Wait times for publicly funded outpatient and community physiotherapy and occupational therapy services: implications for the increasing number of persons with chronic conditions in ontario, Canada

Is Group-Based Physiotherapy a Cost-Effective Intervention Compared to Usual One-on-One Physiotherapy Care in the Management of Musculoskeletal Disorders in Active Military Personnel? An Economic Evaluation Alongside a Pragmatic Randomized Clinical Trial

OBJECTIVE: To conduct a cost-utility analysis of a group physiotherapy intervention, compared to usual care, for musculoskeletal disorders in Canadian military personnel. DESIGN: Economic evaluation alongside a pragmatic randomized clinical trial. METHODS: One hundred and twenty military members presenting with shoulder, knee, ankle, or low back pain were randomized to receive either usual one-on-one physiotherapy care or a group intervention. Cumulative health care costs were prospectively collected over 26 weeks from the perspective of the Canadian Armed Forces. The clinical outcome of the cost-utility analysis was the quality-adjusted life-year (QALY) estimated by the ED-5Q-5L (European Quality of Life 5 Dimensions 5 Level Version) at baseline, 6, 12, and 26 weeks. The incremental cost-effectiveness ratio (ICER) was estimated by the cost difference between interventions (in 2023 Canadian dollars [CAD$]) divided by the effect difference. RESULTS: The mean QALY gain was 0.011 in the group intervention, and 0.010 in the usual care. The average cost for a patient was CAD $532 in the group intervention and CAD $599 in the usual care. The ICER (-$67 000/QALY) indicated that the group intervention was cost-effective, as it costs less than usual care while providing comparable effectiveness. CONCLUSION: Group interventions were cost-effective compared to usual care for treating musculoskeletal disorders in military personnel. J Orthop Sports Phys Ther 2025;55(4):1-10. Epub 26 Feb 2025. doi: 10.2519/jospt.2025.12888.

Transitioning to a virtual post-intensive care rehabilitation service in response to the COVID-19 pandemic: results of multidisciplinary focus-groups

Background

Telehealth has vastly expanded since the SARS-CoV-2 (COVID-19) pandemic and has been widely implemented as an efficient, cost-effective and accepted means of health care delivery, including rehabilitation. Although telerehabilitation is recommended across national guidelines, there is a lack of practical guidance to support clinicians with virtual adaptations.

Aims

This study aimed to describe the key components of a safe and effective virtual post-intensive-care rehabilitation service, through qualitative exploration.

Methods

This is a qualitative study using a focus-group design based upon grounded theory. This study is nested within a service development project, taking place during the COVID-19 pandemic. Focus groups were held after the first wave of the COVID-19 pandemic with key stakeholders from the physiotherapy and critical care departments of a large tertiary hospital in the United Kingdom. Semi-structured questions were used to guide discussions, led by a facilitator and scribe. Transcripts were thematically analysed using an exploratory inductive approach by two researchers then crosschecked.

Findings

Three focus groups were attended by 12 multidisciplinary stakeholders, including six physiotherapists, two administration staff members, two critical-care follow-up nurses and two critical care consultants. Thematic analysis identified seven critical elements for virtual adaptations: (1) safety and risk assessment, (2) assessment and outcome measures, (3) virtual platform, (4) resources and equipment, (5) exercise programme adaptation, (6) exercise monitoring and safety, and (7) privacy and information governance.

Conclusion

Our findings provide practical recommendations for virtual rehabilitation service development and delivery.

Understanding transitions in care for persons with limb loss: a qualitative study exploring health care providers' perspectives

PURPOSE

To explore health care providers' (HCP) experiences related to transitions in care from inpatient rehabilitation to the community for patients with limb loss.

MATERIALS AND METHODS

A qualitative study was conducted using semi-structured interviews. Participants were eligible if they were HCPs currently working in amputation rehabilitation at a rehabilitation hospital in Ontario, Canada, with at least 1-year experience in this setting, and could speak and understand English. Data were analyzed thematically using the six-step process of the DEPICT model dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analyzing and translating.

RESULTS

Fourteen HCPs from a variety of health care professions participated in this study. Five key themes describe participants' perspectives on the factors impacting patients' transition in care following limb loss. Specifically, participants emphasized patient preparedness, HCP follow-up, finances and funding, patient self-management skills, and psychosocial support as factors that could influence the transition in care.

CONCLUSION

This study identified challenges to transitions in care for people with limb loss. Future research is needed to evaluate solutions to address these challenges in transitions in care.

Time to Reflect on Return to Sport Timing Following ACL Reconstruction

The time of return to sport following anterior cruciate ligament (ACL) reconstruction is a commonly discussed topic within clinical settings and the sports medicine literature. Emerging science has demonstrated protective effects of delaying the time of sport clearance on athlete reinjury. Though a single time cutoff is unlikely to be applicable for all athletes, large inconsistencies in the time of return to sport clearance are present in both the literature and within prescribed clinical protocols. A multitude of patient factors, such as perceived function, objective function, confidence, post-operative goals, among others, are vital for how athletes are progressed and released for sport participation. This Current Opinion article is constructed to discuss the time to return to sport after ACL reconstruction-factors that may influence timing decisions, how time is assessed within the scientific literature-and to promote discussion on this common topic within the sports medicine and athletic communities. The aim of the article is not to establish defined clinical time cutoffs for this population.

Group Physical Therapy Programs for Military Members With Musculoskeletal Disorders: A Pragmatic Randomized Controlled Trial

OBJECTIVE: To compare the effects of personalized, supervised group-based programs (ie, group physical therapy programs) and usual one-on-one physical therapy care (ie, usual physical therapy care) on disability for military personnel suffering from low back pain, rotator cuff-related shoulder pain, patellofemoral pain syndrome, or lateral ankle sprain. Secondary outcomes were pain severity, pain-related fear, health-related quality of life, and patients' satisfaction with their condition and care. DESIGN: Non-inferiority pragmatic randomized clinical trial. METHODS: One hundred twenty military personnel from the Canadian Armed Forces, experiencing 1 of 4 targeted musculoskeletal disorders, were consecutively recruited and randomly assigned to group physical therapy programs or usual physical therapy care. Disability, pain severity, pain-related fear, and health-related quality-of-life outcomes were measured at 6, 12, and 26 weeks after baseline. Satisfaction with treatment was evaluated at the end of the intervention. Intention-to-treat analyses using linear mixed models with random effects were used to compare the effects of interventions. Chi-square tests were used to compare satisfaction. RESULTS: There were no significant Time × Group interactions for any of the primary and secondary outcomes (Time × Group: P>.67). Satisfaction with treatment also did not differ between groups (P>.05). Statistically significant and clinically important improvements were observed in both groups for all outcomes after 12 weeks (Time effect: P<.01), except for health-related quality of life (P = .13). CONCLUSION: Group physical therapy programs were not inferior to usual physical therapy care for managing pain, functional capacity, and patients' satisfaction with care of military personnel presenting with various musculoskeletal disorders. Both interventions led to clinical and statistical improvement in pain and function in the mid and long term. Group physical therapy could be an effective strategy to enhance access to care. J Orthop Sports Phys Ther 2024;54(6):1-10. Epub 26 Mar 2024. doi:10.2519/jospt.2024.12342.

Accessibility of Pelvic Floor Physiotherapy for Treating Urinary Incontinence in Older Women in Quebec: An Online Survey

Purpose

This cross-sectional descriptive study describes available pelvic floor physiotherapy (PT) services for older women with urinary incontinence (UI) in Quebec, Canada, and identifies possible affordability barriers.

Methods

From September to December 2019, Quebec physiotherapists practising pelvic floor PT were invited to complete a survey on their clinical practice and perceptions of the affordability of UI treatment for older women.

Results

Eighty-four of the 225 registered pelvic floor physiotherapists (37.3%) filled out the online survey. They worked a median of 32 hours/week in PT, with 15 of those hours (46.9%) in pelvic floor PT and three hours (9.8%) treating UI in older women. Only 13.0% of them offered group treatment, while 84.3% were interested in it. Most of the physiotherapists (92.2%) had met older women in their practice who had reported financial barriers to completing their pelvic floor PT treatment.

Conclusions

The accessibility of UI care in Quebec appears hampered by the limited availability of pelvic floor PT treatments, mainly in public settings, and potential financial constraints. Providing pelvic floor PT to groups could constitute a promising avenue to tackle both issues. Future studies should look at ways of implementing this option.

Effectiveness of Virtual Reality-Based Rehabilitation Interventions in Improving Postoperative Outcomes for Orthopedic Surgery Patients

PURPOSE OF REVIEW

The surge in orthopedic surgeries strains the US healthcare system, necessitating innovative rehabilitation solutions. This review examines the potential of virtual reality (VR)-based interventions for orthopedic rehabilitation.

RECENT FINDINGS

The effectiveness of VR-based interventions in orthopedic surgery patients is scrutinized. While some studies suggest better patient-reported outcomes and satisfaction, mixed results emerge from others, demonstrating comparable or varied results compared to traditional rehabilitation. The underlying mechanisms of VR-based rehabilitation are elucidated, showing its positive impact on proprioception, pain management, agency, and balance. Challenges of unfamiliarity, patient engagement, and drop-out rates are identified, emphasizing the need for tailored approaches. VR technology's immersive environments and multisensory experiences offer a novel approach to addressing functional deficits and pain post-surgery. The conclusion drawn is that VR-based rehabilitation complements rather than replaces conventional methods, potentially aiding in pain reduction and functional improvement. VR-based rehabilitation holds promise for enhancing orthopedic surgery outcomes, presenting a dynamic approach to recovery. Its potential to reshape healthcare delivery and reimbursement structures underscores its significance in modern healthcare. Overall, VR-based rehabilitation offers a promising avenue for optimizing postoperative recovery in orthopedic surgery patients.

Prognostic factors for persistent symptoms in adults with mild traumatic brain injury: an overview of systematic reviews

BACKGROUND

Mild traumatic brain injury (mTBI) is an increasing public health problem, because of its persistent symptoms and several functional consequences. Understanding the prognosis of a condition is an important component of clinical decision-making and can help to guide the prevention of persistent symptoms following mTBI. The prognosis of mTBI has stimulated several empirical primary research papers and many systematic reviews leading to the identification of a wide range of factors. We aim to synthesize these factors to get a better understanding of their breadth and scope.

METHODS

We conducted an overview of systematic reviews. We searched in databases systematic reviews synthesizing evidence about the prognosis of persistent symptoms after mTBI in the adult population. Two reviewers independently screened all references and selected eligible reviews based on eligibility criteria. They extracted relevant information using an extraction grid. They also rated independently the risk of bias using the ROBIS tool. We synthesized evidence into a comprehensive conceptual map to facilitate the understanding of prognostic factors that have an impact on persistent post-concussion symptoms.

RESULTS

From the 3857 references retrieved in a database search, we included 25 systematic reviews integrating the results of 312 primary articles published between 1957 and 2019. We examined 35 prognostic factors from the systematics reviews. No single prognostic factor demonstrated convincing and conclusive results. However, age, sex, and multiple concussions showed an affirmatory association with persistent post-concussion outcomes in systematic reviews.

CONCLUSION

We highlighted the need for a comprehensive picture of prognostic factors related to persistent post-concussion symptoms. We believe that these prognostic factors would guide clinical decisions and research related to prevention and intervention regarding persistent post-concussion symptoms.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020176676.

Physiotherapists’ Perspectives on Type 2 Diabetes Management and as a Primary Condition for Referral to Physiotherapy Services: A Qualitative Descriptive Study

Purpose:

We explored the current and potential role of physiotherapists in the management of people with type 2 diabetes (T2D) and T2D as a primary condition for physiotherapy referral.

Method:

We conducted a qualitative descriptive study. Participants were physiotherapists practicing in community and outpatient settings across Canada. One-on-one telephone interviews were completed to explore provision of physiotherapy care for people with T2D, including current practices and readiness of physiotherapists to provide direct care. We employed thematic analysis for generation of themes from interviews.

Results:

We interviewed 21 participants from eight provinces and territories. Three themes were generated from the data: current approach to T2D management; challenges for physiotherapy integration; and merits of physiotherapy and needed evolution. Participants described that physiotherapists are not part of the healthcare team for T2D management. There is a gap in medical management of T2D that physiotherapy would fill, that is, education and prescription for exercise participation.

Conclusions:

Our findings support a gap in the management of T2D in Canadian healthcare, particularly in reference to physiotherapy. Further, our findings support the need for greater inclusion of physiotherapists for lifestyle counseling with an emphasis on physical activity and exercise for patients at risk of and with T2D to maximize health and improve/maintain function. Studies focusing on accessibility and funding of physiotherapy services are needed to validate these findings.

Signs of Inequitable Access: Users of Private Physiotherapy Services Do Not Reflect the Urban Population in Winnipeg, Manitoba

Purpose: Both private and public funding cover outpatient physiotherapy (PT) in Canada. Knowledge is lacking in who does and does not access PT services, which limits the ability to identify health/access inequities created by current financing structures. This study characterizes the individuals accessing private PT in Winnipeg to better understand whether inequities exist, given the very limited publicly financed PT. Methods: Patients attending PT in 32 private businesses, sampled for geographic variation, completed a survey online or on paper. We compared the sample's demographic characteristics with Winnipeg population data using chi-square goodness-of-fit tests. Results: In total, 665 adults accessing PT participated. Respondents were older and had higher levels of income and education compared to Winnipeg census data (p < 0.001). Our sample included higher proportions of female and White individuals, and lower proportions of Indigenous persons, newcomers, and people from visible minorities (p < 0.001). Conclusions: There are signs that inequities exist in access to PT in Winnipeg; the cohort who access private PT services does not reflect the wider population, which suggests that some segments of the population are not receiving care.

"It feels like an endless fight": a qualitative study exploring healthcare utilization of persons with rheumatic conditions waiting for pain clinic admission

Background

Individuals living with a rheumatic pain condition can face delays in accessing pain clinics, which prevents them from receiving timely treatment. Little is known regarding their specific healthcare utilization in order to alleviate pain while waiting to obtain services in pain clinics. Hence, the aim of this study was to explore the perceptions and experiences of persons living with rheumatic conditions regarding healthcare utilization while waiting to access a pain clinic.

Methods

In this qualitative descriptive study, semi-structured interviews were conducted with adults living with a painful rheumatic condition that reported either being waiting for admission in a pain clinic, having been referred but then denied pain clinic services, or having received services during the previous six months, in the province of Quebec, Canada. The interviews were transcribed verbatim, and an inductive thematic analysis was performed.

Results

Twenty-six individuals were interviewed (22 women and 4 men; mean age 54 ± 10 years). Three themes were identified: 1) lacking guidance in identifying solutions to their complex and multidimensional needs, 2) struggling to obtain and maintain services due to systemic access barriers, and 3) displaying resilience through a search for accessible and sustainable self-management strategies.

Conclusions

The current approaches and structures of health services fail to adequately answer the service needs of individuals experiencing painful rheumatic conditions. Important shifts are required in pain education, in increasing access to multidisciplinary approaches at the primary care level and in breaking down barriers individuals with chronic pain face to receive appropriate and timely care.

Group-based exercice training programs for military members presenting musculoskeletal disorders - protocol for a pragmatic randomized controlled trial

BACKGROUND

Musculoskeletal disorders are a leading cause of morbidity and the most prevalent source of disability among soldiers. Their high prevalence in armed forces and limited ressources have led to problems related to access to physical rehabilitation care. To increase access, supervised group-based exercise programs for the most prevalent musculoskeletal disorders (low back pain, patellofemoral pain, rotator cuff-related shoulder pain or lateral ankle sprain) have been developed at a Canadian Armed forces (CAF) base, but their effectiveness has not been evaluated. The primary objective of this randomized controlled trial is to evaluate the mid- and long-term effects of these group-based training programs on pain severity and functional limitations, in comparison with usual individual physiotherapy care. Secondary objectives include comparing both interventions in terms of health-related quality of life, pain-related fear, and patients' satisfaction.

METHODS

One hundred and twenty soldiers with a new medical referral for physiotherapy services for one of the four targeted musculoskeletal disorders will be consecutively recruited. They will be randomly assigned to either group-based training program or usual individual physiotherapy care, and will take part in the assigned 12-week intervention. There will be four evaluation sessions over 26 weeks (baseline, week 6, 12 and 26). At each follow-up, functional limitations, pain severity, health-related quality of life and pain-related fears will be assessed. Patients satisfaction with treatment will also be evaluated at the end of the intervention period. Either two-way repeated measures ANOVA will be used to analyse and compare the effects of the interventions.

DISCUSSION

This RCT will determine the effectiveness of group-based training programs compared to usual individual physiotherapy care. This new intervention model could represent an efficient, and more pro-active approach to manage a higher number of soldiers with musculoskeletal disorders. It could improve access to physical rehabilitation care and improve the health of soldiers.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT05235152 ), February 11th 2022.

Strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities: A systematic literature review

Objective

Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities.

Methods

We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted.

Results

Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy ( n = 11), occupational therapy ( n = 2), prosthetics ( n = 1), exercise physiology ( n = 1) and multidisciplinary ( n = 4) services. The methodological quality varied ( n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services.

Conclusions

This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

A telephone assessment and advice service within an ED physiotherapy clinic: a single-site quality improvement cohort study

BACKGROUND

In response to issues with timely access and high non-attendance rates for Emergency Department (ED) physiotherapy, a telephone assessment and advice service was evaluated as part of a quality improvement project. This telehealth option requires minimal resources, with the added benefit of allowing the healthcare professional streamline care. A primary aim was to investigate whether this service model can reduce wait times and non-attendance rates, compared to usual care. A secondary aim was to evaluate service user acceptability.

METHODS

This was a single-site quality improvement cohort study that compares data on wait time to first physiotherapy contact, non-attendance rates and participant satisfaction between patients that opted for a service based on initial telephone assessment and advice, versus routine face-to-face appointments. 116 patients were referred for ED physiotherapy over the 3-month pilot at the ED and out-patient physiotherapy department, XMercy University Hospital, Cork, Ireland. 91 patients (78%) opted for the telephone assessment and advice service, with 40% (n=36) contacting the service. 25 patients (22%) opted for the face-to-face service. Data on wait time and non-attendance rates was gathered using the hospital data reporting system. Satisfaction data was collected on discharge using a satisfaction survey adapted from the General Practice Assessment Questionnaire. Independent-samples t-test or Mann Whitney U Test was utilised depending on the distribution of the data. For categorical data, Chi-Square tests were performed. A level of significance of p ≤ 0.05 was set for this study.

RESULTS

Those that contacted the telephone assessment and advice service had a significantly reduced wait time (median 6 days; 3-8 days) compared to those that opted for usual care (median 35 days; 19-39 days) (p ≤ 0.05). There was no significant between-group differences for non-attendance rates or satisfaction.

CONCLUSION

A telephone assessment and advice service may be useful in minimising delays for advice for those referred to ED Physiotherapy for musculoskeleltal problems. This telehealth option appears to be broadly acceptable and since it can be introduced rapidly, it may be helpful in triaging referrals and minimising face-to-face consultations, in line with COVID-19 recommendations. However, a large scale randomised controlled trial is warranted to confirm these findings.

Making Decisions about Service Provision for Clients with Low Back Pain: Perspectives of Canadian Physiotherapy Professionals

Purpose: This study identified the individuals responsible for making decisions about physiotherapy (PT) wait time, frequency of treatment, and treatment duration for persons with low back pain and determined which factors guided these decisions. Method: A cross-sectional survey was sent to Canadian PT professionals treating adult patients with musculoskeletal problems. It included a clinical vignette describing a patient with low back pain. Respondents were asked who made decisions about wait time, treatment frequency, and treatment duration as well as on which factors they based these decisions. Results: Clinicians were most often responsible for making decisions about treatment frequency and duration. Although clinicians and managers or coordinators were mainly responsible for making decisions about wait time, there was more variability depending on sector of care: in the private sector, administrative assistants played a much larger role. Clinical judgment, clinical guidelines, and patients’ demands were the predominant factors influencing wait time and frequency decisions. Treatment duration was related to patients’ goals, clinical progression, patients’ motivation, and patients’ return to work. Conclusions: Decisions about service provision for wait times are made by a range of stakeholders, and a wide variety of factors guide Canadian PT professionals’ decision making. Identifying these factors is essential for informing a discussion of decisions about evidence-based and equitable service delivery so that the actors involved can reach a consensus.

Prioritization of patients access to outpatient augmentative and alternative communication services in Quebec: a decision tool

Purpose: A large number of people living with a chronic disability wait a long time to access publicly funded rehabilitation services such as Augmentative and Alternative Communication (AAC) services, and there is no standardized tool to prioritize these patients. We aimed to develop a prioritization tool to improve the organization and access to the care for this population.Methods: In this sequential mixed methods study, we began with a qualitative phase in which we conducted semi-structured interviews with 14 stakeholders including patients, their caregivers, and AAC service providers in Quebec City, Canada to gather their ideas about prioritization criteria. Then, during a half-day consensus group meeting with stakeholders, using a consensus-seeking technique (i.e. Technique for Research of Information by Animation of a Group of Experts), we reached consensus on the most important prioritization criteria. These criteria informed the quantitative phase in which used an electronic questionnaire to collect stakeholders' views regarding the relative weights for each of the selected criteria. We analyzed these data using a hybrid quantitative method called group based fuzzy analytical hierarchy process, to obtain the importance weights of the selected eight criteria.Results: Analyses of the interviews revealed 48 criteria. Collectively, the stakeholders reached consensus on eight criteria, and through the electronic questionnaire they defined the selected criteria's importance weights. The selected eight prioritization criteria and their importance weights are: person's safety (weight: 0.274), risks development potential (weight: 0.144), psychological well-being (weight: 0.140), physical well-being (weight: 0.124), life prognosis (weight: 0.106), possible impact on social environment (weight: 0.085), interpersonal relationships (weight: 0.073), and responsibilities and social role (weight: 0.054).Conclusion: In this study, we co-developed a prioritization decision tool with the key stakeholders for prioritization of patients who are referred to AAC services in rehabilitation settings.IMPLICATIONS FOR REHABILIATIONStudies in Canada have shown that people in Canada with a need for rehabilitation services are not receiving publicly available services in a timely manner.There is no standardized tool for the prioritization of AAC patients.In this mixed methods study, we co-developed a prioritization tool with key stakeholders for prioritization of patients who are referred to AAC services in a rehabilitation center in Quebec, Canada.

Effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders: a systematic review

PURPOSE

This systematic review aimed to assess the scientific evidence on the effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders.

METHODS

A literature search was conducted in three databases (Medline, CINAHL, and Embase) for articles assessing the effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders. Clinical and health system outcomes were analyzed.

RESULTS

Sixteen studies met the inclusion criteria for this review. The studies varied in designs, settings, and populations. The definition of waiting also varied between studies. The studies were of low to high methodological quality. Waiting for outpatient physiotherapy services was shown to have mixed results on clinical and health system outcomes. Results from included studies suggest the possible detrimental effects of waiting on pain, disability, quality of life, and psychological symptoms in persons with musculoskeletal disorders. There was also evidence of higher healthcare utilization and costs for patients who wait longer before physiotherapy services.

CONCLUSIONS

This review provides mixed evidence that suggest potential detrimental effects on the health of individuals with MSDs and at the health system level. Further high-quality studies are needed, such as longitudinal studies specifically addressing the effects of waiting due to lack of access to physiotherapy services.IMPLICATIONS FOR REHABILITATIONThe findings from this review suggest potential detrimental effects on health outcomes when patients wait longer before receiving physiotherapy services.The findings also suggest higher healthcare utilization and costs for patients with longer wait times compared to those who receive physiotherapy services more rapidly.This review suggests the need to assess and implement strategies and policies to ensure timely access to physiotherapy.

A Preliminary Analysis of a Home-Based Stroke Rehabilitation Program in Windsor, Ontario

Community stroke rehabilitation (CSR) is an effective program for survivors to recover at home supported by a multidisciplinary team. A home-based, specialized CSR program was delivered in Windsor, Ontario, to stroke patients who faced barriers to accessing outpatient services following inpatient rehabilitation. Preliminary results show program patients made significant functional improvements from baseline to program discharge. A subgroup analysis revealed that, after adjusting for age and resource intensity, moderate to severe stroke patients made greater functional gains compared to mild stroke patients. The individualized focus of CSR delivered in the home provides an effective model of rehabilitation for continued stroke care in the community.

Patient prioritization tools and their effectiveness in non-emergency healthcare services: a systematic review protocol

BACKGROUND

Waiting lists should be managed as fairly as possible to ensure that patients with greater or more urgent needs receive services first. Patient prioritization refers to the process of ranking referrals in a certain order based on various criteria with the aim of improving fairness and equity in the delivery of care. Despite the widespread use of patient prioritization tools (PPTs) in healthcare services, the existing literature on this subject has mainly focused on emergency settings. Evidence has not been synthesized with respect to all the non-emergency services.

METHODS

This review aims to perform a systematic synthesis of published evidence concerning (1) prioritization tools' characteristics, (2) their metrological properties, and (3) their effect measures across non-emergency services. Five electronic databases will be searched (Cochrane Library, Ovid/MEDLINE, Embase, Web of Science, and CINAHL). Eligibility criteria guiding data selection will be (1) qualitative, quantitative, or mixed methods empirical studies; (2) patient prioritization in any non-emergency setting; and (3) discussing characteristic, metrological properties, or effect measures. Data will be sought to report tool's format, description, population, setting, purpose, criteria, developer, metrological properties, and outcome measures. Two reviewers will independently screen, select, and extract data. Data will be synthesized with sequential exploratory design method. We will use the Mixed Methods Appraisal Tool (MMAT) to assess the quality of articles included in the review.

DISCUSSION

This systematic review will provide much-needed knowledge regarding patient prioritization tools. The results will benefit clinicians, decision-makers, and researchers by giving them a better understanding of the methods used to prioritize patients in clinical settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018107205.

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: Current Patterns of Canadian Physiotherapy Service Delivery

Purpose: The aim of this study was to describe the current patterns of service delivery of Canadian physiotherapy (PT) professionals working in adult musculoskeletal (MSK) outpatient practice. Methods: A total of 846 Canadian PT professionals working with an adult MSK outpatient clientele participated in an online survey about how they would treat a patient with low back pain (LBP). After reading an online clinical vignette about a fictional patient with varying insurance status, participants answered questions about how they would treat the patient (e.g., wait time, frequency and duration of treatment, time allotted for initial evaluation and treatment), about their actual practice (e.g., number of patients seen per day), and about their work setting. Results: The vignette patients with LBP would typically be seen within 2 weeks, especially in private practice, and most would receive care 2-3 times per week for 1-3 months. Initial evaluations and subsequent treatments would take 31-60 minutes. Two-thirds of participants reported treating 6-15 patients a day in their current practice setting. Differences were found between provinces and territories (with the longest wait time in Quebec), practice settings (with a longer wait time in the public sector), and insurance status (patients covered by workers' compensation are seen more frequently). Conclusion: This study adds to our knowledge of the accessibility of outpatient MSK PT services for patients with LBP in Canada, and it points to potential areas for improvement.

Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System

Background: Physiotherapy and occupational therapy services can play a critical role in maintaining or improving the physical functioning, quality of life, and overall independence of older home care clients. Despite their importance, however, there is limited understanding of the factors that influence how rehabilitation services are allocated to older home care clients. The aim of this pilot study was to develop a preliminary understanding of the factors that influence decisions to allocate rehabilitation therapy services to older clients in the Ontario home care system, as perceived by three stakeholder groups. Methods: Semi-structured interviews were conducted with 10 key informants from three stakeholder groups: case managers, service providers, and health system policymakers. Results: Drivers of the allocation of occupational therapy and physiotherapy for older adults included functional needs and postoperative care. Participants identified challenges in providing home care rehabilitation to older adults, including impaired cognition and limited capacity in the home care system. Conclusions: Considering the changing demands for home care services, knowledge of current practices across the home care system can inform efforts to optimize rehabilitation services for the growing number of older adults. Further research is needed to advance the understanding of, and optimize rehabilitation service allocation to, older frail clients with multiple morbidities. Developing novel decision-support mechanisms and standardized clinical care pathways for older client populations may be beneficial.

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.

Patients' perceptions of navigating "the system" for arthritis management: are they able to follow our recommendations?

PURPOSE

To understand whether a visit to a Hip/Knee Arthritis Assessment Centre (AC), where non-surgical candidates with arthritis are directed toward community resources and provided with a conservative treatment "prescription," contributes to patients' self-management and ability to access community resources.

METHODS

A purposive sample of non-surgical patients was contacted 3-10 months after their AC visit. Three focus groups (n=20) and 20 semi-structured telephone interviews were conducted. Transcripts were systematically coded and analyzed using a qualitative descriptive research methodology.

RESULTS

While participants generally reported that the AC visit improved self-management, analysis identified an emergent theme about the inadequacy of conservative management in general, subdivided into two sub-themes related to (1) limited access to high-quality, non-surgical treatment, such as physiotherapy and (2) health care providers' attitudes and approaches, which do not embrace chronic disease prevention and management.

CONCLUSIONS

An AC visit contributes to arthritis self-management; however, the current health care system does not adequately support conservative treatment of chronic conditions. Treatment guidelines need to be tailored to the local health care context in which they are applied.

Wait times for physical and occupational therapy in the public system for people with arthritis in quebec

PURPOSE

Although arthritis is the leading cause of pain and disability in Canada, and physical therapy (PT) and occupational therapy (OT) are beneficial both for chronic osteoarthritis (OA) and for inflammatory arthritis such as rheumatoid arthritis (RA), there appear to be problems with access to such services. The aim of this study was to document wait times from referral by physician to consultation with PT or OT in the public health care system for people with arthritis in Quebec, Canada.

METHOD

Appointments were requested by telephone, using hypothetical case scenarios; wait times were defined as the time between initial request and appointment date. Descriptive statistics were used to examine the wait times in relation to diagnosis, service provider and geographic area.

RESULTS

For both scenarios (OA and RA) combined, 13% were offered an appointment within 6 months, 13% offered given an appointment within 6-12 months, 24% were told they would need to wait longer than 12 months, and 22% were refused services. The remaining 28% were told they would require an evaluation appointment for functional assessment before being given an appointment for therapy. No difference was found between RA and OA diagnoses.

CONCLUSIONS

Our study suggests that most people with arthritis living in the province of Quebec are not receiving publicly accessible PT or OT intervention in a timely manner.

The distribution of physiotherapists in ontario: understanding the market drivers

PURPOSE

To understand the factors that affect the distribution of physiotherapists in Ontario by examining three potential influences in the multi-payer physiotherapy (PT) market: population need, critical mass (related to academic health science centres [AHSCs]), and market forces.

METHODS

Physiotherapist density and distribution were calculated from 2003 and 2005 College of Physiotherapists of Ontario registration data. Physiotherapists' workplaces were classified as not-for-profit (NFP) hospitals, other NFP, or for-profit (FP), and their locations were classified by census division (CD) types (cities and counties).

RESULTS

Physiotherapist density varied significantly and distribution was neither uniformly responsive to population need, nor driven primarily by market forces. The largest factor was an AHSC in a CD; physiotherapists locate disproportionately in NFP hospitals in AHSCs rather than in the growing FP sector.

CONCLUSIONS

While some patterns can be discerned in the distribution and densities of physiotherapists across Ontario, further work needs to be done to identify why population need and market forces appear to be less influential, and why CDs with AHSCs are so attractive to physiotherapists. With this additional information, it may be possible to identify ways to influence uneven distribution in the future.

Models of integrating physical therapists into family health teams in ontario, Canada: challenges and opportunities

PURPOSE

To explore the potential for different models of incorporating physical therapy (PT) services within the emerging network of family health teams (FHTs) in Ontario and to identify challenges and opportunities of each model.

METHODS

A two-phase mixed-methods qualitative descriptive approach was used. First, FHTs were mapped in relation to existing community-based PT practices. Second, semi-structured key-informant interviews were conducted with representatives from urban and rural FHTs and from a variety of community-based PT practices. Interviews were digitally recorded, transcribed verbatim, and analyzed using a categorizing/editing approach.

RESULTS

Most participants agreed that the ideal model involves embedding physical therapists directly into FHTs; in some situations, however, partnering with an existing external PT provider may be more feasible and sustainable. Access and funding remain the key issues, regardless of the model adopted.

CONCLUSION

Although there are differences across the urban/rural divide, there exist opportunities to enhance and optimize existing delivery models so as to improve client access and address emerging demand for community-based PT services.

Exploring wait list prioritization and management strategies for publicly funded ambulatory rehabilitation services in ontario, Canada: further evidence of barriers to access for people with chronic disease

BACKGROUND

Timely access to publicly funded health services is a priority issue across the healthcare continuum in Canada. The purpose of this study was to examine wait list management strategies for publicly funded ambulatory rehabilitation services in Ontario, Canada.

METHODS

Ambulatory rehabilitation services were defined as community occupational therapy (OT) and physiotherapy (PT) services. A mailed self-administered questionnaire was sent to all 374 Ontario publicly funded sites. Descriptive statistics were used to explore management strategies.

RESULTS

The response rate was 57.2%. Client acuity was the most common method used to prioritize access across all settings. The most frequently reported methods to manage wait lists included teaching self-management strategies (85.0%), implementing attendance policies (69.5%) and conducting wait list audits (67.3%).

CONCLUSION

Ambulatory rehabilitation settings have implemented a number of strategies for wait list management. The results of this study suggest that an increasing number of Ontarians encounter barriers when accessing publicly funded ambulatory rehabilitation services.