General Practitioners' and patients' perceptions towards stratified care: a theory informed investigation

Benjamin Saunders, Bernadette Bartlam, Nadine E Foster, Jonathan C Hill, Vince Cooper, Joanne Protheroe, Benjamin Saunders, Bernadette Bartlam, Nadine E Foster, Jonathan C Hill, Vince Cooper, Joanne Protheroe

Abstract

Background: Stratified primary care involves changing General Practitioners' (GPs) clinical behaviour in treating patients, away from the current stepped care approach to instead identifying early treatment options that are matched to patients' risk of persistent disabling pain. This article explores the perspectives of UK-based GPs and patients about a prognostic stratified care model being developed for patients with the five most common primary care musculoskeletal pain presentations. The focus was on views about acceptability, and anticipated barriers and facilitators to the use of stratified care in routine practice.

Methods: Four focus groups and six semi-structured telephone interviews were conducted with GPs (n = 23), and three focus groups with patients (n = 20). Data were analysed thematically; and identified themes examined in relation to the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. A critical approach was taken in using the TDF, examining the nuanced interrelationships between theoretical domains.

Results: Four key themes were identified: Acceptability of clinical decision-making guided by stratified care; impact on the therapeutic relationship; embedding a prognostic approach within a biomedical model; and practical issues in using stratified care. Whilst within each theme specific findings are reported, common across themes was the identified relationships between the theoretical domains of knowledge, skills, professional role and identity, environmental context and resources, and goals. Through analysis of these identified relationships it was found that, for GPs and patients to perceive stratified care as being acceptable, it must be seen to enhance GPs' knowledge and skills, not undermine GPs' and patients' respective identities and be integrated within the environmental context of the consultation with minimal disruption.

Conclusions: Findings highlight the importance of taking into account the context of general practice when intervening to support GPs to make changes to their clinical behaviour. Findings will inform further stages of the research programme; specifically, the intervention format and content of support packages for GPs participating in a future randomised controlled trial (RCT). This study also contributes to the theoretical debate on how best to encourage clinical behaviour change in general practice, and the possible role of the TDF in that process.

Keywords: Behaviour change interventions; Focus groups; General practice; Interviews; Musculoskeletal conditions; Qualitative; Stratified primary care; Theoretical Domains Framework (TDF).

Figures

Fig. 1
Fig. 1
GP and patient perceptions of stratified care regarding decision-making. Represents diagrammatically the identified relationship between the theoretical domains as explained above, with ‘beliefs about consequences’ in relation to stratified care shown to relate unidirectionally to the domains of ‘knowledge’, ‘skills’ and ‘professional role and identity’; which are in turn shown to relate to the domain of ‘decision processes’
Fig. 2
Fig. 2
Perceived impact of stratified care on the therapeutic relationship. Represents diagrammatically the identified relationship between the theoretical domains as explained above, with ‘beliefs about consequences’ shown to relate unidirectionally to the domains of ‘goals’ and ‘professional role and identity’; which are also represented as relating to one another
Fig. 3
Fig. 3
Factors influencing GPs’ orientation to a primarily biomedical approach. Represents diagrammatically the identified relationship between the theoretical domains as explained above, with ‘environmental context and resources’ shown to relate unidirectionally to ‘professional role and identity’, which in turn relates unidirectionally to the domain of ‘goals’. Additionally ‘beliefs about capabilities’ and ‘emotions: fear’ are shown to mutually relate to one another and to both individually relate to ‘goals’
Fig. 4
Fig. 4
Perceived impact of stratified care on routine consultations. Represents diagrammatically the identified relationship between the theoretical domains as explained above, with ‘environmental context and resources’ shown to relate to ‘goals’, which is in turn displayed as relating unidirectionally to both ‘optimism’ and ‘pessimism’

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Source: PubMed

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