title: The importance of identifying and modifying unemployment predictor variables in the evolution of a novel model of care for low back pain in the general population.
abstract: BACKGROUND
  Care for low back pain (LBP) is costly, fragmented and, in non-compensation populations, rarely specifically addresses factors associated with maintaining employment status or return to work (RTW).
  
  
  OBJECTIVE
  This study aimed to identify modifiable independent risk factors for (1) a negative work status at presentation and (2) a change in work status during treatment in a cohort of LBP patients. The results are intended to inform improvement in best-evidence care pathways to maximize societal outcomes and overall value of a new model of care.
  
  
  METHODS
  A prospective observational study was carried out.
  
  
  METHODS
  Work-eligible, non-workers compensation patients with recurrent or persistent LBP ≥6 weeks and ≤12 months.
  
  
  METHODS
  The Inter-professional Spine Assessment and Education Clinics (ISAEC)-a novel Government-funded shared-care model of management for LBP.
  
  
  METHODS
  This study used the following methods: (1) Cross-sectional analysis of baseline data from the initial ISAEC consultation (t0) from December 2012 to April 2014. Work status at t0 was dichotomized as employed (E) or underemployed (UE; unemployed, modified work duty, or disability). Multivariate logistic regression modeling was used to determine independent predictors of UE status at t0. (2) Bivariate analysis of longitudinal data from t0 to 6 months (t1) to identify risk factors for work status change. Employment journey categorized into four groups: Et0/Et1-employed at t0 and employed at t1; Et0/UEt1-employed at t0 and underemployed at t1; UEt0/Et1-underemployed at t0 and employed at t1; UEt0/UEt1-underemployed at t0 and underemployed at t1.
  
  
  RESULTS
  This study yielded the following results: (1) Initial consultation data on 462 consecutive patients (Et0=344, UEt0=118). Multivariate logistic regression identified legal claim, depression, smoking, and higher STarT Back (or Oswestry Disability Index [ODI]) score as independent risk factors for UEt0. (2) Overall UE rate did not significantly change during longitudinal analysis (n=178, UEt0=25.5%, UEt1=22.9%). However, 10.5% of Et0 became UEt1 (Et0/Et1=102, Et0/UEt1=12). Bivariate analysis identified elevated baseline ODI score as the only significant predictor variable for UEt1 in Et0 cohort (p=.0101). Conversely, ISAEC improved the employment status in 41% of UEt0 to Et1 (UEt0/Et1=16, UEt0/UEt1=23), and the absence of depression was significant for predicting RTW (p=.0001).
  
  
  CONCLUSIONS
  From a societal perspective, employment status as an outcome measure is paramount in assessing the value of a new model of care for LBP. Mitigation strategies for the predictor variables identified will be included in ISAEC pathways to translate clinical improvement into societal added value.
authors.affiliation: Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, University Health Network, 399 Bathurst St East Wing, 1-441, Toronto, Ontario M5T-2S8, Canada; Arthritis Program, Toronto Western Hospital, Toronto, Ontario, Canada.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Harris
authors.affiliation: Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, University Health Network, 399 Bathurst St East Wing, 1-441, Toronto, Ontario M5T-2S8, Canada; Arthritis Program, Toronto Western Hospital, Toronto, Ontario, Canada; Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, Toronto, Ontario, Canada; University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address: raja.rampersaud@uhn.on.ca.
authors.forename: Y Raja
authors.initials: YR
authors.lastname: Rampersaud
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000191:economics / Q000453:epidemiology / Q000534:rehabilitation*; D008297:Male; D008875:Middle Aged; D062707:Return to Work / Q000706:statistics & numerical data; D014478:Unemployment / Q000706:statistics & numerical data*
keywords: Depression; Employment; Low back pain; Model of care; Smoking; Value