject><subject>Indicators</subject><subject>Low back pain</subject><subject>Low Back Pain - physiopathology</subject><subject>Low Back Pain - therapy</subject><subject>Male</subject><subject>Management</subject><subject>Medical diagnosis</subject><subject>Medical research</subject><subject>Medicine and Health Sciences</subject><subject>Methods</subject><subject>Middle Aged</subject><subject>Models, Biological</subject><subject>Observational studies</subject><subject>Orthopedic Procedures</subject><subject>Orthopedic Surgeons</subject><subject>Pain</subject><subject>Patient outcomes</subject><subject>Patients</subject><subject>People and Places</subject><subject>Performance prediction</subject><subject>Primary care</subject><subject>Public health</subject><subject>Questionnaires</subject><subject>Registries</subject><subject>Regression analysis</subject><subject>Regression models</subject><subject>Research and Analysis Methods</subject><subject>Smoking</subject><subject>Social Sciences</subject><subject>Spinal surgery</subject><subject>Spine</subject><subject>Spine (lumbar)</subject><subject>Studies</subject><subject>Surgeons</subject><subject>Surgery</subject><subject>Surgical 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An observational study to further develop the Nijmegen Decision Tool for Chronic Low Back Pain</title><author>van Hooff, Miranda L ; van Dongen, Johanna M ; Coupé, Veerle M ; Spruit, Maarten ; Ostelo, Raymond W J G ; de Kleuver, Marinus</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c692t-de53fa6125ddda5b662962f399379c70e70520419cb75b7222cdfd009e16666d3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2018</creationdate><topic>Adolescent</topic><topic>Adult</topic><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Back pain</topic><topic>Biology and Life Sciences</topic><topic>Bone surgery</topic><topic>Care and treatment</topic><topic>Chronic Pain - physiopathology</topic><topic>Chronic Pain - therapy</topic><topic>Consultation</topic><topic>Decision Making</topic><topic>Diagnostic systems</topic><topic>Epidemiology</topic><topic>Female</topic><topic>Health aspects</topic><topic>Health care</topic><topic>Health sciences</topic><topic>Humans</topic><topic>Indicators</topic><topic>Low back pain</topic><topic>Low Back Pain - 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Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>van Hooff, Miranda L</au><au>van Dongen, Johanna M</au><au>Coupé, Veerle M</au><au>Spruit, Maarten</au><au>Ostelo, Raymond W J G</au><au>de Kleuver, Marinus</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Can patient-reported profiles avoid unnecessary referral to a spine surgeon? An observational study to further develop the Nijmegen Decision Tool for Chronic Low Back Pain</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2018-09-19</date><risdate>2018</risdate><volume>13</volume><issue>9</issue><spage>e0203518</spage><epage>e0203518</epage><pages>e0203518-e0203518</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>Chronic Low Back Pain (CLBP) is a heterogeneous condition with lack of diagnostic clarity. Therapeutic interventions show small effects. To improve outcomes by targeting interventions it is recommended to develop a triage system to surgical and non-surgical treatments based on treatment outcomes. The objective of the current study was to develop and internally validate prognostic models based on pre-treatment patient-reported profiles that identify patients who either respond or do not respond to two frequently performed treatments (lumbar spine surgery and multidisciplinary pain management program).
A consecutive cohort study in a secondary referral spine center was performed. The study followed the recommendations of the PROGRESS framework and was registered in the Dutch Trial Register (NTR5946). Data of forty-seven potential pre-consultation (baseline) indicators predicting 'response' or 'non-response' at one-year follow-up for the two treatments were obtained to develop and validate four multivariable logistic regression models. The source population consisted of 3,410 referred CLBP-patients. Two treatment cohorts were defined: elective 'spine surgery' (n = 217 [6.4%]) and multidisciplinary bio-psychosocial 'pain management program' (n = 171 [5.0%]). Main inclusion criteria were age ≥18, CLBP (≥6 months), and not responding to primary care treatment. The primary outcome was functional ability: 'response' (Oswestry Disability Index [ODI] ≤22) and 'non-response' (ODI ≥41).
Baseline indicators predictive of treatment outcome were: degree of disability (all models), ≥2 previous spine surgeries, psychosocial complaints, age (onset <20 or >50), and patient expectations of treatment outcomes. The explained variances were low for the models predicting response and non-response to pain management program (R2 respectively 23% and 26%) and modest for surgery (R2 30% and 39%). The overall performance was acceptable (c-index; 0.72-0.83), the model predicting non-response to surgery performed best (R2 = 39%; c-index = 0.83).
This study was the first to identify different patient-reported profiles that predict response to different treatments for CLBP. The model predicting 'non-response' to elective lumbar spine surgery performed remarkably well, suggesting that referrals of these patients to a spine surgeon could be avoided. After external validation, the patient-reported profiles could potentially enhance timely patient triage to the right secondary care specialist and improve decision-making between clinican and patient. This could lead to improved treatment outcomes, which results in a more efficient use of healthcare resources.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>30231051</pmid><doi>10.1371/journal.pone.0203518</doi><tpages>e0203518</tpages><orcidid>https://orcid.org/0000-0001-5313-6436</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1932-6203 |
| ispartof | PloS one, 2018-09, Vol.13 (9), p.e0203518-e0203518 |
| issn | 1932-6203 1932-6203 |
| language | eng |
| recordid | cdi_plos_journals_2110055874 |
| source | MEDLINE; DOAJ Directory of Open Access Journals; EZB-FREE-00999 freely available EZB journals; PubMed Central; Free Full-Text Journals in Chemistry; Public Library of Science (PLoS) |
| subjects | Adolescent Adult Aged Aged, 80 and over Back pain Biology and Life Sciences Bone surgery Care and treatment Chronic Pain - physiopathology Chronic Pain - therapy Consultation Decision Making Diagnostic systems Epidemiology Female Health aspects Health care Health sciences Humans Indicators Low back pain Low Back Pain - physiopathology Low Back Pain - therapy Male Management Medical diagnosis Medical research Medicine and Health Sciences Methods Middle Aged Models, Biological Observational studies Orthopedic Procedures Orthopedic Surgeons Pain Patient outcomes Patients People and Places Performance prediction Primary care Public health Questionnaires Registries Regression analysis Regression models Research and Analysis Methods Smoking Social Sciences Spinal surgery Spine Spine (lumbar) Studies Surgeons Surgery Surgical instruments Systematic review Therapeutic applications |
| title | Can patient-reported profiles avoid unnecessary referral to a spine surgeon? An observational study to further develop the Nijmegen Decision Tool for Chronic Low Back Pain |
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