Birkinshaw, Hollie (2021) Investigating the use of stratified primary care for older adults with musculoskeletal pain: a mixed methods study. Doctoral thesis, Keele University.

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Musculoskeletal pain is common in older adults (aged ≥65), but current assessment and management in primary care is suboptimal. Prognostic stratified care matches treatment options to patients based upon their risk of persistent pain six months postconsultation. The aim of this thesis was to investigate the use of stratified care in the management of musculoskeletal pain for older adults.

This thesis was nested within the STarT MSK trial. A sequential mixed methods design (quantitative followed by qualitative) was employed following a review of the literature. Firstly, secondary data analysis was undertaken to investigate differences in older adults’ clinical profiles and the discriminant and predictive validity of the STarT MSK Tool by age. Secondly, 21 interviews with 16 older adults and focus groups with a total of 14 GPs and two physiotherapists were conducted to explore complexity, the elements of a good consultation, and treatment options.

Quantitative analysis found no significant differences between older (≥65) and younger (<65) adults in pain intensity; however older adults reported significantly better mental health, worse physical function, and a higher average number of comorbidities. For older adults, the STarT MSK Tool had poor to acceptable predictive validity when used at point of consultation. Qualitative analysis identified three themes: negotiation, reassurance and age-specific clinician concerns. Integration of stratified care into primary care consultations was acceptable; there were no reports of significant disruption. Dissonance between clinicians’ and older adults’ perspectives were identified regarding mental health, treatment options and acceptance of musculoskeletal pain, requiring negotiation to resolve. Affective and clinical reassurance can facilitate these negotiations for satisfactory outcomes. Clinicians also voiced concerns about managing older adults’ comorbidities, polypharmacy, social situation within the constraints of stratified care and the current health system; notably, the lack of social and community focused treatment options.

Stratified care is acceptable and useful for both patients and clinicians for older adults with musculoskeletal pain. It is important that consultations utilising stratified care maximise non-clinical aspects such as communication, reassurance, shared decisionmaking and empathy, especially where there are clinical complexities to be addressed. It is essential that the discriminant and predictive validity of the STarT MSK Tool is investigated further, to ensure high validity across all age categories. Additionally, incorporation and strengthening of social prescribing treatment options for older people is essential.

Item Type: Thesis (Doctoral)
Subjects: R Medicine > RC Internal medicine > RC925 Diseases of the musculoskeletal system
Divisions: Faculty of Medicine and Health Sciences > School of Primary, Community and Social Care
Contributors: Hill, JC (Thesis advisor)
Bartlam, B (Thesis advisor)
Depositing User: Lisa Bailey
Date Deposited: 10 Jun 2021 16:04
Last Modified: 24 Jun 2021 12:08

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