Evaluation of a Musculoskeletal Digital Assessment Routing Tool (DART): Crossover Noninferiority Randomized Pilot Trial.

BACKGROUND: Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on patients and increasing demand for health care use. Triage directing patients to appropriate level intervention improving health outcomes and efficiency has been prioritized. We developed a musculoskeletal digital assessment routing tool (DART) mobile health (mHealth) system, which requires evaluation prior to implementation. Such innovations are rarely rigorously tested in clinical trials-considered the gold standard for evaluating safety and efficacy. This pilot study is a precursor to a trial assessing DART performance with a physiotherapist-led triage assessment. OBJECTIVE: The study aims to evaluate trial design, assess procedures, and collect exploratory data to establish the feasibility of delivering an adequately powered, definitive randomized trial, assessing DART safety and efficacy in an NHS primary care setting. METHODS: A crossover, noninferiority pilot trial using an integrated knowledge translation approach within a National Health Service England primary care setting. Participants were patients seeking assessment for a musculoskeletal condition, completing a DART assessment and the history-taking element of a face-to-face physiotherapist-led triage in a randomized order. The primary outcome was agreement between DART and physiotherapist triage recommendation. Data allowed analysis of participant recruitment and retention, randomization, blinding, study burden, and potential barriers to intervention delivery. Participant satisfaction was measured using the System Usability Scale. RESULTS: Over 8 weeks, 129 patients were invited to participate. Of these, 92% (119/129) proceeded to eligibility assessment, with 60% (78/129) meeting the inclusion criteria and being randomized into each intervention arm (39/39). There were no dropouts and data were analyzed for all 78 participants. Agreement between physiotherapist and DART across all participants and all primary triage outcomes was 41% (32/78; 95% CI 22-45), intraclass correlation coefficient 0.37 (95% CI 0.16-0.55), indicating that the reliability of DART was poor to moderate. Feedback from the clinical service team led to an adjusted analysis yielding of 78% (61/78; 95% CI 47-78) and an intraclass correlation coefficient of 0.57 (95% CI 0.40-0.70). Participant satisfaction was measured quantitively using amalgamated System Usability Scale scores (n=78; mean score 84.0; 90% CI +2.94 to -2.94), equating to an "excellent" system. There were no study incidents, and the trial burden was acceptable. CONCLUSIONS: Physiotherapist-DART agreement of 78%, with no adverse triage decisions and high patient satisfaction, was sufficient to conclude DART had the potential to improve the musculoskeletal pathway. Study validity was enhanced by the recruitment of real-world patients and using an integrated knowledge translation approach. Completion of a context-specific consensus process is recommended to provide definitive definitions of safety criteria, range of appropriateness, noninferiority margin, and sample size. This pilot demonstrated an adequately powered definitive trial is feasible, which would provide evidence of DART safety and efficacy, ultimately informing potential for DART implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04904029; http://clinicaltrials.gov/ct2/show/NCT04904029. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/31541.

The Effectiveness of Digital Health Interventions in the Management of Musculoskeletal Conditions: Systematic Literature Review.

BACKGROUND: Musculoskeletal conditions are the second greatest contributor to disability worldwide and have significant individual, societal, and economic implications. Due to the growing burden of musculoskeletal disability, an integrated and strategic response is urgently required. Digital health interventions provide high-reach, low-cost, readily accessible, and scalable interventions for large patient populations that address time and resource constraints. OBJECTIVE: This review aimed to investigate if digital health interventions are effective in reducing pain and functional disability in patients with musculoskeletal conditions. METHODS: A systematic review was undertaken to address the research objective. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews before commencement of the study. The following databases were searched: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Cumulative Index to Nursing and Allied Health Literature, and Scopus from January 1, 2000, to November 15, 2019, using search terms and database specific-medical subject headings terms in various combinations appropriate to the research objective. RESULTS: A total of 19 English language studies were eligible for inclusion. Of the 19 studies that assessed musculoskeletal pain, 9 reported statistically significant reductions following digital intervention. In all, 16 studies investigated functional disability; 10 studies showed a statistically significant improvement. Significant improvements were also found in a range of additional outcomes. Due to the heterogeneity of the results, a meta-analysis was not feasible. CONCLUSIONS: This review has demonstrated that digital health interventions have some clinical benefits in the management of musculoskeletal conditions for pain and functional disability. Digital health interventions have the potential to contribute positively toward reducing the multifaceted burden of musculoskeletal conditions to the individual, economy, and society. TRIAL REGISTRATION: PROSPERO CRD42018093343; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=93343.

Quality improvement in physiotherapy services.

Purpose The purpose of this paper is to evaluate a process change in physiotherapy services and to explore factors that may have influenced the outcomes. Design/methodology/approach This is a multiple case study and information was gathered from eight physiotherapy teams over 24 months. Findings The process change was successfully implemented in six teams. It had a clear, positive effect on service quality provided to patients in three teams. Whilst quality also improved in three other teams, other issues make changes difficult to assess. Factors that enabled process change to be effective are suggested. Research limitations/implications The findings are based on results achieved by only eight English teams. Practical implications This process change may be appropriate for other teams providing therapy services if attention is paid to potential enabling factors, and a learning approach is adopted to designing and introducing the change. Originality/value To the best of the authors' knowledge, no other longitudinal process change study in therapy services has been published.

A questionnaire to identify patellofemoral pain in the community: an exploration of measurement properties.

BACKGROUND: Community-based studies of patellofemoral pain (PFP) need a questionnaire tool that discriminates between those with and those without the condition. To overcome these issues, we have designed a self-report questionnaire which aims to identify people with PFP in the community. STUDY DESIGNS: comparative study and cross-sectional study. STUDY POPULATION: comparative study: PFP patients, soft-tissue injury patients and adults without knee problems. Cross-sectional study: adults attending a science festival. INTERVENTION: comparative study participants completed the questionnaire at baseline and two weeks later. Cross-sectional study participants completed the questionnaire once. The optimal scoring system and threshold was explored using receiver operating characteristic curves, test-retest reliability using Cohen's kappa and measurement error using Bland-Altman plots and standard error of measurement. Known-group validity was explored by comparing PFP prevalence between genders and age groups. RESULTS: Eighty-four participants were recruited to the comparative study. The receiver operating characteristic curves suggested limiting the questionnaire to the clinical features and knee pain map sections (AUC 0.97 95 % CI 0.94 to 1.00). This combination had high sensitivity and specificity (over 90 %). Measurement error was less than the mean difference between the groups. Test-retest reliability estimates suggest good agreement (N = 51, k = 0.74, 95 % CI 0.52-0.91). The cross-sectional study (N = 110) showed expected differences between genders and age groups but these were not statistically significant. CONCLUSION: A shortened version of the questionnaire, based on clinical features and a knee pain map, has good measurement properties. Further work is needed to validate the questionnaire in community samples.

Evaluation of a primary care musculoskeletal clinical assessment service: a preliminary study.

OBJECTIVES: To evaluate the clinical effectiveness of a primary care musculoskeletal clinical assessment service (MCAS). The MCAS is a triage and treatment service for the management of patients with musculoskeletal conditions. DESIGN: Prospective observational cohort study. PARTICIPANTS: Consecutive patients with musculoskeletal disorders referred to the MCAS from primary care over a 6-month period. INTERVENTIONS: Patients were managed within the service in accordance with usual MCAS management/treatment pathways. MAIN OUTCOME MEASURES: Previously validated self-administered questionnaires were selected as outcome measures in order to facilitate the use of postal responses. These comprised two generic health status questionnaires (Short Form 36, EuroQol EQ-5D), a pain assessment using a visual analogue scale and two measures of patient satisfaction (Perceived Improvement Evaluation, Deyo and Diehl satisfaction questionnaire). Outcome measures were taken at baseline, and 3 and 12 months after recruitment. RESULTS: In total, 217 patients were recruited into the study. Significant improvement was demonstrated with EuroQol at 3 and 12 months (P=0.043 and 0.035, respectively) and the pain visual analogue scale at 3 and 12 months (P=0.001 and 0.002, respectively). No significant differences were demonstrated with Short Form 36 (P=0.73 and 0.87). The mean patient-perceived improvement was 33% at 3 months and 46% at 12 months. Results showed high levels of patient satisfaction, with 72% of patients indicating total satisfaction with all aspects of the MCAS. CONCLUSIONS: Nationally, models similar to the MCAS have been developed to help improve care for patients and achieve the 18-week access target. This preliminary study shows the possible benefits of adopting this model of care, and identifies the need for further research.

Expectations and satisfaction of patients with low back pain attending a multidisciplinary rehabilitation service.

BACKGROUND AND PURPOSE: To identify the expectations of service, and degree of satisfaction, with a multidisciplinary service for patients with low back pain, and to examine the strength of association between patients' satisfaction and expectations. METHOD: A three-stage study design was used. concerns were identified by a focus group; priority issues were identified by ranking by use of a Delphi consensus questionnaire; satisfaction or expectation questionnaires were also used to rate patients' satisfaction and the degree to which expectations were met. SUBJECTS: Three convenience samples of patients with low back pain were recruited. Ten patients attended the focus group, 55 completed the Delphi consensus questionnaire and 40 completed the satisfaction or expectation questionnaires. RESULTS: Patients rated a clear diagnosis and effective treatment as important, and the ease with which they could access the service and post-discharge follow-up as important issues when judging satisfaction. Patients rated their overall satisfaction and meeting their expectations higher than specific service issues, and the strengths of the associations between the two constructs varied from concern to concern. CONCLUSION: Certain aspects of service provision are rated with greater importance than others when patients judge a service they have experienced. There are differences in the strength of associations between the constructs of patient satisfaction and meeting expectations of service, specific to the individual service concern that is being evaluated. The present study provides more evidence that specific concerns within service provision should be identified before evaluating patients' expectations and satisfaction with the service overall.