Validating an Advanced Practice Physiotherapy Model of Care
Validating an Advanced Practice Physiotherapy Model of Care
Timely access to orthopaedic care is an important problem for the Canadian health care system. Presently, wait times to see an orthopaedic surgeon can exceed two years and with the rapidly aging population as well as the increased incidence of obesity, the need for orthopaedic care is expected to drastically increase in the coming years. Efforts have been made to ensure timely access to orthopaedic care for the population yet, despite an investment in resources, wait times for a consult or for surgery remain excessively long.
Traditionally, the orthopaedic surgeon is the only health care provider seen when a patient is referred for an orthopaedic consultation but, with the increased demand for orthopaedic care, this model may no longer be viable. The orthopaedic surgeon is a highly trained surgeon and, with the current model in place, he/she spends a considerable amount of time seeing non-surgical cases that were referred to the orthopaedics service. In fact, certain studies have reported that 55% to 90% of patients newly referred to the orthopaedics department are not candidates for surgeries and would likely benefit from conservative treatment.
New models of care have emerged where interdisciplinary collaboration is favored; in these new models, physiotherapists replace orthopaedic surgeons as the first person seen when the patient is referred to the orthopaedics service and only surgical candidates or complex cases are referred to the surgeon. These models aim at improving access to care, with equal or better effectiveness, while containing costs and retaining patient satisfaction. Many countries have already implemented these models and have defined an "advanced practice" or extended scope role for physiotherapists in which they formulate a diagnosis, triage potential surgical candidates, order imaging or laboratory tests and prescribe medication for patients with musculoskeletal disorders. With the emergence of these new advanced practice models, there is a need to evaluate their efficacy and efficiency.
A recent systematic review done by our team concluded that there is emerging evidence suggesting that physiotherapists in advanced practice physiotherapy roles provide comparable or better care than physicians for patients with musculoskeletal disorders. However, these studies varied in terms of design and settings and often suffered from methodological biases. This review also highlighted that validation of the APP model needs to include the following outcomes: 1- medical diagnostic agreement, triaging agreement of potential surgical candidates or clinical recommendations between advanced practice physiotherapists (APPs) and physicians; 2- effectiveness and efficiency of treatment provided by APPs; 3) economic evaluations (cost-effectiveness) of treatments provided by APPs; 4) patients satisfaction and 5) accessibility to care.
A few studies have looked at validation of the advanced practice physiotherapy model in the context of orthopaedic care. Daker-White et al. designed a randomized clinical trial (RCT) in a British orthopaedic clinic, comparing APP care to orthopaedic surgeons in training and found that APPs were as effective as junior doctors to treat patients with musculoskeletal disorders while ordering less diagnostic tests and reducing direct medical costs. Patient satisfaction was also higher for the APP care. Other studies have looked at diagnostic validity and diagnostic concordance between APPs and surgeons for patients seen in an outpatient orthopaedic clinic and have found that for diagnosis and for determining whether patients would benefit from conservative care or surgical review, agreement may range from good to excellent (range κ = 0.69 to 1.00) and treatment recommendations agreement is fair to very good (range κ = 0.52 to 0.70). In terms of patients' satisfaction, one study found that patient satisfaction with advanced practice physiotherapy care was as high as with traditional care by orthopaedic surgeons for patients following total hip or knee replacement.
As part of the validation process following the recent implementation of an APP in the outpatient orthopaedic clinic at the Sacré-Coeur Hospital of Montreal, in Montreal, Canada, the objectives of the current study were to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, health care resource use and patient satisfaction in this new model of care.
Background
Timely access to orthopaedic care is an important problem for the Canadian health care system. Presently, wait times to see an orthopaedic surgeon can exceed two years and with the rapidly aging population as well as the increased incidence of obesity, the need for orthopaedic care is expected to drastically increase in the coming years. Efforts have been made to ensure timely access to orthopaedic care for the population yet, despite an investment in resources, wait times for a consult or for surgery remain excessively long.
Traditionally, the orthopaedic surgeon is the only health care provider seen when a patient is referred for an orthopaedic consultation but, with the increased demand for orthopaedic care, this model may no longer be viable. The orthopaedic surgeon is a highly trained surgeon and, with the current model in place, he/she spends a considerable amount of time seeing non-surgical cases that were referred to the orthopaedics service. In fact, certain studies have reported that 55% to 90% of patients newly referred to the orthopaedics department are not candidates for surgeries and would likely benefit from conservative treatment.
New models of care have emerged where interdisciplinary collaboration is favored; in these new models, physiotherapists replace orthopaedic surgeons as the first person seen when the patient is referred to the orthopaedics service and only surgical candidates or complex cases are referred to the surgeon. These models aim at improving access to care, with equal or better effectiveness, while containing costs and retaining patient satisfaction. Many countries have already implemented these models and have defined an "advanced practice" or extended scope role for physiotherapists in which they formulate a diagnosis, triage potential surgical candidates, order imaging or laboratory tests and prescribe medication for patients with musculoskeletal disorders. With the emergence of these new advanced practice models, there is a need to evaluate their efficacy and efficiency.
A recent systematic review done by our team concluded that there is emerging evidence suggesting that physiotherapists in advanced practice physiotherapy roles provide comparable or better care than physicians for patients with musculoskeletal disorders. However, these studies varied in terms of design and settings and often suffered from methodological biases. This review also highlighted that validation of the APP model needs to include the following outcomes: 1- medical diagnostic agreement, triaging agreement of potential surgical candidates or clinical recommendations between advanced practice physiotherapists (APPs) and physicians; 2- effectiveness and efficiency of treatment provided by APPs; 3) economic evaluations (cost-effectiveness) of treatments provided by APPs; 4) patients satisfaction and 5) accessibility to care.
A few studies have looked at validation of the advanced practice physiotherapy model in the context of orthopaedic care. Daker-White et al. designed a randomized clinical trial (RCT) in a British orthopaedic clinic, comparing APP care to orthopaedic surgeons in training and found that APPs were as effective as junior doctors to treat patients with musculoskeletal disorders while ordering less diagnostic tests and reducing direct medical costs. Patient satisfaction was also higher for the APP care. Other studies have looked at diagnostic validity and diagnostic concordance between APPs and surgeons for patients seen in an outpatient orthopaedic clinic and have found that for diagnosis and for determining whether patients would benefit from conservative care or surgical review, agreement may range from good to excellent (range κ = 0.69 to 1.00) and treatment recommendations agreement is fair to very good (range κ = 0.52 to 0.70). In terms of patients' satisfaction, one study found that patient satisfaction with advanced practice physiotherapy care was as high as with traditional care by orthopaedic surgeons for patients following total hip or knee replacement.
As part of the validation process following the recent implementation of an APP in the outpatient orthopaedic clinic at the Sacré-Coeur Hospital of Montreal, in Montreal, Canada, the objectives of the current study were to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, health care resource use and patient satisfaction in this new model of care.
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