Developing a theory-informed intervention using primary care clinicians' perceptions of stratified care for musculoskeletal conditions

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The problem

Musculoskeletal conditions represent a considerable burden both for patients and primary care, and current usual care follows a stepped care model. Stratified primary care involves the use of a screening tool to identify patients' risk of persistent disabling pain and matching patient subgroups to appropriate early treatment options to maximise treatment benefit and increase healthcare efficiency.Building on a successful model of stratified care for low back pain, the STarT-Musc programme is developing a new model for patients with the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain). The aim of this study was to investigate the perceptions of primary care clinicians about the acceptability of stratified care and the anticipated barriers and facilitators to its future use in clinical practice, in order to inform subsequent stages of the intervention.

The approach

Four focus groups and six semi-structured telephone interviews were conducted with GPs recruited from practices participating the STarT-Musc research programme and from clinical networks (n=23 participants), and one focus group with community physiotherapists from clinical networks (n=5 participants). Data were analysed using the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. The analysis extended beyond much of the previous research using the TDF by exploring the interrelated nature of domains and how these manifested in the data, allowing for a more in-depth, nuanced examination of the emerging themes.


Analysis of identified themes highlighted relationships between different TDF domains. Though variation was present across the dataset, barriers identified included perceptions that stratified care would not significantly add to clinicians' existing knowledge and skills , and that the screening tool could disrupt the flow of the consultation (environmental context ). This anticipated disruption led to concerns about restricted clinical autonomy (identity and professional role ). However, factors such as easy access to patient advice literature and the potential for stratified care to give clinicians greater confidence in treatment decisions (reinforcement ) were highlighted as facilitators to adoption, leading to greater optimism about the approach.


This qualitative study will inform further stages of our research programme, particularly the format of the intervention and the contents and methods of our clinician support packages for GPs participating in the STarT-Musc cluster randomised trial. Based on the findings, support packages will educate GPs about the potential benefits of stratified care vis-à-vis stepped care, presenting evidence of our previous research on stratified care in back pain and evidence regarding similar prognostic factors across pain sites. We will demonstrate to GPs how stratified care can be effectively integrated into the consultation with minimal disruption. These findings also have theoretical implications in the way in which the TDF has been applied, demonstrating how relationships between domains can be explored.


  • Ben Saunders
  • Bernadette Bartlam
  • Nadine Foster
  • Joanne Protheroe