PRISM: The PRimary Care Individual Social Norms MSK Data Dashboard: a Cluster Randomised Feasibility Trial in Clinician Management of Musculoskeletal Patients.
Trial Snapshot
- Phase
- Not Applicable
- Status
- Recruiting
- Sponsor
- University College, London
- Enrollment
- 60
- Locations
- 2
- Primary Endpoint
- Feasibility - Number of Participants recruited to the study
Study Overview
Brief Summary
Background:
20 million people in UK have musculoskeletal (MSK) aches and pains. They commonly see their GP about this problem, but practices are so busy that it can mean a long wait for appointments. First Contact Practitioner (FCPs) are now working in the GP practices to see patients with MSK problems instead of their GP. A national evaluation has found this to be working well.
For FCPs working in GP practices there is more clinical risk. The patients have not been previously screened by a doctor to ensure there is no medical cause for their pain. The Chartered Society of Physiotherapists (CSP) has advised that all FCPs be clinicians with the highest level of experience, known as Advanced Practitioners. However the demand for FCPs far outweighs the number of Advanced Practitioners available so physiotherapists being hired have less experience.
Evidence shows that clinicians of different experience levels have different decision-making strategies which may cause unwarranted variation in care. A new method is needed for oversight and support of the FCPs. Clinical supervision is commonly utilised in the NHS and in physiotherapy teams. It is a space to reflect on a clinician's performance and create learning opportunities.
This research suggests an individual data dashboard, shared only with individuals and their supervisor, that feeds back a clinician's own decision-making data to them, relative to their peers. For example, the participant is "in the top 20% of MRI requesters" or "in the top 20% of those referring to social prescribing". This type of feedback is known as 'social norms' feedback. It has been proven to be an effective way to change healthcare workers behaviour. The intervention will be called PRISM: Primary Care Individual Social Norms MSK Data Dashboard.
Aims To explore the feasibility of a randomised clinical trial comparing the clinical decision-making behaviour of FCP services using the PRISM Dashboard and a usual service with no clinician feedback.
Design & Methods:
This research is a feasibility trial, a process to assess whether a future full scale clinical trial within the NHS would work. It will take place across 4 different Primary Care commissioning areas to determine the possibility of recruitment, retention, outcome collection and whether people will use the intervention.
PPIE for this research included one primary care PPI rep, one digital interventions PPI rep and 3 Healthwatch PPI reps. Engaging different PPI sources enabled participation from different social , cultural and ethnic backgrounds.
Dissemination I will communicate research updates and outputs in conferences, via social media, blogs, newsletters and podcasts. I will use my own network as well as the reach of collaborators in this work, ie. Healthwatch, NHS England/Improvement, The (CSP), the physiotherapy digital network, Keele University and UCL research networks.
Detailed Description
SUMMARY BACKGROUND AND RATIONALE
Over 20 million people in the UK live with a musculoskeletal (MSK) condition; accounting and one in three GP consultations . The Fuller Stocktake Report from NHS England described services as "stretched beyond capacity" with "signs of genuine and growing discontent" . The NHS, in keeping with the international trend to include non GP clinicians in the Primary Care workforce) have incorporated pharmacists, physiotherapists, practice nurses and physician associates within the primary care workforce to address the challenges of capacity and demand.
In the UK, patients with MSK problems consult a First Contact Practitioner (FCP) based in primary care instead of their GP, improving patient access to MSK management and freeing GP capacity . FCPs service in the UK, Sweden and Canada were found to be acceptable and effective in national evaluations .
The Chartered Society of Physiotherapy (CSP) and Health Education England (HEE) called for FCPs to be 'Advanced Practitioners' , a certification conferred officially on those with particular expertise. This was deemed necessary to meet the level of risk associated with having a clinical case load of patients who have not been screened by a doctor. However the pool of APs is limited and less experienced FCPs have been recruited into these posts.
FCPs in GP practices, work alone and lack the peer support of a typical physiotherapy department. Unfortunately, data suggests that less experienced FCPs are less likely to provide evidence-based MSK care. Clinical audits of FCP decision-making in over 2000 patients, from the Midlands and London, shows distinct differences in decision-making where Band 7 FCPs were almost twice as likely as Band 8 colleagues to send the patient to the GP for a second opinion, they underutilised 'social prescribing' and 'shared decision-making tools' and ordered more MRIs than their more experienced colleagues. The appropriate use of skills such as imaging requests and onward referrals should be utilised with consistency and in step with evidence-based guidance.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Treatment
- Masking
- Single (Outcomes Assessor)
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Inclusion and
Exclusion Criteria
- •for Sites and Individual FCPs Site Inclusion Criteria
- •FCPs (First Contact Physiotherapists) must have regular clinical supervision by a more experienced physiotherapist.
- •Health Care Professionals Council (HCPC) registered Physiotherapists.
- •Provide physiotherapy to NHS patients.
- •Able to send monthly data uploads to the UCL Data Safe Haven to be added to the PRISM dashboard.
- •Patient Inclusion Criteria
- •18 years of age and above.
- •Registered with a GP practice that is a Participant Identification Centre for this study.
- •Consented to provide outcome measures as part of the trial process.
- •Site Exclusion Criteria
- •No clinical supervision by a more experienced physiotherapist available currently or in practice for the FCPs.
- •Community service physiotherapy.
- •Unable to send data to the UCL Data Safe Haven monthly.
- •Patient Exclusion Criteria
- •Non-musculoskeletal (MSK) problem.
- •Insufficient level of English understanding and expression to allow independent completion of assessment instruments.
- •Lacking capacity or unwilling to consent.
- •Patients who attended FCP but were not treated as they were found to have been an inappropriate referral.
Arms & Interventions
usual care group
This group will receive usual care and the clinicians will receive no information about their performance.
Intervention: THe usual care intervention is a first contact physiotherapy service. (Other)
PRISM Intervention Group
This group will receive the PRISM dashboard on a monthly basis to be discussed in clinical supervision. It will show them where their clinical behaviours sits relative to their patients. The control will be treatment as usual.
Intervention: PRISM dashboard is a data report (Behavioral)
Outcomes
Primary Outcomes
Feasibility - Number of Participants recruited to the study
Time Frame: Baseline
The investigators are measuring recruitment so that we can understand the probability that we could recruit to a future trial.
Secondary Outcomes
- Feasibility - Number of Participants retained to the study at 3 and 6 months(3 and 6 months)
- Number of outcomes collected as a measure of feasibility(0,3 (patients)and 0,3 and 6 months (FCPs))
- Completeness of outcomes as a % per outcome(0,3 (patients)and 0,3 and 6 months (FCPs))
- Feasibility of recording the number of clinical supervision sessions that utilise the PRISM dashboard as recorded in a supervision log(monthly for 6 months)
- Clinical Supervision Log(monthly for 6 months)
- Feasibility of participants engaging with the dashboard intervention in a future trial(monthly for 6 months)
- Feasibility - Means of collecting data per participant.(monthly for 6 months)
- Manchester Clinical Supervision Scale (MCSS)(0 3 and 6 months)
- Clinical Activity data(monthly for 6 months)
- EQ5D5L(0,3 months (EQ5D))
- Cost per Intervention(6 months only)
- MSK HQ(0,3 months)
- Social Norms(monthly for 6 months)
- Carbon analysis(6 months)