Abstract
Musculoskeletal conditions represent one of the largest causes of years lived with disability in high-income economies. These conditions are predominantly managed in primary care settings, and yet, there is a paucity of evidence on which approaches work well in increasing the uptake of best practice and in closing the evidence-to-practice gap. Increasingly, musculoskeletal models of service delivery (as components of models of care) such as integrated care, stratified care and therapist-led care have been tested in primary health care pathways for joint pain in older adults, for low back pain and for arthritis. In this chapter, we discuss why implementation of these models is important for primary care and how models are implemented using three case examples: we review implementation theory, principles and outcomes; we consider the role of health economic evaluation; and we propose key evidence gaps in this field. We propose the following research priorities for this area: investigating the generalisability of models of care across, for example, urban and rural settings, and for different musculoskeletal conditions; increasing support for self-management; understanding the importance of context in choosing a model of care; detailing how implementation has been undertaken; and evaluation of implementation and its impact.
Why implementation of musculoskeletal models of care is important in primary care settings
Primary health care was defined by the World Health Organisation (WHO) as ‘… the first level of contact of individuals, the family and the community with the national health system ……. and constitutes the first element of a continuing health care process’ . Primary care settings are the locations where this type of care is delivered, and for brevity, it will be henceforth referred to as ‘primary care’. Although systems of delivery of primary care vary across and within countries, it is the setting in which the vast majority of people first seek help with musculoskeletal conditions and in which many are cared for, and as such, an effective primary care system is central to musculoskeletal health service provision. With its proximity to the community it serves, primary care is directly affected by the high prevalence and impact of musculoskeletal conditions in the community.
The community burden of musculoskeletal conditions in high-income economies is high and rising, placing increasing burden primary care . Most commonly, these conditions include arthritis and low back pain. The prevalence of inflammatory arthritis, while about 2%, incurs huge economic costs to the system and patient, requiring early diagnosis in primary care and management with disease-modifying drugs to maximise outcomes . It is the rising burden of disabling low back pain, osteoarthritis (OA) and falls (especially in those with osteoporosis and skeletal fragility) that will, given that they are highly prevalent and currently managed in primary care, principally affect the primary care workload. This is evidenced for OA and low back pain by data from UK and Swedish general practice records, which indicate that over a 7-year period 11% (Sweden) and 21% (UK) of all registered patients consult for low back pain and of the patients aged 45 years and over, 31% and 35%, respectively, consult for OA . These findings are in line with the Australian data that show low back pain and OA are both in the top 10 of the most common reasons for presenting to a general practitioner (GP) . Projected increases in such a burden as identified by the Global Burden of Disease Study are likely to add significantly to the primary care workload. In addition to future rising demand for primary care, there is a present gap between the recommended practice and day-to-day practice: surveys suggest that current primary care for back pain and OA is suboptimal when judged against quality standards derived from clinical practice guideline recommendations . Implementation of models of care may be helpful in bridging this gap and guiding more sustainable and efficient health care.
A model of care has been defined as ‘an evidence-informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers’ and addresses system-level delivery and specific service provision in different parts of the system. For clarity in this chapter, the term ‘model of service delivery’ is used when describing issues related to the provision of care at an operational or service level.
Speerin et al. reviewed models of care for musculoskeletal conditions, giving a range of exemplars from different settings, and a WHO report identified the opportunities to improve musculoskeletal health outcomes afforded by implementation of models of care . Models of care and models of service delivery go beyond clinical practice guidelines in that they not only address what care should be delivered (often derived from guideline recommendations) but also the practical delivery issues of who is to deliver care, when and where care is best delivered and the details of how it is to be delivered and re-evaluated. These are important issues to be addressed in primary care given its multidisciplinary workforce; links with secondary and tertiary care services; and its often complex, and frequently changing, organisational structures .
Specifically in general practice, there are issues arising from the need to (i) provide a generalist service (primary health practitioners do not just care for people with musculoskeletal conditions and have many demands on their time and professional development), (ii) provide holistic care for people with several long-term conditions (musculoskeletal conditions need to be managed in the context of multiple morbidity) and (iii) meet the ever-rising demand for generalist services from an ageing population. The rationale for the holistic care of people with musculoskeletal conditions is that (i) multimorbidity is increasingly becoming the norm in patients with painful conditions such as low back pain and OA: a primary care database study from Scotland reported that only 13% of patients with a painful condition did not have at least one other long-term condition and 46% had three or more other conditions ; (ii) a high proportion of people with a chronic physical ill health report chronic pain: a community survey from Australia reported that 15 out of the 17 chronic conditions studied were significantly associated with pain ; (iii) lifestyle treatments, such as increasing physical activity and losing weight, recommended for common musculoskeletal conditions are equally beneficial for many other chronic conditions and so merit being promoted in a holistic manner; (iv) pain, such as joint pain, is often a barrier to increasing physical activity and patients need help in managing this to enable them to gain the benefits of increasing physical activity in other chronic conditions such as diabetes and heart disease ; and (v) multimorbidity can result in a considerable treatment burden for patients and a holistic approach can help to reduce this .
Whilst primary care offers a generalist approach, and older adults with comorbidities represent a large proportion of the population consulting here, services in secondary care and beyond are often not readily integrated into primary care and coverage of community services can be patchy. It is often left to the patient and their carer to be the coordinator of their care across a range of services, and the ‘hard work’ of being a patient with comorbidities in the health care system has been recognised .
In summary, implementation of musculoskeletal models of care in primary care settings is needed to address current gaps in and future demand for the provision of primary care for people with musculoskeletal conditions.
How to implement: overview and application of theory for implementing musculoskeletal models of care
Implementation has been defined as the process of ‘active and planned efforts to mainstream an innovation within an organisation’ and use of theory to inform this process has been strongly advocated . Many theories, models and frameworks have been developed and used for implementation and the reader is directed to recent narrative reviews for an overview of their range and purpose . There are some key implementation principles , which the use of theory can help operationalise, and have been summarised as follows:
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Adopt a systematic and stepwise approach to planning and execution
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Have a full understanding of the context for the process of change, including an analysis of current performance in the area in question
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Have a well-defined proposal for change, which can be clearly presented
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Understand the determinants for change: the barriers and facilitators
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Develop and deliver an implementation intervention that addresses relevant determinants for change
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Involve all those in whom change is desired at all stages
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Continuously evaluate and adjust the implementation approach if needed
Despite the range of theories available to plan and develop, understand and describe, and evaluate models of care, there is still an evidence-to-practice gap in primary care . Interventions tested in primary care such as educational outreach, incentives, computer prompts, and clinical champions appear to give only small benefits, and there is no evidence that multimodal approaches are advantageous, but the success of a chosen intervention to implement a model of service delivery is dependent on the context in which it is used . For example, in the context of national recommendations for the care and management of a musculoskeletal condition, implementation of a model of service delivery to increase the uptake of the recommendations for that condition may be given higher priority than if there was no national guidance for that condition.
This section describes the approach employed by the authors in using theory to practically design implementation interventions for GPs to enhance the management of low back pain and OA and is given to illustrate how theory could be used in implementing specific components of musculoskeletal models of care.
The first step was to develop what has been termed the ‘concrete proposal’ for change : a detailed specification of the desired new way of working. In the context of implementing a model of care, this would require the model to be clearly defined in detail. It is recommended that this is undertaken systematically and with the involvement of the ‘target group’ (the people and organisations who will be asked to work according to the model) as stakeholder engagement is a key mechanism for enhancing implementation.
The second step was to undertake an analysis of the GPs (as the identified ‘target group’) to understand the barriers to and incentives for adopting the new way of working, and at this step, the theoretical domains framework was utilised . This framework was developed to enable the many psychological theories on ‘determinants of behaviour change’ (factors that determine the extent to which change will occur) to be used in one overarching framework. The behaviour change determinants are grouped into 12 domains, for example, ‘knowledge’, ‘skills’, ‘beliefs about consequences’ and ‘environmental context and resources’, and the domains provide a theory-derived list of factors to be explored in the ‘target group’. When implementing a model of care, this approach would require the model to be presented to the ‘target group’, for example, in focus group workshops, followed by a semi-structured discussion that is recorded and analysed to identify the relevant determinants, for example, a lack of skills in some of those who are to deliver care aligned to the model or a belief in others that the consequence of operationalising the new model would be no better (or worse) than the current practice.
Having identified the relevant determinants in step 2, the third step was to select ‘behaviour change techniques’ to effect change in these determinants, and for this a model that maps behaviour change techniques (BCTs) to the domains of the theoretical domains framework was utilised . The model was developed by identifying and defining a list of ‘behaviour change techniques’ described in the literature and mapping each to one or more of the domains, for example, the use of rehearsal of skills with feedback to target a skills gap. The selected BCTs were incorporated into the implementation intervention: a series of workshops that GPs were invited to attend.
In summary, many theories, models and frameworks have been developed to inform the process of implementation, and we have illustrated, using one example, how theory can be used in a doable and practical manner to develop interventions to support implementation and can be used to implement models of care. The steps outlined earlier have recently been described in a framework to develop, implement and evaluate models of care for musculoskeletal health . The framework has been designed by experts from 30 nations of varying wealth and offers a helpful synthesis on how to approach implementation.
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Back pain and OA are the most prevalent musculoskeletal conditions managed in primary care
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Efforts to improve primary care of musculoskeletal health should focus on implementation of models of care for these conditions to ensure the right care is delivered at the right time by the right team in the right place
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Implementation theory can help to design and implement models of musculoskeletal care and guide evaluation
Moving from research evidence to implementation of models of care at scale: Using theory to support implementation.
Introduction
In their study of models of care for musculoskeletal health, Speerin et al. identified a range of programmes for the prevention and management of musculoskeletal conditions. In this chapter, we have selected three models of service delivery within primary health care to illustrate how implementation theory can be used in practice. We describe each model of service delivery, as reflected in contemporary models of care, and where indicated, which implementation theory has been used ( Table 1 ).
| Model of care | Which programme? | Where implemented? | What constitutes the model of care? | Who delivers the model of care? | How is the model of care implemented? | Outcomes |
|---|---|---|---|---|---|---|
| Integrated care | Managing osteoarthritis in consultations (MOSAICS) JIGSAW Joint Implementation of osteoarthritis guidelines in the West Midlands, UK (Based on MOSAICS study) | UK general practice | Use of an electronic OA template to record key Quality Indicators of OA care. PLUS A model OA consultation with a GP: offers of referral to practice nurse. | General practitioner and practice nurse linked consultation | Adults 45 years and over presenting to their General Practitioner with joint pain (hip, knee, hand, foot), clinical diagnosis; exclusion of red flags. OA e-template fires. GP makes, gives, explains the OA diagnosis, gives OA guidebook; analgesia; offers referral to practice nurse. Practice nurse up to 4 sessions supporting self-management: OA guidebook; exercise/physical activity advice using Arthritis Research UK booklets; weight management; analgesia. | Uptake of Quality Indicators of OA for the core non-pharma and pharma recommendations from the National Institute of Health and Care Excellence |
| Stratified care | STarT Back: Subgroups for Targeted Treatment (STarT) Low Back pain http://www.keele.ac.uk/sbst/ | Initially UK, subsequently overseas including Australia, Denmark, Scandinavia, Canada, USA | Patient information; training for psychologically informed physiotherapy; 9-item STarT Back screening tool embedded in general practice electronic medical record systems; e-templates for general practice fire on Read codes. | General practitioners and physiotherapists | Patient consulting with low back pain in general practice, GP enters a Read code for low back pain which fires an e-template prompt to screen for red flags and complete the 9-item STarT Back screening tool, completes tool in real time consultations, tool auto-calculates score and identifies level of risk of persistent disabling low back pain (low, medium, high risk). Low risk = support for self-management of back pain by GP; medium risk referral for physiotherapy; high risk = referral for psychologically informed physiotherapy | Improved clinical outcome for patients at 4 and 12 months Improved patient satisfaction Credible and acceptable to patients Reduced time off work Stratified care was cheaper: Saving an average £34 per individual (health costs) Saving an average £675 per individual (societal costs) Key cost savings GP consultations Visits to NHS consultants Investigations MRI; x-rays Epidural injections Other private healthcare Medication Changes in physiotherapy pathway Low risk = Reduced referral Medium risk = More referrals early High risk patients = More referrals early |
| Primary therapist model | Arthritis Rehabilitation and Education Program http://arthritis.ca/manage-arthritis/living-well-with-arthritis/living-well-in-your-province/living-well-in-ontario/therapy-services | Services are offered in all of the Provincial health regions, delivering education and care at select Arthritis Society offices, Ontario, Canada, in primary health care clinics, in specialised rheumatology clinics, at home, through a variety of groups, and through telemedicine. | Assessment, diagnosis, triage and independent management of selected musculoskeletal and arthritic disorders | Arthritis Society employs Physiotherapists (PT), Occupational Therapists (OT) and Social Workers | Clients with a confirmed physician diagnosis of arthritis are able to self-refer; referrals also are accepted from other health professionals. The therapist functions as a case manager and multi-skilled rehabilitation professional |
A model of integrated service delivery for joint pain in older adults: Managing Osteoarthritis in Consultations (MOSAICS)
The first model describes how innovations developed and tested in a research context (the MOSAICS trial) – co-created by GPs, practice nurses, patients and researchers – can be successfully modified and piloted to implement at scale an enhanced care pathway for OA in primary care (Joint Implementation of Guidelines for Osteoarthritis in the West Midlands (JIGSAW)). MOSAICS was tested in a cluster trial to determine the uptake of the core recommendations from OA guidelines; the clinical effectiveness of the model on any changes in health status; and the consequences and cost utility of the new approach. The benefit of the cluster trial design was that it allowed testing of the whole system approach within a defined protocol. The implementation that followed was in response to a strong pull from stakeholders and allowed further testing, adaptation and scale-up in real-world practice. Flow Chart 1 describes some of the lessons learnt during the process of moving from a funded research proposal, with oversight of a clinical trials unit, delivered by a multidisciplinary research team to a defined group of general practices, to implementation of innovations developed by the research, with oversight of clinical commissioning groups (CCGs), delivered by a multidisciplinary implementation team to an expanding number of general practices.
The model of service delivery
The model of integrated care of joint pain in older adults (MOSAICS) was developed to operationalise, in general practice in United Kingdom (UK), the UK 2008 National Institute of Health and Care Excellence (NICE) OA Guidelines , and it describes how initial GP care can be integrated with follow-up practice nurse care and the provision of written patient information. The model focussed on six NICE OA Guideline recommendations: (i) obtaining verbal and written information, (ii) advice to exercise and increase physical activity and (iii) interventions to achieve weight loss should be core treatments for all people with OA; i(v) paracetamol and (v) topical nonsteroidal anti-inflammatory drugs (NSAIDs) should be first-line treatments for analgesia and (vi) a holistic approach to assessment and treatment should be adopted to help people take better self-care of their joint pain and OA.
The three elements of the Whole Systems Informing Self-management Engagement (WISE) approach underpinned the development of the MOSAICS model: relevant and accessible patient information, professionals responsive to the needs of patients and good access to care services ( Fig. 1 ).
The MOSAICS model describes the care that should be offered to adults aged 45 years and over who present to their GP with peripheral joint pain in the hands, knees, hips and feet (a focus of the NICE guidance). It consists of three components: (i) an initial consultation with a GP, followed by (ii) up to four consultations with a practice nurse in an OA clinic, with (iii) the Keele OA Guidebook to support care ( Fig. 2 ).
The delivery of the model is supported by an e-template ( Fig. 3 ) embedded in the GP clinical computer system, and both prompt for key aspects of care and enable delivery of care to be coded in the electronic patient record .
Implementation of the model of service delivery
The model has been implemented as a trial intervention in a cluster randomised control trial (the MOSAICS trial) to investigate the acceptability, feasibility and effectiveness of implementing the 2008 NICE OA Guideline in general practice and subsequently in day-to day practice in UK general practices through the Joint Implementation of Osteoarthritis Guidelines in the West Midlands (JIGSAW) Programme (see Chapter 8). The sections later describe aspects of implementation of the model in the two settings.
Implementation as a research trial intervention
Four of the eight practices recruited were randomly assigned to the intervention, while the remaining four continued with the e-template alone. To deliver the GP component of the MOSAICS model of care, an intervention was designed using the implementation theory to effect change in GP clinical practice necessary for GPs, in the four intervention arm practices of the MOSAICS trial, to deliver their component of the MOSAICS model of care (the GP consultation – see Fig. 2 ). Its development utilised the approach described earlier and has been described in detail elsewhere . In summary, (i) a concrete proposal for change was developed through consensus and focus group work; (ii) determinants of change were identified through further focus group work and classified using the theoretical domains framework; and iii) a programme for a series of workshops to deliver the implementation intervention was developed in four stages: content defined, BCTs selected, mode of delivery agreed and local practicalities addressed. The workshop programme is detailed in Table 2 . In brief, workshop 1 was delivered to the Primary Health Care Team (2 h), which covered how OA is managed, OA knowledge update, NICE guidance, case histories and the OA consultation. Workshop 2 was for GPs (2 h) and covered discussion and reflection (video-recorded simulated consultations) and skills training. Workshop 3 for GPs included knowledge updates, discussion and reflection, agenda for skills training and the aide-memoire. The final workshop for GPs included action planning and review of audit data.
| Time (minutes) | Activity |
|---|---|
| Workshop 1 – attendees: primary healthcare team from a single practice (GPs, practice nurses, practice manager*, receptionists 1 ) Duration: 2 h . 1* – for first hour only | |
| 5 | Introductions – facilitators and practice attendees |
| 20 | How is OA managed in your practice? Mapping practice, and local community and secondary care, resources for OA (interactive session with discussion recorded on flipchart) |
| 25 | OA knowledge update on pathophysiology, definition and diagnosis, prevalence, prognosis and patient experience of OA (didactic session with discussion) |
| 10 | Information on the NICE OA Guideline, support for self-management, the OA Guidebook, the model OA consultation (didactic session with discussion) |
| 5 | Break and non-clinical staff leave |
| 20 | Presentation and discussion of case histories (GPs previously requested to bring). Difficulties in managing OA – what do GPs and nurses want from the sessions and what would aid them in managing OA (interactive session with issues recorded on flipchart and to be addressed in workshop 3) |
| 25 | Details of the model OA consultation – how to deliver it in day-to-day practice – GP and practice nurse roles. Aide-memoire introduced (didactic session with discussion) |
| 10 | Conclusion and outline of workshops 2 and 3. GPs given the DVD of simulated patient consultation 2 and asked to view in preparation for workshop 2 2 – all GPs were invited to undertake a video-recorded consultation with a simulated OA patient prior to workshop 1 |
| Workshop 2 – attendees: GPs from two practices. 3 Duration: 2 h 3 – GPs from two practices came together for workshops 2 and 3 | |
| 10 | Introductions – facilitators and GPs. Reflection on, and unanswered questions from, workshop 1. |
| 20 | Discussion and reflection on video-recorded simulated patient OA consultations. Comparison between current practice and model OA consultation. Agenda for skills training agreed (interactive session with ‘agenda’ recorded on flipchart) |
| 10 | Introduction to skills training: description of purpose and methods – the GPs were asked to work as a team, trying out in turn bite-sized parts of the consultation with discussion and feedback from colleagues and facilitators (didactic session with discussion) |
| 10 | Break |
| 60 | Skills training: working through the agenda set earlier. Particular emphasis on communication, use of language for giving and explaining the diagnosis and patient-centred approach (led by an experienced GP educator) |
| 10 | Reflection and conclusion. Aide-memoire discussed. Preparation for second video-recorded simulated patient consultation. 4 Outline of workshop 3 4 – All GPs were invited to undertake a second video-recorded consultation between workshops 2 and 3 |
| Workshop 3 – attendees: GPs from two practices. Duration: 2 h | |
| 40 | Knowledge update: addressing needs identified in workshop 1 and questions from GPs and covering: diagnosing OA clinically and ‘top tips’ for managing OA (interactive session led by academic rheumatologist) |
| 10 | Discussion and reflection on second video-recorded consultation. Agenda for skills training agreed (interactive session with ‘agenda’ recorded on flipchart) |
| 10 | Break |
| 50 | Skills training: as for workshop 2 |
| 10 | Conclusion and general reflection. Aide-memoire discussed. GPs invited to complete satisfaction questionnaires. Outline of workshop 4 |
| Workshop 4 – attendees: GPs and practice nurses from a single practice. Duration: 1 h | |
| 40 | Action planning on delivery of the model OA consultation in the practice. Final version of the aide-memoire agreed. |
| 10 | Presentation of baseline data on OA consultations in the practice (an OA data collection template had been installed in the practices for the 6 months prior to the training) |
| 10 | Conclusion and thanks. Attendance certificates issued. |
GPs in the four intervention arm practices attended these workshops, and change in clinical practice was evaluated through the use of video-recorded consultations with simulated patients and an audit of delivery of the GP consultation during the trial.
Practice nurses were invited to a 4-day training programme at Keele University to implement the ‘OA clinic’ ; see Fig. 4 , which describes the content of the nurse training programme delivered by the study team.
On further testing, adaptation and scale-up in real-world practice, at a half-way point in the trial, a stakeholder conference was held and clinical case studies were shared by colleagues involved in the programme. For example, a practice nurse described an 80-year-old lady she had seen in the ‘OA clinic’ whose husband ‘wouldn’t let her do anything’ because she had osteoarthritis. The practice nurse described how delighted the patient was in being told that keeping moving was key to self-management. ‘She was over the moon. It was like a new lease of life. She’d got her guidebook – she used it quite a lot. At her final consultation, she virtually skipped into the room. It was just brilliant to see her because she’d done so well’ (Nurse Practitioner, MOSAICS Stakeholder Conference 2013).
The stakeholder conference proved to be a key factor in the transition from research into implementation. The MOSAICS study generated grass roots interest and support, with GPs and practice nurses reporting greater confidence in managing OA and patients feeling that their joint problems were taken seriously. In addition, the health professionals realised that the core management principles for OA were the same as those for other long-term conditions (LTCs) and that the knowledge and skills they developed were transferable across a range of LTCs.
Following the stakeholder conference, a GP champion and practice nurse asked the trial team for support in rolling the model consultation out into local practices in a pilot. The aim of the pilot was to develop an enhanced care pathway for OA based on the trial intervention. The setting was a cluster of local general practices in South Shropshire, West Midlands, UK.
The research trial had developed four key innovations that formed the practice intervention to deliver the enhanced OA model:
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An OA guidebook written by patients and health professionals for patients
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A model OA consultation for primary care to deliver NICE recommendations
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Training for GPs and practice nurses to deliver the model consultation
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The development and capture of quality indicators (QIs) of care (through an OA e-template and self-reported questionnaire)
The model of care was evaluated using OA QIs embedded in the general practice OA e-template ( Fig. 3 ) and through a patient-reported OA-QI UK questionnaire .
The practice nurse training was reviewed and reduced to 2 days following evaluation, and GPs worked in partnership with an implementation team at Keele University to identify funding to roll out the four key innovations described earlier. The Joint Implementation of Osteoarthritis Guidelines in the West Midlands (JIGSAW) Programme was piloted to test out the practicalities of implementing the enhanced OA pathway.
JIGSAW identified 15 general practices in the local CCG to be pilot sites. A meeting of stakeholders from each of these practices was convened by the lead GP champion to introduce the proposal and the Keele team. Across these sites, more GP champions (four) and practice nurses (two) were recruited to support colleagues in clusters of up to four practices. Workshops based on the research training for the MOSAICS trial ( Table 2 ) were delivered to the clinical champions at two practice-based meetings to introduce them to the role.
A 2-h evening meeting was then convened to launch JIGSAW in all practices and practice staff. Practice staff met their nominated clinical champion and participated in round table discussions. Topics such as the quality of the evidence, clinical pathways, funding and barriers to uptake were debated. A patient story was used by the GP champion to illustrate the potential benefits of using NICE recommendations in routine care. Practitioners agreed to adopt the OA e-template (used to capture QIs of care) to audit current practice and evaluate successful implementation. A dedicated health informatics specialist from the trial team supported local practices to install the template. A training Digital Video Disc (DVD) was available to guide its use. On the basis of the pilot study, further funding was secured (JIGSAW is further described in Chapter 8).
In summary, JIGSAW has shown that innovations developed and tested in a research context (the MOSAICS trial) – co-created by GPs, practice nurses, patients and researchers – can be successfully modified and piloted to implement at large scale an enhanced care pathway for OA in primary care.
A model of stratified care: Subgroups for Targeted Treatment
The second model describes a research study investigating screening and targeting of matched treatments for back pain (STarT Back) and its subsequent uptake informed by a parallel research study of implementation potential (IMPaCT Back) . The STarT Back approach has been adopted widely with examples of where it has been refined to fit with local needs ( http://www.keele.ac.uk/sbst/ ).
In 2011, Hill et al. published the STarTBack trial. STarT Back is an example of a stratified care approach for low back pain and matches patients to treatments based on prognosis or risk of poor clinical outcome ( Table 3 ).
| Level of outcome measure | Description | Back pain and OA examples | Data collection options |
|---|---|---|---|
| Patient level | Impact on patients of the model of care | Pain and function, quality of life | Self-reported questionnaires, interviewer-administered questionnaires |
| Provider level | Impact on health care provider of the model of care | OA: Increased rate of referral for exercise prescription LBP: Decreased rate of X-ray referrals | Administrative/clinical database Quality indicators Questionnaires, interviews with providers |
| System/society level | Impact on the health system of the model of care | Healthcare costs, waiting times for knee replacement | Administrative database Questionnaires |
The model of primary care is a collaborative GP–physiotherapist-integrated model of service delivery with patient-centred support for self-management and use of a stratification tool that allows for matching of treatment to the level of risk of persistent, disabling, low back pain (low, medium or high risk). Those at low risk are supported with a self-management plan and those at medium and high risk are referred for physiotherapy, with those at high risk being offered enhanced physiotherapy with a psychologically informed intervention .
The STarT Back approach uses a simple nine-item tool to match patients to treatment packages appropriate for them. This has been shown to significantly decrease disability due to back pain, reduce time off work and save money by making better use of health resources as this new model results in greater health benefits, achieved at a lower average health-care cost, with an average saving to health services of £34.39 per patient and societal savings of £675 per patient . The STarT Back website shares the knowledge, resources and experiences of the STarT Back approach for use by clinicians, providers, researchers and patients ( http://www.keele.ac.uk/sbst/ ).
In parallel to the randomised controlled trial to evaluate effectiveness , Foster and colleagues studied the potential for implementation of this risk stratification and matched treatment approach for back pain in primary care (the IMplementation to improve Patient Care through Targeted treatment (IMPaCT) Back study) . The implementation study showed that this approach can be successfully embedded into routine primary care . The IMPaCT Back study used the normalisation process theory (NPT) to understand and evaluate the potential for uptake of this stratified care approach prior to the completion of the STarT Back trial. The four key ‘how’ stages of NPT include (i) ‘sense-making’ of the approach (e.g. distinguishing it from usual practice), (ii) participation in the new strategy (from the health care professional perspective), iii) taking action to embed the new approach into routines and iv) monitoring the sustainability of any change. Sanders et al. found that GPs in IMPaCT Back perceived back pain as a low clinical priority and highlighted the importance of practical and integrated decision tools to assist in adoption and engagement with STarT Back. Without knowledge of the STarT Back trial results at the time, low back pain was generally perceived by GPs as an ‘uninteresting’ and a clinically unchallenging health problem . Physiotherapists in contrast were keen to adopt the STarT Back approach, and they perceived that it enhanced their role in the management of Low Back Pain (LBP) .
GPs who manage a whole range of conditions have been supported to use the STarT Back approach with the help of implementation strategies outlined by Lau et al. , e.g. knowledge mobilisation fellows, clinical champions, electronic templates embedded in routine consultations that prompt screening for red flags, the nine-item STarTBack tool that auto-calculates the score in real time consultations illustrating level of risk, automated access to evidence based patient information and direct electronic referral to physiotherapy for those in medium- and high-risk categories ( http://www.keele.ac.uk/sbst/ ).
The STarT Back approach has also been adopted widely in the UK and overseas and has been refined by local general practice, physiotherapy champions and knowledge mobilisation fellows to fit with local needs ( http://www.keele.ac.uk/sbst/ ).
A dedicated implementation team, led by a knowledge mobilisation fellow (Stevenson) who was funded by the National Institute of Health Research, UK, worked closely with the research team to enhance the uptake of STarT Back. Using the findings from IMPaCT Back, the team worked with local GPs, patients, commissioners and providers and developed, tested and evaluated the uptake of the electronic STarT Back e-template. They installed the e-template initially in 17 general practices and audited with 866 patients who consulted about low back pain during that time. Locally, 190 physiotherapists have been trained to deliver the matched treatments used in the stratified care approach.
Case studies can help to illustrate the basis of decision-making for GPs on how to integrate the STarTBack Tool in consultations for back pain (e.g. http://www.gmc-uk.org/3_20_MSK_May_2014.pdf_56885470.pdf (accessed 25/02/16)). (See also Supplementary material S2.1 Case Study .)
The STarTBack tool has been translated into 12 languages. Services overseas who are adopting a stratified care approach for back pain include Australia, Denmark, Scandinavia, Canada and the United States. InterMountain Healthcare (based in Salt Lake City) have implemented this for use in Utah and Idaho (across 22 hospitals and 185 clinics); Fair View Healthcare have integrated STarT Back into their electronic patient record (EPIC) and across their services in Minnesota and are collaborating with group health cooperatives, who have implemented the STarT Back approach in Seattle. The Ontario government and the Centre for Effective Clinical Practice have adopted the STarTBack approach into their guidelines, and in Denmark, the government has approved the training of 1000 physiotherapists using translated versions of the training materials ( http://www.keele.ac.uk/sbst/commissioners/impact/ ).
The STarT Back approach now features as a recommendation in the draft 2016 NICE Low Back Pain Guideline.
From discipline-specific to the primary therapist model of service delivery
The Arthritis Society, Ontario Division, Canada, has a long history of providing community-based physiotherapy, occupational therapy and social work services in the home, clinic and through groups as well as individual clients of all ages with arthritis. These services have been and continue to be provided at no cost to the client under the Arthritis Rehabilitation and Education Programme ( http://arthritis.ca/manage-arthritis/living-well-with-arthritis/living-well-in-your-province/living-well-in-ontario/therapy-services ), which is funded by the Ontario Ministry of Health and Long-term Care ( http://www.health.gov.on.ca/en/ ). Until April 1994, care was provided as discipline-specific services with each service requiring a separate referral, assessment and treatment planning and implementation. It was recognised that there was duplication of services resulting in lost efficiencies (increased travel time, increased charting time) and often lack of continuity of care and a sense of intrusion given the multiple providers by clients . These challenges led the Society to propose and, with funder approval, institute a primary therapist model of care in 1994, which continues today.
In the primary therapist model, clients with a confirmed physician diagnosis of arthritis can self-refer to the programme; referrals are also accepted from other health professionals. The therapist functions as a case manager and multi-skilled rehabilitation professional . The first available physiotherapist or occupational therapist assesses the client to initiate education and treatment; other health disciplines serve a consultative role as needed. Transition to a primary therapist model was enabled as, although the disciplines had functioned independently, some aspects of the model were already in place. Specifically, all therapists received the same specialised training in the assessment of polyarthritis , and the core assessment components and charting requirements were the same for each discipline. In moving to the primary therapist model, skills of each discipline were enhanced through targeted education to enable therapists to utilise each other in a consultative role rather than having to transfer care to another discipline . For example, the physiotherapist would consult the occupational therapist in recommending off-the-shelf splints to a client rather than transferring the client’s care to the occupational therapist.
The Society employs physiotherapists, occupational therapists and social workers, all of whom receive specialised training in arthritis management (Assessment of Inflammatory Polyarthritis Training Programme, now being offered as the Clinical Practice Skills in Inflammatory Arthritis Programme) . Additionally, some of the Society therapists have been trained through the Advanced Clinician Practitioner in Arthritis Care Programme and are able to assess, diagnose, triage and independently manage select musculoskeletal and arthritic disorders . Working in an advanced practice role, these healthcare providers perform complete joint examinations, review laboratory and radiology results (in many cases, they are also able to order additional tests) and coordinate care with other providers. All primary therapists consult with the client’s primary care physician or rheumatologist if a change in the patient’s status requires additional review and consideration of change in management.
Primary therapist services currently are offered in all of the health regions in Ontario, Canada, delivering education and care at select Arthritis Society offices, in primary health care clinics, in specialised rheumatology clinics, at home, through a variety of groups and through telemedicine. This primary therapist model and work within advanced practice roles has facilitated and been integrated into models of care in partnership with other healthcare providers in many jurisdictions to target care gaps and needs (e.g. triage for early access to a rheumatologist for patients with inflammatory arthritis requiring Disease Modifying Anti-Rheumatic Drugs (DMARDS), triage of surgical candidates for hip or knee replacement and ongoing follow-up for stable patients).
Positive health outcomes, including symptom management and improved function and quality of life, were demonstrated for people with rheumatoid arthritis in the initial programme evaluation , and these results were supported in a subsequent randomised trial comparing the primary therapist model with traditional outpatient rehabilitation services by physiotherapists or occupational therapists . An analysis of cost-effectiveness from a societal perspective suggested that mean quality-adjusted life years (QALYs) increased for the primary therapist model compared with the traditional physiotherapists (PT) or occupational therapists (OT) delivered in an outpatient setting; however, this difference between the treatment groups was not statistically significant . Given the high variability in the incremental cost-effective ratios in the sensitivity analyses, the authors suggested that strategies to reduce costs need to be considered before the primary therapist model could be recommended for widespread implementation in other jurisdictions. No evaluation data have been published in relation to OA or other types of arthritis.
The primary therapist model development and implementation provides a contrast to the primary care OA and stratified care for back pain models. In the former, recognising the initial primary therapist model was developed and implemented more than 30 years ago, the model has evolved as evidence has accumulated related to best practice care and effective delivery models, including changing health professional roles and processes of care delivery. Province-wide implementation occurred through a single oversight entity, The Arthritis Society, building partnerships with local communities and healthcare providers to contextualise service delivery to the community needs. This contextualisation is evident in the range of services and the variety in the programming and location of delivery (e.g. group, individual, home, clinic). Evaluation of the model in a ‘pure’ research paradigm is limited with the Society responsible for meeting criteria determined with the funder. In contrast, the primary care OA and back pain models evolved through a more traditional evidence-pipeline, with evidence first generated in the context of a randomised controlled trial. The two newer primary care models have the advantage of being developed within a growing culture of implementation research and knowledge mobilisation practice and therefore have implementation frameworks such as those of Nilsen and Briggs et al. to plan, develop, understand and evaluate the model of service delivery. Research on implementation of such models can therefore facilitate implementation activity much earlier in a research cycle.
Summary
Three models of primary care have been described in detail: an integrated model of care, stratified care model and a primary therapist model of musculoskeletal care. Models have developed different approaches to tackle best care for patients with peripheral OA, low back pain and arthritis. Whilst such models differ, they all implement frontline recommendations in primary health care. Within the spectrum of musculoskeletal conditions managed in primary care, models have been successfully tailored to different conditions: integrated care for a LTC such as OA, stratified care for non-specific LBP and multidisciplinary care for arthritis.
We have proposed a number of recommendations for implementing evidence-based innovations mapped to the context within which any implementation is proposed, e.g. governmental, policy; organisational barriers and facilitators, e.g. primary care systems and processes; and professional considerations such as roles and attitudes to change and innovation. Successful pilots can lead to wider uptake and adoption and spread at a pace and scale in high-income countries.
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Models of Care for musculoskeletal health: Moving towards meaningful implementation and evaluation across conditions and care settings
Development and implementation of Models of Care for musculoskeletal conditions in middle-income and low-income Asian countries
Models of Care for addressing chronic musculoskeletal pain and health in children and adolescents
Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture
Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work
Osteoarthritis: Models for appropriate care across the disease continuum
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