Patients’ and clinicians’ perspectives on a ‘fast-track’ pathway for patients with sciatica in primary care: qualitative findings from the SCOPiC stratified care trial

Abstract

Background: Sciatica is common and associated with significant impacts for the individual and society. The SCOPiC randomised controlled trial (RCT) (trial registration: ISRCTN75449581) tested stratified primary care for sciatica by subgrouping patients into one of three groups based on prognostic and clinical indicators. Patients in one group were 'fast-tracked' for a magnetic resonance imaging (MRI) scan and spinal specialist opinion. This paper reports qualitative research exploring patients' and clinicians' perspectives on the acceptability of this 'fast-track' pathway. Methods: Semi-structured interviews were conducted with 20 patients and 20 clinicians (general practitioners, spinal specialist physiotherapists, spinal surgeons). Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and 'boundary objects' concept. Results: Whilst the 'fast-track' pathway achieved a degree of 'coherence' (i.e. made sense) to both patients and clinicians, particularly in relation to providing early reassurance based on MRI scan findings, it was less 'meaningful' to some clinicians for managing patients with acute symptoms, reflecting a reluctance to move away from the usual 'stepped care' approach. Both groups felt a key limitation of the pathway was that it did not shorten patient waiting times between their spinal specialist consultation and further treatments. Conclusion: Findings contribute new knowledge about patients' and clinicians' perspectives on the role of imaging and spinal specialist opinion in the management of sciatica, and provide important insights for understanding the 'fast-track' pathway, as part of the stratified care model tested in the RCT. Future research into the early referral of patients with sciatica for investigation and specialist opinion should include strategies to support clinician behaviour change; as well as take into account the role of imaging in providing reassurance to patients with severe symptoms in cases where imaging reveals a clear explanation for the patient's pain, and where this is accompanied by a thorough explanation from a trusted clinical expert.

The Impact of Reassurance on Musculoskeletal (MSK) Pain: A Qualitative Review

“…A total of 993 studies were identified through database searching, of which 23 studies were [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ] included for qualitative synthesis, with a total of 451 patients (271 were female, 180 male). See Supplementary Material File S1 Table S1 for details of the excluded articles and the demographics for the included studies and Supplementary Material File S1 Table S2 for detailed data extraction tables.…”

“…The number of other allied health care professionals could not be obtained from the manuscripts. A total of 8 studies [ 23 , 24 , 25 , 26 , 30 , 32 , 34 , 35 ] focused on physician encounters. A total of seven studies focused on physiotherapist interactions within interventions [ 27 , 31 , 37 , 39 , 44 , 45 ].…”

Integrating clinician support with intervention design as part of a programme testing stratified care for musculoskeletal pain in general practice

“…There is a wealth of literature on the development of theory-informed interventions that aim to change clinician behaviour, with varying results (see, for instance: [24][25][26][27]). Much of this literature focuses on development of behaviour change interventions themselves, and on evaluating clinicians' and patients' uptake and engagement [28][29][30]; and this research has highlighted some similar challenges to those identified here, including the practical and time issues involved in engaging clinicians, and the challenge of achieving clinician 'buy in' . There has been a lack of focus in the literature, however, on specifically developing the clinician support to enable successful delivery of interventions in RCTs, as reported here, which we argue is a crucial element of intervention development that is often overlooked.…”

Clinical pathways for the management of low back pain from primary to specialised care: a systematic review

“…Following removal of duplicates and application of inclusion/exclusion criteria, 27 full text published papers and one service evaluation report were included in the final analysis. Three publications related to the same research study [16][17][18], including a Health Technology Assessment (HTA) report [16], RCT [17] and a qualitative study [18].…”