Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial

Stratified health care for low back pain using the STarT Back approach: holy grail or doomed to fail?

ABSTRACT

There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes.

Patient acceptance of care of a novel care pathway for those at risk of poor outcomes from musculoskeletal pain: A mixed methods study

OBJECTIVE

Investigate people's acceptance of specialist musculoskeletal care within a new care pathway for common musculoskeletal conditions (low back pain, neck pain/whiplash, knee osteoarthritis).

DESIGN

Convergent parallel mixed methods design referencing the Theoretical Framework of Acceptability. The study included a subset of participants (n = 29) at-risk of poor outcomes from the intervention arm of the PAthway of CarE for common musculoskeletal conditions (PACE-MSK) trial. In the PACE-MSK arm, participants received specialist physiotherapist care as an adjunct to the care provided by their primary healthcare professional(s). One-to-one semi-structured interviews were conducted around 3-months after commencing in the trial. Quantitative data were collected at baseline and 3-month follow-up (health-related quality of life, pain self-efficacy, global perceived change, satisfaction).

RESULTS

Five themes were identified (Expectations and beliefs shaped patient experience; Clinical expertise and competence influence acceptance; Person-centred care; Mechanisms facilitating beneficial responses to care; Gaps in care pathway implementation). There were positive individual changes in physical quality of life for 17/29 (59%) participants, mental health quality of life for 12/29 (41%), pain self-efficacy for 8/29 (28%) and global perceived change for 19/29 (66%). Management met expectations with the majority reporting high levels of satisfaction. Integrating the qualitative and quantitative data with the Theoretical Framework of Acceptability, there were complementary meta-inferences in the constructs of 'ethicality', 'intervention coherence', 'self-efficacy' and 'affective attitude'. Divergence was identified in 'perceived effectiveness'.

DISCUSSION

In general, there was positive acceptance of the care pathway by participants. Specialist physiotherapists' care was perceived as a positive addition to usual care.