Physiotherapy practice in the private sector: organizational characteristics and models

Validation of the International Classification of Functioning, Disability, and Health (ICF) core set for post-acute musculoskeletal conditions in a primary care physiotherapy setting from the perspective of patients using focus groups

PURPOSE

To validate the comprehensive ICF core set for post-acute musculoskeletal conditions from the perspective of patients in a primary care physiotherapy setting.

MATERIALS AND METHODS

A qualitative study was conducted with patients suffering from musculoskeletal problems. A phenomenological approach based on focus groups was used to identify the most relevant aspects related to physical therapy care in their condition. The data were analyzed using a meaning condensation procedure, identifying relevant themes and concepts. The identified concepts were linked to the ICF and compared to the ICF core set for post-acute musculoskeletal conditions.

RESULTS

Forty-three patients were included in eight focus groups. A total of 1281 relevant concepts were extracted and related to 156 ICF second-level entities. Entities in the ICF core set for post-acute musculoskeletal conditions were 95.7% confirmed. Eighty-nine additional second-level ICF entities were identified.

CONCLUSIONS

Entities in the ICF core set for post-acute musculoskeletal conditions are relevant to patients seen in primary care physical therapy units. However, there are areas of functioning related to community health care not covered by this ICF-based tool.IMPLICATIONS OF REHABILITATIONAn ICF-based framework is feasible for the assessment of musculoskeletal conditions.Post-acute musculoskeletal ICF core set was confirmed in patient focus groups.Additional ICF categories emerged for a primary care physical therapy setting.Community features of functioning could be addressed by a tailored ICF core set.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia

OBJECTIVES

To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.

DESIGN

We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.

SETTING

Australian primary care.

PARTICIPANTS

Registered physiotherapists who are members of a practice-based research network (n=31).

RESULTS

The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.

CONCLUSION

High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Professional development needs and decision-making of new graduate physiotherapists within Australian private practice settings

INTRODUCTION

Professional development contributes to new graduate health professionals' transition into the workplace. Current literature indicates that new graduate physiotherapists are often underprepared to work within private practice settings, however little is known of their professional development needs to facilitate their transition.

OBJECTIVES

This study aimed to understand new graduate physiotherapists' perceived needs and decision-making for professional development within private practice settings.

METHODS

This study used a qualitative interpretative phenomenological approach. A sample of new graduate physiotherapists employed within private practice settings (n = 14) participated in semi-structured telephone interviews, after being selected through convenience and randomized sampling. Interview data was subject to thematic analysis.

RESULTS

Four key themes emerged from the data: 1) practical and commercial relevance; 2) influence of self and others in decision-making; 3) professional development as a social construct; and 4) access is critical.

CONCLUSION

New graduate physiotherapists expressed needs for practically and clinically relevant professional development within formal and informal settings, and this extended to non-clinical skills specific to private practice. Their decision-making was shaped by social influences and perceived barriers to access. This study has identified implications for employers and professional development providers to support and cater to new graduate physiotherapists' perceived needs for professional development, which may facilitate their transition into private practice.

The effectiveness of rehabilitation of patients with injuries as part of the Social Insurance Institution's disability prevention

BACKGROUND

Injuries are the cause of professional and social deactivation. The rehabilitation program provided under Social Security prevention pension enables earlier rehabilitation measures.

OBJECTIVE

The study's aim was to determine the efficiency of the rehabilitation as a part of Social Security prevention pension in the group of patients after limb injuries depending on the time when rehabilitation was undertaken.

METHODS

The study was a retrospective data analysis, based on medical histories of 93 patients after injuries, rehabilitated as part of Social Security prevention pension from January 2016 until July 2017. The effects of rehabilitation were assessed in 2 groups: early (up to 6 months from the injury) and late rehabilitation (over 6 months). Medical effects are based on measurements of the motion range in extremities' joints, functional test results and final evaluation of the rehabilitation.

RESULTS

For both groups, the motion range of most joints improved. Improvement among the group of early rehabilitated patients concerned everyday activities (p = 0.035), the results of medical rehabilitation (p = 0.046) and also the results of the functional tests.

CONCLUSION

Comprehensive rehabilitation of patients after the injuries in Social Security prevention pension leads to better medical effects. The results are better for earlier rehabilitated patients.

Validation of the international classification of functioning, disability, and health (ICF) core sets for musculoskeletal conditions in a primary health care setting from physiotherapists' perspective using the Delphi method

PURPOSE

To analyze the possibilities of using ICF core sets for musculoskeletal conditions in primary care physiotherapy units of the Health Service of "Castilla y León" (Spain).

METHODS

A three-round Delphi study was conducted by physiotherapists working in a primary care setting. The data obtained were linked to second-level ICF categories and their relevance was assessed by the participants. The most relevant categories were compared with those present in the existing ICF core sets for musculoskeletal conditions.

RESULTS

Eighty-four physiotherapists participated in the survey. The consensus was reached for 45 ICF categories and 5 personal factors after the survey. Thirty-five of these categories were present in the Comprehensive Core Set for post-acute Musculoskeletal Conditions. In addition, 35 categories present in the core set were not considered relevant from the participants' perspective.

CONCLUSIONS

Physiotherapists mainly considered movement-related categories as relevant. The ICF core set for post-acute musculoskeletal conditions comprises many of these categories and can therefore be taken as a basis for the adoption of ICF in the clinical context.

RELEVANCE

Primary care physiotherapists should be aware of the advantages of using ICF in their clinical settings.Implications for RehabilitationThis study shows which body functions and structures, activities and participation, environmental factors, and personal characteristics are relevant from primary care physiotherapists' perspective assessing persons with musculoskeletal conditions.The Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions includes most of the categories identified in this study, but they need to be refined to fully represent the primary care physiotherapists' perspective.The results of this study support the use of the Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions as a basis for operationalizing ICF in this clinical setting.

Greek physiotherapists' contemporary knowledge and practice for lateral elbow tendinopathy: An online survey

OBJECTIVES

To investigate physiotherapists' current knowledge and practice in the management of patients with lateral elbow tendinopathy, to explore associations between the participants' education and management preferences and to identify potential evidence-to-practice gaps by making comparisons with recent research recommendations.

DESIGN

An on-line cross-sectional survey.

SUBJECTS

Registered physiotherapists working in Greece with previous experience in the management of lateral elbow tendinopathy.

RESULTS

Three hundred and seventy eight responses met the inclusion criteria. Most responders (70.4%-91.5%) use pain provocation tests for the diagnosis of the condition, while a limited proportion uses patient rated outcome measures (6.9%-13%). Supervised exercise is the mainstay of rehabilitation (92.6%), followed by adjunctive research recommended treatment techniques such as manual therapy (72%) and advice (59.5%). Up to 83.6% of participants use adjunctive treatment techniques that are not recommended or without research recommendation (such as electrophysical agents, ice etc.). Physiotherapists with post-graduate education in musculoskeletal physiotherapy are almost three times more likely to choose only research recommended treatment approaches. There is a lack of consensus in an optimal exercise programme (type, volume, duration etc.) in patients with lateral elbow tendinopathy.

CONCLUSION

Despite research recommendations a limited use of patient rated outcome measures in lateral elbow tendinopathy is recorded. Supervised exercise is the first line treatment option for most physiotherapists, although the optimal application is still unclear. A large proportion of physiotherapists apply adjunctive treatment techniques that are either ineffective or poorly researched suggesting a substantial evidence-to-practice gap. Better access to knowledge, organisational and peer-support can potentially help to bridge this gap.

Clients and conditions encountered by final year physiotherapy students in private practice. A retrospective analysis

Currently little is known about the clients and conditions final-year physiotherapy students are exposed to in private practice settings. The aim of this study is to describe the clients and conditions encountered by final-year physiotherapy students during a six-week full-time private practice clinical placement. Client data of conditions were collected over 11 years (2008-2018) from final year physiotherapy students' client reports in a university clinic, Christchurch, New Zealand. Data for anatomical site and pathology were categorized using the Orchards Sports Injury Classification System 10 and descriptive analyses completed. Students saw a mean of 22 (SD 5) unique clients. The anatomical sites most encountered were the shoulder (97.4% of students), lumbar spine (96.3%), knee (95.8%) and ankle (91.2%). The pathologies most encountered were joint sprain (100%), muscle injury (90%), and tendon injury (88.4%). While final year physiotherapy students are exposed to a substantial number of clients encompassing major regions and condition types, this exposure is limited in scope. The findings offer a basis for discussion about what clinical exposure to clients and conditions might best support the transition from physiotherapy student to new graduate in private practice settings.

Work Readiness of New Graduate Physical Therapists for Private Practice in Australia: Academic Faculty, Employer, and Graduate Perspectives

OBJECTIVE

The purpose of this study is to explore academic faculty, employer, and recent graduate perspectives of the work readiness of Australian new graduate physical therapists for private practice and factors that influence new graduate preparation and transition to private practice.

METHODS

This study used a mixed-methods design with 3 surveys and 12 focus groups. A total of 112 participants completed a survey, and 52 participated in focus groups. Descriptive statistics were used to summarize the quantitative data, and thematic analysis was used to analyze the qualitative data. Triangulation across participant groups and data sources was undertaken.

RESULTS

Australian new graduate physical therapists were perceived to be "somewhat ready" for private practice and "ready" by their third year of employment. Participants proposed that new graduates bring enthusiasm, readiness to learn, and contemporary, research-informed knowledge. New graduates were also perceived to find autonomous clinical reasoning and timely caseload management difficult; to have limited business, marketing, and administration knowledge and skills; and to present with underdeveloped confidence, communication, and interpersonal skills. Factors perceived to influence graduate transition included private practice experience, such as clinical placements and employment; employer and client expectations of graduate capabilities; workplace support; university academic preparation and continuing education; and individual graduate attributes and skills.

CONCLUSION

Australian new graduate physical therapists have strengths and limitations in relation to clinical, business, and employability knowledge and skills. New graduate work readiness and transition may be enhanced by additional private practice experience, employer and client expectation management, provision of workplace support, and tailored university and continuing education.

IMPACT

The number of new graduate physical therapists employed in private practice in Australia is increasing; however, until this study, their work readiness for this setting was unknown. This exploration of new graduate performance in private practice and transition can help to increase understanding and enhancement of work-readiness.

The characteristics of Queensland private physiotherapy practitioners' interprofessional interactions: a cross-sectional survey study

Effective interprofessional collaboration (IPC) contributes to superior patient outcomes, facilitates cost-efficient health care, and increases patient and practitioner satisfaction. However, there is concern that IPC may be difficult to implement in clinical settings that do not conform to formal team-based processes, such as mono-professional physiotherapy private practice facilities. The aim of this study was to describe the characteristics of private physiotherapy practitioners' interprofessional interactions, including their experiences and perceptions regarding IPC. A custom developed cross-sectional online survey instrument was used to collect data from physiotherapists employed in private practice facilities in Queensland, Australia. In all, 49 (20% response rate) physiotherapists completed the survey. Only a small proportion (14%) indicated that their interprofessional interactions were a daily occurrence, and less than one-third of all respondents (31%) participated in formal, multi-professional face-to-face planned meetings. Most participants (76%) reported a moderate-to-high level of satisfaction regarding their interprofessional interactions. Despite low self-reported levels of interprofessional activity and other data indicating that IPC is necessary for holistic patient care, this study shows that physiotherapists were predominately satisfied when interacting with health practitioners from various professional backgrounds. Further research is required to inform the implementation of robust strategies that will support sustainable models of IPC in physiotherapy private practice.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study

BACKGROUND

At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings.

METHODS

The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients.

DISCUSSION

This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

Predictors of physical therapists' intentions to counsel for smoking cessation: Implications for practice and professional education

OBJECTIVE

This study explored factors predicting intention (predominant construct in social cognitive behavioral models) for smoking cessation (SC) counseling that may provide salient information for designing/targeting SC counseling training for physical therapists (PTs). Design: Cross-sectional questionnaire survey of PTs licensed to practice in Canada. Methods: Self-efficacy items and PT views were assessed for internal consistency (Cronbach's α) and data reduced using principal axis factor analysis. Hierarchical linear regression modeling assessed predictors of intention to counsel for SC. Results: Internal consistency: self-efficacy and PT views: r = 0.937, r = 0.821, respectively. Factor structures from self-efficacy: "skills and knowledge" and "clinic incidentals" (57% total variance); from PT views': "professional role" and "role modeling" (63.8% total variance). Significant predictors of intent to counsel for SC were "professional role" (β = 0.54, p ≤ 0.001), and "skills and knowledge" (β = 0.23, p ≤ 0.001). Conclusions: Physical therapists' intent to engage in SC counseling increases when they consider it their "professional role." Encouraging PTs to view SC counseling as a professional role as well as increasing SC counseling self-efficacy focusing on skills and knowledge to do so needs to be incorporated into entry-level academic physical therapy programs and continuing professional PT education.

An observational study of Australian private practice physiotherapy consultations to explore the prescription of self-management strategies

OBJECTIVE

The aim of the study was to explore the types of self-management strategies prescribed; the number of strategies and the overall length of time allocated to self-management prescription, by consultation type and by injury location, in physiotherapy consultations.

METHODS

A cross-sectional, observational study of 113 physiotherapist-patient consultations was undertaken. Regression analyses were used to determine whether consultation type and injury location were associated with the number of strategies prescribed and the length/fraction of time spent on self-management.

RESULTS

A total of 108 patients (96%) were prescribed at least one self-management strategy - commonly exercise and advice. The mean length of time spent on self-management was 5.80 min. Common injury locations were the neck (n = 40) and lower back (n = 39). No statistically significant associations were observed between consultation type or injury location for either outcome (number of strategies and the length/fraction of time allocated to self-management prescription).

CONCLUSION

Physiotherapists regularly spend time prescribing self-management strategies such as exercise, advice, and the use of heat or ice to patients receiving treatment linked to a range of injury locations. This suggests that self-management is considered to be an important adjunct to in-clinic physiotherapy. The practice implications of this are that clinicians should reflect on how self-management strategies can be used to maximize patient outcomes, and whether the allocation of consultation time to self-management is likely to optimize patient adherence to each strategy.

Variations in demand and provision for publicly funded outpatient musculoskeletal physiotherapy services across Quebec, Canada

RATIONALE

The prevalence of musculoskeletal disorders is high and expected to increase in the next decade. Persons suffering from musculoskeletal disorders benefit from early physiotherapy services. However, access to publicly funded physiotherapy services has been shown to be compromised by long waiting times and limited availability of resources in many countries around the world. Decisions on resource allocation may create geographic disparities in provision and access to services, which may result in inequity in access.

AIMS AND OBJECTIVES

This study aimed to assess variations in demand and provision of publicly funded outpatient physiotherapy services across the province of Quebec, Canada, as well as to assess the demand to provision relationship.

METHODS

We conducted a secondary analysis of data retrieved from the 2008 Quebec Health Survey and data obtained from a survey of hospitals in the province of Quebec in 2015. We used geographic information systems analyses and descriptive analyses to assess geographic variations and the relationship between demand and provision.

RESULTS

Our results indicate substantial variations in the provision and demand for physiotherapy services in the province of Quebec. The variations in service provision did not follow the variations in demand. Long waiting times and insufficient provision of services were found in many regions.

CONCLUSIONS

The variations in provision of physiotherapy services between regions reported in our study did not correspond to the variations in demand. Such geographic variations and demand to provision mismatches may create inequity in access to services, especially for those unable to afford private services.

Low Back Pain: Investigation of Biases in Outpatient Canadian Physical Therapy

BACKGROUND

Previous research suggested that physical therapy services can be influenced by patient characteristics (age, sex, socioeconomic status) or insurance status rather than their clinical need.

OBJECTIVE

The aim of this study was to determine whether patient-related factors (age, sex, SES) and the source of reimbursement for physical therapy services (insurance status) influence wait time for, frequency of, and duration of physical therapy for low back pain.

DESIGN

This study was an empirical cross-sectional online survey of Canadian physical therapy professionals (defined as including physical therapists and physical rehabilitation specialists).

METHODS

A total of 846 physical therapy professionals received 1 of 24 different (and randomly selected) clinical vignettes (ie, patient case scenarios) and completed a 40-item questionnaire about how they would treat the fictional patient in the vignette as well as their professional clinical practice. Each vignette described a patient with low back pain but with variations in patient characteristics (age, sex, socioeconomic status) and insurance status (no insurance, private insurance, Workers' Compensation Board insurance).

RESULTS

The age, sex, and socioeconomic status of the fictional vignette patients did not affect how participants would provide service. However, vignette patients with Workers' Compensation Board insurance would be seen more frequently than those with private insurance or no insurance. When asked explicitly, study participants stated that insurance status, age, and chronicity of the condition were not factors associated with wait time for, frequency of, or duration of treatment.

LIMITATIONS

This study used a standardized vignette patient and may not accurately represent physical therapy professionals' actual clinical practice.

CONCLUSIONS

There appears to be an implicit professional bias in relation to patients' insurance status; the resulting inequity in service provision highlights the need for further research as a basis for national guidelines to promote equity in access to and provision of quality physical therapy services.

Inter-Professional Practices of Private-Sector Physiotherapists for Low Back Pain Management: Who, How, and When?

Purpose: Although there have been increasing demands for health care providers to take part in inter-professional practices in recent years, very little attention has been paid to the actualization of such practices in the private sector. This study describes private-sector physiotherapists' inter-professional practices regarding low back pain (LBP) management and identifies organizational and provider-level variables associated with the intensity of such practices. Method: A total of 327 randomly selected physiotherapists were surveyed in the province of Quebec. Data were analyzed using descriptive and multiple regression analyses. Results: Physiotherapists reported frequent interactions with other physiotherapists (daily/weekly for 52.6%), family physicians (51.0%), and physiotherapy (PT) assistants (45.2%), but infrequent interactions with psychologists (3.6%), neurosurgeons (0.9%), and chiropractors (0.3%). Frequently reported means of interactions were written and oral messages sent through clients (55.1% and 24.1%, respectively), face-to-face unplanned discussions (41.9%), and faxed or mailed letters (23.2%). Variables associated with the intensity of inter-professional practices (mean of 6.7 [SD 1.7] out of 10 on the Intensity of Interprofessional Practices Questionnaire for Private Sector Physiotherapists) were related to physiotherapists' clientele, social activities with other providers, and perceptions of inter-professional practices as well as organizational models, vision, and provision of PT training. Conclusions: There is room to improve inter-professional practices with private-sector physiotherapists involved in managing LBP. Targets for action include physiotherapists and their workplaces.

Access to publicly funded outpatient physiotherapy services in Quebec: waiting lists and management strategies

PURPOSE

Problems with access to outpatient physiotherapy services have been reported in publicly funded healthcare systems worldwide. A few studies have reported management strategies aimed at reducing extensive waiting lists, but their association with waiting times is not fully understood. The purpose of this study was to document access to public outpatient physiotherapy services for persons with musculoskeletal disorders in hospitals and explore organizational factors associated with waiting time.

METHODS

We surveyed outpatient physiotherapy services in publicly funded hospitals in the province of Quebec (Canada).

RESULTS

A total of 97 sites responded (99%) to the survey. The median waiting time was more than six months for 41% of outpatient physiotherapy services. The waiting time management strategies most frequently used were attendance and cancelation policies (99.0%) and referral prioritization (95.9%). Based on multivariate analyses, the use of a prioritization process with an initial evaluation and intervention was associated with shorter waiting times (p = 0.008).

CONCLUSIONS

Our findings provide evidence that a large number of persons wait a long time for publicly funded physiotherapy services in Quebec. Based on our results, implementation of a prioritization process with an initial evaluation and intervention could help improve timely access to outpatient physiotherapy services. Implications for Rehabilitation Access to publicly funded outpatient physiotherapy services is limited by long waiting times in a great proportion of Quebec's hospitals. The use of a specific prioritization process that combines an evaluation and an intervention could possibly help improve timely access to services. Policy-makers, managers, and other stakeholders should work together to address the issue of limited access to publicly funded outpatient physiotherapy services.