IMPLEMENTATION OF A RISK- STRATIFIED, GUIDELINE-BASED PATHWAY OF CARE TO IMPROVE HEALTH OUTCOMES FOR WHIPLASH: A MULTI-CENTRE RANDOMISED CONTROLLED TRIAL

T. Rebbeck¹, A.N. Bandong², A. Leaver¹, C. Ritchie³, N. Armfield³, M. Arora⁴, I. Cameron⁴, L. Connelly⁵, R. Daniell⁶, M. Gillett⁷, R. Ingram¹, J. Jagnoor⁸, J. Kenardy⁹, G. Mitchell¹⁰, K. Refshauge¹, S. Scotti Requena¹¹, S. Robins³, M. Sterling³

¹University of Sydney, Faculty of Medicine and Health, Sydney, Australia, ²The University of the Philippines, Department of Physical Therapy, Manila, Philippines, ³RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre of Research Excellence, The University of Queensland, Brisbane, Australia, ⁴The University of Sydney & Northern Sydney Local Health District, John Walsh Centre for Rehabilitation Research, Kolling Institute, St Leonards, Australia, ⁵University of Queensland, Centre for the Business and Economics of Health, Brisbane, Australia, ⁶Belconnen Physiotherapy Clinic, Canberra, Australia, ⁷Royal North Shore Hospital, Emergency Department, Sydney, Australia, ⁸University of New South Wales, The George Institute for Global Health, School of Population Health, Sydney, Australia, ⁹University of Queensland, School of Psychology, Brisbane, Australia, ¹⁰University of Queensland, Primary Care Clinical Unit, School of Medicine, Brisbane, Australia, ¹¹University of Melbourne, Centre for Mental Health, Melbourne School of Population and Global Health, Melbourne, Australia

Background: Current pathways of care for whiplash follow a bio-medically oriented “stepped care model”, where when initial care fails, care is often stepped up to higher cost, lower value care such as imaging and surgery. This approach delays appropriate care for those who need it and does not allow for the heterogeneity of whiplash presentations. Risk-stratified care, whereby care is provided based on risk of good or poor recovery, has improved outcomes for low back pain but has not yet been evaluated in people with whiplash.

Purpose: This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared to usual care (UC) in people with acute whiplash on 1) patient health outcomes and 2) health care received.

Methods: Multi-centre two-arm parallel randomised controlled trial conducted in primary care, Australia.Participants were people with acute whiplash (n=216), their primary health care professionals (HCPs) (n=54) and whiplash specialists (n=16).Participants were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group; low risk participants received guideline-based advice and exercise supported by an online resource. Medium/high risk participants were referred to a whiplash specialist who assessed modifiable risk factors, then determined further care.The UC group received care from their primary HCP without knowledge of risk status. Primary outcomes were Neck Disability Index (NDI) and Global Rating of Change (GRC) at 3 months.Secondary outcomes included pain self-efficacy. Health care received was collected in both trial arms. Analysis was blinded to group and used intention to treat and linear mixed models. Trial was registered at Australian New Zealand Clinical Trials Registry (N12615001367538).

Results: 216 participants (July 2017 - Dec 2020) were randomised to CPC (n=109) and UC (n=107).There was no difference between groups for the NDI (MD (95% CI) -2.34 (-7.44 to 2.76)) or GRC (MD (95% CI) 0.08 (-0.55 to 0.70)) at 3 months. There was a significant change in pain self-efficacy at 3 months ((MD 95%CI 4.59 (0.25 to 8.94)). Type of care received was similar between groups, however those at low risk generally received less imaging and referrals. Baseline risk category did not modify the effect of treatment. No adverse events were reported.

Conclusions: Implementation of this CPC in its current form did not improve neck disability or recovery, but had a minimal effect on pain self-efficacy. Modifications are required before widespread implementation.

Implications: This pathway supports implementation of minimal care for those at low risk of a poor outcome. Modifications to the medium/ high risk pathway are recommended, and may include: greater attention to training, considering using whiplash specialists for people at medium risk and not recovering and engaging patients in decisions about specialist care.

Funding acknowledgements: National Health and Medical Research Council (NHMRC), Motor Accidents Insurance Commission Queensland (MAIC), State Insurance Regulatory Authority (SIRA)NSW (GNT1075736).

Keywords:
Whiplash
Stratified care
Clinical pathways

Topics:
Musculoskeletal: spine
Service delivery/emerging roles
Pain & pain management

Did this work require ethics approval? Yes

Institution: University of Sydney, University of Queensland, Sydney Local Health District.

Committee: Human Ethics Committees of the Above

Ethics number: 2014/778; 2015001908/HREC15/RPAH/73; HREC/15/RPAH/73.