Primary care physiotherapists ability to make correct management decisions – is there room for improvement? A mixed method study

Abstract

Background With increasing interest in direct access to physiotherapy, it is important to consider the physiotherapists (PTs) ability to make correct management decisions, because identification of differential diagnostic pathologies and timely referral for specialist care is vital for patient safety. The aims of the study were to investigate PTs ability to make correct management decisions in patients presenting with musculoskeletal conditions and to identify explanatory factors associated with this ability. Furthermore, we wanted to explore the PTs views on the identified factors. Methods The study was a mixed methods study with an explanatory sequential design consisting of a questionnaire survey and semi-structured interviews. The questionnaire comprised 12 clinical vignettes describing patient scenarios for musculoskeletal conditions, non-critical medical conditions and critical medical conditions. Based on this, the PTs indicated whether the patient should be managed by the PT or were in need of medical referral. Associations between correct decisions and explanatory variables was analyzed by mixed- effects logistic regression. Interviews were performed with nine PTs to explore their reactions to the results. A directed content analysis was performed. Results A total of 195 PTs participated in the questionnaire survey and 9 PTs were interviewed. Overall, PTs were more likely to make correct management decisions in the musculoskeletal conditions category, whereas wrong decisions were more often chosen for underlying medical conditions categories. Positive associations between correct management decision in the critical medical category were found for experience: odds ratio (OR) 2.73 (1.33;5.57) and passed quality audit OR 2.90 (1.50;5.58). In the interviews, PTs expressed concerns about the differential diagnostic abilities. They all noted, that experience is immensely important in the clinical reasoning process because the ability to recognise diagnostic patterns evolves over time. Furthermore, the quality audit seems to address and systematize the clinical reasoning process and workflow within the clinics. Conclusion The lack of ability to make correct management decision in critical medical categories and the uncertainties expressed by PT’s should raise concern, as direct access to physiotherapy is already well-established and the results indicate that patient safety could be at risk. The findings that experience and passed quality audit was associated with correct management decisions highlights the need for ongoing awareness and education into differential diagnostics.

The Ability of Austrian Qualified Physiotherapists to Make Accurate Keep-Refer Decisions and to Detect Serious Pathologies Based on Clinical Vignettes: Protocol for a Cross-sectional Web-Based Survey

“…After reading each clinical vignette, participants will be asked to decide if this is (a) an MSK condition, which does not need referral to a medical doctor (keep); (b) a noncritical medical condition, which needs referral to a medical doctor, while the patient can be treated by a physiotherapist (keep-refer); and (c) a critical medical condition, which needs immediate referral to a medical doctor and treatment by the physiotherapist should be stopped (refer). The vignettes (used with permission) have been validated by a panel of medical doctors and expert physiotherapists [ 6 ].…”

“…If the participants answer this question with “no,” they will be thanked for their interest and then will automatically be prevented from continuing with the survey. The validity of some of the vignettes in the Austrian health care system was also questioned; therefore, after elaborate discussions, the originally envisioned vignettes by Jette et al [ 23 ] were replaced by the more current vignettes of Budtz et al [ 6 ]. The feedback from the pilot was collected and incorporated into the existing survey.…”

“…Recent data from Denmark demonstrated that the overall prevalence of serious pathologies affecting the MSK system is at present comparatively low (2.3%) [ 5 ]. For instance, the prevalence of malignant neoplasms affecting the MSK system was 1.13% [ 6 ]. These figures are consistent with those from previous studies that reported a prevalence of metastatic spinal cancer as a serious cause of low back pain below 1% in primary care [ 7 - 10 ].…”

“…Previous cross-sectional studies on qualified physiotherapists in the United States [ 22 - 26 ], Germany [ 27 ], Switzerland [ 28 ], Denmark [ 6 ], on Doctor of Physical Therapy students in the United States [ 29 ], and on European final year undergraduate physiotherapy students [ 30 ] have raised some concern about the physiotherapists’ ability to decide when physiotherapy is indicated (keep), or not (refer), and their ability to accurately detect the presence of serious pathologies based on clinical vignettes. Having said this, numerous case studies and case series within the literature highlight that physiotherapists can become key in the detection of serious pathologies in a clinical setting [ 31 , 32 ].…”

“…Considering the above-outlined changes to the Austrian health care sector and challenges of an increasingly aging society, this knowledge gap needs to be addressed. To fill this knowledge gap, we propose a cross-sectional web-based survey using validated clinical vignettes [ 6 ].…”