Protheroe Joanne, Saunders Benjamin, Hill Jonathan C, Chudyk Adrian, Foster Nadine E, Bartlam Bernadette, Wathall Simon, Cooper Vincent
Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK.
STARS Research and Education Alliance, Surgical Treatment and Rehabilitation Service, The University of Queensland and Metro North Hospital and Health Service, Brisbane, QLD, Australia.
BMC Fam Pract. 2021 Jul 26;22(1):161. doi: 10.1186/s12875-021-01507-8.
Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to early treatment options. The STarT-MSK programme developed and tested a new stratified primary care intervention for patients with common musculoskeletal (MSK) conditions in general practice. Stratified care involves changing General Practitioners' (GPs) behaviour, away from the current 'stepped' care approach to identifying early treatment options matched to patients' risk of persistent pain. Changing healthcare practice is challenging, and to aid the successful delivery of stratified care, education and support for GPs was required. This paper details the iterative development of a clinician support package throughout the lifespan of the programme, to support GPs in delivering the stratified care intervention. We argue that clinician support is a crucial aspect of the intervention itself, which is often overlooked.
Qualitative research with patients and GPs identified barriers and facilitators to the adoption of stratified care, which were mapped onto the Theoretical Domains Framework (TDF). Identified domains were 'translated' into an educational paradigm, and an initial version of the support package developed. This was further refined following a feasibility and pilot RCT, and a finalised support package was developed for the main RCT.
The clinician support package comprised face-to-face sessions combining adult-learning principles with behaviour change theory in a multimethod approach, which included group discussion, simulated consultations, patient vignettes and model consultation videos. Structured support for GPs was crucial to facilitate fidelity and, ultimately, a successful trial. Clinician support is a two-way process- the study team can learn from and adapt to specific local factors and issues not previously identified. The support from senior clinicians was required to ensure 'buy in'. Monitoring of GP performance, provision of regular feedback and remedial support are important aspects of effective clinician support.
Designing effective clinician support from the onset of trial intervention design, in an evidence-based, theory-informed manner, is crucial to encourage active engagement and intervention fidelity within the trial, enabling the delivery of a robust and reliable proof-of-principle trial. We offer practical recommendations for future general practice interventions.
分层护理涉及根据关键特征（如预后风险）对患者进行分组，并将这些亚组与早期治疗方案相匹配。STarT-MSK项目针对基层医疗中患有常见肌肉骨骼疾病的患者，开发并测试了一种新的分层初级护理干预措施。分层护理需要改变全科医生（GP）的行为，从当前的“阶梯式”护理方法转变为识别与患者持续性疼痛风险相匹配的早期治疗方案。改变医疗保健实践具有挑战性，为了帮助成功实施分层护理，需要对全科医生进行教育和支持。本文详细介绍了在该项目的整个周期中临床医生支持包的迭代开发过程，以支持全科医生实施分层护理干预。我们认为临床医生支持是干预本身的一个关键方面，但常常被忽视。
对患者和全科医生进行定性研究，确定采用分层护理的障碍和促进因素，并将其映射到理论领域框架（TDF）上。将确定的领域“转化”为一种教育范式，并开发了支持包的初始版本。在可行性研究和试点随机对照试验之后，对其进行了进一步完善，并为主要随机对照试验开发了最终的支持包。
临床医生支持包包括面对面的课程，采用多方法将成人学习原则与行为改变理论相结合，其中包括小组讨论、模拟会诊、患者案例和示范会诊视频。对全科医生的结构化支持对于确保依从性以及最终成功开展试验至关重要。临床医生支持是一个双向过程——研究团队可以从以前未发现的特定当地因素和问题中学习并进行调整。需要资深临床医生的支持以确保“接受”。对全科医生表现的监测、定期反馈和补救支持是有效临床医生支持的重要方面。
从试验干预设计开始就以循证、理论指导的方式设计有效的临床医生支持，对于鼓励试验中的积极参与和干预依从性至关重要，从而能够开展一项强有力且可靠的原理验证试验。我们为未来的基层医疗干预提供了实用建议。
