Results Summary

What was the research about?

Back pain is a common problem that makes it hard for people to work, move around, or take care of themselves and their families. The STarT Back strategy is a computer-assisted program that doctors and physical therapists can use to identify treatment options appropriate for patients’ risk for ongoing back pain.

In this study, the research team wanted to learn if using the STarT Back strategy helped improve patients’ back pain and ability to move. The team compared patients in clinics that used STarT Back with patients in clinics that didn’t use it.

What were the results?

The study found no differences in patient outcomes or in use of appropriate treatments between patients in clinics that used STarT Back and patients in clinics that didn’t use it.

Who was in the study?

The study included 1,701 patients in Washington State. Of these, 79 percent were white, and 48 percent were over age 60. All patients had back pain without a specific cause, such as an injury.

What did the research team do?

The research team assigned three clinics, by chance, to use the STarT Back strategy and three clinics not to use it. The STarT Back strategy included a questionnaire that patients answered to estimate their risk of ongoing back pain. In the clinics that used the STarT Back strategy, doctors or physical therapists entered patients’ answers to the questionnaire. The program used the answers to predict whether patients would have a low, medium, or high risk of ongoing, disabling pain that would keep them from being able to move around easily. The program also recommended treatment options appropriate for each patient’s level of risk. The doctor could then talk with the patient about the treatment options. Clinic staff used STarT Back for about 50 percent of visits related to low back pain. The clinics that didn’t use STarT Back treated patients with low back pain as they usually did.

Next, the team asked patients about their back pain two weeks after their first doctor’s visit and again two and six months later.

People in the community with experience with chronic pain and primary care doctors worked with the research team during this study.

What were the limits of the study?

Patients had started treatment when the research team first asked about their back pain. As a result, patients’ responses may not accurately reflect the effects of using STarT Back compared with usual care. The team studied only one healthcare system in Washington State. The results may be different for other clinics or locations.

Future research could look at ways to make sure doctors use the STarT Back questionnaire with all patients and then recommend appropriate treatments for patients in each risk category.

How can people use the results?

Researchers can look at other ways to help patients with low back pain get appropriate treatments based on their risk of ongoing pain and distress.

Final Research Report

View this project's final research report.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Reviewers’ comments and the investigator’s changes in response included the following:

  • The awardee addressed reviewers’ confusion about the timing of this study in the context of a larger, system-wide initiative to change low back pain care within Group Health Cooperative (now Kaiser Permanent Washington). The awardee explained that the dissemination of the system-wide initiative was passive. The investigator noted that the initiative was not mandatory but it represented usual care in the comparison clinics. The awardee explained that it implemented the quality improvement intervention, STarT Back, only in the three study clinics, which required training for physicians and other staff.
  • In response to reviewer questions, the awardee explained that stakeholder engagement was influential in deciding on outcome measures and messaging for study participants but was not a factor in the design of the study. The awardee noted that the stakeholders did not have expertise in study design.
  • The reviewers noted that the 12-day span between participants’ study entry and baseline data collection could have allowed for patients to improve before the collection of baseline data, resulting in the intervention’s small effect size. The awardee acknowledged this as a limitation of the study.
  • The reviewers asked the awardee to add information to the background and discussion sections describing similarities and differences between the current study and a previous study of the same intervention in the United Kingdom. The awardee posited possible reasons that patients receiving the intervention showed improvement in the United Kingdom but not in the United States. The investigator based its reasoning on differences in healthcare structure in the two countries. The awardee also noted that the UK intervention primarily focused on physical therapy, rather than the multiple treatment options in the current study. The awardee also noted that in the current study, patients had more disability related to low back pain than patients did in the UK study.

Conflict of Interest Disclosures

Project Information

Dan Cherkin, PhD, MS
Kaiser Foundation Health Plan of Washington^
Evaluation of a Patient-Centered Risk Stratification Method for Improving Primary Care for Back Pain

Key Dates

December 2012
July 2018

Study Registration Information

^Group Health Cooperative was aquired by Kaiser Permanente in February 2017.


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Last updated: January 25, 2023