Physiotherapists’ and general practitioners’ views of self-referral and physiotherapy scope of practice: results from a national trial

Acceptability of a task sharing and shifting model between family physicians and physiotherapists in French multidisciplinary primary healthcare centres: a cross-sectional survey

OBJECTIVES

The rising prevalence of musculoskeletal disorders increases pressure on primary care services. In France, patients with musculoskeletal disorders are referred to physiotherapist (PT) by family physician (FP). To improve access to musculoskeletal care, a new model of task sharing and shifting is implemented between FPs and PTs for patients with acute low back pain. This new model enables French PTs to expand their usual scope of practice by receiving patients as first-contact practitioner, diagnosing low back pain, prescribing sick leave and analgesic medication. The aim of this study is to investigate the acceptability of FPs and PTs regarding this new model.

DESIGN

A cross-sectional survey design was used. Acceptability was measured using a questionnaire on the perception of the model and the perception of PTs' skills to manage low back pain. Descriptive analyses were performed to compare results among participants.

SETTING

French FPs and PTs working in multidisciplinary primary healthcare centres were invited to complete an online survey.

PARTICIPANTS

A total of 174 respondents completed the survey (81 FPs and 85 PTs).

RESULTS

A majority of participants had a positive perception of the task sharing and shifting model. A majority of the participants were mostly or totally favourable towards the implementation of the model (FPs: n=46, 82% and PTs: n=40, 82%). The perceived level of competencies of PTs to manage acute low back pain was high. The confidence level of FPs was higher than that of PTs regarding PTs' ability to adequately diagnose low back pain, refer patient to physiotherapy and prescribe sick leave or analgesic medication.

CONCLUSION

Based on this limited sample of participants, there appears to be good acceptability of the task sharing and shifting model for acute low back pain. Additional studies are needed to better determine the factors affecting the acceptability of such a model.

Strategies to Increase Access to Outpatient Physiotherapy Services: A Scoping Review

Purpose: Multiple Canadian jurisdictions have curtailed public funding for outpatient physiotherapy services, impacting access and potentially creating or worsening inequities in access. We sought to identify evaluated organizational strategies that aimed to improve access to physiotherapy services for community-dwelling persons. Method: We used Arksey and O'Malley's scoping review methods, including a systematic search of CINAHL, MEDLINE, and Embase for relevant peer-reviewed texts published in English, French, or German, and we performed a qualitative content analysis of included articles. Results: Fifty-one peer-reviewed articles met inclusion criteria. Most studies of interventions or system changes to improve access took place in the United Kingdom (17), the United States (12), Australia (9), and Canada (8). Twenty-nine studies aimed to improve access for patients with musculoskeletal conditions; only five studies examined interventions to improve equitable access for underserved populations. The most common interventions and system changes studied were expanded physiotherapy roles, direct access, rapid access systems, telerehabilitation, and new community settings. Conclusions: Studies evaluating interventions and health system changes to improve access to physiotherapy services have been limited in focus, and most have neglected to address inequities in access. To improve equitable access to physiotherapy services in Canada, physiotherapy providers in local settings can implement and evaluate transferable patient-centred access strategies, particularly telerehabilitation and primary care integration.

Factors influencing utilization of physiotherapy services by patients and people living with disability at Busia County Referral Hospital in Kenya

Background

Physiotherapy, a component of primary health care, could be a remedy for physical challenges permeating widely in the world community due to non-communicable diseases trauma and infections.

Objectives

To establish the level of knowledge about physiotherapy and the association between level of knowledge and demographic profile among people living with disabilities and physiotherapy patients and how it influences utilization of physiotherapy services in Busia, Kenya.

Method

This was a descriptive cross-sectional quantitative study. One hundred fifty-eight participants were involved. Physiotherapy patients and people living with disabilities male and female above 18 years were purposively selected, and they completed self-administered questionnaires between August and November 2019. Data was cleaned, organized, and scientifically analyzed.

Results

Most of patients and PWD (67%) attended treatment sessions once a week only as there is inadequacy to meet their needs of treatment and it is difficult for them (87.42%) to recommend physiotherapy to others for they had lower level of knowledge of the importance of physiotherapy. The main challenge for patients and PWD to attend physiotherapy was lack of money (55.71%) and distance to hospital (63.3%).

Conclusion

Lower utilization of physiotherapy services in Busia County could be due to inadequate knowledge about physiotherapy, lack of finances to pay for physiotherapy, attitude of the health care providers towards physiotherapy, and inadequate infrastructure. There is a need to create awareness about physiotherapy and integrate physiotherapy service at all levels of practice of the components of primary health care in order for Busia community to benefit.

Evaluation of the First Contact Physiotherapy (FCP) model of primary care: a qualitative insight

OBJECTIVE

First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the qualitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against pre-agreed success criteria.

DESIGN AND SETTING

A mixed-methods 24-month service evaluation involving FCP sites across England.

METHODS

Data were collected at 2 time points, year 1 and year 2. Data were collected using individual interviews and focus groups, transcribed verbatim and analysed using a hybrid inductive and deductive thematic analysis. Participants were recruited from all stakeholder groups; patients, physiotherapists, general practitioners and administration staff.

RESULTS

A total of 6 sites were recruited over both rounds of data collection demonstrating a wide range of service models. Thirty-nine participants were recruited including fourteen patients. All six qualitative success criteria were met. GPs' discourse reflected confidence in the FCP service and competence of the FCPs. Patient discourse reflected self-efficacy and confidence in self-management techniques and reported FCP as a positive experience. FCPs saw providing advice about work related issues as integral to their role and patient discourse reflected perceived benefit from the advice offered. Staff discourse reflected a positive experience of working with, and in, the FCP services.

CONCLUSION

Ahead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful insights and recommendations to facilitate successful FCP implementation in terms of patient outcome and experience, and staff experience.

Cross-sectional UK survey of advanced practice physiotherapy: characteristics and perceptions of existing roles

Background/aims

Few studies have investigated the characteristics of advanced practice physiotherapy in the UK to evaluate current context and implementation. The aim of this study was to understand how advanced practice physiotherapy is implemented in the UK.

Methods

A cross-sectional online descriptive national questionnaire was developed, using a previous survey and literature, comprising 33 closed, Likert-scale and open questions. Data analysis was undertaken using frequencies and thematic analysis. All 646 members of the Advanced Practice Physiotherapy Network were invited to participate.

Results

A total of 142 (22% response) reported 13 job titles; 40% had experienced ≥1 title change; most (50.7%) preferred ‘advanced practice physiotherapist’. High level job satisfaction was identified but barriers prevent fulfilment of the four advanced practice physiotherapy pillars: clinical practice, leadership and management, education and research. High level clinical skills and facilitating patient pathways were key to role differentiation. Problems included lack of support, inconsistency between responsibility and reward, and no consistent framework for advanced practice physiotherapy roles.

Conclusions

Advanced practice physiotherapists are largely satisfied, but significant variation exists in titles and implementation of roles. A consistent advanced practice physiotherapy framework is required.

Physiotherapists' perspectives on barriers to implementation of direct access of physiotherapy services in the United Arab Emirates: A cross-sectional study

Background

There are two primary ways of accessing physiotherapy for service users around the world. The direct access, as opposed to the indirect access which requires a referral from a general physician, has several merits including better quality, timeliness, cost effectiveness of treatment and better probability of preventing acute conditions from turning into chronic ailments. Despite these benefits, several countries including the UAE, do not allow direct access to physiotherapists. This study aims to understand the level of awareness among practicing physiotherapists in the United Arab Emirates (UAE) about direct access and to determine whether any of their demographic variables influence the way they perceive the concept. Further, the study sought to explore the perceived barriers and benefits of direct access according to the participating physiotherapists.

Subjects and methods

An observational cross-sectional study was employed. The questionnaire survey developed by Bury and Stokes in 2013 was adapted and employed in this study. The instrument had six sections with close-ended items using a Likert five-point scale to rate them. Two hundred and sixty-four physiotherapists answered the questionnaire shared with them through a web link. Finally, MANOVA was employed to explore any influence of demographic variables on the opinions of the respondents.

Results

The findings showed that 70% of participants were aware about direct access while nearly 30% were completely unaware. Younger physiotherapists were more willing to endorse the practice whereas older ones were more apprehensive of the barriers. The main barriers reported were the limited support from the physicians and policy makers, professional autonomy, and the limited scope of practice for the physiotherapists, as well as evidence-based practice. The impact of demographic variables on direct access indicated that physiotherapists under the age of 23 endorsed direct access more strongly than other age groups.

Conclusion

More efforts are needed to implement direct access in the UAE, considering the benefits of improved professional status, cost savings, patient satisfaction, and higher efficiency. This study recommends leadership support, professional autonomy, and mentorship as possible ways to achieve this goal.

Implementing patient direct access to musculoskeletal physiotherapy in primary care: views of patients, general practitioners, physiotherapists and clinical commissioners in England

PURPOSE

Musculoskeletal problems are the leading cause of chronic disability. Most patients in the UK seek initial care from general practitioners (GPs), who are struggling to meet demand. Patient direct access to National Health Service physiotherapy is one possible solution. The purpose of this study was to understand the experiences of patients, GPs, physiotherapists and clinical commissioners on direct access in a region in England with it commissioned.

METHODS

The study was informed by Normalisation Process Theory (NTP). Data collection was via semi-structured individual face-to-face and telephone interviews with 22 patients and 20 health care professionals (HCPs). Data were analysed thematically using NPT.

RESULTS

Three themes emerged: understanding physiotherapy and the direct access pathway; negotiating the pathway; making the pathway viable. HCPs saw direct access as acceptable. Whilst patients found the concept of direct access, those with complex conditions continued to see their GP as first point of contact. Some GPs and patients reported a lack of clarity around the pathway, reflected in ambiguous paperwork and inconsistent promotion. Operational challenges emerged in cross-disciplinary communication and between HCPs and patients, and lack of adequate resources.

CONCLUSION

Direct access to NHS musculoskeletal physiotherapy is acceptable to patients and HCPs. There is need to ensure: effective communication between HCPs and with patients, clarity on the scope of physiotherapy and the direct access pathway, and sufficient resources to meet demand. Patient direct access can free GPs to focus on those patients with more complex health conditions who are most in need of their care.

Online application for self-referral of the patients with breast symptoms

Introduction

The study aimed to devise a self-referral mobile/web application for patients with new breast symptoms, giving them an outcome, thus bypassing the need for primary care consultation.

Methods

The online application was designed on the automated algorithm based on evidence-based guidelines for referral to breast onco-plastic units. A retrospective questionnaire-based anonymous survey was carried out at the breast unit in Southend University Hospital (January 2019 to March 2020). The outcome of the patients was recorded, the same data was entered in the software and its outcome was compared with their clinic outcome to assess and validate the software. Chi-square and t-test were used in formulating results.

Results

Data was collected for 366 patients who were referred urgently to the clinic. Only 50.5% (n = 186) were appropriately referred, with the main complaint being breast lump (94.1%). 39.6% of referred patients did not require a secondary care referral. Sensitivity and specificity for identifying patients requiring urgent referral was 100% and 98%, respectively.

Conclusion

A significant number of urgent referrals to breast units do not require urgent specialist referral, and this results in a big strain on the hospital service. The discussed self-referral pathway is a promising alternative with the potential to reduce workload in primary and secondary care and improve patient satisfaction.

•

Half of urgent GP referrals to Breast oncoplastic units were inappropriate.

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The proposed self-referral mobile application had 100% sensitivity and 98% specificity.

•

The app will allow to choose and book appointment thus improving compliance.

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The app will reduce inappropriate referrals and will cater to patient satisfaction .

The professional development and career journey into musculoskeletal first contact physiotherapy: a telephone interview study

(a)Background: Musculoskeletal (MSK) first contact physiotherapy (FCP) is being rolled out in the National Health Service, but limited research exists on career pathways into MSK FCP, or on pre-and-post-registration educational preparation for the knowledge and skills that are required for musculoskeletal first contact physiotherapy. (b) Objectives: From the perspectives of existing MSK FCPs, the study sought to understand the pre-and-post-registration professional developmental journey into musculoskeletal first contact physiotherapy. (c) Methods: Semi-structured interviews over the telephone were conducted with a self-selected and snowball sample of 15 MSK FCPs from across Britain. Framework analysis was used to analyze the interview transcripts. (d) Results: Four overarching themes were identified: (1) Decision to choose a career path as a MSK FCP; (2) Relevancy of pre-registration physiotherapy (PT) education for MSK FCP; (3) Relevancy of post-registration continuing professional development for MSK FCP, and; (4) Improving pre-registration PT education for the foundational knowledge and skills required to work in musculoskeletal first contact physiotherapy. Each overarching theme generated several subthemes. (e)Conclusion: The research contributes to understanding the career pathway into the MSK FCP role and showed what relevant knowledge and skills were acquired for this role at pre-and-post registration levels. Findings will inform guidance for pre-registration PT curriculum development.

Identifying goals, roles and tasks of extended scope physiotherapy in Dutch primary care- an exploratory, qualitative multi-step study

BACKGROUND

Rising healthcare costs, an increasing general practitioner shortage and an aging population have made healthcare organization transformation a priority. To meet these challenges, traditional roles of non-medical members have been reconsidered. Within the domain of physiotherapy, there has been significant interest in Extended Scope Physiotherapy (ESP). Although studies have focused on the perceptions of different stakeholders in relation to ESP, there is a large variety in the interpretation of ESP.

AIM

To identify a paradigm of ESP incorporating goals, roles and tasks, to provide a consistent approach for the implementation of ESP in primary care.

METHODS

An exploratory, qualitative multi-step design was used containing a scoping review, focus groups and semi-structured interviews. The study population consisted of patients, physiotherapists, general practitioners and indirect stakeholders such as lecturers, health insurers and policymakers related to primary care physiotherapy. The main topics discussed in the focus groups and semi-structured interviews were the goals, skills and roles affiliated with ESP. The 'framework' method, developed by Ritchie & Spencer, was used as analytical approach to refine the framework.

RESULTS

Two focus groups and twelve semi-structured interviews were conducted to explore stakeholder perspectives on ESP in Dutch primary care. A total of 11 physiotherapists, six general practitioners, five patients and four indirect stakeholders participated in the study. There was a lot of support for 'decreasing healthcare costs', 'tackling increased health demand' and 'improving healthcare effectiveness' as main goals of ESP. The most agreement was reached on 'triaging', 'referring to specialists' and 'ordering diagnostic imaging' as tasks fitting for ESP. Most stakeholders also supported 'working in a multidisciplinary team', 'working as a consultant' and 'an ESP role separated from a physiotherapist role' as roles of ESP.

CONCLUSIONS

Based on the scoping review, focus groups and interviews with direct and indirect stakeholders, it appears that there is sufficient support for ESP in the Netherlands. This study provides a clear presentation of how ESP can be conceptualized in primary care. A pilot focused on determining the feasibility of ESP in Dutch primary care will be the next step.

Algorithm-Based Online Software for Patients' Self-Referral to Breast Clinic as an Alternative to General Practitioner Referral Pathway

Introduction

The study aimed to assess the accuracy of online software in the use of self-referral to breast surgery clinics for patients with new signs and symptoms. The study also evaluated the appropriateness of GP referrals to breast clinics and evaluated patients' perceptions of an online self-referral portal to the breast clinic for the assessment of breast signs and symptoms. 

Design and methods

The pilot study was divided into two phases. In the first phase, prospective questionnaire-based data was collected from patients who were referred by a GP and presented to the regional breast unit with new signs and symptoms for breast conditions, Princess Alexandra Hospital NHS Trust (May - October 2018). The questionnaire assessed the time at each stage required by the patient to have a visit at the breast unit. It also asked the patient's opinion about an online self-referral portal to the surgical clinic. They were given hypothetical scenarios to evaluate their understanding of breast conditions. In the second phase, the patients presenting to symptomatic breast clinics were provided with the iPad to fill in their medical information in the online software. The data was collected between July and October 2019. The software algorithm was based on the National Institute of Clinical Health and Excellence (NICE) guidelines for breast conditions (2015). Breast surgeons’ recommendations acted as a standard to evaluate the accuracy of GPs' referrals and software outcome for each patient. 

Results

There were 80 patients (mean age 49.1 [SD: 17.7], all females) included in the first phase of the study. The most common clinical presentation was a breast lump (47.6%), followed by breast pain (26.9%) and nipple changes (7.9%). Breast surgeons considered appropriate 75.6% of the referrals made by the GP. Seventy-two percent of the patients got an urgent appointment to see their GP, and 94.8% of the patients were urgently referred by their GP to see the breast surgeon. Only 37.8% of the urgent referrals were correctly referred as urgent. Having a direct online referral system for breast conditions will be beneficial for patients was agreed by 78.4%. The majority (98.1%) of the participants answered correctly for the hypothetical questions requiring breast surgeon review. In the second phase, there were a total of 86 patients with a mean age of 43.9 (SD: 13.3). The most common presentation was breast lump (n=68, 79.1%) and other presentations included breast pain, nipple changes, and discharge. The GPs' accuracy of correct referral was 69.1%. One third (30.9%) of the referrals could have been managed in the community or as a routine review by the breast surgeon. In comparison, the online software's accuracy was 85.1% accurate (p=0.001). The accuracy for detecting patients who needed urgent breast clinic review was 100% for online software. 

Conclusion

A large proportion of referrals could have been dealt with in the community or referred routinely. Patients would prefer a direct online referral system to the breast clinic. They understand red flag signs and symptoms. Online software has the potential to streamline patients for symptomatic breast clinics. It can reduce the burden on the GPs who are constantly under pressure to diagnose patients accurately and refer to the correct specialty appropriately within a short time.

Orthopaedic consultant surgeons perceptions of an advanced practice physiotherapy service in paediatrics: A qualitative study

OBJECTIVES

The objective of this study is to determine orthopaedic consultants' perceptions of an advanced practice physiotherapy (APP) service in paediatrics.

DESIGN

This is a qualitative study that use semi-structured interviews to explore consultant doctors' experiences of an APP paediatric orthopaedic service and its development. Data were transcribed verbatim and subsequently underwent thematic analysis.

PARTICIPANTS

Five orthopaedic consultants in two hospital settings participated, and all of whom had experience of working with paediatric orthopaedic APPs.

RESULTS

Seven themes were derived from the analysis, with all participants in the study identifying factors affecting the development of the service and demonstrating broad support for the APP role, with benefits noted as including improved efficiency of service, expansion of skill mix within the team, positive impressions of the standard of care and improved education and liaison with the families and community practitioners at large.

CONCLUSIONS

This paper highlights many of the factors that should be considered when introducing an APP service in an outpatient setting. This study demonstrates consistent cross-site positive regard in the skill and competency of the APP in paediatric orthopaedics, to enhance orthopaedic services for children.

Advanced musculoskeletal physiotherapy practice: Informing education curricula

INTRODUCTION

Physiotherapists are operating at an advanced level of practice, usually on ad hoc basis with inhouse training, in response to the increasing burden of musculoskeletal (MSK) disorders. Discrepancies in role-specific education of advanced practice physiotherapists (APPs) creates challenges in ensuring a quality service, workforce mobility and formal recognition. This study reviewed existing MSK APP competency frameworks and education offerings, and explored physiotherapist learning needs with a view to informing international standardisation of MSK APP education curricula.

METHODS

A scoping review of the literature and relevant university and regulatory websites identified APP competency frameworks and education curricula, which were verified by international experts. Content analysis, performed on the identified competencies and modules, produced a list of themes existing in MSK advanced practice internationally. A survey based on those themes identified the learning priorities of physiotherapists (n = 25) participating in an APP symposium in Ireland.

RESULTS

Six APP competency frameworks and eleven curricula from the UK, Canada and Australia were identified. Themes emerging, regarding MSK APP practice internationally, included both entry-level physiotherapy (e.g., Assessment and Diagnosis) and traditionally medically-controlled tasks (e.g., Injection Therapy), as well as Research, Leadership, Service Development, Professional-related Matters and Education. Participating physiotherapists more commonly prioritised competencies which would be deemed beyond entry level physiotherapy skills (i.e., Radiology versus Manual Therapy).

CONCLUSION

Despite variances in profiles of APPs both between and within countries, common themes emerged regarding their expected competencies and skills. This study provides the foundation for the adoption of internationally-recognised MSK APP competencies and education standards.

Advanced musculoskeletal physiotherapy practice in Ireland: A National Survey

BACKGROUND

Since 2011, advanced practice physiotherapists (APPs) have triaged the care of patients awaiting orthopaedic and rheumatology consultant/specialist doctor appointments in Ireland. APP services have evolved across the major hospitals (n = 16) and, after 5 years, profiling and evaluation of APP services was warranted. The present study profiled the national musculoskeletal APP services, focusing on service, clinician and patient outcome factors.

METHODS

An online survey of physiotherapists in the allocated APP posts (n = 25) explored: service organization; clinician profile and experience of the advanced role; and patient wait times and outcome measures. Descriptive statistics were used to analyse hospital- and clinician-specific data, and a content analysis was performed to explore APP experiences.

RESULTS

A 68% (n = 17) response from 13 sites was achieved, whereby 20 whole-time APP posts existed in services led by 91 consultant doctors. Co-location of APP and consultant clinics at 11 sites facilitated joint medical-APP processes, with between-site differences in autonomy to screen referral letters, and arrange investigations, injections and surgery. Although 83% had postgraduate qualifications, APPs also availed themselves of informal role-specific training. Positive APP experiences related to learning opportunities and clinical support networks but experiences were consultant dependent, with further service developments and formal training required to manage workloads. APPs reported reduced wait times and most commonly chose to capture function/disability in future evaluations.

CONCLUSIONS

Variances existed in the organizational design and operating of APP services. Although highly experienced and qualified, APPs welcomed additional formal training and support, due to the complex, more medical nature of APP roles. Further formal evaluation, capturing patient outcomes, is proposed.

Medicines management activity with physiotherapy and podiatry: A systematic mixed studies review

OBJECTIVE

Making best use of existing skills to increase service capacity is a global challenge. The aim was to systematically review physiotherapy and podiatrist prescribing and medicines management activity, including evidence of impact on patient care, levels of knowledge and attitudes towards extended medicines role.

METHODS

A search of MEDLINE, CINAHL, and Cochrane databases, using terms to identify prescribing and medicines management across a range of roles, was conducted from January 1985 to May 2016 for physiotherapy, and January 1968 to May 2016 for podiatry. Hand searching of citations and databases from professional organisations was undertaken. Data were extracted and analysed descriptively, and quality appraised by 2 reviewers using the mixed methods appraisal tool.

RESULTS

1316 papers were identified, and 21 included in the review. No studies were identified that reported prescribing and no studies specific to podiatry met the inclusion criteria. Physiotherapists were highly involved in administering medicines, providing medicines advice, and recommending new medicines. Patient satisfaction, cost and outcomes were equivalent when comparing physiotherapist-led injection therapy to traditional care. Pharmacology knowledge was variable and unmet training needs identified.

CONCLUSION

Medicines management practices were identified in physiotherapy and positive outcomes of extended scope physiotherapy. There was a lack of evidence regarding podiatric practice. Review of educational preparation for medicines management is recommended along with evaluation of medicines management practice.

Views of general practitioners toward physiotherapy management of osteoarthritis-a qualitative study

Background: Osteoarthritis (OA) is a major cause of pain and physical disability, and general practitioners (GPs) are usually the first point of contact for patients. Physiotherapy has been shown as effective in the management of lower-limb OA. The aim was to explore the beliefs of GPs on the physiotherapy management of lower-limb OA in primary care. Methods: This is a qualitative study evaluating GP views about physiotherapy in Sheffield, South Yorkshire, UK. Participating GPs were recruited by systematic sampling, and invitation was given to GPs in 10 practices in the four localities in Sheffield. Semistructured interviews were completed and framework analysis was used to analyze the data. Results: Eight GPs were interviewed and six themes emerged from analysis of the data: perspective on OA, management strategy, views on patients, views on physiotherapy, working collaboratively, and suggestions for service improvements. GPs had a positive impression and knowledge of physiotherapy, but lacked understanding of the processes involved in treatment and limited awareness of clinical guidelines regarding the management of OA. Improvements in communication and collaborative working were critical issues suggested by the participants. Conclusion: This study found that GPs who were interviewed had a limited understanding on the role of physiotherapists and of clinical guidelines. Interprofessional communication was not as good as it should have been. A reconfiguration of the Sheffield musculoskeletal pathway may help achieve more effective collaborative working and a better outcome for patients.

Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial

BACKGROUND

Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes.

METHODS

This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites.

DISCUSSION

If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.

Physiotherapy-as-first-point-of-contact-service for patients with musculoskeletal complaints: understanding the challenges of implementation

BACKGROUND

Primary care faces unprecedented challenges. A move towards a more comprehensive, multi-disciplinary service delivery model has been proposed as a means with which to secure more sustainable services for the future. One seemingly promising response has been the implementation of physiotherapy self-referral schemes, however there is a significant gap in the literature regarding implementation. Aim This evaluation aimed to explore how the professionals and practice staff involved in the delivery of an in-practice physiotherapy self-referral scheme understood the service, with a focus on perceptions of value, barriers and impact. Design and setting A qualitative evaluation was conducted across two UK city centre practices that had elected to participate in a pilot self-referral scheme offering 'physiotherapy-as-a-first-point-of-contact' for patients presenting with a musculoskeletal complaint.

METHODS

Individual and focus group interviews were conducted amongst participating physiotherapists, administration/reception staff, general practitioners (GPs) and one practice nurse (in their capacity as practice partner). Interview data were collected from a total of 14 individuals. Data were analysed using thematic analysis.

RESULTS

Three key themes were highlighted by this evaluation. First, the imperative of effecting a cultural change - including management of patient expectation with particular reference to the belief that GPs represented the 'legitimate choice', re-visioning contemporary primary care as a genuine team approach, and the physiotherapists' reconceptualisation of their role and practices. Second, the impact of the service on working practice across all stakeholders - specifically re-distribution of work to 'unburden' the GP, and the critical role of administration staff. Finally, beliefs regarding the nature and benefits of physiotherapeutic musculoskeletal expertise - fears regarding physiotherapists' ability to work autonomously or identify 'red flags' were unfounded.

CONCLUSION

This qualitative evaluation draws on the themes to propose five key lessons which may be significant in predicting the success of implementing physiotherapy self-referral schemes.

Prescription medication by physiotherapists: a Brazilian view of the United Kingdom, Canada, Australia and New Zealand

Many health systems (HS) have adopted novel models of care which have included non-medical prescription (NMP) by physiotherapists. The aim of this study was to verify in the literature the existence of this practice and its possible benefits. A literature review was carried out through search on Science Direct, PubMed, SciELO, Lilacs and Google Scholar, and in the World Confederation for Physical Therapy and Chartered Society of Physiotherapy websites. In recent decades the United Kingdom adopted the NMP for health professionals, followed by Canada. In Australia and New Zealand physiotherapists have acted in the prescription and administration of medications under medical orders, which is the first step into independent prescription. Brazilian physiotherapists cannot prescribe any medication, despite of high demands from patients in the Brazilian HS, shortage of physicians in many regions and bureaucracy in accessing health services. The adoption of NMP by physiotherapists may play an important role in the HS, and it seems to be an inevitable achievement in the next years in Australia and New Zealand. The main benefits include decreasing bureaucracy for assistance, population demands for medication as well as major professional refinement.

Health-related quality of life and musculoskeletal function in patients with musculoskeletal disorders: after compared to before short-term group-based aqua-exercises

This study assessed health-related quality of life (HRQoL) and musculoskeletal function in patients with musculoskeletal disorders after participation in group-based aqua-exercising, compared to before participation. Physiotherapists instructed group-based aqua-exercising for 30 min twice a week for 8 weeks in 39 patients (81% women, mean age 55 ± 12 years), with musculoskeletal disorders located in the back (28%), neck (17%), general myalgia (21%), lower extremities (9%), shoulder (7%) and multiple/other regions (18%). Before and after the aqua-exercising, physiotherapists assessed patients’ musculoskeletal function categorized using Goal Attainment Scaling, and HRQoL was measured using EuroQol 5 Dimensions (EQ-5D). The median EQ-5D score was 0.36 (25th–75th percentiles 0.09–0.69) at the start, and after the intervention improved to 0.62 (0.09–0.73) (p = 0.038). The EQ-5D score and musculoskeletal function improved in 49% (EQ-5D) and 34% (physiotherapist assessment), were stable in 33% and 63%, and worsened in 18% and 7% of patients, respectively. In conclusion, comparable with improvements previously seen after more time-consuming exercise periods, patients with musculoskeletal disorders had improved HRQoL after 8 weeks of aqua-exercising compared to before exercising. This uncontrolled feasibility study does not reveal whether this was the result of aqua-exercising. The effects and costs need to be evaluated in randomized controlled studies.

The perception of physical therapy leaders in Saudi Arabia regarding physical therapy scope of practice in primary health care

[Purpose] To explore the views of the physical therapy service leaders in Saudi Arabia regarding the integration of physical therapy service in primary health care settings. [Subjects and Methods] A self-administered questionnaire consisting of both open and closed ended questions was distributed during May–July 2013 via email to physical therapy leaders representing different regions and health care providers in Saudi Arabia. [Results] Twenty-six participants answered the questionnaire. Eighty five percent of the sample had ≥ 10 years of experience with 57.6% of them holding a post-graduate degree. Participants were from different health care providers and represented different geographical regions of Saudi Arabia. Eighty one percent of the sample reported that the adoption of physical therapy services in primary health care would be advantageous, as it would offer earlier access to health care and would be more cost-effective. The respondents also stated that such a service would contribute towards the prevention of common non-communicable health diseases. [Conclusion] The results of this survey provide generally positive recommendations for the provision of physical therapy service in Saudi Arabia primary health care centers. However, challenges and barriers identified by this study require consideration during the development of the service.

Ordering diagnostic imaging: a survey of ontario physiotherapists' opinions on an expanded scope of practice

PURPOSE

To explore Ontario physiotherapists' opinions on their ability to order diagnostic imaging (DI).

METHODS

An online questionnaire was sent to all registered members of the College of Physiotherapists of Ontario. Descriptive statistics were calculated using response frequencies. Practice characteristics were compared using χ(2) tests and Wilcoxon rank-sum tests.

RESULTS

Of 1,574 respondents (21% response rate), 42% practised in orthopaedics and 53% in the public sector. Most physiotherapists were interested in ordering DI (72% MRI/diagnostic ultrasound, 78% X-rays/computed tomography scans). Respondents with an orthopaedic caseload of 50% or more (p<0.001) and those in the private sector (p<0.001) were more interested in ordering DI. Respondents preferred a DI course that combined face-to-face and Web-based components and one that was specific to their area of practice. Most respondents perceived minimal barriers to the uptake of ordering DI, and most agreed that support from other health care professionals would facilitate uptake.

CONCLUSION

The majority of Ontario physiotherapists are interested in ordering DI. For successful implementation of a health care change, such as physiotherapists' ability to order DI, educational needs and barriers to and facilitators of the uptake of the authorized activity should be considered.

An overview of 5 years of patient self-referral for physical therapy in the Netherlands

BACKGROUND

Self-referral for physical therapy was introduced in 2006 in the Netherlands. Internationally, debate on self-referral is still ongoing.

OBJECTIVE

The aim of this study was to evaluate the effects of self-referral for physical therapy in the Netherlands, focusing on volume of general practice and physical therapy care (incidence rates and utilization of services).

DESIGN

The study was based on monitoring data from existing data sources.

METHODS

Longitudinal electronic medical record data from general practitioners (GPs) and physical therapists participating in the NIVEL Primary Care Database were used, as well as public data from Statistics Netherlands. Descriptive statistics and Poisson multilevel regression analyses were used for analyzing the data.

RESULTS

Incidence rates of back (including low back), shoulder, and neck pain in general practice declined slightly from 2004 to 2009. No linear trends were found for number of contacts in GP care for back (including low back) and neck pain. The number of patients visiting physical therapists and the proportion of self-referrers are growing. Self-referrers receive treatment less often after initial intake than referred patients, and the mean number of visits is lower.

LIMITATIONS

This study was based on data of various patient populations from existing data sources.

CONCLUSIONS

The current study indicates that self-referral in the Netherlands has fulfilled most expectations held prior to its introduction, although no changes to the workload of GP care have been found. Use of physical therapy grew, but due to population aging and increasing prevalence of chronic diseases, it remains unclear whether self-referral affects health care utilization. Therefore, cost-benefit analyses are recommended.

Is physiotherapy self-referral with telephone triage viable, cost-effective and beneficial to musculoskeletal outpatients in a primary care setting?

OBJECTIVE

The aim of the present study was to establish if physiotherapy self-referral (SR) is viable, cost effective and beneficial to musculoskeletal outpatients in a primary care setting.

SETTING

In an urban National Health Service (NHS) primary care physiotherapy service, waiting times, attendance rates and treatment ratios (thus, episode-of-care costs) were deemed unsustainable. The introduction of 'Any Qualified Provider' is imminent and will drive NHS physiotherapy services to compete directly with private counterparts. Current literature, healthcare policy and the Chartered Society of Physiotherapy strongly advocate SR to promote value for money and improve the patient experience.

DESIGN

A repeated measure prospective cohort study introduced an SR pathway parallel to existing general practice (GP) referrals and compared costs, attendance and data relating to the patient experience across groups.

RESULTS

SR referral groups were found to have a higher proportion of female patients presenting with acute conditions. Cost minimization analysis indicated an average 32.3% reduction in episode-of-care cost with an SR-initiated intervention. An estimated cost minimization of between £84,387.80 and £124,472.06 was calculated if SR were to be expanded service-wide. SR referral reduced waiting times and improved patient satisfaction relating to waiting times and communication compared with traditional pathways.

CONCLUSIONS

The results of the present study showed that the introduction of the described SR pathway was feasible, cost-effective and offered comparable care. Certain aspects of the SR patient experience compared more favourably than those studied in traditional GP referral routes. They also added to an existing body of evidence supporting SR with a variety of administrative processes in various socioeconomic settings.

Extending the authority for sickness certification beyond the medical profession: the importance of 'boundary work'

Background

The study aimed to explore the views of general practitioners (GPs), nurses and physiotherapists towards extending the role of sickness certification beyond the medical profession in primary care.

Methods

Fifteen GPs, seven nurses and six physiotherapists were selected to achieve varied respondent characteristics including sex, geographical location, service duration and post-graduate specialist training. Constant-comparative qualitative analysis of data from 28 semi-structured telephone interviews was undertaken.

Results

The majority of respondents supported the extended role concept; however members of each professional group also rejected the notion. Respondents employed four different legitimacy claims to justify their views and define their occupational boundaries in relation to sickness certification practice. Condition-specific legitimacy, the ability to adopt a holistic approach to sickness certification, system efficiency and control-related arguments were used to different degrees by each occupation. Practical suggestions for the extension of the sickness certification role beyond the medical profession are underpinned by the sociological theory of professional identity.

Conclusions

Extending the authority to certify sickness absence beyond the medical profession is not simply a matter of addressing practical and organisational obstacles. There is also a need to consider the impact on, and preferences of, the specific occupations and their respective boundary claims. This paper explores the implications of extending the sick certification role beyond general practice. We conclude that the main policy challenge of such a move is to a) persuade GPs to relinquish this role (or to share it with other professions), and b) to understand the ‘boundary work’ involved.

Health care utilisation and out-of-pocket expenditure associated with back pain: a nationally representative survey of Australian women

BACKGROUND

Back pain impacts on a significant proportion of the Australian population over the life course and has high prevalence rates among women, particularly in older age. Back pain care is characterised by multiple practitioner and self-prescribed treatment options, and the out-of-pocket costs associated with consultations and self-prescribed treatments have not been examined to date.

OBJECTIVE

To analyse the extent of health care practitioner consultations and self-prescribed treatment for back pain care among Australian women, and to assess the self-reported costs associated with such usage.

METHODS

Survey of 1,310 women (response rate 80.9%) who reported seeking help for back pain from the '1946-51 cohort' of the Australian Longitudinal Study on Women's Health. Women were asked about their use of health care practitioners and self-prescribed treatments for back pain and the costs associated with such usage.

RESULTS

In the past year 76.4% consulted a complementary and alternative practitioner, 56% an allied health practitioner and 59.2% a GP/medical specialist. Overall, women consulted with, on average, 3.0 (SD = 2.0) different health care practitioners, and had, on average, 12.2 (SD = 9.7) discrete health care practitioner consultations for back pain. Average self-reported out-of-pocket expenditure on practitioners and self-prescribed treatments for back pain care per annum was AU$873.10.

CONCLUSIONS

Multiple provider usage for various but distinct purposes (i.e. pain/mobility versus anxiety/stress) points to the need for further research into patient motivations and experiences of back pain care in order to improve and enhance access to and continuity of care. Our results suggest that the cost of back pain care represents a significant burden, and may ultimately limit women's access to multiple providers. We extrapolate that for Australian working-age women, total out-of-pocket expenditure on back pain care per annum is in excess of AU$1.4 billion, thus indicating the prominence of back pain as a major economic, social and health burden.

Primary healthcare professionals' experiences of the sick leave process: a focus group study in Sweden

PURPOSE

The aim of this study was to explore primary healthcare (PHC) professionals' experiences of the sick leave process.

METHODS

This is an explorative study using data from four semi-structured focus group discussions with a purposeful sample of PHC professionals in Östergötland County, Sweden. Content analysis with an inductive approach was used in the analysis.

RESULTS

Four key themes emerged from the analysis; priority to the sick leave process, handling sickness certifications, collaboration within PHC and with other stakeholders, and work ability assessments. Patients' need for sick leave was handled from each professional group's perspective. Collaboration was considered important, but difficult to achieve and all the competencies available at the PHC centre were not used for work ability assessments. There was insufficient knowledge of patients' work demands and contact with an employer was rare, and the strained relationship with the social insurance officers affected the collaboration.

CONCLUSIONS

This study highlights the challenges physicians and other PHC professionals face when handling the need for sick leave, especially when encountering patients with symptom-based diagnoses, and the influence of non-medical factors. Hindrances to good practice were increased demands, collaboration, and role responsibility. The challenges in the sick leave process concerned both content and consequences related to poor collaboration within PHC and with representatives from various organizations, primarily employers and social insurance officers. Further research on how to develop a professional approach for handling the sick leave process is needed.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of 'PhysioDirect' telephone assessment and advice services for physiotherapy

BACKGROUND

As a result of long delays for physiotherapy for musculoskeletal problems, several areas in the UK have introduced PhysioDirect services in which patients telephone a physiotherapist for initial assessment and treatment advice. However, there is no robust evidence about the effectiveness, cost-effectiveness or acceptability to patients of PhysioDirect.

OBJECTIVE

To investigate whether or not PhysioDirect is equally as clinically effective as and more cost-effective than usual care for patients with musculoskeletal (MSK) problems in primary care.

DESIGN

Pragmatic randomised controlled trial to assess equivalence, incorporating economic evaluation and nested qualitative research. Patients were randomised in 2 : 1 ratio to PhysioDirect or usual care using a remote automated allocation system at the level of the individual, stratifying by physiotherapy site and minimising by sex, age group and site of MSK problem. For the economic analysis, cost consequences included NHS and patient costs, and the cost of lost production. Cost-effectiveness analysis was carried out from the perspective of the NHS. Interviews were conducted with patients, physiotherapists and their managers.

SETTING

Four community physiotherapy services in England.

PARTICIPANTS

Adults referred by general practitioners or self-referred for physiotherapy for a MSK problem.

INTERVENTIONS

Patients allocated to PhysioDirect were invited to telephone a senior physiotherapist for initial assessment and advice using a computerised template, followed by face-to-face care when necessary. Patients allocated to usual care were put on to a waiting list for face-to-face care.

MAIN OUTCOME MEASURES

Primary outcome was the Short Form questionnaire-36 items, version 2 (SF-36v2) Physical Component Score (PCS) at 6 months after randomisation. Secondary outcomes included other measures of health outcome [Measure Yourself Medical Outcomes Profile, European Quality of Life-5 Dimensions (EuroQol health utility measure, EQ-5D), global improvement, response to treatment], wait for treatment, time lost from work and usual activities, patient satisfaction. Data were collected by postal questionnaires at baseline, 6 weeks and 6 months, and from routine records by researchers blind to allocation.

RESULTS

A total of 1506 patients were allocated to PhysioDirect and 743 to usual care. Patients allocated to PhysioDirect had a shorter wait for treatment than those allocated to usual care [median 7 days vs 34 days; arm-time ratio 0.32, 95% confidence interval (CI) 0.29 to 0.35] and had fewer non-attended face-to-face appointments [incidence rate ratio 0.55 (95% CI 0.41 to 0.73)]. The primary outcome at 6 months' follow-up was equivalent between PhysioDirect and usual care [mean PCS 43.50 vs 44.18, adjusted difference in means -0.01 (95% CI -0.80 to 0.79)]. The secondary measures of health outcome all demonstrated equivalence at 6 months, with slightly greater improvement in the PhysioDirect arm at 6 weeks' follow-up. Patients were equally satisfied with access to care but slightly less satisfied overall with PhysioDirect compared with usual care. NHS costs (physiotherapy plus other relevant NHS costs) per patient were similar in the two arms [PhysioDirect £ 198.98 vs usual care £ 179.68, difference in means £ 19.30 (95% CI -£ 37.60 to £ 76.19)], while QALYs gained were also similar [difference in means 0.007 (95% CI -0.003 to 0.016)]. Incremental cost per QALY gained was £ 2889. The probability that PhysioDirect was cost-effective at a £ 20,000 willingness-to-pay threshold was 88%. These conclusions about cost-effectiveness were robust to sensitivity analyses. There was no evidence of difference between trial arms in cost to patients or value of lost production. No adverse events were detected.

CONCLUSIONS

Providing physiotherapy via PhysioDirect is equally clinically effective compared with usual waiting list-based care, provides faster access to treatment, appears to be safe, and is broadly acceptable to patients. PhysioDirect is probably cost-effective compared with usual care.

Non-medical prescribing by physiotherapists: issues reported in the current evidence

Physiotherapists should be proactive in preparing themselves to participate in innovative models of health care, which are emerging from the healthcare workforce reforms in Australia. One challenging outcome of workforce change is physiotherapy (non-medical) prescribing (NMP), which is part of the extension of scope of physiotherapy practice. This paper summarises the current evidence base for Australian physiotherapists seeking to obtain prescribing rights. A targeted literature review was undertaken through EBSCO Host, Cochrane, Medline, SportsDiscus, Cinahl, Healthsource and Google.com using broad search terms to identify peer-reviewed and grey literature pertaining to NMP by physiotherapists, nationally and internationally. No critical appraisal was undertaken however literature was structured into the NHMRC hierarchy of evidence. Themes raised in the included literature were reported descriptively. There were six relevant peer-reviewed articles, of hierarchy levels III_3 and IV. There was however, comprehensive and recent grey literature to inform Australian physiotherapy NMP initiatives. Themes included the need for standard National action in relation to legislative and regulatory/registration issues, appropriate education, credentialing and supervisory requirements for physiotherapy prescribing. Many lessons can be learnt from the literature, including the importance of planned, uniform National action (rather than piecemeal state-by-state initiatives). Essential elements include appropriate training and skills-based recognition within the discipline and the broader health team, and the need to overtly demonstrate effectiveness and safety. Regularly-evaluated service-delivery models which support NMP by physiotherapists are further required, to demonstrate efficiency, timeliness, patient centredness and equity.

A global view of direct access and patient self-referral to physical therapy: implications for the profession

BACKGROUND

International policy advocates for direct access, but the extent to which it exists worldwide was unknown.

OBJECTIVE

The purpose of this study was to map the presence of direct access to physical therapy services in the member organizations of the World Confederation for Physical Therapy (WCPT) in the context of physical therapist practice and health systems.

DESIGN

A 2-stage, mixed-method, descriptive study was conducted.

METHODS

A purposive sample of member organizations of WCPT in Europe was used to refine the survey instrument, followed by an online survey sent to all WCPT member organizations. Data were analyzed using descriptive statistics, and content analysis was used to analyze open-ended responses to identify themes.

RESULTS

A response rate of 68% (72/106) was achieved. Direct access to physical therapy was reported by 58% of the respondents, with greater prevalence in private settings. Organizations reported that professional (entry-level) education equipped physical therapists for direct access in 69% of the countries. National physical therapy associations (89%) and the public (84%) were thought to be in support of direct access, with less support perceived from policy makers (35%) and physicians (16%). Physical therapists' ability to assess, diagnose, and refer patients on to specialists was more prevalent in the presence of direct access.

LIMITATIONS

The findings may not be representative of the Asia Western Pacific (AWP) region, where there was a lower response rate.

CONCLUSIONS

Professional legislation, the medical profession, politicians, and policy makers are perceived to act as both barriers to and facilitators of direct access. Evidence for clinical effectiveness and cost-effectiveness and examples of good practice are seen as vital resources that could be shared internationally, and professional leadership has an important role to play in facilitating change and advocacy.

Defining, agreeing on, and testing an international physical therapy core data set: results of a feasibility study involving seven countries

BACKGROUND

To date, there has been no attempt to describe or compare physical therapy as practiced globally, nor any evidence that an international data set exists to support this effort. It is known that research evidence can be used in strategic and tactical ways, especially within the highly politicized context of the policy arena. The International Private Practitioners Association recognized the potential value a global evidence base could have in influencing policy and supporting professional development in a number of countries, yet it lacked a mechanism to achieve these aims.

OBJECTIVES

The purposes of this study were: (1) to identify and test an international data set, definitions, and means of data collection and (2) to establish views in relation to the value of international collaborations.

DESIGN

A mixed, prospective design was used in the study.

METHOD

Phase 1 (2006-2007) involved the development of a data set, definitions, and Web-based and paper-based data collection options involving 98 physical therapists from 68 physical therapy practices in 7 countries. Phase 2 (2008-2009) involved testing of the data set in 34 practices involving 3,195 patient episodes and included physical therapist feedback of experience, local relevance of the data set, and value of international collaborations.

RESULTS

Testing confirmed the relevance and reliability of the data set and definitions and a preference for Web-based data collection (74.0%). Physical therapist feedback supported these findings. Most respondents (60.0%-100.0%) reported the value of further international collaborations for their profession nationally or internationally.

LIMITATIONS

Although a true international collaboration, the limited sample size should be recognized.

CONCLUSIONS

It is possible to develop an agreed-upon international data set and means of data collection. Testing appears to support its acceptability and relevance for use in practice. Participants highly valued the opportunity to undertake international collaborations that may benefit their profession nationally and internationally. Further testing and use of the data set are advocated before final validation is sought.

Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care

OBJECTIVES

To evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner (GP).

DESIGN

An observational, retrospective cohort study reviewing medical records, and a separate consecutive non-randomised study of patient satisfaction.

SETTING

Primary healthcare centre.

PARTICIPANTS

Four hundred and thirty-two patients with musculoskeletal disorders, primarily assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction questionnaire.

INTERVENTIONS

Primary assessment and management of patients with musculoskeletal disorders.

MAIN OUTCOME MEASURES

Data from medical records within 3-month after the visit, and patient satisfaction questionnaire.

RESULTS

Eighty-five percent (367/432) of patients did not need to see a GP. Serious pathologies were found among the 6% (26/432) of patients who were referred to a GP by a physiotherapist, but no serious pathologies were found among the 9% (39/432) of patients who subsequently returned for a GP appointment for the same disorder. Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP. Patients also had higher confidence in the ability of physiotherapists to assess their disorder (P<0.002).

CONCLUSION

Physiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP, patients with confirmed serious pathologies were identified by the physiotherapists, and patients were satisfied with assessment by a physiotherapist.

What do GPs feel about sickness certification? A systematic search and narrative review

Abstract Objective. To identify GPs' attitudes towards sickness certification. Design. Systematic search and narrative review identifying themes around attitudes towards sickness certification. Results. Eighteen papers were identified for inclusion in the review; these included qualitative, quantitative, and systematic reviews. The papers were predominantly from Scandinavia and the UK. Three themes were identified from the literature: conflict, role responsibility, and barriers to good practice. Conflict was predominantly centred on conflict between GP and patients regarding the need for a certificate, but there was also conflict between all stakeholders. Role responsibility focused on the multiple roles GPs had to fulfil, and barriers to good practice were identified both within and outside the healthcare system. Conclusion. Any potential for changing the certification system needs to focus on reducing the potential for conflict, clarification of the roles of all stakeholders, and improving access to specialist occupational health and rehabilitation services.