Stratified primary care versus non-stratified care for musculoskeletal pain: qualitative findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

Abstract

Background: Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to appropriate early treatment options. The STarT MSK feasibility and pilot cluster randomised controlled trial (RCT) examined the feasibility of a future main trial and of delivering prognostic stratified primary care for patients with musculoskeletal pain. The pilot RCT was conducted in 8 UK general practices (4 stratified care; 4 usual care) with 524 patients. GPs in stratified care practices were asked to use i) the Keele STarT MSK development tool for risk-stratification and ii) matched treatment options for patients at low-, medium-and high-risk of persistent pain. This paper reports on a nested qualitative study exploring the feasibility of delivering stratified care ahead of the main trial. Methods: 'Stimulated-recall' interviews were conducted with patients and GPs in the stratified care arm (n = 10 patients; 10 GPs), prompted by consultation recordings. Data were analysed thematically and mapped onto the COMB behaviour change model; exploring the Capability, Opportunity and Motivation GPs and patients had to engage with stratified care. Results: Patients reported positive views that stratified care enabled a more 'structured' consultation, and felt tool items were useful in making GPs aware of patients' worries and concerns. However, the closed nature of the tool's items was seen as a barrier to opening up discussion. GPs identified difficulties integrating the tool within consultations (Opportunity), but found this easier as it became more familiar. Whilst both groups felt the tool had added value, they identified 'cumbersome' items which made it more difficult to use (Capability). Most GPs reported that the matched treatment options aided their clinical decision-making (Motivation), but identified some options that were not available to them (e.g. pain management clinics), and other options that were not included in the matched treatments but which were felt appropriate for some patients (e.g. consider imaging). Conclusion: This nested qualitative study, using the COMB model, identified amendments required for the main trial including changes to the Keele STarT MSK tool and matched treatment options, targeting the COMB model constructs, and these have been implemented in the current main trial. Trial registration: ISRCTN 15366334.

Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

“…However, the length of time taken to recruit participants was over twice as long as expected (28 rather than 12 weeks), and GPs completed the Keele STarT MSK Tool in fewer patient cases than we had hoped for (they used it in 32% of patient cases when the target was > 50%). The nested qualitative study findings [41] and feedback discussions with participating GPs explored the reasons why only two of the four prespecified pilot trial success criteria were met. These identified in the particular challenge of using the EMR template and stratified care intervention when MSK pain was not the primary reason for the consultation.…”

“…The study design was a pragmatic, feasibility and pilot, two-parallel arm (1:1 ratio), cluster RCT in 8 general practices, with a nested qualitative study reported separately [41]. A cluster RCT was chosen over an individual patient randomisation design as stratified MSK care involves GPs using a slightly different consultation approach following specific training, as well as the use of a bespoke electronic medical record (EMR) template, which was only possible to implement at a practice level without causing a high probability of intervention contamination across arms [42].…”

“…GP fidelity to choosing recommended matched treatment options (shown in Table 2) achieved "complete success" with 81% of patients at low risk, 89% for medium risk and 87% for patients at high risk being correctly matched to a recommended treatment. Through the nested qualitative research (reported separately, [41]) and feedback discussions with the participating GPs about the reasons for the low rate of completion of the tool, we gathered a number of insights to inform the main trial. Firstly, GPs perceived that the using the whole EMR template increased their consultation workload and asked for the treatment options to be simplified.…”

Patients’ Views on the Implementation Potential of a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study

“…19 In previous studies physiotherapists, physicians as well as patients described positive experiences or expectations for such a use of the STarT-Back-Tool. 3,27,28 The participants' perceptions about which professional should carry out the risk stratification varied. It was stated that physicians, like physiotherapists, could do it, while some questioned if the job could be done by clinic assistants.…”

Computer-Based Stratified Primary Care for Musculoskeletal Consultations Compared With Usual Care: Study Protocol for the STarT MSK Cluster Randomized Controlled Trial

“…Second, we agreed on evidence-based recommended matched treatment options for patients in each subgroup following a systematic review [ 22 ] and expert consensus process [ 23 ]. Third, we conducted an external feasibility and pilot randomized trial with 524 patients from 8 general practices (4 intervention and 4 control) [ 21 , 24 ]. The pilot trial confirmed the acceptability of using a stratified care approach in primary care consultations and also helped to refine our recruitment, retention, and sample size estimates, ahead of the main trial.…”