Implementing the Keele stratified care model for patients with low back pain: an observational impact study

Adrian Bamford, Andy Nation, Susie Durrell, Lazaros Andronis, Ellen Rule, Hugh McLeod

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Background: The Keele stratified care model for management of low back pain comprises use of the prognostic STarT Back Screening Tool to allocate patients into one of three risk-defined categories leading to associated risk-specific treatment pathways, such that high-risk patients receive enhanced treatment and more sessions than medium- and low-risk patients. The Keele model is associated with economic benefits and is being widely implemented. The objective was to assess the use of the stratified model following its introduction in an acute hospital physiotherapy department setting in Gloucestershire, England.

Methods: Physiotherapists recorded data on 201 patients treated using the Keele model in two audits in 2013 and 2014. To assess whether implementation of the stratified model was associated with the anticipated range of treatment sessions, regression analysis of the audit data was used to determine whether high- or medium-risk patients received significantly more treatment sessions than low-risk patients. The analysis controlled for patient characteristics, year, physiotherapists’ seniority and physiotherapist. To assess the physiotherapists’ views on the usefulness of the stratified model, audit data on this were analysed using framework methods. To assess the potential economic consequences of introducing the stratified care model in Gloucestershire, published economic evaluation findings on back-related National Health Service (NHS) costs, quality-adjusted life years (QALYs) and societal productivity losses were applied to audit data on the proportion of patients by risk classification and estimates of local incidence.

Results: When the Keele model was implemented, patients received significantly more treatment sessions as the riskrating increased, in line with the anticipated impact of targeted treatment pathways. Physiotherapists were largely
positive about using the model. The potential annual impact of rolling out the model across Gloucestershire is a gain in approximately 30 QALYs, a reduction in productivity losses valued at £1.4 million and almost no change to NHS costs.
Conclusions: The Keele model was implemented and risk-specific treatment pathways successfully used for patients presenting with low back pain. Applying published economic evidence to the Gloucestershire locality suggests that
substantial health and productivity outcomes would be associated with rollout of the Keele model while being cost-neutral for the NHS.
Original languageEnglish
Article number66
Number of pages15
JournalBMC Musculoskeletal Disorders
Publication statusPublished - 3 Feb 2017


  • Low back pain
  • Stratified care model
  • STarT Back Screening Tool
  • IMPaCT Back
  • Implementation study
  • Physiotherapy
  • Economic evaluation


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