Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial

Bornhöft, Lena; Larsson, Maria; Nordeman, Lena; Eggertsen, Robert; Thorn, Jörgen

doi:10.1177/1759720x19827504

Cited by 37 publications

(46 citation statements)

References 51 publications

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“…However, outcomes of care and safety were consistently similar across these studies, although it must be noted that available studies were not designed to robustly assess potential harm or adverse outcomes from the introduction of direct access. Though small and similarly not powered to examine equivalence of GP-led care over direct access for MSK patients, a recent trial also finds no significant differences in pain, and functional disability [41]. The services proposed here therefore seem to be a more efficient and less costly service model for patients with MSK conditions and/or have potential to help reduce GP workload.…”

Section: Implications For Future Practice Health Care Planning and Rmentioning

confidence: 78%

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain

et al. 2020

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Introduction The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services. Methods A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted. Results 9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct

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Section: Implications For Future Practice Health Care Planning and Rmentioning

confidence: 78%

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain

et al. 2020

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“…Standard praxis for the management of MSD in primary care is for a GP to make an initial assessment and provide first-line treatment, referring to other care-givers as necessary [8]. Inadequacies in current management have been reported which affect health resource use [9, 10] and may even affect clinical course for MSD [11]. GPs frequently refer to physiotherapists in their management of MSDs [12–14].…”

Section: Introductionmentioning

confidence: 99%

“…For conditions not requiring immediate GP assessment or treatment, the triage model aims to provide immediate contact with other appropriate professions. According to this model, most patients seeking help for MSD are triaged by nurses directly to physiotherapists for initial examination and treatment, reducing the burden on GPs and likely leading to a different clinical course [11, 19]. The triage model has been evaluated from the organisational perspective and has been shown to have many advantages, such as increased access, improved work environment, and good patient satisfaction, without leading to any serious adverse events [22].…”

Section: Introductionmentioning

confidence: 99%

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

Bornhöft

Thorn

Svensson

et al. 2019

BMC Musculoskelet Disord

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Background 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. Methods Nurse-assessed patients with MSD ( N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year 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. 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. Conclusion 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. Trial registration ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.

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“…In terms of comparing our results to other published evidence, Bornhoft and Larsson et al 21 compared similar care pathways (PT and physician) after nurse triage though differences in outcome measures prevent direct comparison with our results. They also found no significant difference in most of their measures out to 50 weeks.…”

Section: Discussionmentioning

confidence: 70%

“…A second randomized trial using PhysioDirect (a telephone assessment and advice system developed in the United Kingdom), assessed the ability of PTs to triage care over the phone 20 . A third randomized trial compared the ability of PTs and general practitioners to manage patients' musculoskeletal pain, following triage by a nurse practitioner 21 . Each of these randomized trials investigates novel primary care PT programs.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Physical Therapy and Physician Pathways for Employees with Recent Onset Musculoskeletal Pain: A Randomized Controlled Trial

Ojha

Fritz

Malitsky

et al. 2020

PM&R

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Background Life expectancy of the U.S. population will continue to rise, increasing the workforce demands in the treatment of musculoskeletal pathologies. With a declining primary care physician workforce, physical therapists (PT) may be in a unique situation to help absorb this demand. Objective Our primary objective was to compare physical function between two primary care groups, a “physical therapy‐led pathway” versus “physician‐led pathway” in the management of recent‐onset musculoskeletal pain at 1‐month follow‐up. Our secondary objectives were to compare other patient‐important outcomes between the groups at 1 month and health utilization at 1 month and 1 year. Methods A pragmatic randomized controlled trial with a 1‐year follow‐up was conducted, enrolling 150 university employees with recent onset musculoskeletal pain. Participants were randomized at first contact to either a PT‐led pathway or physician‐led pathway. The primary outcome was change in Patient‐Reported Outcomes Measurement Information System (PROMIS) ShortForm v1‐Physical Function 10a at 1 month; groups were compared with repeated measurement of analysis of variance and chi‐square for both primary and secondary outcomes, except for satisfaction score at 1 month, which was cross‐sectionally compared by independent two‐sample t‐test. At 1 year, healthcare utilization was assessed through medical record extraction, and healthcare utilization was converted to total episodic standard cost. Utilization was compared between groups using chi‐square and Wilcoxon rank‐sum tests. Results Both groups demonstrated improvement at 1‐month follow‐up but showed no significant between‐group difference in mean PROMIS scores at 1 month (PT‐led pathway vs physician‐led pathway, 2.04, [95% CI ‐0.28 to 4.36]; P = .082). At 1 year, there was no difference in healthcare utilization or cost between groups. No harm or misdiagnosis was found, filed, or reported by participants at 1 year. Conclusion This study shows equivalence in outcomes for two low‐cost musculoskeletal care pathways with no risk of harm. These results reinforce other findings in the literature that support PTs as safe and effective initial providers for individuals with musculoskeletal disorders.

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Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial

Cited by 37 publications

References 51 publications

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain

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

Comparison of Physical Therapy and Physician Pathways for Employees with Recent Onset Musculoskeletal Pain: A Randomized Controlled Trial

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