S. Lafrance1,2, J.-G. Lapalme1,2, M. Méquignon2, C. Santaguida3, J. Fernandes4,5, F. Desmeules1,2
1University of Montreal, School of Rehabilitation Science, Montreal, Canada, 2Maisonneuve-Rosemont Hospital Research Center, Orthopedic Clinical Research Unit, Montreal, Canada, 3McGill University Health Center, Department of Neurology and Neurosurgery, Montreal, Canada, 4University of Montreal, Department of Surgery, Montreal, Canada, 5Hôpital du Sacré-Coeur de Montréal Research Center, Montreal, Canada
Background: Timely access for specialized medical care in orthopaedic, neurosurgery or rheumatology for patients with spinal disorders is problematic. Long wait times to access care has been associated with deterioration in pain, disability and health-related quality of life. The use of advanced practice physiotherapy (APP) models of care has been proposed as a potential solution. Evidence suggests that APP models of care does improve access to care while delivering at least comparable quality of care for adults with general musculoskeletal disorders. However, systematic appraisal of evidence on APP models in specialized secondary care for adults with spinal pain has yet to be undertaken.
Purpose: To appraise the available evidence on APP models in specialized secondary care such as orthopaedic, neurosurgery or rheumatology for adults with spinal pain.
Methods: Literature Search
Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL.
Study Selection
To be included, studies needed to address the impact of APP models in specialized secondary care regarding diagnostic accuracy, triage or management of adults with spinal pain. APP models of care were defined as models involving a higher level of practice, and responsibilities for physiotherapists including role enhancement and medical role substitution with or without the addition of medical or controlled acts. All study designs were considered for inclusion. Two reviewers independently reviewed titles and abstracts to identify studies of interest.
Data Synthesis
Eligible studies were appraised with the Effective Public Health Practice Project tool. Results from randomized controlled trials (RCTs) with similar outcome measures were pooled into meta-analysis. Standardized mean differences (SMD) were calculated. Proportion of patients independently managed by APPs among all included studies was calculated. Stakeholders and patients' satisfaction across all studies were transformed in percentage and weighted means were calculated. A qualitative analysis of the evidence was also performed for other outcomes.
Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL.
Study Selection
To be included, studies needed to address the impact of APP models in specialized secondary care regarding diagnostic accuracy, triage or management of adults with spinal pain. APP models of care were defined as models involving a higher level of practice, and responsibilities for physiotherapists including role enhancement and medical role substitution with or without the addition of medical or controlled acts. All study designs were considered for inclusion. Two reviewers independently reviewed titles and abstracts to identify studies of interest.
Data Synthesis
Eligible studies were appraised with the Effective Public Health Practice Project tool. Results from randomized controlled trials (RCTs) with similar outcome measures were pooled into meta-analysis. Standardized mean differences (SMD) were calculated. Proportion of patients independently managed by APPs among all included studies was calculated. Stakeholders and patients' satisfaction across all studies were transformed in percentage and weighted means were calculated. A qualitative analysis of the evidence was also performed for other outcomes.
Results: Eighteen studies (n=9,405), including two RCTs and sixteen observational studies were included. Fourteen studies were considered of moderate quality. Pooled results for change in pain-related disability reported no significant difference between APP and usual medical care (UMC) (SMD: 0.05 in favour of UMC; 95%CI: -0.32 to 0.42; n=225; p=0.78). Mean wait time for initial consultation was lower with APP care (1 to 9.4 weeks) than with UMC (23 to 65 weeks). Following the implementation of APP models of care, wait time for a consultation with a medical specialist was also reduced (reduction from 6 to 16 weeks). Physiotherapists in APP models of care managed independently 89.2% of the patients referred (n=8,393). In all included studies, stakeholders and patients’ satisfaction was higher with APP care.
Conclusion(s): APP models of care and UMC likely results in comparable pain-related disability improvement for adults with spinal pain. However, APP models of care have the potential to improve health care access by reducing wait time for consultation in specialized medical care while demonstrating high level of satisfaction among stakeholders and patients.
Implications: Our review present moderate quality evidence to support the implementation of APP models of care.
Funding, acknowledgements: Dr. Desmeules’ CIHR Program New Investigator Salary and Research Award (201609NCR-375311-130299) and Simon Lafrance, scholarship (HMR, REPAR and Société Inclusive).
Keywords: Advanced practice physiotherapy, Health care system, Spine
Topic: Service delivery/emerging roles
Did this work require ethics approval? No
Institution: Hôpital Maisonneuve-Rosemont Research Center
Committee: Hôpital Maisonneuve-Rosemont Ethics Committee
Reason: Systematic review does not require ethics approval
All authors, affiliations and abstracts have been published as submitted.
