EARLY PHYSICIAN NOTIFICATION OF PATIENT DISABILITY RISK AND CLINICAL GUIDELINES AFTER LOW-BACK INJURY - A RANDOMIZED, CONTROLLED TRIAL

Study Design. Back-injured workers with high disability risk scores on a predictive questionnaire participated in a randomized, controlled t rial of physician notification, with outcomes follow-up 3 months after injury. Objectives. To test whether physician intervention improves r eturn to work and self-assessment outcomes for people at relatively hi gh risk for disability. Summary of Background Data. Only a small numbe r of back-injured workers suffer significant disability. Quick identif ication of these people would facilitate more efficient targeting and trials of interventions. Controlling variations in practice through pr actice guidelines has been recommended as a promising strategy for imp roving care and reducing disability. Methods. Workers filing back inju ry reports responded to a disability prediction questionnaire. Those w ith high risk scores were randomly assigned to control or intervention groups. Patient-designated physicians in the intervention group recei ved two letters identifying the patient's risk and making recommendati ons for care, including the Agency for Health Care Policy and Research 's algorithms for acute low back pain. Predictive accuracy of the ques tionnaire and efficacy of physician intervention were evaluated on the basis of work status and self-assessments 3 months after injury. Resu lts. Of the 268 workers completing the questionnaire portion of the st udy, 32 (12%) were out of work because of back pain 3 months after inj ury. The questionnaire's predictive accuracy included maximum kappa of 0.277 and a receiver operating curve area of 0.78. Fifty-three people completed the physician intervention trial. The intervention had no s ignificant impact on return to work, self-assessed pain, or satisfacti on with health care. Conclusions. Stratification of back-injured peopl e according to disability risk can increase intervention efficiency by identifying those who require treatment and sparing those who do not. The apparent failure of risk notification and practice guidelines to reduce disability in this study may be improved by different applicati on methods in the future.