Key Points Question Is the transition from acute to chronic low back pain (LBP) associated with risk strata, defined by a standardized prognostic tool, and/or with early exposure to guideline nonconcordant care? Findings In this cohort study of 5233 patients with acute LBP from 77 primary care practices, nearly half the patients were exposed to at least 1 guideline nonconcordant recommendation within the first 21 days after the index visit. Patients were significantly more likely to transition to chronic LBP as their risk on the prognostic tool increased and as they were exposed to more nonconcordant recommendations. Meaning In this study, the transition rate to chronic LBP was substantial and increased correspondingly with risk strata and early exposure to guideline nonconcordant care.

Background: Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability. Methods: We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: Clini-calTrials.gov NCT02647658 Findings: Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2¢1, 95% CI -4.9À0.6; p = 0.12). Opioids and imaging were prescribed in 22%À25% and 23%À26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups. Interpretation: There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines.

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Background: Nationally, there is an expectation that residents and fellows participate in quality improvement (QI), preferably interprofessionally. Hospitals and educators invest time and resources in projects, but little is known about success rates or what fosters success. Purpose: To understand what proportion of trainee QI projects were successful and whether there were predictors of success. Methods: We examined resident and fellow QI projects in an integrated healthcare system that supports diverse training programs in multiple hospitals over 2 years. All projects were reviewed to determine whether they represented actual QI. Projects determined as QI were considered completed or successful based on QI project sponsor self-report. Multiple characteristics were compared between successful and unsuccessful projects. Results: Trainees submitted 258 proposals, of which 106 (41.1%) represented actual QI. Non-QI projects predominantly represented needs assessments or retrospective data analyses. Seventy-six percent (81/106) of study sponsors completed surveys about their projects. Less than 25% of projects (59/258) represented actual QI and were successful. Project category was predictive of success, specifically those aimed at preventive care or education. Conclusion: Less than a quarter of trainee QI projects represent successful QI. Implications: Hospitals and training programs should identify interventions to improve trainee QI experience.

Objectives: Spinal Muscular Atrophy (SMA), a rare genetic neuromuscular disorder, is characterized by a loss of motor neurons leading to progressive muscle weakness, atrophy and functional limitations. This study was conducted to explore: which mobility gains are important in later-onset SMA (Type II or III) from the caregiver and patient perspective and how they map onto the Hammersmith Functional Motor Scale Expanded (HFMSE). Methods: In 2017, a Web-based survey of SMA Type II/III was administered to caregivers (CG) of affected children and adult patients (AP) to assess the importance of specific mobility gains and determine how SMA impacts physical functioning, activities of daily living (ADLs) and health-related quality of life (HRQOL). Follow-up telephone interviews were conducted among a sub-sample of survey participants to explore identified themes and discuss relevance of HFMSE items. Results: The survey was completed by 36 CG and 52 AP. Interviews were conducted with 20 CG and 21 AP. Affected children were aged 2-17 years; AP were 20-77 years. Both Type II/III participants voiced the desire to gain the ability to walk above all other physical functions and reported self-care and independence as important impacts. Type II participants also desired basic motor functions such as increased strength, arm use, sitting, and rolling. Type III participants desired standing, using stairs, and core and full body use. CG cited their child's independence, whereas AP focused on self-reliance and the ability to perform ADLs, as important themes. All HFMSE items equate to some physical function that was important to participants with either SMA Type II/III, covering the full range of relevant physical mobilities identified. Conclusions: Even basic improvements in the physical functions on the HFMSE can have real impact upon later-onset SMA patients in terms of mobility, ADLs, and HRQOL. Activities were dependent upon current mobility level.