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Right treatment, right patient

Study
Screening instrument
Randomised trial
Results
Comment

In his ground-breaking classic book on evidence-based healthcare [1], Muir Gray has a chapter entitled 'Doing the right things right'. It is always worth re-reading, and it is also worth extending, perhaps to whether we do the right things, to the right patients, at the right time, and do we do them right? An intriguing study from Norway suggests that treating the right patient right can have real benefits [2].

Study

Actually there were two studies in one. The main study looked at different levels of intervention for people off sick from work with musculoskeletal problems for more than eight weeks. The subsidiary study examined the effectiveness of treatment depending on an initial prognosis determined by a screening instrument.

The setting was the area around Bergen, with a population of 270,000. Participants were recruited from sickness insurance records if they were off work for eight weeks or more. The total approached was 1,988 (0.74% of the total population). Because some people did not accept the invitation to participate, the final sample was 654 individuals (33% of the total).

Screening instrument

This consisted of a questionnaire and a structured examination by a physiotherapist. The details are too many to explain here, but in a fairly simple process participants were graded as having a good, medium or poor prognosis to return to work.

Randomised trial

A properly randomised open study involved three treatments:

  1. Ordinary treatment described referral back to a general practitioner.
  2. Light multidisciplinary treatment and follow up comprised a lecture on exercise and lifestyle and fear avoidance advice, with information and feedback. Patients were encouraged gradually to increase their activity level. Patients received individual exercise programmes. Some were referred to physiotherapists. Over a year each patient received an average of three individual follow ups.
  3. Extensive multidisciplinary treatment and follow up involved a more intensive treatment program lasting for four weeks, with six hour sessions five days a week. It involved cognitive-behavioural modification, education, exercise and occasional workplace interventions. Patients were encouraged to take responsibility for their own health and lifestyle. Follow up over one year with individual pain management programmes.

The outcome was return to work by one year after the intervention, which took place about two months after screening. A cost benefit analysis was also carried out for the light and extensive multidisciplinary treatments. Economic returns were measured in terms of productivity gain when patients returned to work minus the costs of the treatment programmes.

Results

At baseline the three treatment groups were well matched. The mean age was 44 years, about two thirds were women, and three quarters of patients had back pain or neck or shoulder pain. About half were considered to have a medium prognosis for return to work, 22% had a good prognosis and 28% a poor prognosis. More patients had returned to work at one year with a good prognosis or medium prognosis than with a poor prognosis (Table 1).

Table 1: Return to work and initial prognosis

Initial prognosis Percent in work at one year
Good 61
Medium 57
Poor 44

Ordinary treatment led to fewer patients at work at one year (50%) than either the light or extensive multidisciplinary treatments (60%).

Table 2: Results of different treatment strategies with medium and poor prognosis

Percent in work at one year
Initial prognosis Ordinary treatment Light multidisciplinary Extensive multidisciplinary
Medium 48 63 62
Poor 37 44 55

Most patients returned to work if they were given treatment appropriate to their screening category (Figure 1). Between 55% and 64% returned to work when given the right treatment.

Figure 1: Treating the right patients right

If screening results rather than randomisation had been the determining factor for the type of treatment, then productivity gains would have outweighed the cost of treatment by $800 per treated patient.

Comment

What we have here is a demonstration from a randomised trial that doing the right thing for the right patient pays dividends. The benefits are to the patients who get back to work, and benefit because of it, and society, which benefits because the productivity gains outweigh the costs of getting people back to work. Whether this would be true in societies other than Norway is another matter.

The general principle seems sound. One size does not fit all, and the average results from studies need not apply to individuals. It sounds more complicated, but actually is not. It comes down to a greater appreciation of the benefits of triage, or diagnosis, or prognosis. All topics where evidence is painfully thin.

References:

  1. JA Muir Gray. Evidence-based healthcare. Churchill Livingstone, 1997. ISBN 0-443-05721-4.
  2. EM Haland Haldorsen et al. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain 2002 95: 49-63.

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