Clinical Outcomes Review within a Musculoskeletal (MSK) Risk Stratified Model of Care


Measuring the clinical effectiveness of all healthcare services is a fundamental component of evaluating the impact care has on the service user. A community-based MSK physiotherapy service in Mid Essex has been using a validated and multi-dimensional outcome tool, the Musculoskeletal Health Questionnaire (MSK-HQ), since April 2017 to evaluate clinical effectiveness.

The service also recognised the importance of working in different ways to improve efficiency and matching treatments based on prognostic subgroups (stratified care) has been shown to be both clinically and cost-effective in the management of low back pain using the STarT Back Screening Tool.  However, risk stratified care for all MSK disorders is in its relative infancy, with the Keele STarT MSK Tool yet to be fully validated scientifically, although Keele University granted permission for the MSK physiotherapy service to use the tool for clinical purposes in April 2018. 

The service was therefore able to collect data from all appropriate MSK patients receiving treatment from April 2018 to March 2019 to evaluate whether good clinical outcomes and positive patient experience were demonstrated whilst delivering a more efficient risk-stratified care approach.


All service users who were ≥ 13 years old completed the MSK-HQ and either the STarT Back Screening or Keele STarT MSK Tool depending on their problem prior the initial assessment.

Clinicians were encouraged to discharge ‘Low Risk’ patients according to the STarT Back Screening or Keele STarT MSK Tool scoring with advice and guidance following the initial assessment.  Provision of patient information leaflets and signposting to online resources on the physiotherapy page of the website was offered to these patients. 

‘Medium and High risk’ patients were managed as clinically appropriate and all patients completed a MSK-HQ and Friends and Family Test (FFT) feedback at discharge. 

6-monthly reports were run to collect data on staff compliance, service performance and patient experience.  Patients who demonstrated an increase of 6 or more in the MSK-HQ score at discharge were taken as a clinically significant improvement in health status related to their MSK disorder based on guidance from the MSK-HQ developer



Data collected from April 2018 to March 2019 involving 3068 patients across the whole service demonstrated a mean score of 81% patients who showed a clinically significant improvement following treatment.  Mean average change in MSK-HQ score for all service users was +14.6, which was significantly higher than the ≥6 clinically important threshold.

74% of ‘Low Risk’ patients were discharged following the initial assessment and 99% of this sample would recommend the service to others from the FFT feedback, which was equivalent patient experience to service users receiving a course of treatment.  The one area that this patient group consistently reported could be improved was to receive this one-off assessment and advice appointment quicker.

As well as efficiencies being achieved with managing the majority of ‘Low Risk’ patients with one contact, the mean average number of contacts for the ‘Medium and High Risk’ group were also significantly lower than the previous year at 3.2 and 3.3 contacts respectively.

Cost and savings

No direct costs incurred to carry out this service transformation and review as performed internally, within the MSK physiotherapy service.

Increased productivity and reduced number of patient contacts demonstrated a clear efficiency saving, without compromising quality of patient care.


This audit has proven that targeting treatment to the level of need using a prognostic stratification tool delivers excellent clinical outcomes within an efficient model of care for patients with MSK related problems being managed in a community-based setting.  Both commissioning and providing similar models for MSK Physiotherapy services should be considered across the UK.

Robust clinical outcome data collection using the MSK-HQ has enabled individual and service performance monitoring and highlighted areas for further training and development.  Further observations reviewing different MSK conditions and/or risk subgroups will help to identify areas for greater focus ensure optimal patient care within current resources.

The review has provided further supporting evidence for developing more sophisticated digital risk stratification systems for service users to access at the point of referral especially for the ‘Low Risk’ patients, who do not require much input based on the audit findings.  This work stream will feed into a larger project being carried out within the service and organisation looking at the use of Artificial Intelligence (AI) to help navigate and support patients through the system so that they receive the appropriate level of care they need as early as possible.

Ongoing trends for MSK risk stratified care and subsequent clinical outcomes will be continuallymeasured within the service on a 6-monthly basis and changes to patient care will be made where the need arises.

Top three learning points

  • Significant improvements in patient’s health related to a MSK disorder can be achieved despite low number of contacts
  • ‘Low Risk’ MSK patients can be effectively managed and are satisfied with a one-off assessment and advice appointment including patient information resources
  • Risk stratified care for patients with MSK disorders should be used in primary care and make better use of MSK physiotherapy services for the patients who most need face to face treatment

Funding acknowledgements

This work was not funded

Additional notes

See link below for news story on the introduction of the MSK-HQ within the Physiotherapy Outpatients Service at Provide:

See links below for further information on the MSK-HQ and Keele STarT MSK Tool:

The service plans to be involved with the developers of the MSK-HQ and Keele STarT MSK Tool to help contribute to a standardised MSK dataset in the future for national benchmarking of MSK services.

For further information about this Innovation contact Luke Tandy.