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Improving the management of musculoskeletal conditions: can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study

09 Feb 2019


To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice.


Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series.

Setting and participants

36 general practices in East London.


Informed by the results of a Cochrane review on educational interventions to improve general practitioners’ (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review.

Main outcome measures

Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention.


Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%).


A quality improvement-based approach to referral management which values GPs’ professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.

Click here to view the full article which appeared in BMJ Open