A quantitative study of shoulder pain management by primary care physicians in Qatar

Abstract

Background: Patients with shoulder pain are mainly managed in primary care. There have been studies in other countries which suggested low confidence among general practitioners in diagnosing and managing shoulder pain, with frequent use of investigations. No comparable studies are available in Qatar. We conducted this study to understand the variations of practice amongst primary care physicians in patients with shoulder pain. We also aimed to assess the association between practice decisions and selected characteristics of physicians, such as their grade and musculoskeletal training or qualification. We hope our study will improve our knowledge of this subject and provide empirical evidence if a gap exists between practice and best evidence. Methods: We conducted an online cross-sectional survey of all primary care physicians working within 27 health centers under the PHCC. Participation in this survey was voluntary and online survey responses were anonymous. The survey questionnaire included questions on participant characteristics and clinical scenarios describing the two most common shoulder pain presentations in primary care i.e., Rotator cuff tendinopathy and adhesive capsulitis. The response options for both scenarios were listed under categories of diagnosis, investigations, clinical management and referrals. Results: 28% of physicians responded to email request with three quarters being male. Most of the responders were consultants and had more than 10 years of clinical experience. About one in five physicians reported to have musculoskeletal experience or qualifications. 73% of responders felt a CME session will be useful. In the first scenario, 49% felt confident about the RCT diagnosing with 31% who didn’t feel any investigation was required. From responders who chose to investigate, a nearly equal number selected plain shoulder radiography (71%) and Ultrasound scan (70%). For AdhC scenario, 64% of responders felt confident about the diagnosis. However, 78% chose investigation; the most common investigations were USS (65%), plain shoulder radiography (62%) and Blood test (58%). In both scenarios, USS was selected mainly to confirm diagnosis while shoulder radiography was considered to exclude other diagnosis. The most recommended treatment for both presentations was analgesia (RCT 86%, AdhC 82%) followed by physiotherapy (RCT 84%, AdhC 82%). 56% opted to refer RCT to secondary care compared to 62% for the AdhC. Association analysis revealed that junior grade responders were more likely to refer patient to specialist (RCT scenario, p=0.022) and relied more frequently on shoulder radiography (AdhC Scenario, p=0.022). Association analysis of previous MSK experience showed a statistically significant tendency to request blood tests and shoulder radiography by physicians with previous MSK experience (p= 0.022). Conclusion: This survey in Qatar identifies a reliance on frequent use of investigations in the management of common shoulder pain presentations. A tendency to choose early referral to secondary care was also noted especially amongst junior grade physicians. We hope with more experience and CME training they may feel more confident in their decision making and less inclined to refer in future. However, the low response rate to the survey means that caution needs to be exercised in generalising the findings due to potential non-response bias. Key words. Shoulder pain management, Primary care, Qatar.