Stratification of spine patients based on self-reported clinical symptom classes: Evaluation of long-term outcomes and subsequent interventions

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Abstract

Background

Prior work by our group developed a stratification tool based on four PROMIS domains for patients with low back pain (LBP). Our study aimed to evaluate the ability of our previously developed symptom classes to predict long-term outcomes, and determine whether there were differential treatment effects by intervention.

Methods

This was a retrospective cohort study of adult patients with LBP seen in spine clinics in a large health system between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes as part of routine care at baseline and again at 12-months follow-up. Latent class analysis identified symptom classes based on PROMIS domain scores (physical function, pain interference, social role satisfaction, and fatigue) that were ≥1 standard deviation worse (meaningfully worse) than the general population. The ability of the profiles to predict long-term outcomes at 12-months was evaluated through multivariable models. Differences in outcomes by subsequent treatments (physical therapy, specialist visits, injections, and surgery) were investigated.

Results

There were 3,236 adult patients (average age 61.1 ± 14.2, 55.4% female) included in the study with three distinct classes identified: mild symptoms ( n = 986, 30.5%), mixed ( n = 798, 24.7%) with poor scores on physical function and pain interference but better scores on other domains, and significant symptoms ( n = 1,452, 44.9%). The classes were significantly associated with long-term outcomes, with patients with significant symptoms improving the most across all domains. Utilization differed across classes, with the mixed symptom class receiving more PT and injections and significant symptom class receiving more surgeries and specialist visits.

Conclusions

Patients with LBP have distinct clinical symptom classes which could be utilized to stratify patients into groups based on risk of future disability. These symptom classes can also be used to provide estimates of the effectiveness of different interventions, further increasing the clinical utility of these classes in standard care.

Related collections

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Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

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Author and article information

Contributors

Brittany Lapin

Journal

Journal ID (nlm-ta): N Am Spine Soc J

Journal ID (iso-abbrev): N Am Spine Soc J

Title: North American Spine Society Journal

Publisher: Elsevier

ISSN (Electronic): 2666-5484

Publication date PMC-release: 22 February 2023

Publication date Collection: June 2023

Publication date (Electronic): 22 February 2023

Volume: 14

Electronic Location Identifier: 100205

Affiliations

[a ]Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States

[b ]Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States

[c ]Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States

[d ]Department of Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States

[e ]Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States

[f ]Center for Value-Based Care Research, Community Care, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States

Author notes

[* ]Corresponding author. Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA. Tel.: (216)-308-5259; fax: (216)-636-1040. LapinB@ 123456ccf.org

Article

Publisher Item ID: S2666-5484(23)00007-0 Publisher ID: 100205

DOI: 10.1016/j.xnsj.2023.100205

PMC ID: 10031537

PubMed ID: 36970061

SO-VID: c1b3c796-3229-4f83-ba7a-c95d064131bf

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 9 December 2022

Date revision received : 14 February 2023

Date accepted : 14 February 2023

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