ABSTRACT
BACKGROUND CONTEXT: The Spanish National Health Service (SNHS) is a tax-funded public organization that provides free health care to every resident in Spain. PURPOSE: To develop models for predicting the evolution of low back pain (LBP) in routine clinical practice within SNHS. STUDY DESIGN: Analysis of a prospective registry in routine clinical practice, in 17 centers across SNHS. PATIENT SAMPLE: Patient sample includes 4,477 acute and chronic LBP patients treated in primary and hospital care. OUTCOME MEASURES: Pain and disability, measured through validated instruments. METHODS: Patients treated for LBP were assessed at baseline and 3 months later. Data gathered were the following: sex, age, employment status, duration of pain, severity of LBP, pain down to the leg (LP) and disability, history of lumbar surgery, diagnostic procedures undertaken, imaging findings, and treatments used throughout the study period. Three separate multivariate logistic regression models were developed for predicting a clinically relevant improvement in LBP, LP, and disability at 3 months. RESULTS: In total, 4,261 patients (95.2%) attended follow-up. For all the models, calibration was reasonable and the area under the receiver operating characteristic curve was ≥0.640. For LBP, LP, and disability, factors associated with a higher probability of improvement at 3 months were the following: not having undergone lumbar surgery, higher baseline scores for the corresponding variable, lower ones for the rest, and being treated with neuroreflexotherapy. Additional factors were the following: for LBP, shorter pain duration; for LP, not undergoing electromyography; and for disability, shorter pain duration, not being diagnosed with disc degeneration, and being treated with muscle relaxants and not opioids. CONCLUSIONS: A prospective registry can be used for developing predictive models to quantify the odds that a given LBP patient will experience a clinically relevant improvement. This may empower patients for an informed shared decision making.
Subject(s)
Disability Evaluation , Low Back Pain/diagnosis , National Health Programs , Acute Pain , Chronic Pain , Disease Progression , Female , Humans , Logistic Models , Low Back Pain/physiopathology , Male , Middle Aged , Models, Statistical , Multivariate Analysis , National Health Programs/statistics & numerical data , Pain Measurement/statistics & numerical data , Predictive Value of Tests , Prognosis , Prospective Studies , Registries , Spain , Treatment OutcomeABSTRACT
BACKGROUND CONTEXT: Experimental studies suggest that catastrophizing may worsen the prognosis of low back pain (LBP) and LBP-related disability and increase the risk of chronicity. PURPOSE: To assess the prognostic value of baseline catastrophizing for predicting the clinical evolution of LBP patients in routine clinical practice and the association between the evolution of pain and catastrophizing. STUDY DESIGN/SETTING: Prospective study in routine clinical practice of the Spanish National Health Service. PATIENT SAMPLE: One thousand four hundred twenty-two acute and chronic adult LBP patients treated in primary and hospital care. OUTCOME MEASURES: Pain, disability, and catastrophizing measured through validated instruments. METHODS: Patients were managed according to routine clinical practice. Outcome measures were assessed at baseline and 3 months later. Logistic regression models were developed to estimate the association between baseline catastrophizing score and the improvement of LBP and disability, adjusting for baseline LBP and leg pain (LP) severity, disability, duration of the pain episode, workers' compensation coverage, radiological findings, failed back surgery, and diagnostic procedures and treatments undertaken throughout the study. Another model was developed to estimate the association between the evolution of LBP and the change in catastrophizing, adjusting for the same possible confounders plus the evolution of LP and disability. Models were repeated excluding the treatments undergone after the baseline assessment. RESULTS: Regression models showed that the degree of baseline catastrophizing does not predict the evolution of LBP and disability. Conversely, as the degree of pain improvement increases, so does the odds ratio for improvement in catastrophizing, ranging from three (95% confidence interval [95% CI], 2.00-4.50; p<.001) for improvements in pain between 1.1 and 4 visual analog scale (VAS) points, to 7.3 (95% CI, 3.49-15.36; p<.001) for improvements in pain more than 6.1 VAS points. Similar results were obtained when treatments were excluded from the models. CONCLUSIONS: In routine practice, assessing the baseline score for catastrophizing does not help clinicians to predict the evolution of LBP and disability at 3 months.
Subject(s)
Catastrophization/psychology , Low Back Pain/psychology , Catastrophization/complications , Female , Humans , Male , Middle Aged , National Health Programs , Pain Measurement , Prognosis , Spain , Surveys and QuestionnairesABSTRACT
BACKGROUND: The primary care reform (PCR) has give rise to some major changes in the nursing profession. The objectives of this study are to analyze the achievements made by the nurses, to identify the problems they currently have in primary care and to suggest some lines along which work can be done for the future. METHOD: Qualitative research (focal group method). Eight groups were made segmented by occupational category and the position held. Scope of the analysis: the role of nurses, services supply and organization, participation and management, marketing and training. RESULTS: In the opinion of those surveyed, the PCR has entailed a broadening of the nurses' skills, although their role is still well-defined. The nurses are of the opinion that there is no listing of services inherent to nursing despite the leading role they obviously play in home care and health education. The need has been identified of assess the existing health programs in terms of results. Concerning to health services organization, main problems were related to the lack of adapting staffing in keeping with the rise in population and difficulties of internal communications within the health professional teams and the very small degree to which nursing services are disseminated. The need is felt of broadening pre-diploma training with regard to some subjects (health education) and skills (teamwork). CONCLUSIONS: Although the PCR has meant improvements for the nurses, solutions have as yet to have been provided to some aspects (including defining a listing of services, adapting staffing, internal communications, marketing, training) and given the opportunity the transferring of authorities over health care entail, further progress must be made toward innovative proposals to improve the health services.
Subject(s)
Focus Groups , Primary Nursing/standards , Quality Assurance, Health Care , Health Care Reform , Humans , Nurse's Role , Qualitative Research , SpainABSTRACT
Fundamento. La reforma de la atención primaria (RAP) ha dado lugar a mejoras importantes en la profesión enfermera. Objetivos del estudio: analizar los logros obtenidos por las enfermeras, identificar los problemas que tienen actualmente en atención primaria y proponer líneas de trabajo para el futuro. Método: Investigación cualitativa (técnica del grupo focal). Se realizaron ocho grupos segmentados según la categoría profesional y el puesto desempeñado. Dimensiones de análisis: rol de la enfermera, oferta y organización de servicios, participación y gestión, marketing y formación. Resultados: Para los entrevistados, la RAP ha supuesto una ampliación de las competencias de las enfermeras, aunque su rol sigue sin estar bien definido. Consideran que no existe una cartera de servicios propia de enfermería, a pesar de su claro protagonismo en atención domiciliaria y educación para la salud. Se ha identificado la necesidad de revisar, en términos de resultados, los programas de salud existentes. Se comentan dificultades relacionadas con la falta de ajuste de las plantillas en relación con el incremento poblacional. Destacan problemas de comunicación interna en los equipos y la escasa la difusión de los servicios de enfermería. Se percibe la necesidad de ampliar la formación pregrado en algunos contenidos (educación para la salud) y habilidades (trabajo en equipo).Conclusiones: Si bien la RAP ha supuesto mejoras para las enfermeras, quedan aspectos por resolver (definición de cartera de servicios, ajuste de plantillas, comunicación interna, marketing, formación, entre otros) y dada la oportunidad que representan las transferencias sanitarias hay que avanzar hacia propuestas innovadoras para mejorar los servicios de salud (AU)
Background: The primary care reform (PCR) has give rise to some major improvements in the nursing profession. The objectives of this study are to analyze the achievements made by the nurses, to identify the problems they currently have in primary care and to suggest some lines along which work can be done for the future. Method: Qualitative research (focal group method). Eight groups were made segmented by occupational category and the position held. Scope of the analysis: the role of nurses, services supply and organization, participation and management, marketing and training. Results: In the opinion of those surveyed, the PCR has entailed a broadening of the nurses' skills, although their role is still well-defined. The nurses are of the opinion that there is no listing of services inherent to nursing despite the leading role they obviously play in home care and educating health education. The need has been identified of assess the existing health programs in terms of results. Concerning to health services organization, main problems were related to the lack of adapting staffing in keeping with the rise in population and difficulties of internal communications within the health professional teams and the very small degree to which nursing services are disseminated. The need is felt of broadening pre-diploma training with regard to some subjects health education) and skills (teamwork). Conclusions: Although the PCR has meant improvements for the nurses, solutions have as yet to have been provided to some aspects (including defining a listing of services, adapting staffing, internal communications, marketing, training ) and given the opportunity the transferring of authorities over health care entail, further progress must be made toward innovative proposals to improve the health services (AU)
