Shared decision-making around analgesia for musculoskeletal pain in primary care consultations

Abstract

Background
Musculoskeletal (MSK) pain is a major health problem worldwide and in UK primary care. Shared decision-making (SDM) is a process advocated by UK policy directives whereby a general practitioner (GP) and patient share information and the patient is supported to consider options. How decisions around analgesia for MSK pain are shared in primary care consultations is poorly understood.

Methods
A systematic review and narrative synthesis explored factors affecting the process of SDM in prescribing analgesia for MSK pain in primary care consultations. Secondary analysis of a dataset selected from 195 digital video-recorded primary care consultations explored how decisions around analgesia for MSK pain were negotiated, how far the decisionmaking process was shared and how factors affected the process of SDM. 48 recorded consultations with 15 UK GPs discussing analgesia for MSK pain with patients were analysed. Framework analysis drew on principles of discourse analysis and integrated findings of the systematic review, a model of SDM and input from a patient research user group (RUG). The patient RUG collaborated throughout the research.

Results
The review identified 15 possible factors affecting SDM in eight studies. The patient RUG identified an additional 30 factors absent in the literature which were important to patients. SDM involved multiple decisions, and was negotiated in three phases and through implicit and overt communication. Eight factors identified as affecting SDM in consultations included: patient-GP relationship, time spent discussing the MSK condition and the patient’s health literacy. A spectrum of SDM was characterised into three different styles of SDM: Elwyn’s model, stepwise and GP SDM.

Conclusions
Negotiation of SDM around analgesia for MSK pain in primary care consultations is a complex and implicit process, occurring along a spectrum of SDM. Current models and measures need to be tailored to facilitate integration of SDM into clinical practice.