Improving Musculoskeletal Care Quality With a Web-Based Clinical Decision Support System in UK Primary Care: Mixed Methods Cluster-Randomized Controlled Trial.

Background: Musculoskeletal (MSK) conditions account for one in seven general practice consultations in the United Kingdom. Despite national guidelines, suboptimal care remains common. Digital clinical decision support systems (CDSSs) offer a promising route to improve care quality but have not been robustly evaluated in MSK primary care. Objective: This study aimed to evaluate the efficacy, clinical effectiveness and cost-effectiveness, carbon reduction, safety, and implementation of a CDSS (CrossCover) for MSK consultations in UK general practice. Methods: We conducted a mixed methods, cluster-randomized controlled trial in 19 general practices between February and July 2024. Practices were randomized 1:1, stratified by list size. Intervention practices received training and access to the web-based CDSS for 3 months. We analyzed anonymized electronic health records to identify all adult MSK consultations. The primary outcome was the proportion of patient records containing one or more of 12 predefined non-evidence-based management options, assessed by blinded clinical review of 120 patient records (60 per arm). Reviewers assessed the complete 3-month record in both arms; in the intervention arm, suboptimal management was counted only where it occurred at a consultation in which the CDSS was used. Secondary outcomes included intention-to-treat treatment comparisons of self-management advice, prescriptions, referrals, and imaging. Clinician engagement, safety, environmental and economic modeling, and clinician experiences from semistructured interviews were evaluated. Outcome assessors were blinded; clinicians were not. Results: Among 10,182 eligible patients with MSK conditions (4268 intervention; 5914 control), the CDSS was used in 365 (8.6%) patient cases. Intention-to-treat analysis identified that the intervention increased self-management alone. Per-protocol analysis demonstrated that when used, suboptimal care arose in 3% (2/60) of CDSS-guided consultations vs 25% (15/60) of control consultations (adjusted odds ratio 12.30, 95% CI 2.52-59.9; Conclusions: When used, the CrossCover CDSS significantly reduced suboptimal primary care MSK management. However, while safety and clinician feedback were favorable, overall engagement was limited, underscoring the need for improved digital integration, workflow alignment, and implementation support.