Referring to multimodal rehabilitation for patients with musculoskeletal disorders – a register study in primary health care

Abstract

BackgroundIn 2008, the Swedish government introduced a National Rehabilitation Program, in which the government financially reimburses the county councils for evidence-based multimodal rehabilitation (MMR) interventions. The target group is patients of working age with musculoskeletal disorders (MSD), expected to return to work or remain at work after rehabilitation. Much attention in the evaluations has been on patient outcomes and on processes. We lack knowledge about how factors related to health care providers and community can have an impact on how patients have access to MMR. The aim of this study was therefore to study the impact of health care provider and community related factors on referrals to MMR in patients with MSD applying for health care in primary health care.MethodsThis was a primary health care-based cohort study based on prospectively ascertained register data. All primary health care centres (PHCC) contracted in Region Skåne in 2010-2012, referring to MMR were included (n = 153). The health care provider factors studied were: community size, PHCC size, public or private PHCC, whether or not the PHCCs provided their own MMR, burden of illness and the community socioeconomic status among the registered population at the PHCCs. The results are presented with descriptive statistics and for the analysis, non-parametric and multiple linear regression analyses were applied.ResultsPHCCs located in larger communities sent more referrals/1000 registered population (p = 0.020). Private PHCCs sent more referrals/1000 registered population compared to public units (p = 0.035). Factors related to more MMR referrals/1000 registered population in the multiple regression analyses were PHCCs located in medium and large communities and with above average socioeconomic status among the registered population at the PHCCs, private PHCC and PHCCs providing their own MMR. The explanation degree for the final model was 24.5%.ConclusionsWe found that referral rates to MMR were positively associated with PHCCs located in medium and large sized communities with higher socioeconomic status among the registered population, private PHCCs and PHCCs providing their own MMR. Patients with MSD are thus facing significant inequities and were thus not offered the same opportunities for referrals to rehabilitation regardless of which PHCC they visited.

Evaluation of a multimodal pain rehabilitation programme in primary care based on clinical register data: a feasibility study

“…Complex clinical and practical assessments are made before decisions to refer to MMR. Referrals to MMR are also associated with caregiver and community-related factors (Sennehed et al, 2017). The clinical considerations made in primary care before referral to MMR are multifaceted and complex and contributes to bias by indication.…”

“…Previous studies confirm the significance of important factors for RTW, such as workplace physical demands (Steenstra et al, 2016), social class and educational level (Ropponen et al, 2011), psychosocial factors (Laisne et al, 2013) and income before treatment (Streibelt and Egner, 2013). Furthermore, a recent study indicates that socio-economic status may influence referring to MMR (Sennehed et al, 2017). In the initial cohorts (MMR n = 2140 and reference n = 56 300), the proportion of patients with disability pension one year before baseline were 22% in the MMR cohort and 10% in the reference cohort.…”

“…An assumption behind a retrospective matching design is that there is a random distribution of MSP patients receiving MMR or not. However, referral to MMR has been found to be associated with caregiver and community-related factors (Sennehed et al, 2017). In summary, there is a lack of controlled trials and evaluations of MMR in primary care, especially for patients on shorter sick leave.…”