Zadro J1,2, O'Keeffe M1,2, Maher C1,2
1The University of Sydney, School of Public Health, Faculty of Medicine and Health, Sydney, Australia, 2Sydney Local Health District, Institute for Musculoskeletal Health, Sydney, Australia
Background: Low-value healthcare provides little-to-no benefit or causes harm, and diverts resources from high-value care that is cost-effective. Physiotherapy is an important health discipline to explore low-value care because the profession is growing rapidly and physiotherapists commonly treat people with some of the leading causes of global disability, including low back pain (LBP) and knee osteoarthritis. Low-value care is receiving substantial attention in medicine and is starting to receive attention in physiotherapy. However, it is unclear what proportion of physiotherapy provided to patients with LBP and knee osteoarthritis is high-value, low-value, or of unknown value.
Purpose: To determine the proportion of physiotherapy for LBP and knee osteoarthritis that is high-value, low-value, or of unknown-value.
Methods: We performed an electronic keyword search in numerous databases combining terms synonymous with “treatment practices” and “physiotherapy”. Articles that quantified physiotherapy treatment practices for non-specific LBP and knee osteoarthritis through surveys, vignettes, audits of clinical notes, and other methods were included. Two reviewers independently performed the selection of studies and rated the methodological quality of included studies using a modified version of the Downs and Black checklist; resolving any disagreements by discussion or consultation with a third reviewer. Extracted data was double-checked by a second reviewer to ensure accuracy. Physiotherapy interventions in the included studies were classified as high-value, low-value or of unknown value. High or low-value care was inferred from the National Institute for Health and Care Excellence (NICE) guidelines or high-quality systematic reviews. Care of unknown value included interventions where evidence from guidelines or systematic reviews was inconclusive. The proportion of physiotherapists that provided all 'essential' guideline recommendations provided an estimate for high-value care (e.g. advice to keep active, reassurance and advice on self-management for LBP). The proportion of low-value care and care of unknown value was determined by extracting the most common low-value and unknown-value intervention from each study. We used medians and the interquartile range (IQR) to report the proportion of physiotherapy that was high-value, low-value, or of unknown value. Analyses were separated by self-reported treatment practices and audits of treatment practices.
Results: After screening 8,507 titles and abstracts, and 253 full-texts articles, 60 articles were included (51 investigated treatment practices for LBP). Self-reported treatment practices for LBP demonstrated that 35% (IQR: 16%-56%, n=9 studies) of physiotherapy is high-value, 44% (IQR: 34%-64%, n=24) is low-value and 72% (IQR: 45%-88%, n=24) is of unknown value. For knee osteoarthritis these proportions were 59% (IQR: 49%-65%, n=5), 39% (34%-52%, n=5) and 93% (IQR: 83%-100%, n=6). Audits of treatment practices demonstrated that these proportions were 50% (IQR: 32%-62%, n=5), 18% (10%-36%, n=15) and 43% (IQR: 31%-81%, n=23) for LBP, and 65% (IQR: 65%-66%, n=2), 21% (n=1) and 53% (IQR: 42%-64%, n=2) for knee osteoarthritis.
Conclusion(s): Only 35-65% of physiotherapists provide high-value care for LBP and knee osteoarthritis, while 18-44% provide care that is ineffective or recommended against in clinical practice guidelines.
Implications: There is an urgent need to improve the quality of physiotherapy for LBP and knee osteoarthritis.
Keywords: Physiotherapy, low-value, treatment practices
Funding acknowledgements: No funding was received to conduct this study.
Purpose: To determine the proportion of physiotherapy for LBP and knee osteoarthritis that is high-value, low-value, or of unknown-value.
Methods: We performed an electronic keyword search in numerous databases combining terms synonymous with “treatment practices” and “physiotherapy”. Articles that quantified physiotherapy treatment practices for non-specific LBP and knee osteoarthritis through surveys, vignettes, audits of clinical notes, and other methods were included. Two reviewers independently performed the selection of studies and rated the methodological quality of included studies using a modified version of the Downs and Black checklist; resolving any disagreements by discussion or consultation with a third reviewer. Extracted data was double-checked by a second reviewer to ensure accuracy. Physiotherapy interventions in the included studies were classified as high-value, low-value or of unknown value. High or low-value care was inferred from the National Institute for Health and Care Excellence (NICE) guidelines or high-quality systematic reviews. Care of unknown value included interventions where evidence from guidelines or systematic reviews was inconclusive. The proportion of physiotherapists that provided all 'essential' guideline recommendations provided an estimate for high-value care (e.g. advice to keep active, reassurance and advice on self-management for LBP). The proportion of low-value care and care of unknown value was determined by extracting the most common low-value and unknown-value intervention from each study. We used medians and the interquartile range (IQR) to report the proportion of physiotherapy that was high-value, low-value, or of unknown value. Analyses were separated by self-reported treatment practices and audits of treatment practices.
Results: After screening 8,507 titles and abstracts, and 253 full-texts articles, 60 articles were included (51 investigated treatment practices for LBP). Self-reported treatment practices for LBP demonstrated that 35% (IQR: 16%-56%, n=9 studies) of physiotherapy is high-value, 44% (IQR: 34%-64%, n=24) is low-value and 72% (IQR: 45%-88%, n=24) is of unknown value. For knee osteoarthritis these proportions were 59% (IQR: 49%-65%, n=5), 39% (34%-52%, n=5) and 93% (IQR: 83%-100%, n=6). Audits of treatment practices demonstrated that these proportions were 50% (IQR: 32%-62%, n=5), 18% (10%-36%, n=15) and 43% (IQR: 31%-81%, n=23) for LBP, and 65% (IQR: 65%-66%, n=2), 21% (n=1) and 53% (IQR: 42%-64%, n=2) for knee osteoarthritis.
Conclusion(s): Only 35-65% of physiotherapists provide high-value care for LBP and knee osteoarthritis, while 18-44% provide care that is ineffective or recommended against in clinical practice guidelines.
Implications: There is an urgent need to improve the quality of physiotherapy for LBP and knee osteoarthritis.
Keywords: Physiotherapy, low-value, treatment practices
Funding acknowledgements: No funding was received to conduct this study.
Topic: Musculoskeletal: spine; Musculoskeletal: lower limb; Professional practice: other
Ethics approval required: No
Institution: The University of Sydney
Ethics committee: Human Research Ethics Committee
Reason not required: Systematic review
All authors, affiliations and abstracts have been published as submitted.
