Imaging for common musculoskeletal conditions in primary care: rationale and decision making.

Musculoskeletal pain conditions are one of the most common reasons for primary care consultation and are often associated with requests for diagnostic imaging, including x-ray, ultrasound and Magnetic Resonance Imaging (MRI). However, imaging findings are often not well associated with patients presenting symptoms and rarely offer useful guidance for further management.

One of the priorities of the Musculoskeletal Pain research programme, and the wider Research Institute (RI), is to better understand the role of diagnosis of common musculoskeletal conditions to better inform the development of clinically and cost-effective interventions. Hence, understanding the reasons why diagnostic imaging is requested by primary care clinicians and patients and how the information gained is used to guide decisions about treatment will directly contribute to this priority while developing clinical academic capacity, contributing to research outputs, including peer-reviewed publications, and facilitating public engagement.

Aims:
The aim of this study is to better understand the reasons for requesting imaging for patients with common musculoskeletal pain conditions, including back, neck, shoulder, hip and knee pain, from the perspective of the referring clinician and patients. A secondary aim is to understand how the imaging findings are used; including how such information might guide treatment and referral for further clinical opinion. Such new knowledge would provide a basis on which interventions, for example decision support tools and educational packages, could be developed to optimise requests for diagnostic imaging and to aid interpretation of imaging results for the most common musculoskeletal pain conditions.

Objectives & methods:
Phase 1: Systematic scoping review of the literature with the primary objective of better understanding current best practice guidance in relation to when and why diagnostic imaging for common musculoskeletal pain conditions in primary care should be requested. A secondary objective of this review would be to synthesise guidance about how diagnostic imaging should be interpreted for common musculoskeletal pain conditions, although limited guidance is expected in this regard. The review would include retrieval and synthesis of regional, national and international guidelines as well as other literature including clinical viewpoints and discussion articles. The review findings will form the basis for Phase 2, the qualitative investigation.

Phase 2: Qualitative studies with patients (approx. n = 20), primary care clinicians including GPs, nurses and physiotherapists (approx. n = 20), and radiographers, sonographers or radiologists (those reporting on the scan) (approx. n = 10). The qualitative interviews would be conducted with primary care clinicians and patients for whom imaging for a musculoskeletal pain condition has been requested and undertaken with the aim of understanding the reasons for requesting imaging from the perspective of the clinicians and patients, the tensions between current best practice guidance and current practice in requesting imaging, and perceived needs of clinicians and patients with regard to imaging requests. The interviews would also explore how the results of the imaging have been interpreted and used to inform further management, and the issues arising from this. Working alongside selected general practice’s that employ GPs, physiotherapists and/ or nurses as primary care clinicians involved in the assessment and management of patients with musculoskeletal pain, a pragmatic approach to recruitment and data collection will be taken. Recruitment will begin by searching of clinical records and also, for patients, opportunistically during clinic appointments. Data collection will be undertaken via face-to-face or telephone interviews according to interviewee preference. The interviews will be audio-recorded and transcribed before being analysed thematically (Kendall et al 2009).

Phase 3: Synthesis of a logic model for how a new intervention might work to better support good decision-making about imaging for MSK patients in primary care. The logic model would form the basis on which future educational resources and decision support tools could be based.