Currently accepted at: Journal of Medical Internet Research
Date Submitted: Dec 16, 2025
Date Accepted: Aug 10, 2026
This paper has been accepted and is currently in production.
It will appear shortly on 10.2196/89734
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Improving the quality of musculoskeletal care through a clinical decision support system: mixed-methods evaluation of CrossCover in UK primary care
ABSTRACT
Background:
Musculoskeletal (MSK) conditions account for one in seven general practice consultations in the UK. Despite national guidelines, sub-optimal 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:
To evaluate the effectiveness, safety, and implementation of a CDSS (CrossCover) for MSK consultations in UK general practice.
Methods:
We conducted a mixed-methods, cluster-randomised controlled trial in 19 general practices between February and July 2024. Practices were randomised 1:1, stratified by list size. In intervention practices, clinicians received training and access to the CDSS for three months. We analysed anonymised electronic health records to identify all adult MSK consultations. The primary outcome was the proportion of consultations involving one of 12 predefined non-evidence-based management options, assessed through blinded clinical review of 120 consultations (60 per group). Intervention group inclusion was limited to consultations where the CDSS was actively used. Secondary outcomes included treatment patterns (e.g. self-management advice, prescriptions, referrals, imaging), clinician engagement, safety, environmental and economic modelling, and clinician experiences from semi-structured interviews. Outcome assessors were blinded; clinicians were not.
Results:
Sub-optimal care was identified in 3.3% (2/60) of intervention consultations versus 25% (15/60) of control consultations (adjusted OR 12.30, 95% CI 2.52–59.9; p=0.002). Among 10,182 eligible records (4,268 intervention; 5,914 control), the CDSS was used in 365 cases (8.6%). CDSS use was associated with increased delivery of self-management advice and community referrals, and reduced prescribing and fit-note use. Safety concerns were logged in 6.6% of uses; no high-risk issues were identified. Environmental modelling estimated an 18% reduction in carbon emissions and 10% annual cost savings if the intervention were scaled. Interviews (n=18) highlighted positive perceptions of the tool’s content and safety netting but noted challenges in integration and incentives for uptake.
Conclusions:
The CrossCover CDSS significantly reduced sub-optimal clinical management of MSK presentations in general practice. While safety and clinician feedback were favourable, uptake was limited, underscoring the need for improved digital integration, workflow alignment, and implementation support. Clinical Trial: ISRCTN12407653
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