Background & Aims
Musculoskeletal (MSK) conditions impose a substantial burden on Australian primary care. To address this challenge, a new PAthway of CarE (PACE) has been proposed. This pathway involves referring individuals with MSK conditions at risk of poor outcome to specialist physiotherapists (SPs), who then collaborate with primary healthcare practitioners (PHCPs). However, it is unclear whether the involvement of SPs will influence the way in which PHCPs practice or whether PHCPs and SPs will effectively integrate the new pathway of care into their practice. The primary aim of this study was to compare the care received by patients in the PACE to usual care. The secondary aim was to assess adoption of PACE by both PHCPs and SPs.
Methods
This study employed a mixed-method approach within a randomised controlled trial. PHCPs (n=146) were invited to participate if patients in the PACE trial nominated them as their PHCP. SPs (n=50) who were Fellows of the Australian College of Physiotherapy were invited. During the study, the PHCPs provided care for 164 patients and the SPs provided care for 150 patients. Patients had been risk-stratified using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire and randomised to usual care or PACE. In the usual care group, no effort was made to alter care. In the PACE group, patients at risk were referred to a SP who collaboratively determined the pathway of care. Health professional practice outcomes (e.g., referred for imaging, referrals, use of a risk screening tool, care pathway recommended) were evaluated via a questionnaire completed at three months. Differences between groups and qualitative data were analysed.
Results
PHCPs in the PACE group referred fewer patients for imaging and to medical/surgical specialists compared to PHCPs in the usual care group. Patients seen by SPs in the PACE group were referred less frequently for imaging and less to medical/surgical specialists than patients at risk seen by PHCPs in the usual care group. The qualitative findings suggested PHCPs in the usual care group frequently ordered imaging for pathoanatomical analysis and referred to medical/surgical specialists for second opinions. SPs’ referred for worsening symptoms and outlined specific diagnoses to rule in/out. The majority of PHCPs (92%), irrespective of group, were not utilising risk screening tools to assess a person’s risk of poor outcome. Less than 50% of SPs collaborated with PHCPs about their shared patients. 64.7% of SPs chose the specialist-led care pathway over the shared care pathway. SPs reported choosing a specialist-led care pathway due to practitioner, patient or system factors.
Conclusions
The implementation of the new clinical pathway of care (PACE) enhanced guideline-based care, particularly in managing patients at high-risk of poor outcome, compared to usual care. In the PACE group, PHCPs showed a significant reduction in ordering imaging and a decrease in medical and surgical referrals. This positive outcome could be attributed to the engagement of specialist physiotherapists in managing patients at high risk. However, there is room for improvement in the adoption of the PACE model by PHCPs, as indicated by infrequent use of risk screening tools. Further, greater collaboration between SPs and PHCPs could promote the use of a shared care pathway instead of relying on a specialist-led care pathway.
References
Ritchie C, Jull G et al: Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial). BMJ Open 2021, 11(12):e057705.
2.Kang K, Evans K, Simic M, Ferreira P, Bandong AN, Coates S, Beales D, Rebbeck T: Impact of an interactive workshop on specialist physiotherapists’ practice when implementing a new clinical care pathway for people with musculoskeletal conditions. Musculoskeletal science & practice 2022, 57:102466.
3.Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf FM, Davis D, Odgaard?Jensen J, Oxman AD: Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009(2).
4.Castro HM, Ferreira JC: Linear and logistic regression models: when to use and how to interpret them? J Bras Pneumol 2023, 48(6):e20220439.
5.Braun V, Clarke V: Using thematic analysis in psychology. Qualitative Research in Psychology 2006, 3:77-101.
Presenting Author
Kwangil Kang
Poster Authors
Kwangil Kang
Doctor of Philosophy
The University of Sydney
Lead Author
Topics
- Other