Referrals to physiotherapy: the relation between the number of referrals, the indication for referral and the inclination to refer

Referral practices of medical practitioners in central South Africa to physiotherapy services for patients living with musculoskeletal conditions

BACKGROUND

Musculoskeletal diseases (MSDs) are a major cause of disability worldwide. It is essential to address effective MSD management, including appropriate referrals to physiotherapists and other healthcare professionals. Limited information is available regarding the referral practices of medical practitioners for patients with MSD. The doctors' referral practices to physiotherapists can impact the patient population and the South African health system.

OBJECTIVES

To investigate or understand the referral practices of medical practitioners in Bloemfontein, South Africa, to physiotherapy services, for individuals living with MSD.

METHOD

A quantitative study approach, implementing a semi-structured questionnaire, was used. Forty-nine participants completed the questionnaire.

RESULTS

The referral of patients with MSDs by medical practitioners to physiotherapy services varied and multidimensional factors influenced their referral practices. Medical practitioners were unsure of the specific role played by physiotherapists in the management of individuals living with MSD. A need for improved relationships and communication between medical practitioners and physiotherapists was identified.

CONCLUSIONS

Medical practitioners regularly referred individuals living with MSD to physiotherapists, but referral practices should be optimised in terms of evidence-based practice and the use of specialised physiotherapy services. In an attempt to decrease the burden of MSD, adequate awareness should be created for improved referral practices between medical practitioners and physiotherapists.

CLINICAL IMPLICATIONS

Collaborative development of detailed guidelines for apt, evidence-based referrals should be developed, to ensure early detection and management of individuals living with MSD. Health care professionals should be educated and encouraged to refer individuals living with MSD to physiotherapists for appropriate management with clinical benefits including improvement of HRQOL and cost effectiveness of this management not only to the individual but also to the health system in South Africa. Physiotherapists should try to communicate their role in the treatment of individuals living with MSD to medical practitioners for the benefit of the patient.

The likelihood of general practitioners referring patients to physiotherapists is low for some health problems: secondary analysis of the Bettering the Evaluation and Care of Health (BEACH) observational study

QUESTIONS

Which health problems do medical general practitioners (GPs) most commonly refer to physiotherapists? What is the likelihood of GPs referring patients for specific health problems?

DESIGN

Secondary analysis of data from the Bettering the Evaluation and Care of Health (BEACH) study, which is a national observational study of Australian general practice clinical activity.

PARTICIPANTS

People at GP encounters between April 2010 and March 2015.

OUTCOME MEASURES

The outcomes were the proportion of all (new) health problems that were referred to a physiotherapist, the distribution of health problems referred to physiotherapists, and the likelihood of referral of (all and new) specific health problems to physiotherapists.

RESULTS

There were 6904 referrals to a physiotherapist from 775893 GP encounters, which equated to 0.89% (95% CI 0.86 to 0.92). Among the 286858 new health problems, 2987 were referred to a physiotherapist (1.04%, 95% CI 0.99 to 1.09). The health problems that were most commonly referred were back complaints (18.6%), sprains (10.3%) and osteoarthritis (8.6%). However, when these three problems presented as a new health problem, the likelihood of referral was low (14.4, 11.9 and 5.4%, respectively). The new health problems most likely to result in a referral were acquired deformity of the spine (which includes kyphoscoliosis, kyphosis, lordosis and scoliosis) (17.7%, 95% CI 8.2 to 27.2) and neck complaints (17.4%, 95% CI 14.3 to 20.6).

CONCLUSIONS

Most referrals made to physiotherapists were for musculoskeletal problems. However, even among the most commonly referred problems (such as back complaints and osteoarthritis), the likelihood of referral was low when they presented as a new problem. There is an opportunity to increase referrals from general practice to physiotherapy for many common conditions with effective physiotherapy interventions. [Dennis S, Watts I, Pan Y, Britt H (2018) The likelihood of general practitioners referring patients to physiotherapists is low for some health problems: secondary analysis of the Bettering the Evaluation and Care of Health (BEACH) observational study. Journal of Physiotherapy 64: 177-181].

Awareness, perceptions and beliefs about physiotherapy held by physicians working in Saudi Arabia: a cross-sectional study

[Purpose] Over the years physiotherapy has been recognized as a popular mode of treatment that decreases the disability and dependency rate of patients. However, there is still a need for its recognition in multidisciplinary health care structures. If a physician were well aware of how a physical therapist could help with treatment if patients and prevent complications, hospital patient load could be decreased to a greater extent. The aim of this study was to study the awareness, perception and beliefs of physicians working in Saudi Arabia about physiotherapy. [Subjects and Methods] Three hundred fifteen members of the Saudi Commission for Health Specialties (SCFHS) with different specialties, nationalities, designation, and work experience, working in various hospitals in 5 regions of Saudi Arabia were invited to participate in this study. A 22-item questionnaire was used for data collection including sections on physicians’ demographics, educational levels and knowledge about physiotherapy. [Results] After applying the inclusion and exclusion criteria, data from 280 respondents was used for analysis. Seventy-five percent of respondents reported to having some knowledge of physiotherapy, and 11% of them referred patients to physiotherapy departments regularly, while 14% referred patients occasionally. To the best of our knowledge, this is first study performed in Saudi Arabia to evaluate awareness of physicians about the physiotherapy profession. [Conclusion] The results of this study highlight the need to organize various workshops and lectures about the effectiveness of physiotherapy in various diseases for physicians, on a regular basis, to update them with evidence-based treatment. It is the responsibility of physical therapists to raise the perceptions of other healthcare professionals about their profession.

Patient adherence in an individualized rehabilitation programme: A clinical follow-up

Aims: This investigation aims to describe patients with longstanding pain who did not complete their participation and/or participated infrequently in physiotherapy (PT) treatment based on their own activity and responsibility, and in addition to understand the phenomenon of adherence from a behavioural theoretical perspective. Methods: The phenomenon compliance/adherence was studied in relation to health locus of control (HLC) factors and health belief (HB) variables. Outcome measures were based on a questionnaire answered by all patients before the beginning of treatment. Definitions of adherence were completed treatment period and exercise frequency respectively. Patients completing treatment were compared with those who did not. Exercise frequencies of those completing treatment were also studied. Results: Those who did not complete treatment reported higher pain intensity, higher Oswestry score, and worse general health than those completing treatment. Results also showed that those who exercised once a week or less often valued the significance of healthcare treatment less, perceived higher pain intensity, presented a higher Oswestry score, worse general health, more pain locations, lower expectations, were younger and almost solely women, than those who exercised more often. Conclusions: Individuals exercising irregularly were above all women. This fact needs further investigation. Individuals' belief in treatment effects is of significance to adherence. Adherence is a comprehensive concept and depending on how we look at it we find different populations.

Medicare rebate for specialist medical practitioners from physiotherapy referrals: analysis of the potential impact on the Australian healthcare system

Abstract

OBJECTIVE

To identify and examine the likely impact on referrals to specialist medical practitioners, cost to government and patient out-of-pocket costs by providing a rebate under the Medicare Benefits Scheme to patients who attend a specialist medical practitioner upon referral direct from a physiotherapist.

METHODS

A model was constructed to synthesise the costs and benefits of referral with a rebate. Data to inform the model was obtained from administrative sources and from a direct survey of physiotherapists.

RESULTS

Given that six referrals per month are made by physiotherapists for a specialist consultation, allowing direct referral to medical specialists and providing patients with a Medicare rebate would result in a likely cost saving to the government ofup to $13 million per year. A range of sensitivity analyses were conducted with all scenarios resulting in some cost savings.

CONCLUSIONS

The impact of the proposed policy shift to allow direct referral of patients by physiotherapists to specialist medical practitioners and provide patients with a Medicare rebate would be cost saving.

Orthopedic surgeon perspectives on appropriate referral of trauma patients to physical therapy (PT)

OBJECTIVES

To evaluate orthopedic surgeon referral of trauma patients to PT.

DESIGN

Cross-sectional survey.

SETTING

Alberta, Canada.

PARTICIPANTS

Orthopedic surgeons and residents.

METHODS

A web-based survey was utilized to poll orthopedic surgeons and residents on referral practices. Statistical analysis using Kruskal-Wallis One-Way Analysis of Variance by Ranks; Post hoc analysis using the minimum significant difference method for multiple comparisons and nonparametric correlations using Spearman's rho.

RESULTS

The overall response rate was 48 %. Key indications for referral were range of motion deficits, failure to progress, strength and gait training. Of those surveyed, 72.5 and 26.1 % felt that there was either moderate or significant improvement following PT, respectively. Years in practice had a significant effect on survey responses. Residents and surgeons in practice for >20 years viewed PT as being less important in orthopedic trauma (p < 0.05) and were less likely to refer orthopedic trauma patients to PT (p < 0.05). Residents were less likely to view PT in orthopedic trauma as evidence-based (0.05) and more likely to disagree with the statement that formalized PT results in better outcomes than a prescribed home exercise program (p < 0.05).

CONCLUSIONS

There are potential differences in the referral practices of orthopedists of varying levels of experience. Although outcome is viewed as positive following PT, it appears that many orthopedists view a prescribed home exercise program as an acceptable equivalent to formalized PT in the setting of orthopedic trauma. Future research should be directed at determining indicators for formalized PT.

Orthopedic surgeons and physical therapists differ in assessment of need for physical therapy after traumatic lower-extremity injury

BACKGROUND

Lower-extremity injuries constitute the leading cause of trauma hospitalizations among people under the age of 65 years. Rehabilitation has the potential to favorably influence the outcomes associated with traumatic lower-extremity injuries.

OBJECTIVES

The objectives of this study were to explore variability in surgeon and physical therapist assessments of the need for physical therapy in patients with traumatic lower-extremity injuries and to determine the factors associated with assessments of need.

DESIGN

This study was a retrospective cohort investigation.

METHODS

Participants were 395 patients treated by reconstruction in the Lower-Extremity Assessment Project. They were evaluated at 8 level I trauma centers at 3, 6, and 12 months after hospitalization by an orthopedic surgeon and a physical therapist to determine the need for physical therapy. Analyses included multilevel logistic regression.

RESULTS

Chi-square analyses showed that surgeon and therapist assessments of need differed statistically across trauma centers. Surgeons were more likely to assess a need for therapy at 3 months when participants had low work self-efficacy, impaired knee flexion range of motion (ROM), and weight-bearing limitations and at 6 and 12 months when participants had impaired knee flexion ROM and weight-bearing and balance limitations. Therapists were more likely to assess a need for therapy at 3 months when participants had moderate to severe pain and at 6 and 12 months when participants had low work self-efficacy, pain, impaired knee flexion ROM, and balance limitations.

CONCLUSIONS

The results revealed variability in assessments of the need for physical therapy at the provider and trauma center levels. Differences in provider assessments highlight the need for communication and further investigation into the outcomes and timing of physical therapy for the treatment of traumatic lower-extremity injuries.

Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: results of a national survey of orthopedic trauma surgeons

BACKGROUND

Variation in referral rates for physical therapy exists at both the individual physician and practice levels.

OBJECTIVE

The purpose of this study was to explore the influence of physician and practice characteristics on referral for physical therapy in patients with traumatic lower-extremity injury.

DESIGN

A cross-sectional survey was conducted.

METHODS

In 2007, a Web-based survey questionnaire was distributed to 474 surgeon members of the Orthopaedic Trauma Association. The questionnaire measured physician and practice characteristics, outcome expectations, and attitude toward physical therapy. Referral for physical therapy was based on case vignettes.

RESULTS

The response rate was 58%. Surgeons reported that 57.6% of their patients would have a positive outcome from physical therapy and 24.2% would have a negative outcome. The highest physical therapy expectations were for the appropriate use of assistive devices (80.7%) and improved strength (force-generating capacity) (76.4%). The lowest outcome expectations were for improvements in pain (35.9%), coping with the emotional aspects of disability (44.1%), and improvements in workplace limitations (51.4%). Physicians reported that 32.6% of their patients referred for physical therapy would have no improvement beyond what would occur with a surgeon-directed home exercise program. Multivariate analyses showed positive physician outcome expectations to have the largest effect on referral for physical therapy (odds ratio=2.7, P<.001).

CONCLUSIONS

The results suggest that orthopedic trauma surgeons refer patients for physical therapy based mostly on expectations for physical and motor outcomes, but may not be considering pain relief, return to work, and psychosocial aspects of recovery. Furthermore, low referral rates may be attributed to a preference for surgeon-directed home-based rehabilitation. Future research should consider the efficacy of physical therapy for pain, psychosocial and occupational outcomes, and exploring the differences between supervised physical therapy and physician-directed home exercise programs.

Unexplained severe chronic pain in general practice

The aim of this study was to estimate the prevalence of unexplained severe chronic pain (USCP) in general practice and to report medical as well as psychological descriptions of patients suffering from this condition.A total of 45 GPs in 35 different practices included patients throughout the year 1996. Patients were included according to the following criteria: between 18 and 75 years of age; pain which had lasted at least 6 months; pain is the most prominent aspect in the clinical presentation; pain is serious enough to justify clinical attention; pain has led to obvious discomfort and disability in daily life for at least for 1 month. Medical aspects were measured with the IASP taxonomy while psychological aspects were derived from the MPI. The overall prevalence of USCP was 7.91 per 1000 enlisted patients. Estimates ranged between 1.87 in the youngest age group and 13.50 in the 55-59 age category. The lower back and lower limbs were most frequently affected and 31% of the patients had pain in more than three major body sites. Pain was most frequently associated by the musculoskeletal system and most often (nearly) continuous. Mean severity of current pain was 3.7 on a scale from 0 (indicating no pain) to 6 (indicating a lot of pain). Mean rating of 'average pain in the last week' was 4.1. Regarding the psychosocial and behavioural aspects of pain, 27% of the patients could be described as perceiving severe pain while gaining social support for it. Fourteen per cent felt in the category 'pain combined with affective and relational distress' and 10% was classified as 'coping well with pain intensities lower than those of the other groups'. The other half of the patients were on average or not classifiable on these aspects. Unexplained severe chronic pain lasting more than 6 months had on overall prevalence of 7.91 per 1000 enlisted patients, ranging from 1.87 in the youngest to 13.50 in the oldest patients in these 35 general practices in The Netherlands. Our prevalence estimate of USCP is low compared to other studies on chronic pain. Probably for three reasons: Firstly, our study was confined to unexplained pain and not all chronic pain. Secondly, our inclusion criteria focused the attention of very severe chronic pain patients, and thirdly, we have defined 'chronic' as more than 6 months, while others have been using shorter time spans.

Educating patient educators: enhancing instructional effectiveness in physical therapy for low back pain patients

The objective of this research project was to study the effectiveness of a training program for the enhancement of patient education skills in physical therapy. In this paper the improvement of five of these skills is tested. These skills are aimed at a better monitoring of adherence problems during the treatment and at enhancing self-efficacy of the patient after treatment. In order to test the effectiveness of the program, complete treatments of 19 physiotherapists have been assessed before (1142 sessions, 130 patients) and after (775 sessions, 88 patients) the training program. Information on the instructions and solutions given to the patients was obtained with a registration form, completed after each session by the physiotherapist. The patient's perception of the effectiveness and feasibility of instructions was obtained from questionnaires, completed by the patient on three occasions. After the training only a minority of the trained skills appeared to be improved. All in all, the training program was not very effective. More effort is needed to develop training programs aimed at promoting patients' self-efficacy as well as measurement instruments to assess the effects of such programs.

Trends in HIV-related consultation in Dutch general practice

New medicine against AIDS and a possible changing attitude towards AIDS will affect the role of the general practitioner (GP). We aim to explore and assess the changing role of the GP in preventing and detecting AIDS, which will be done by providing insight into the changing numbers and content of HIV-related consultations in the general practice. Since 1988 a representative sample of 63 Dutch GPs have participated in a network. They recorded all face-to-face consultations with non HIV-infected patients in which the subject of AIDS was brought up. Timetrend analysis is used to investigate variations over time in the number and content of the consultations, GPs' actions and patients' characteristics. The influence of a rural or urban setting and the characteristics of the patients who are involved are also taken into account. Until 1994 a significant increase was found in the number of consultations. In highly urban areas the number of consultations is higher and still growing, whereas physicians in rural areas see fewer patients every year. The most important topic of conversation was the request for an HIV test (74%). This figure grew over the years, as did the number of tests performed. GPs became less passive and restrictive in advising tests. The group of patients has also changed, e.g. patients do not mostly belong to traditional risk groups anymore, and are significantly younger. AIDS seems to have become more familiar to patients and doctors. A lot of general information is available from different sources. Because of this change in attitude and knowledge of patients, the GPs' role as it relates to AIDS is becoming more specific in tracing infected patients and giving customized information to individuals. Patients visit their physicians less often because of concerns about AIDS, but the GP continues to fulfil a very important role in the prevention and detection of AIDS.

Incidence of severe acute renal failure in adults: results of a community based study

OBJECTIVE

To determine the age related incidence of severe acute renal failure in adults in two health districts in England.

DESIGN

Prospective study of patients identified as having severe acute renal failure within a two year period; subsequent monitoring of outcome for a further two years.

SETTING

Two health districts in Devon.

SUBJECTS

Those adults in a population of 444,971 who developed severe acute renal failure (serum creatinine concentration > 500 mumol/l) for the first time during two years, with subsequent fall of the serum creatinine concentration below the index value.

MAIN OUTCOME MEASURES AND RESULTS

125 adults (140 per million total population yearly, 172 per million adults) developed severe acute renal failure, of whom 90 (72%) were over 70. Age related incidence rose from 17 per million yearly in adults under 50 to 949 per million yearly in the 80-89 age groups. In 31 patients (25%) the cause was prostatic disease, which was related to a good prognosis (84% (26) alive at three months). Overall survival was 54% (67) at three months and 34% (42) at two years and was not significantly age related. 18 per million total population yearly (22 per million adult population) received acute dialysis. Referral rate for specialised opinion was 51 per million total population yearly with an estimated appropriate referral rate of 70 per million per year.

CONCLUSIONS

The incidence of severe acute renal failure in the community is at least twice as high as the incidence reported from renal unit based studies. Prostatic disease, a preventable and treatable problem, is the most common cause. Survival figures indicate that age alone should not be a bar to specialist referral or treatment.

Patient-related predictors of rehabilitation use for community-dwelling older Americans

OBJECTIVE

To determine patient factors that predict use of physical or occupational therapy (PT/OT) services by elderly people.

DESIGN

Time-series study of the relationship of PT/OT use to a variety of characteristics present at baseline.

PARTICIPANTS

Eight-hundred nine community-dwelling men and women aged 65 and older.

SETTING

The Medicare Screening and Health Promotion Trial at UCLA.

MAIN OUTCOME MEASURES

Use of PT/OT services, as reported in a telephone survey 1 year after initial information was obtained on the same subjects by the baseline telephonic survey.

RESULTS

Fifteen percent of the sample used PT/OT within 12 months of baseline. In multiple logistic regression analysis, PT/OT use was significantly less frequent among racial minorities, less well educated groups, and the oldest age group. PT/OT use was higher among those who had both functional disability and the presence of arthritis, heart or lung disease, or a prior history of stroke. However, neither functional disability alone nor the presence of arthritis, cardiovascular or lung disease, in the absence of limited functioning, was associated with PT/OT use. Patients who had obtained a pneumococcal vaccination or used transportation services were also more likely to receive PT/OT.

CONCLUSIONS

Our findings suggest that there may be important sociodemographic inequalities in the use of rehabilitation services and raise the possibility of inappropriate underuse in certain subgroups. Additional studies are needed to determine whether similar inequalities of PT/OT use are found in other populations and whether rehabilitation is effective in various subgroups.