Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems: pragmatic randomised controlled trial

Abstract

Objectives To assess the clinical effectiveness, effect on waiting times, and patient acceptability of PhysioDirect services in patients with musculoskeletal problems, compared with usual care.Design Pragmatic randomised controlled trial to assess equivalence in clinical effectiveness. Patients were individually randomised in a 2:1 ratio to PhysioDirect or usual care.Setting Four physiotherapy services in England.Participants Adults (aged ≥18 years) referred by general practitioners or self referred for musculoskeletal physiotherapy.Interventions PhysioDirect services invited patients to telephone a physiotherapist for initial assessment and advice, followed by face-to-face physiotherapy if necessary. Usual care involved patients joining a waiting list for face-to-face treatment.Main outcome measures Numbers of appointments, waiting time for treatment, and non-attendance rates. Primary outcome was physical health (SF-36v2 physical component score) at six months. Secondary outcomes included four other measures of health outcome, mental component score and scales from the SF-36v2, time lost from work, and patient satisfaction and preference. Participants were not blind to allocation, but outcome data were collected blind to allocation.Results Of 1506 patients allocated to PhysioDirect and 743 to usual care, 85% provided primary outcome data at six months (1283 and 629 patients, respectively). PhysioDirect patients had fewer face-to-face appointments than usual care patients (mean 1.91 v 3.11; incidence rate ratio 0.59 (95% confidence interval 0.53 to 0.65)), a shorter waiting time (median 7 days v 34 days; arm time ratio 0.32 (0.29 to 0.35)), and lower rates of non-attendance (incidence rate ratio 0.55 (0.41 to 0.73)). After six months’ follow-up, the SF-36v2 physical component score was equivalent between groups (adjusted difference in means −0.01 (−0.80 to 0.79)). Health outcome measures suggested a trend towards slightly greater improvement in the PhysioDirect arm at six week follow-up and no difference at six months. There was no difference in time lost from work. PhysioDirect patients were no more satisfied with access to physiotherapy than usual care patients, but had slightly lower satisfaction overall at six months (difference in satisfaction −3.8% (−7.3% to −0.3%); P=0.031). PhysioDirect patients were more likely than usual care patients to prefer PhysioDirect in future. No adverse events were detected.Conclusions PhysioDirect is equally clinically effective compared with usual care, provides faster access to physiotherapy, and seems to be safe. However, it could be associated with slightly lower patient satisfaction.Trial registration Current Controlled Trials ISRCTN55666618.

A pragmatic randomised controlled trial of ‘PhysioDirect’ telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation

“…It is the first study assessing the cost-effectiveness of a PhysioDirect service including a large sample of patients with a wide range of musculoskeletal problems based across a number of locations 15. It uses a rigorous study design and conforms to CONSORT guidelines 46.…”

“…The trial and its clinical findings have been reported in full elsewhere 15 23. The aim of the evaluation was to provide information about the long-run costs and benefits of the alternative methods of running a physiotherapy service for this patient group so with that in mind we excluded the initial set up costs associated with establishing the new telephone service, including the training undertaken by the practitioners 24.…”

“…The intervention has been reported in detail elsewhere 15 23. Patients randomised to the PhysioDirect service received an invitation to telephone a senior (band 6 or above) specially trained physiotherapist, who assessed their musculoskeletal problem with the aid of previously developed computerised templates 23.…”

“…These vary in format though they commonly involve a physiotherapist assessing a patient's musculoskeletal pain problem over the telephone, sometimes supported by computerised assessment templates, offering tailored, self-management advice supplemented by written advice sent by post. Alternatively if the assessment findings suggest that face-to-face care is needed this is arranged, and patients who are initially managed by telephone advice can call back for further advice and/or face-to-face treatment 15. There is, however, limited evidence about the costs and benefits of this approach within physiotherapy.…”

Shortage of general practitioners in the NHS

“…For example, programmes that allow patients to see physiotherapists directly without requiring a referral from a general practitioner can help reduce demands on general practices and provide an alternative, cost effective care pathway for patients with musculoskeletal problems. 8 More NHS services should be accessible by patients without a referral from a general practitioner-for example, exercise and weight reduction programmes, antenatal services, podiatry, termination of pregnancy services, and services for drugs and alcohol misuse. 9 An increasing administrative burden on physicians is a global phenomenon, 10 a barrier to primary care recruitment in the UK and elsewhere, and a brake on efficiency.…”