A new pilot trial led by Keele University to help GPs decide which treatment to offer patients with common aches and pains has shown promising initial findings to help reduce painkiller prescriptions and the use of x-rays.

The trial investigated if using stratified care – the matching of patients to specific treatments – was feasible and acceptable to GPs as an alternative to conventional care. This involved a tailored approach to manage musculoskeletal (MSK) pain that challenges the existing one-size-fits-all care recommended in current NHS guidelines, which leaves as many as 80% of people still reporting pain or disability a year after consulting their GP.

In the UK, common musculoskeletal problems such as back, shoulder, and knee pain account for 14% of GP appointments, and global estimates suggest that they are the leading cause of disability worldwide. In addition, consultation rates in the UK are increasing, with doctor appointments for musculoskeletal pain increasing by 19% over a five-year period (from 310 to 370 million).

The research, funded by the National Institute for Health Research (NIHR) and published in the journal BioMed Central (BMC) Family Practice, was led by a team in Keele University’s School of Primary, Community and Social Care.

The pilot trial, called “STarT MSK”, investigated the feasibility of GPs delivering a stratified care approach during routine patient consultations and led to a 20% reduction in opioid prescriptions over six months in the four intervention GP practices compared to the four control GP practices. The approach included a short 10-item questionnaire to classify individuals into one of three groups (low, medium or high-risk of persistent pain and disability) followed by matching the patient to a recommended treatment option.

GPs were given specific training to use new software in their existing computer systems to guide them towards recommended treatments options for each patient risk group, and the system also provided them with individual monthly feedback on their decisions in comparison with colleagues.

The trial is part of a six-year programme of research led by NIHR Professor Nadine Foster. The investigators recruited 524 adults with back, neck, knee, shoulder or multi-site pain from eight GP practices within the West Midlands region. The study used questionnaires to measure patient outcomes over six months as well as reviewing GP medical records to assess if the new approach changed GP decision-making, such as painkillers prescribed, treatments selected and referrals made. They also interviewed patients and GPs to explore whether they found the new approach useful and acceptable.

The results found that the new approach was acceptable to GPs and patients, GPs used the short questionnaire with many of their patients and selected one of the recommended treatment options in 85% of cases. The new approach also led to positive changes in clinical decision-making, such as greater provision of high quality written educational information for patients, more referrals to services like physiotherapy for patients at risk of poor outcome, fewer prescriptions for strong painkillers known as opioids and fewer x-rays.

NIHR Professor Foster said: “This large pilot randomised trial highlights that this new way of working, known as stratified care, can be used by GPs and patients, and they find it acceptable. The changes we have observed in clinical decision-making after using the STarT MSK tool mean that care is more evidence-based. A future main trial with many more patients is now ongoing.”

Dr Jonathan Hill, physiotherapist and senior lecturer from Keele University, said: “Although trials have reported the benefits of a wide range of treatments such as patient information, encouraging physical activity, and return to work programmes, there remains a lack of evidence about which patients are likely to benefit from which interventions, partly accounting for the wide variation in clinical practice for these patients.

“As it is impractical and unnecessary to offer everyone further treatments after seeing a GP, it is an international priority to find better ways to identify which patients to avoid over-medicalising and which to identify for more intensive and targeted care.”

Following the success of the pilot trial, and with positive feedback from GPs and patients, the team from Keele University has refined the new approach and is now carrying out a definitive trial with 1,200 patients and 24 GP practices, with the results expected in summer 2020.

Source: Keele University