Integrating clinician support with intervention design as part of a programme testing stratified care for musculoskeletal pain in general practice

Abstract

Background Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to early treatment options. The STarT-MSK programme developed and tested a new stratified primary care intervention for patients with common musculoskeletal (MSK) conditions in general practice. Stratified care involves changing General Practitioners’ (GPs) behaviour, away from the current ‘stepped’ care approach to identifying early treatment options matched to patients’ risk of persistent pain. Changing healthcare practice is challenging, and to aid the successful delivery of stratified care, education and support for GPs was required. This paper details the iterative development of a clinician support package throughout the lifespan of the programme, to support GPs in delivering the stratified care intervention. We argue that clinician support is a crucial aspect of the intervention itself, which is often overlooked. Methods Qualitative research with patients and GPs identified barriers and facilitators to the adoption of stratified care, which were mapped onto the Theoretical Domains Framework (TDF). Identified domains were ‘translated’ into an educational paradigm, and an initial version of the support package developed. This was further refined following a feasibility and pilot RCT, and a finalised support package was developed for the main RCT. Results The clinician support package comprised face-to-face sessions combining adult-learning principles with behaviour change theory in a multimethod approach, which included group discussion, simulated consultations, patient vignettes and model consultation videos. Structured support for GPs was crucial to facilitate fidelity and, ultimately, a successful trial. Clinician support is a two-way process– the study team can learn from and adapt to specific local factors and issues not previously identified. The support from senior clinicians was required to ensure ‘buy in’. Monitoring of GP performance, provision of regular feedback and remedial support are important aspects of effective clinician support. Conclusion Designing effective clinician support from the onset of trial intervention design, in an evidence-based, theory-informed manner, is crucial to encourage active engagement and intervention fidelity within the trial, enabling the delivery of a robust and reliable proof-of-principle trial. We offer practical recommendations for future general practice interventions.

Validation of the German version of the STarT-MSK-Tool: A cohort study with patients from physiotherapy clinics

“…Another strength of the STarT-MSK is that matched treatments were compiled and instruments assisting clinicians in decision-making are under development [24,28,63]. Such instruments help the clinician to address the patients' needs more specifically, eg.…”

Risk-based stratified primary care for common musculoskeletal pain presentations (STarT MSK): a cluster-randomised, controlled trial

“…GPs in practices allocated to the intervention group were supported to deliver risk-based stratified care using a bespoke computer-based template, including the riskstratification tool, and risk-matched treatment options for patients at low, medium, or high risk of poor disability or pain outcomes. 19,20 Briefly, there were 15 risk-matched treatment options (appendix pp 8-9). The intervention aimed to encourage GPs to use less prescribing of longterm opioids, neuromodulators, muscle relaxants and corticosteroid injections, less unnecessary referrals (eg, to imaging and specialist orthopaedics), and less sick certification (particularly for low-risk patients); and more written self-management advice, simple over-the-counter analgesics, earlier referral to physiotherapy (for patients at medium or high risk), plus further GP assessment to address complexities such as comorbidities, distress, and emerging frailty (for patients at high risk).…”

“…GPs also received a 1 h training update to share and discuss the first of their monthly feedback reports, showing individual GP intervention fidelity, with peer-to-peer comparisons. 20 In the usual care group, patients with musculoskeletal pain consulting their GP received treatment as usual. This approach typically includes advice and education, medication, referral for investigations or tests, or referral to other services, such as physiotherapy, or secondary care specialists, such as orthopaedics and rheumatology, without the use of risk-stratification tools to support decision making.…”