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

Abstract

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. MethodsWe 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.

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

“…Patients in the stratified care arm of the trial showed a small but not statistically significant difference in time to first resolution of symptoms (those managed using stratified care reached resolution 2 weeks earlier than those in non-stratified care; a median of 10 weeks versus 12 weeks) [10]. Similarly, exploratory, pre-specified subgroup analysis showed a small difference of 1 week (median) in time to resolution of symptoms, in favour of stratified care for the 'fast-track' patient group.…”

“…As a result, the UK Spinal Taskforce [11] identified the need for evidence on the clinical and cost effectiveness of early referral of patients with severe symptoms for consideration of treatments such as surgery or spinal epidural injections, to assess whether 'fast-tracking' a group of patients can lead to improvement in these patients' outcomes. See [10] full details of the trial procedures.…”

“…After that point, patient care and any onward treatments such as injections or surgery followed routine NHS practice and waiting times. The trial showed that this stratified care model was not superior to usual, non-stratified care for the primary outcome: time to first symptom resolution [ 10 ]. The majority of participants in both of the arms of the trial reported resolution over the 12 months of the trial.…”

“…These findings help us to better understand this aspect of the stratified care intervention tested in the trial. Based on the RCT findings outlined earlier (see [10] for further details), there is no strong justification to implement this model of stratified care for patients with sciatica, but other models of stratification could be developed and would require testing. With this in mind, the qualitative findings presented here have implications for future intervention design, as well as future management of patients with sciatica.…”

Management approach combining prognostic screening and targeted treatment for patients with low back pain compared with standard physiotherapy: A systematic review & meta‐analysis

“…However, a trial by Magel et al (2017) found no significant differences in pain reduction between stratified care and usual group for patients in the mediumand high-risk groups at 1-year follow-up. Furthermore, a recent study by Konstantinou et al (2020) found that the use of stratified care for patients with sciatica in primary care was not better than usual care for either clinical or economic outcomes. In 2020, a pilot and feasibility study by Hill et al (2020) investigated the stratified versus non-stratified care for MSK pain, including back, neck, shoulder, knee or multi-site, in primary care using the Keele STarT Musculoskeletal Tool.…”