title: STEMS pilot trial: a pilot cluster randomised controlled trial to investigate the addition of patient direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain.
abstract: Around 17% of general practitioner (GP) consultations are for musculoskeletal conditions, which will rise as the population ages. Patient direct access to physiotherapy provides one solution, yet adoption in the National Health Service (NHS) has been slow.
  
  
  
  A pilot, pragmatic, non-inferiority, cluster randomised controlled trial (RCT) in general practice and physiotherapy services in the UK.
  
  
  
  Investigate feasibility of a main RCT.
  
  
  
  Adult patients registered in participating practices and consulting with a musculoskeletal problem.
  
  
  
  4 general practices (clusters) randomised to provide GP-led care as usual or the addition of a patient direct access to physiotherapy pathway.
  
  
  
  Process outcomes and exploratory analyses of clinical and cost outcomes.
  
  
  
  Participant-level data were collected via questionnaires at identification, 2, 6 and 12 months and through medical records.
  
  
  
  The study statistician and research nurses were blinded to practice allocation.
  
  
  
  Of 2696 patients invited to complete study questionnaires, 978 participated (intervention group n=425, control arm n=553) and were analysed. Participant recruitment was completed in 6 months. Follow-up rates were 78% (6 months) and 71% (12 months). No evidence of selection bias was observed. The direct access pathway was used by 90% of patients in intervention practices needing physiotherapy. Some increase in referrals to physiotherapy occurred from one practice, although waiting times for physiotherapy did not increase (28 days before, 26 days after introduction of direct access). No safety issues were identified. Clinical and cost outcomes were similar in both groups. Exploratory estimates of between group effect (using 36-item Short Form Health Survey (SF-36) Physical Component Summary (PCS)) at 6 months was -0.28 (95% CI -1.35 to 0.79) and at 12 months 0.12 (95% CI -1.27 to 1.51).
  
  
  
  A full RCT is feasible and will provide trial evidence about the clinical and cost-effectiveness of patient direct access to physiotherapy.
  
  
  
  ISRCTN23378642.
authors.affiliation: Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
authors.forename: Annette
authors.identifier: 0000-0002-9810-7994
authors.initials: A
authors.lastname: Bishop
authors.affiliation: Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
authors.forename: Reuben O
authors.initials: RO
authors.lastname: Ogollah
authors.affiliation: Health Economics Unit, University of Birmingham, Birmingham, UK.
authors.forename: Sue
authors.initials: S
authors.lastname: Jowett
authors.affiliation: Health Economics Unit, University of Birmingham, Birmingham, UK.
authors.forename: Jesse
authors.initials: J
authors.lastname: Kigozi
authors.affiliation: Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Tooth
authors.affiliation: Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
authors.forename: Joanne
authors.initials: J
authors.lastname: Protheroe
authors.affiliation: Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
authors.forename: Elaine M
authors.initials: EM
authors.lastname: Hay
authors.affiliation: Centre for Academic Primary Care, University of Bristol, Bristol, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Salisbury
authors.affiliation: Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
authors.forename: Nadine E
authors.initials: NE
authors.lastname: Foster
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D005260:Female; D058006:General Practice; D058005:General Practitioners; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D009140:Musculoskeletal Diseases / Q000628:therapy; D059352:Musculoskeletal Pain / Q000628:therapy*; D026741:Physical Therapy Modalities; D010810:Physical and Rehabilitation Medicine; D010865:Pilot Projects; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D012017:Referral and Consultation; D012107:Research Design; D013222:State Medicine; D011795:Surveys and Questionnaires; D006113:United Kingdom
keywords: PRIMARY CARE; Patient direct access; feasibility and pilot trial; musculoskeletal; physiotherapy