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Improving the management of musculoskeletal conditions: can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study
  1. Victoria Tzortziou Brown1,
  2. Martin Underwood2,3,
  3. Olwyn M Westwood4,
  4. Dylan Morrissey1
  1. 1 Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  2. 2 Warwick Medical School, Warwick University, Coventry, UK
  3. 3 University Hospitals of Coventry and Warwickshire, Coventry, UK
  4. 4 CHLS Central Office, Brunel University London, London, Uxbridge, United Kingdom
  1. Correspondence to Dr Victoria Tzortziou Brown; v.tzortzioubrown{at}


Objectives To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice.

Design Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series.

Setting and participants 36 general practices in East London.

Intervention Informed by the results of a Cochrane review on educational interventions to improve general practitioners’ (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review.

Main outcome measures Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention.

Results Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%).

Conclusions A quality improvement-based approach to referral management which values GPs’ professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.

  • health policy
  • primary care
  • musculoskeletal disorders
  • quality In health care
  • clinical audit

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  • Patient consent for publication Not required.

  • Contributors All authors (VTB, MU, OMW and DM) designed the evaluation of the intervention. VTB led on the implementation, designed data collection tools, monitored data collection, wrote the statistical analysis plan, cleaned and analysed the data and drafted and revised the paper. She is guarantor. All remaining authors (MU, OMW and DM) contributed to the development of core ideas, the analysis plan, interpretation of the results and the drafting of the paper. NHS Tower Hamlets Clinical Commissioning Group (CCG) implemented and funded the intervention as part of the local network improvement scheme. The clinical pathways were developed in collaboration with the Clinical Academic Group (CEG), Centre of Primary Care and Public Health, Barts and The London School of Medicine and Dentistry.

  • Funding This work was supported by Arthritis Research UK (grant number 18678). Two of the authors are part-funded by the National Institute for Health Research (NIHR) (grant numbers GPPH1C6R and CATSCL-2013-04-003).

  • Competing interests All authors have completed the ICMJE uniform disclosure form at Arthritis Research UK has funded the submitted work. Dr Tzortziou Brown is part funded by the National Institute for Health Research (NIHR) (grant number GPPH1C6R). ProfessorUnderwood was chair of the NICE accreditation advisory committee until March2017 for which he received a fee. He is chief investigator or coinvestigator onmultiple previous and current research grants from the UK National Institutefor Health Research, Arthritis Research UK and is a coinvestigator on grantsfunded by the Australian NHMRC. He has received travel expenses for speaking atconferences from the professional organisations hosting the conferences. He isa director and shareholder of Clinvivo that provides electronic data collectionfor health services research. He is part of an academic partnership with Sercorelated to return to work initiatives. He is a coinvestigator on a studyreceiving support in kind from Orthospace. He is an editor of the NIHR journalseries for which he receives a fee. Professor Morrissey is part funded by the NIHR/HEE Senior Clinical Lecturer scheme (CAT SCL-2013-04-003). Professor Westwood declared no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years. All authors declared no other relationships or activities that could appear to have influenced the submitted work.

  • Ethics approval The National Research Ethics Service (NRES) was contacted and confirmed in writing that ethical approval for the project was not required from the NHS research ethics committee (REC). Additionally, the Joint Research & Development office at Barts and The London was contacted and confirmed the same. Ethical approval was therefore granted by QMUL and permission to use the relevant data was also granted by the Governance Team of NHS North East London and The City.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The investigators will share data used in developing the results presented in this manuscript on request to the corresponding author.

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