Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care.

Zouch, James; Bhimani, Nazim; Bussières, André; Ferreira, Manuela; Foster, Nadine E; Ferreira, Paulo

Abstract

The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone. A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with musculoskeletal conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or musculoskeletal presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. Patients with musculoskeletal conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care. Patients with musculoskeletal conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care. [Abstract copyright: © The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association.]

Citation

Zouch, J., Bhimani, N., Bussières, A., Ferreira, M., Foster, N. E., & Ferreira, P. (in press). Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care. Physical Therapy, pzae066. https://doi.org/10.1093/ptj/pzae066

• Journal Article Type: Article
• Acceptance Date: Apr 24, 2024
• Online Publication Date: May 2, 2024
• Deposit Date: May 20, 2024
• Journal: Physical therapy
• Print ISSN: 0031-9023
• Publisher: Oxford University Press
• Peer Reviewed: Peer Reviewed
• Pages: pzae066
• DOI: https://doi.org/10.1093/ptj/pzae066
• Keywords: Musculoskeletal Pain, Prognosis, Primary Health Care, Effect Modifiers, Back Pain
• Public URL: https://keele-repository.worktribe.com/output/829591