B. Saunders1, K. Konstantinou1,2, M. Artus1, N.E. Foster1,3, B. Bartlam1
1Keele University, Primary Care Centre Versus Arthritis, Keele Medical School, Newcastle-under-Lyme, United Kingdom, 2Haywood Hospital, Midlands Partnership Foundation NHS Trust, Staffordshire, United Kingdom, 3Keele University, Keele Clinical Trials Unit (CTU), Newcastle-under-Lyme, United Kingdom
Background: Sciatica is common and associated with significant impacts for the individual and society. The SCOPiC randomised controlled trial (RCT) in the UK (trial registration: ISRCTN75449581) compared stratified care for sciatica, which involved allocating patients into one of three groups based on prognostic and clinical indicators, with usual non-stratified care. Patients in one group in the stratified care arm of the trial were ‘fast-tracked’ to receive an MRI scan and spinal specialist opinion.
Purpose: This paper reports on nested qualitative research exploring patients’ and clinicians’ perspectives on the acceptability of this novel ‘fast-track’ pathway. Exploring how an intervention is perceived and experienced by patients and clinicians provides important context for interpreting the outcomes of pragmatic trials.
Methods: Semi-structured interviews were conducted with 20 patients with sciatica participating in the trial and 20 clinicians (general practitioners, spinal specialist physiotherapists, spinal surgeons). Interview data were analysed thematically, drawing on the constant comparison method. Findings were then mapped onto two theoretical frameworks ─ Normalisation Process Theory (NPT) and ‘boundary objects’ concept, to explore the degree to which patients and clinicians saw the ‘fast-track’ pathway as ‘making sense’ in the context of clinical practice, and whether it aligned with the respective priorities of the different participant groups.
Results: Whilst the ‘fast-track’ pathway achieved a degree of ‘coherence’ (i.e. made sense) to both patients and clinicians, particularly in providing early reassurance to patients based on MRI scan findings, the pathway was less ‘meaningful’ to some clinicians for managing patients with acute symptoms (i.e. up to 2 months), reflecting their expectation of natural resolution in most cases, and subsequently a reluctance to move away from the usual ‘stepped care’ approach in the management of sciatica. Both clinicians and patients felt that a key limitation of the ‘fast-track’ pathway was although patients had their MRI and spinal specialist assessment more quickly than normal, if invasive treatments such as spinal injections or surgery were warranted, patients still had to join usual National Health Service (NHS) waiting lists for these procedures.
Conclusion(s): Findings provide important insights for understanding the ‘fast-track’ pathway, as part of the stratified care model tested in the RCT. Whilst both patients and clinicians reported benefits of the ‘fast-track’ pathway, there was collective clinical reluctance to consider invasive treatments early on. In this respect, therefore, this facet of the stratified care model tested was not consistently helpful to clinicians in their discussions with their patients about management options, although it proved useful for some patients.
Implications: The SCOPiC trial results showed that this stratified care model was not superior to usual, non-stratified care for the primary outcome: time to symptoms resolution. The qualitative findings have potential implications for future intervention design. In particular, future research exploring early referral of patients with sciatica with severe symptoms for consideration of treatments such as surgery or spinal epidural injections must account for and address the difficulties in bringing about clinician behaviour change, given that the current stepped care approach was found to be strongly embedded in routine practice.
Funding, acknowledgements: National Institute for Health Research (NIHR) Health Technology Assessment Programme (NIHR HTA project number 12/201/09).
Keywords: Sciatica, Stratified care, Qualitative
Topic: Musculoskeletal: spine
Did this work require ethics approval? Yes
Institution: NHS Research Ethics Service
Committee: NHS Research Ethics Service (NRES) Committee West Midlands – Solihull
Ethics number: 15/WM/0078
All authors, affiliations and abstracts have been published as submitted.
