medwireNews: Risk stratification in the primary care setting may not lead to significant improvements in pain or function for people with musculoskeletal disorders, but may have benefits for clinical decision-making, the UK-based STarT MSK trial shows.
Patients from 24 practices presenting with common musculoskeletal disorders (back, neck, knee, shoulder, and multi-site pain) had similar time-averaged pain intensity over 6 months irrespective of whether they were allocated to primary care practices supported to deliver risk-based stratified care or usual care.
The 515 patients who were stratified as being at low, medium, or high risk for disability or increased pain outcomes based on a bespoke computer-based template, including the STarT (musculoskeletal) MSK tool, and had their treatment recommended accordingly from a total of 15 options had a pain intensity score of 4.4 points out of a possible 10 points, which was not significantly different to the 4.6 points among 663 patients who received usual care.
There was also no significant difference between the two groups for standardized function scores.
“The findings of this trial contrast with our previous successful stratified care trial in patients with low back pain in the UK,” note Jonathan Hill (Keele University, UK) and colleagues in The Lancet Rheumatology.
One possible explanation for the inconclusive outcome of the current study was that the stratification tool was completed in less than 30% of consultations, which the team reports was primarily due to “the current time-pressured context of UK primary care and GPs [general practitioners] feeling the stratification tool added time to the consultation.”
Another reason cited by commentators Fiona Stanaway and Katy Bell, both from the University of Sydney in New South Wales, Australia, was the “very restricted evidence base for the risk-matched treatment pathways.”
They continue: “Even if we assume that the risk-based treatments were at least somewhat effective, as these were not always implemented, potential benefits were unable to be realized.”
For example, among those identified as high risk by the STarT MSK tool, just 75% were given a recommended risk-matched treatment option, Stanaway and Bell point out.
“A reason for this could be the unavailability of particular treatment options in the UK National Health Service,” they note.
Hill and co-researchers therefore believe that “the key challenge for future trials of risk-based stratified care among patients with musculoskeletal pain is, first, to find more feasible methods to stratify patients in short consultations, and, second, to provide more effective treatments for those at increased risk.”
They add: “Without overcoming these challenges, trials risk becoming a test of stratified care implementation rather than effectiveness.”
The researchers did find, however, that patients’ satisfaction was greater with risk-stratification and there was some benefit on clinical decision-making, with “greater provision of written information and prescribing of simple over-the-counter analgesics.” Also, qualitative findings showed “positive GP feedback, suggesting the approach improved their consideration of psychosocial factors and decision making, and helped with negotiations around patient expectations, such as unwarranted imaging,” they add.
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Lancet Rheumatol 2022; doi:10.1016/S2665-9913(22)00159-X
Lancet Rheumatol 2022; doi:10.1016/S2665-9913(22)00187-4