The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581)

Predictors of outcome in sciatica patients following an epidural steroid injection: the POiSE prospective observational cohort study protocol

INTRODUCTION

Sciatica can be very painful and, in most cases, is due to pressure on a spinal nerve root from a disc herniation with associated inflammation. For some patients, the pain persists, and one management option is a spinal epidural steroid injection (ESI). The aim of an ESI is to relieve leg pain, improve function and reduce the need for surgery. ESIs work well in some patients but not in others, but we cannot identify these patient subgroups currently. This study aims to identify factors, including patient characteristics, clinical examination and imaging findings, that help in predicting who does well and who does not after an ESI. The overall objective is to develop a prognostic model to support individualised patient and clinical decision-making regarding ESI.

METHODS

POiSE is a prospective cohort study of 439 patients with sciatica referred by their clinician for an ESI. Participants will receive weekly text messages until 12 weeks following their ESIand then again at 24 weeks following their ESI to collect data on leg pain severity. Questionnaires will be sent to participants at baseline, 6, 12 and 24 weeks after their ESI to collect data on pain, disability, recovery and additional interventions. The prognosis for the cohort will be described. The primary outcome measure for the prognostic model is leg pain at 6 weeks. Prognostic models will also be developed for secondary outcomes of disability and recovery at 6 weeks and additional interventions at 24 weeks following ESI. Statistical analyses will include multivariable linear and logistic regression with mixed effects model.

ETHICS AND DISSEMINATION

The POiSE study has received ethical approval (South Central Berkshire B Research Ethics Committee 21/SC/0257). Dissemination will be guided by our patient and public engagement group and will include scientific publications, conference presentations and social media.

Endoscopic discectomy of the herniated intervertebral disc and changes in quality-of-life EQ-5D-5L analysis

Herniated lumbar discs are a common cause of low back pain, which can negatively impact the quality of life of working-age individuals. This study aimed to evaluate changes in the quality of life in patients with sciatica who underwent endoscopic discectomy, a minimally invasive surgical procedure. The study (ClinicalTrials.gov NCT02742311) included 470 patients who underwent transforaminal, interlaminar, or translaminar endoscopic discectomy. Quality of life and pain perception were evaluated by comparing statistically weighted values of EQ-5D-5L, EQ-VAS, Oswestry disability index, and numerical pain scales for lower limb and back pain before and 12 months after the endoscopic procedure. After the procedure, there was a significant improvement in the reduction of back and lower limb pain, as well as in all monitored questionnaires (P < .001), which persisted 12 months after the endoscopy. All evaluated dimensions of the EQ-5D-5L questionnaire indicated a significant improvement in the assessed quality of life (P < .001). The study showed that percutaneous endoscopic lumbar discectomy is an effective pain-treating intervention that can improve the quality of life. There was no observed difference in the percentage of complications or re-herniations when comparing the transforaminal and interlaminar, approaches.

Clinical and cost-effectiveness of bracing in symptomatic knee osteoarthritis management: protocol for a multicentre, primary care, randomised, parallel-group, superiority trial

BACKGROUND

Brace effectiveness for knee osteoarthritis (OA) remains unclear and international guidelines offer conflicting recommendations. Our trial will determine the clinical and cost-effectiveness of adding knee bracing (matched to patients' clinical and radiographic presentation and with adherence support) to a package of advice, written information and exercise instruction delivered by physiotherapists.

METHODS AND ANALYSIS

A multicentre, pragmatic, two-parallel group, single-blind, superiority, randomised controlled trial with internal pilot and nested qualitative study. 434 eligible participants with symptomatic knee OA identified from general practice, physiotherapy referrals and self-referral will be randomised 1:1 to advice, written information and exercise instruction and knee brace versus advice, written information and exercise instruction alone. The primary analysis will be intention-to-treat comparing treatment arms on the primary outcome (Knee Osteoarthritis Outcomes Score (KOOS)-5) (composite knee score) at the primary endpoint (6 months) adjusted for prespecified covariates. Secondary analysis of KOOS subscales (pain, other symptoms, activities of daily living, function in sport and recreation, knee-related quality of life), self-reported pain, instability (buckling), treatment response, physical activity, social participation, self-efficacy and treatment acceptability will occur at 3, 6, and 12 months postrandomisation. Analysis of covariance and logistic regression will model continuous and dichotomous outcomes, respectively. Treatment effect estimates will be presented as mean differences or ORs with 95% CIs. Economic evaluation will estimate cost-effectiveness. Semistructured interviews to explore acceptability and experiences of trial interventions will be conducted with participants and physiotherapists delivering interventions.

ETHICS AND DISSEMINATION

North West Preston Research Ethics Committee, the Health Research Authority and Health and Care Research in Wales approved the study (REC Reference: 19/NW/0183; IRAS Reference: 247370). This protocol has been coproduced with stakeholders including patients and public. Findings will be disseminated to patients and a range of stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN28555470.

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

BACKGROUND

Sciatica has a substantial impact on patients and society. Current care is 'stepped', comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics.

OBJECTIVES

The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care.

DESIGN

This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial.

SETTING

Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK.

PARTICIPANTS

Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery.

INTERVENTIONS

In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service.

MAIN OUTCOME MEASURES

The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost-utility analysis was undertaken over 12 months. A qualitative study explored patients' and clinicians' views of the fast-track care pathway to a spinal specialist.

RESULTS

A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy.

CONCLUSIONS

The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration.

LIMITATIONS

Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results.

FUTURE WORK

Other approaches to stratified care may provide superior outcomes for sciatica.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN75449581.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.

Patients' and clinicians' perspectives on a 'fast-track' pathway for patients with sciatica in primary care: qualitative findings from the SCOPiC stratified care trial

BACKGROUND

Sciatica is common and associated with significant impacts for the individual and society. The SCOPiC randomised controlled trial (RCT) (trial registration: ISRCTN75449581 ) tested stratified primary care for sciatica by subgrouping patients into one of three groups based on prognostic and clinical indicators. Patients in one group were 'fast-tracked' for a magnetic resonance imaging (MRI) scan and spinal specialist opinion. This paper reports qualitative research exploring patients' and clinicians' perspectives on the acceptability of this 'fast-track' pathway.

METHODS

Semi-structured interviews were conducted with 20 patients and 20 clinicians (general practitioners, spinal specialist physiotherapists, spinal surgeons). Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and 'boundary objects' concept.

RESULTS

Whilst the 'fast-track' pathway achieved a degree of 'coherence' (i.e. made sense) to both patients and clinicians, particularly in relation to providing early reassurance based on MRI scan findings, it was less 'meaningful' to some clinicians for managing patients with acute symptoms, reflecting a reluctance to move away from the usual 'stepped care' approach. Both groups felt a key limitation of the pathway was that it did not shorten patient waiting times between their spinal specialist consultation and further treatments.

CONCLUSION

Findings contribute new knowledge about patients' and clinicians' perspectives on the role of imaging and spinal specialist opinion in the management of sciatica, and provide important insights for understanding the 'fast-track' pathway, as part of the stratified care model tested in the RCT. Future research into the early referral of patients with sciatica for investigation and specialist opinion should include strategies to support clinician behaviour change; as well as take into account the role of imaging in providing reassurance to patients with severe symptoms in cases where imaging reveals a clear explanation for the patient's pain, and where this is accompanied by a thorough explanation from a trusted clinical expert.

Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial

Background

Sciatica has a substantial impact on individuals and society. Stratified care has been shown to lead to better outcomes among patients with non-specific low back pain, but it has not been tested for sciatica. We aimed to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care.

Methods

We did a two-parallel arm, pragmatic, randomised controlled trial across three centres in the UK (North Staffordshire, North Shropshire/Wales, and Cheshire). Eligible patients were aged 18 years or older, had a clinical diagnosis of sciatica, access to a mobile phone or landline number, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery. Patients were recruited from general practices and randomly assigned (1:1) by a remote web-based service to stratified care or usual care, stratified by centre and stratification group allocation. In the stratified care arm, a combination of prognostic and clinical criteria associated with referral to spinal specialist services were used to allocate patients to one of three groups for matched care pathways. Group 1 was offered brief advice and support in up to two physiotherapy sessions; group 2 was offered up to six physiotherapy sessions; and group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomisation. The primary outcome was self-reported time to first resolution of sciatica symptoms, defined as “completely recovered” or “much better” on a 6-point ordinal scale, collected via text messages or telephone calls. Analyses were by intention to treat. Health-care costs and cost-effectiveness were also assessed. This trial is registered on the ISRCTN registry, ISRCTN75449581.

Findings

Between May 28, 2015, and July 18, 2017, 476 patients from 42 general practices around three UK centres were randomly assigned to stratified care or usual care (238 in each arm). For the primary outcome, the overall response rate was 89% (9467 of 10 601 text messages sent; 4688 [88%] of 5310 in the stratified care arm and 4779 [90%] of 5291 in the usual care arm). Median time to symptom resolution was 10 weeks (95% CI 6·4–13·6) in the stratified care arm and 12 weeks (9·4–14·6) in the usual care arm, with the survival analysis showing no significant difference between the arms (hazard ratio 1·14 [95% CI 0·89–1·46]). Stratified care was not cost-effective compared to usual care.

Interpretation

The stratified care model for patients with sciatica consulting in primary care was not better than usual care for either clinical or health economic outcomes. These results do not support a transition to this stratified care model for patients with sciatica.

Funding

National Institute for Health Research.

New insight to the characteristics and clinical course of clusters of patients with imaging confirmed disc-related sciatica

BACKGROUND

Referral to secondary care is common for a considerable proportion of patients with persistent sciatica symptoms. It is unclear if information from clinical assessment can further identify distinct subgroups of disc-related sciatica, with perhaps different clinical courses.

AIMS

This study aims to identify and describe clusters of imaging confirmed disc-related sciatica patients using latent class analysis, and compare their clinical course.

METHODS

The study population were 466 patients with disc-related sciatica. Variables from clinical assessment were included in the analysis. Characteristics of the identified clusters were described and their clinical course over 2 years was compared.

RESULTS

A four-cluster solution was optimal. Cluster 1 (n = 110) had mild back and leg pain; cluster 2 (n = 59) had moderate back and leg pain; cluster 3 (n = 158) had mild back pain and severe leg pain; cluster 4 (n = 139) had severe back and leg pain. Patients in cluster 4 had the most severe profile in terms of disability, distress and comorbidity and the lowest reported global change and the smallest proportion of patients with a successful outcome at 2 years. Of the 135 patients who underwent surgery, 42% and 41% were in clusters 3 and 4, respectively.

CONCLUSIONS

Using a strict diagnosis of sciatica, this work identified four clusters of patients primarily differentiated by back and leg pain severity. Patients with severe back and leg pain had the most severe profile at baseline and follow-up irrespective of intervention. This simple classification system may be useful when considering prognosis and management with sciatica patients.

SIGNIFICANCE

Using data from a large observational prospective study, this work identifies four distinct clusters of patients with imaging confirmed disc-related sciatica. This classification could be used when considering prognosis and management with sciatica patients at their initial consultation.

Systematic Review of Decision Analytic Modelling in Economic Evaluations of Low Back Pain and Sciatica

BACKGROUND

Low back pain (LBP) and sciatica place significant burden on individuals and healthcare systems, with societal costs alone likely to be in excess of £15 billion. Two recent systematic reviews for LBP and sciatica identified a shortage of modelling studies in both conditions.

OBJECTIVES

The aim of this systematic review was to document existing model-based economic evaluations for the treatment and management of both conditions; critically appraise current modelling techniques, analytical methods, data inputs, and structure, using narrative synthesis; and identify unresolved methodological problems and gaps in the literature.

METHODS

A systematic literature review was conducted whereby 6512 records were extracted from 11 databases, with no date limits imposed. Studies were abstracted according to a predesigned protocol, whereby they must be economic evaluations that employed an economic decision model and considered any management approach for LBP and sciatica. Study abstraction was initially performed by one reviewer who removed duplicates and screened titles to remove irrelevant studies. Overall, 133 potential studies for inclusion were then screened independently by other reviewers. Consensus was reached between reviewers regarding final inclusion.

RESULTS

Twenty-one publications of 20 unique models were included in the review, five of which were modelling studies in LBP and 16 in sciatica. Results revealed a poor standard of modelling in both conditions, particularly regarding modelling techniques, analytical methods, and data quality. Specific issues relate to inappropriate representation of both conditions in terms of health states, insufficient time horizons, and use of inappropriate utility values.

CONCLUSION

High-quality modelling studies, which reflect modelling best practice, as well as contemporary clinical understandings of both conditions, are required to enhance the economic evidence for treatments for both conditions.

Subgrouping patients with sciatica in primary care for matched care pathways: development of a subgrouping algorithm

Background

Sciatica is a painful condition managed by a stepped care approach for most patients. Currently, there are no decision-making tools to guide matching care pathways for patients with sciatica without evidence of serious pathology, early in their presentation. This study sought to develop an algorithm to subgroup primary care patients with sciatica, for initial decision-making for matched care pathways, including fast-track referral to investigations and specialist spinal opinion.

Methods

This was an analysis of existing data from a UK NHS cohort study of patients consulting in primary care with sciatica (n = 429). Factors potentially associated with referral to specialist services, were identified from the literature and clinical opinion. Percentage of patients fast-tracked to specialists, sensitivity, specificity, positive and negative predictive values for identifying this subgroup, were calculated.

Results

The algorithm allocates patients to 1 of 3 groups, combining information about four clinical characteristics, and risk of poor prognosis (low, medium or high risk) in terms of pain-related persistent disability. Patients at low risk of poor prognosis, irrespective of clinical characteristics, are allocated to group 1. Patients at medium risk of poor prognosis who have all four clinical characteristics, and patients at high risk of poor prognosis with any three of the clinical characteristics, are allocated to group 3. The remainder are allocated to group 2. Sensitivity, specificity and positive predictive value of the algorithm for patient allocation to fast-track group 3, were 51, 73 and 22% respectively.

Conclusion

We developed an algorithm to support clinical decisions regarding early referral for primary care patients with sciatica. Limitations of this study include the low positive predictive value and use of data from one cohort only. On-going research is investigating whether the use of this algorithm and the linked care pathways, leads to faster resolution of sciatica symptoms.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2686-x) contains supplementary material, which is available to authorized users.

Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC)

BACKGROUND

Adalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early.

METHODS

A pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months' duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase.

RESULTS

The internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants.

CONCLUSIONS

Improved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN14569274 . Registered on 15 December 2014.

Advancing practice for back pain through stratified care (STarT Back)

BACKGROUND

Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care.

RESULTS

The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care.

CONCLUSIONS

The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.

Investigations for radiculopathy: The patient perspective. A qualitative, interpretative inquiry

BACKGROUND

Clinical guidelines recommend that investigations, such as magnetic resonance imaging, are offered only when likely to change management. Meanwhile, the optimal process of diagnosing radiculopathy remains uncertain and, in clinical practice, differences of opinion can occur between patient and clinician regarding the perceived importance of investigations.

OBJECTIVES

To explore peoples' experiences of investigations and the effect of concordance between clinical presentation and investigation findings.

METHODS

In this qualitative study, 14 participants who had recently undergone investigations for a clinical presentation of radiculopathy were purposively recruited from an NHS, Primary Care Service in the United Kingdom. Based on the principles of interpretative phenomenological analysis, individual, semi-structured interviews were recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically.

FINDINGS

Although people reported wanting investigations to understand the cause of symptoms and inform management, access to them was reported to be difficult and protracted. When investigations revealed potentially relevant findings, people experienced relief, validation, empowerment and decisive decision-making. Disappointment emerged, however, regarding treatment options and waiting times, and long-term prognosis. When investigations failed to identify relevant findings, people were unable to make sense of their symptoms, relinquish their search to identify the cause, or to move forward in their management.

CONCLUSIONS

This study provides the first reported in-depth interpretation of peoples' experience of undergoing investigations specifically for radiculopathy. Important implications have been identified for: investigation referral criteria; shared-decision-making; information sharing and managing expectations and disappointment. CLINICALTRIALS.

GOV REFERENCE

UOS-2307-CR.