Karstens S.1,2, Kuithan P.3, Joos S.4, Hill J.C.5, Wensing M.2, Steinhaeuser J.6, Krug K.2, Szecsenyi J.2
1Trier University of Applied Sciences, Therapeutic Sciences, Trier, Germany, 2University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany, 3SRH Hochschule Heidelberg, Department of Therapeutic Sciences, Heidelberg, Germany, 4University of Tuebingen, Department of General Practice, Tuebingen, Germany, 5Keele University, Institute of Primary Care and Health Sciences, Keele/Stoke-on-Trent, United Kingdom, 6University Hospital Schleswig-Holstein Campus Luebeck, Institute of Family Medicine, Luebeck, Germany
Background: Stratified care is an evolving concept in physiotherapy. Following the Subgroups for Targeted Treatment (STarT)-Back-Approach, patients with low back pain are allocated to one of three groups based on their prognosis for persistent disabling pain using the STarT-Back-Tool. Patients at low risk receive a one-off assessment- and advice-session to support self-management. Patients at medium risk receive evidence-based physiotherapy. Those at high risk receive combined physical and psychological treatment. The approach has demonstrated clinical and cost effectiveness, but the vast majority of German physiotherapists are not familiar with it.
Purpose: To explore physiotherapists' perceptions about implementing the STarT-Approach in Germany.
Methods: Three two-hour think-tank workshops with physiotherapists were conducted during which information and research evidence for the STarT-Approach were given. This was followed by focus groups using a semi-structured interview guideline. Discussions were audio recorded, transcribed and coded using a content analysis approach with main themes deductively derived using the Consolidated Framework for Implementation Research: intervention, setting and individual characteristics.
Results: Overall, participants (4 male/15 female, mean age 41.2 (SD 8.6) years) endorsed the STarT-Approach. The following key issues were developed from the discussions:
Intervention theme (15 subthemes): The participants questioned whether the STarT-Back-Tool was sufficiently comprehensive to effectively stratify patients. They felt this approach had the potential to increase treatment efficiency. However, they highlighted differences between it and current practice, requiring a rethinking for clinicians and patients. Some of the physiotherapists felt the flexibility of the approach was positive, whilst others asked for further standardisation of the treatments to be applied within each subgroup.
Setting theme (26 subthemes): On a professional organisational level, participants discussed the approach as a chance to initiate a change in remuneration and to increase decision-making authority. Implementation would require some readjustments within clinics and their interprofessional networks. Concerns were raised that implementation might result in fewer long-term patients and, in this way, mean a negative influence on a constant source of income.
Individual characteristics theme (8 subthemes): A willingness to change was noted. Participants described that they were trained with a strong biomedical focus during undergraduate training and that the vast majority of physiotherapists prefers hands-on programmes for postgraduate training. It was discussed if the current lack of psychosocial skills training could be compensated by clinical experience and an empathetic approach to patient care.
Conclusion(s): The perceptions of German physiotherapists about the STarT-Approach were positive, despite some concerns that it was quite different from current practice. Significant training obstacles to implementing the approach were identified, including recognition that currently skills to address psychosocial factors are not always sufficiently integrated into training and clinical practice.
Implications: Barriers and enablers to implementing the STarT-Back stratified care approach in Germany were highlighted. Barriers include the current biomedical focus of existing treatment, orientation of professional training, and prescription and remuneration structures. Strategies are needed to encourage German physiotherapists to further develop clinical competencies and to more comprehensively address patients psychosocial aspects by leveraging given willingness to change.
Funding acknowledgements: Sven Karstens was funded partly by the young scientists programme of the German network ´Health Services Research Baden-Württemberg´.
Topic: Professional issues
Ethics approval: Ethical approval was granted by the Ethics Committee of the University of Heidelberg
(registration ID: S-414/2013)
All authors, affiliations and abstracts have been published as submitted.
