Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis

BACKGROUND

Advanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians' burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD).

OBJECTIVES

To compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs.

METHODS

This trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time.

DISCUSSION

MSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05545917 . Registered on September 19, 2022.

Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department

Background

Overcrowding in emergency departments (ED) is a major concern worldwide. To answer increasing health care demands, new models of care including advanced practice physiotherapists (APP) have been implemented in EDs. The purpose of this study was to assess diagnostic, treatment and discharge plan concordance between APPs and ED physicians for patients consulting to the ED for minor musculoskeletal disorders (MSKD).

Methods

Patients presenting to two EDs in Montréal (Canada) with a minor MSKD were recruited and independently assessed by an APP and ED physician. Both providers had to formulate diagnosis, treatment and discharge plans. Cohen’s kappa (κ) and Prevalence and Bias Adjusted Kappas (PABAK) with associated 95%CI were calculated. Chi Square and t-tests were used to compare treatment, discharge plan modalities and patient satisfaction between providers.

Results

One hundred and thirteen participants were recruited, mean age was 50.3 ± 17.4 years old and 51.3% had an atraumatic MSKD. Diagnostic inter-rater agreement between providers was very good (κ = 0.81; 95% CI: 0.72–0.90). In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (κ = 0.27; PABAK = 0.27; 95% CI: 0.07–0.45; p = 0.003). There was a moderate inter-rater agreement (κ = 0.46; PABAK = 0.64; 95% CI: 0.46–0.77) for discharge plans. High patient satisfaction was reported with no significant differences between providers (p = 0.57).

Conclusion

There was significant agreement between APPs and ED physicians in terms of diagnosis and discharge plans, but more discrepancies regarding treatment plans. These results tend to support the integration of APPs in ED settings, but further prospective evaluation of the efficiency of these types of models is warranted.

Medication recommendation by physiotherapists: A survey of Québec physiotherapists' opinions regarding a new interprofessional model of care with pharmacists

BACKGROUND

To improve the efficiency of the health care system, new interprofessional models of care are emerging. In 2015, two provincial professional colleges, regulating the practice of physiotherapists and that of pharmacists in the province of Québec, Canada, developed a new interprofessional model of care. This model is designed to guide non-prescription medication recommendations by physiotherapists treating patients in primary care with neuromusculoskeletal disorders (NMSKD) with the collaboration of pharmacists.

PURPOSE

To assess Québec physiotherapists' interests to use this model and explore their opinions concerning their ability to recommend non-prescription medications to patients in primary care with NMSKD.

METHODS

An email invitation to complete an electronic survey was sent in February 2016 to all the Ordre professionnel de la physiothérapie du Québec's registered physiotherapists. The survey included a questionnaire with 31 questions divided into 5 sections. Descriptive analyses and Chi-square tests (χ² ) were performed to compare proportions (%) across demographic and clinical characteristics.

RESULTS

Two hundred twenty-five physiotherapists completed the full survey. Of these, 70% of respondents knew of the model of care, but only 15% had previously used it. Perceived workload increase was one major reason reported for this lack of use (51%). Most of the respondents had a positive perception of this model and interactions with pharmacists and were confident regarding their ability to safely recommend medication (63%). However, 63% believed that further training was necessary to enable physiotherapists to provide efficient and safe non-prescription medication recommendations to patients with NMSKD.

CONCLUSIONS

Overall, physiotherapists have a positive perception of this model, but there remain opportunities for increased integration into practice. Most respondents believe that additional training is required regarding non-prescription medication recommendations.