The purpose of this trial was to compare the effectiveness of an APP model of care with usual ED physician care, in terms of patient health-related outcomes, satisfaction and care processes for patients presenting to the ED for a minor MSKDs.
This trial was a multicenter stepped-wedge cluster pragmatic randomized controlled trial (RCT). Six Canadian EDs were randomized to a treatment sequence where patients suffering from minor MSKDs were either managed by an advanced practice physiotherapist or received usual ED physician care. The main outcome measure was the Brief Pain Inventory Questionnaire ( Pain Severity sub-scale, BPI-S and the Pain Interference on function sub-scale, BPI-I) . The primary endpoint was the BPI-I at 4 weeks. Secondary measures included satisfaction with received care (VSQ-9 questionnaire), and the collection of health care process data (wait times and length of stay). Data collection took place at inclusion, at discharge, 4, 12, and 26 weeks. Analyses were performed using linear mixed models with a random effect for patients and sites and fixed effects for timepoints, intervention status (group) and interaction, as well as for randomization sequence within the stepped wedge design.
Six hundred and sixty-three participants were included (n=287 APP care, n=376 physician care). Mean age of participants was 45.7 years old (SD:18.8) and 52.9% were women. The majority of participants presented to the ED for an ankle or foot (33.6%), a knee (23.7%) or a low back (21.1%) MSKDs. There was a significant group-by-time interaction on the BPI-I Scale (p=0.029) in favor of the APP intervention compared to usual physician care. There was no significant between groups differences for the primary endpoint at 4 weeks on the BPI-I (mean difference: -0.44/10; 95%CI -0.93 to 0.05), but significant differences were measured at 12 weeks (mean difference: -0.66/10; 95%CI (-1.16 to -0.15) and at 26 weeks (mean difference -0.62/10; 95%CI (-1.12 to -0.11). These differences favoring APP care may or may not be considered clinically important. There was no significant group-by-time interaction on the BPI-S (p=0.149). Satisfaction with care was significantly higher with APP care than usual ED physician care and participants receiving APP care had significantly shorter wait time and slightly shorter length of stay (p0.001).
Integration of advanced practice physiotherapy into EDs for the management of adults with minor MSKDs lead to equal or potentially slightly better clinical outcomes than traditional medical care, while also improving access to care and increasing patient satisfaction.
Innovative APP models of care for adults presenting with an MSKD have the potential to help relieve pressure in EDs while providing more efficient care.
emergency department
musculoskeletal disorders
