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- Bornhöft, Lena, et al.
(author)
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Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial
- 2019
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In: Therapeutic Advances in Musculoskeletal Disease. - : SAGE Publications. - 1759-720X .- 1759-7218. ; 11
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Journal article (peer-reviewed)abstract
- Background: Physiotherapists and general practitioners (GPs) both act as primary assessors for patients with musculoskeletal disorders in primary care. Previous studies have shown that initial triaging to physiotherapists at primary healthcare centres has advantages regarding efficiency in the work environment and utilization of healthcare. In this study, we aimed primarily to determine whether triaging to physiotherapists affects the progression of health aspects over time differently than traditional management with initial GP assessment. The secondary aim was to determine whether triaging to physiotherapists affects patients' attitudes of responsibility for musculoskeletal disorders. Methods: This was a pragmatic trial where both recruitment and treatment strategies were determined by clinical, not study-related parameters, and was initiated at three primary care centres in Sweden. Working-age patients of both sexes seeking primary care for musculoskeletal disorders and nurse assessed as suitable for triaging to physiotherapists were randomized to initial consultations with either physiotherapists or GPs. They received self-assessment questionnaires before the initial consultation and were followed up at 2, 12, 26 and 52 weeks with the same questionnaires. Outcome measures were current and mean (3 months) pain intensities, functional disability, risk for developing chronic musculoskeletal pain, health-related quality of life and attitudes of responsibility for musculoskeletal conditions. Trends over time were analysed with a regression model for repeated measurements. Results: The physiotherapist-triaged group showed significant improvement for health-related quality of life at 26 weeks and showed consistent but nonsignificant tendencies to greater reductions of current pain, mean pain in the latest 3 months, functional disability and risk for developing chronic pain compared with traditional management. The triage model did not consistently affect patients' attitudes of responsibility for musculoskeletal disorders. Conclusions: Triaging to physiotherapists for primary assessment in primary care leads to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with musculoskeletal disorders. ClinicalTrials.gov identifier: NCT148611.
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| 2. |
- Bornhöft, Lena, et al.
(author)
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More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment.
- 2019
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In: BMC musculoskeletal disorders. - : Springer Science and Business Media LLC. - 1471-2474. ; 20:1
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Journal article (peer-reviewed)abstract
- A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment.Nurse-assessed patients with MSD (N=55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results.The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis.From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings.ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.
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| 3. |
- Bornhöft, Lena
(author)
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Direct triaging to physiotherapist in primary care - development and evaluation of a triage model
- 2019
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Doctoral thesis (other academic/artistic)abstract
- Background: There is evidence that early contact with physiotherapists leads to advantages for patients with musculoskeletal disorders. Many patients, however, initially seek contact with general practitioners (GPs) within primary care for musculoskeletal disorders. This often delays or replaces physiotherapist contact. Management interventions which ensure that appropriate patients are initially examined by physiotherapists may lead to advantages for patients, the healthcare system and the community. Aim: The general aim for this thesis was to develop a triage model for primary care with focus on musculoskeletal disorders and evaluate its effects on patients’ health and attitudes as well as on its effects for other relevant stake-holders. Methods: Paper I is a descriptive study examining the development process of the triage model and its effects on access and efficiency at a primary healthcare centre. Paper II is a case-control study which compares the utilization of medical services between patients with musculoskeletal disorders, who were triaged directly to physiotherapist for initial assessment and treatment, and similar patients who were initially assessed by a GP. Paper III is based on a randomized controlled trial (RCT) and evaluates the effects of direct triaging to physiotherapist on patients’ health and attitudes. Paper IV is a cost-effectiveness assessment, which compares the costs in relation to health effects for patients who have been triaged directly to physiotherapists, and is based on the same RCT as Paper III. Results: The triage model led to increased access, more efficient use of the personnel, greater patient satisfaction and a better work environment compared with the traditional primary care management model which was employed earlier. Patients who were triaged directly to physiotherapists utilized significantly fewer medical services during the following year compared to patients with initial contact with GPs in the retrospective study. Various health aspects, such as progression of pain, function and risk for chronicity, showed common tendencies to better values for the group initially assessed by physiotherapists in the RCT, and health-related quality of life was significantly improved. It is unclear how patient attitudes of responsibility for musculoskeletal disorders were affected by triaging to physiotherapists. The cost-efficiency assessment favoured triaging to physiotherapists over traditional management, showing greater health gains at lower costs from a societal perspective. Conclusions: Many positive effects of triaging directly to physiotherapists in primary care were found for patients, the healthcare organization and society. The studies in this thesis contribute to a small but growing bank of knowledge about the advantages of using physiotherapists as initial assessors in primary care. The triage model studied here seems to offer a feasible alternative to traditional management of musculoskeletal disorders within primary care.
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