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Table 4 Key findings by criteria service areas

From: The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

  Resource impact Quality of life Patient/ provider satisfaction Integration Access Equity Effectiveness Appropriateness Acceptability Implementation challenges Impact on future use of health care services
1. Physiotherapy interventions for musculoskeletal conditions For non-urgent MSK patients, physiotherapists found to be highly effective gatekeepers to surgical care, providing appropriate assessment and management of patient needs; reduces costs of outpatient care [16] Clear relationship between improved functioning and impact on quality of life Patient satisfaction with physiotherapy treatment correlated to personal responsibility for managing disorder; recommend adjusting treatment to match attitude or attempt to change attitude [17]. As a provider, very rewarding area to work; client-centred approach; increases therapist’s drive to improve their skills Physiotherapy can fill gaps for someone who is below threshold of MSK health; helps to raise client to minimum threshold so they can then move into the community and access personal trainers Limited impact on concurrent use of other services: possibly better use of surgeons’ time Disparity between patients not privately insured and those insured; similarly with on-site access versus off-site. Access tied to SES; few resources for those with low income Outpatient multidisciplinary treatment program for sick-listed workers highly effective in improving physical functioning, physical disabilities, and kinesiophobia compared to usual care; no significant difference in cost- effectiveness on the societal level as compared to usual care Orthopedic surgeons more likely to refer patients to PT than primary physicians; self-referral patients had lower PT visits than physician referred [17]. Need to increase therapy resources to address barriers to access [18] Some services are quite uncomfortable (e.g., shoulders); but generally, clients do not stop due to discomfort; have to put treatment into broader picture of helping the client which may, at times, be painful Public does not necessarily know what physiotherapy is; people who might benefit may not know how to access services or are unaware of how it would be beneficial. Need public and other professionals to be more aware of skills and impact of PT Creating individualized programs and allowing for independent care outside of physiotherapy can result in lifelong changes: 8 weeks post-physiotherapy may not result in significant changes; however, large changes at 12-month; in addition, if re-injury occurs, costs are much lower
2. Physiotherapy interventions for low back pain Physiotherapist-led pain management classes offer a cost-effective alternative to usual outpatient physiotherapy and are associated with less healthcare use [19] Reduces pain and improves functioning, especially for chronic condition (confirmed through the administration of pre and post surveys) Hands on individual care that results in patient satisfaction; individualized care with education is key element on satisfaction Earlier position in the continuum of care would produce greater benefits; ironically, in rural areas, can typically get an MRI quicker then PT services Main impact is on freeing up surgeon’s time by moving the triaging activity to the physiotherapist No identifiable sub-population disproportionally affected by LBP although more women get treatment then men Significant impact on risk of worsening disability and time off-work [20]. About 80 to 90% of all cases are resolved, i.e. patients experience a normal lifestyle except for the odd episodic recurrence Incidence of LBP is steady but proportion of cases that evolve to chronic condition is increasing; this process accelerates access to treatment thereby reducing the risk of the condition becoming chronic. Patients are more likely to participate in exercise programs that reflect their preferences, circumstances and abilities; recommend collecting patient preferences before starting treatment [21] Requirements for triaging program: Cooperation from surgeons; Specialized training for the physiotherapist Long-term impact will be on the proportion of cases that become chronic (chronic LBP affects mobility which has psychological impacts as well as physical impacts through the limitation on the ability to exercise)
3. Rehabilitation services in the intensive care unit With physiotherapy, functional ability at time of discharge from ICU is higher, leading to reduced costs such as multi-system de-conditioning with long- term bed rest Impact of ICU physiotherapy on QoL is mainly through prevention of problems resulting from an ICU stay. These problems are a direct determinant of where patients goes next, e.g., nursing home or own home Significant provider satisfaction in this field in assisting people to move earlier along with greater patient connection; physiotherapy is a constant; promotes relationship building ICU is extremely multi-disciplinary; no practitioner can act in isolation and therefore coordination occurs across disciplines, in this context, physiotherapist chart notes have a direct impact on how the patient is treated on the ward PT can affect LOS in ICU ICU population is heterogeneous; equity not an issue Two key areas of impact: Early mobility Ventilator weaning Patients are becoming far more complex with co-morbidities – physiotherapists look at patients holistically versus possible fragmentation of specialized services Involves hard work but no different than other PT services Specialized equipment required Ability to go home earlier with physiotherapy service ; however, longer term utilization is less likely to be impacted
4. Physiotherapy interventions for chronic disease management Service is found to be sufficiently cost-effective to be included in the coverage provided by some privately-funded extended health care plans Because of the mobility concern, the impact of physiotherapy on QoL is connected primarily to increased level of activity and functioning. Many disease specific research findings Ranges of improvement but chronic disease by definition will not be ‘curative’; PT best viewed as an integral part of multi-modal team of care Without physiotherapy, patients would be on waitlists for physician services or surgery; assists with filling gaps When physiotherapy conducted alongside physicians, physicians’ capacity increases No impact Because patients’ problems are multi-faceted and require multiple interventions (e.g. medication, surgery), PT role in designing exercise programs that take all of these factors into consideration is central to overall effectiveness Growing problem, especially with an aging population Important to measure and track progress as an incentive Expertise is available, especially if physiotherapists are used to plan and supervise activities, while assistants provide instruction and oversee individual exercise programs (see: CLCS model in community centres in Quebec) Significant prevention potential that can have a large impact on future use of resources
5. Rehabilitation services for chronic lung disease Multidisciplinary, outpatient pulmonary rehab (PR) program substantially reduced health resources use in patients with moderate, severe and very severe COPD. The mean incremental cost of adding rehabilitation to standard care was a savings of $152 per patient [22] PR shown to improve quality of life (Rubi; McCarroll); PR deals with physical function, but also with the psychological aspects through education Patients who have received PR often want to be re-admitted after their next exacerbation There is poor continuum of care for COPD patients. Current care is focused on responding to exacerbations Use of PR results in less exacerbations, fewer ER visits and reduced number of unscheduled GP visits COPD does not disproportionally affect any specific ‘disadvantaged’ group There is strong evidence demonstrating a reduction in dyspnea, increased exercise tolerance, improved health related quality of life and cost-effectiveness [23] COPD is a significant chronic disease in terms of incidence and prevalence: fourth or fifth leading cause of death Patients typically want to return to treatment No specialized resources needed; physiotherapists can be trained quickly in the specifics of this service; exercise equipment used is standard Patients receiving PR are, in the long run, more likely to stay at home longer, therefore postponing institutionalization
6. Rehabilitation services for cardiovascular disease Outpatient CR less expensive than inpatient yet similar effectiveness CR significantly improved QoL scores, reduced depression and had positive effect on psychosocial measures Service can be fully tailored to the client’s situation Clients come from diagnosis of cardiovascular condition then transition to local, ongoing, community services; CR plays an essential role in facilitating this transition Impact on the use of other health services is not immediate (except for length of hospital stay) Women, the elderly, ethnic minority groups access CR less. Very little information on why subgroups have lower rates of access CR reduces the risk of cardiac and general mortality rates by 25-30% There is a growing referral rate AND a growing uptake rate because of increased awareness (referral rate) and improvements in services (uptake rate) The services are mostly about teaching so there is no physical pain. Changes in lifestyle being promoted can be difficult to adopt None noted Services reduce the likelihood of recurrence of the problems and reduces the seriousness of future problems
7. Rehabilitation services following joint arthroplasty When comparing the cost-effectiveness of an accelerated perioperative care and rehabilitation protocol with that of a more standard protocol for patients treated with total hip arthroplasty, beginning from the first visit before the operation to one year postoperatively, a study found the accelerated intervention to be more effective with an average of $4000 reduction in treatment costs with a 0.08 QALY gain; also more cost-effective for total knee arthroplasty with no difference in QALYs [24] PT provides both earlier functionality and a better end point Postoperative, active physical therapy increases satisfaction and helps to meet patient expectations [25] Impact on continuum of care comes from accelerating patient’s progression through the care process Will reduce doctor visits More difficult to access PT services in rural settings Using team approach, patients had large improvements in outcome measures during the rehabilitation stay and 6-month follow-up [26] Joint arthroplasty volume is driven by demographics High acceptability No significant HR or equipment challenges No evidence of impact on future use of health care services (3+years)
8. Rehabilitation services following stroke Very early mobilisation (VEM) more cost-effective than standard care and improved outcomes Research findings still lacking; recent innovations in diagnosis, management, and rehabilitation have resulted in measurable improvements in clinical and functional outcomes after acute stroke; however, despite improvements in medical management, quality of life is not necessarily improving post stroke [27] Programs are meant to be patient-centered: this is the goal; limitation is in resource constraints which reduces ability to customize treatment plans Key component of the continuum of care; If there is not sufficient physiotherapy services LOS is longer and/or the patient does not do as well Very limited impact on the concurrent utilization of other services Increased odds of problems from a past stroke associated with failure to access OT/PT services, lower monthly income, and age Comparing specialized outpatient therapy to no treatment, 14 RCTs found that therapy-based outpatient rehab was associated with a reduction in the odds of poor outcome and increased daily living and personal activity scores Stroke is a significant condition in terms of incidence; physiotherapy is an integral part of its treatment Stroke causes fear in patients, which increases treatment acceptance rate; physiotherapy focuses on restoring physical function and in so doing, provides positive feedback Requires more rehab beds and/or specialized units Improved physical function and has direct impact on social function; minimizes the future use of health care services
9. Physiotherapy services in the emergency department Can reduce LOS for some patients; facilitates flow in the ER Services address fear and uncertainty around risks when discharged Potentially better client satisfaction: less pain, reduces short-term disability, improves function and safety Important ‘triaging’ role in the continuum Sizeable impact on rate of return visits to emergency Rate of emergency visits not clearly related to being part of any disadvantaged populations At system and provider levels, there is limited research evidence on the value of an emergency department physiotherapy service; at patient level, there is high-level evidence of benefits in terms of improved pain control and reduced disability in the short term There is an increase in ED attendances, therefore an increased need for emergency PT services Sometimes ‘forces’ the realization that the patient is at a time of life where there is a loss of independence and a need for mobility aids or assistance Increased volume comes with a need for observation beds and sub-acute beds Patients are flagged earlier for present and potential problems and can be followed/assisted in the community
10. Home based rehabilitation services Significant cost aversion; mobility assessment, keeping people independent in their homes; prevention of falls and providing a safe environment within the home context Impact of PT can include increased social interaction; improved personal and domestic activities; improved health status; improved subjective quality of life; reduced caregiver burden Patient satisfaction is clear (but typically is not tracked by formal instruments); one measure of satisfaction is that the clients pay for subsequent visits; verbal feedback from clients is very positive; while anecdotal, the high level of satisfaction is clear Service is extremely relevant to service integration; big gap in the continuum of care from hospital to home; a lot of people discharged from the hospital and in need of home-based service but are not receiving it or receive it in a very limited manner, i.e., no active rehab post discharge, rather patients are given a walker or basic level of information Reduces LOS and hospitalisations Inequities exist between Provinces: those without financial means do not have access to home-based rehab services in some Provinces; those with chronic conditions are more vulnerable and need more follow-up; currently, there is no support from the public system to help these individuals When comparing adults 70 years or older with one or more functional problems who received a home-based programme of occupational therapy and physiotherapy to a control group, a significant reduction in mortality rate was found (5.6% vs 13.2%); individuals with a moderate risk of mortality in the intervention groups also showed a significant reduction at 16.7% vs. 28.3% [28] Home-based therapy increases access, in particular for patients with greater medical complexities Main issue is the payment required for services Have to have the right provider: not every physiotherapist can provide this service; broad experience base is required to be effective and proficient; therapist works on their own which means there are no second opinions; some anxiety in providing in-home services and worker safety can be a concern Home-based services are expensive with respect to time to travel and low volume however this needs to be considered in light of potential decrease in utilization of future service needs; in the long term, this is a very efficient use of societal resources
11. Rehabilitation services for falls Treatment for falls was 1.8 times more costly than implementing a fall prevention program Specialized balance program for women with osteoporosis significantly improved quality of life, physical function, symptoms, social interaction and overall wellbeing [29] Falls prevention programming is a new field, to date has not drawn adequate attention Not really part of a continuum of care in most cases Fall prevention service does not reduce client’s use of other services; greatest impact on future service use Programs tend to target seniors and diabetics Exercise program significantly reduces the risk of death, of falling and hospitalisation or transfer to a nursing home Need to get out in front to provide prospective services instead of providing service retrospectively No physical risks or discomfort but psychological ‘discomfort’ as fall prevention associated with a loss of independence More awareness with health care professionals generally Substantial impact especially in the subset of cases where falls can be avoided
12. Rehabilitation services for pediatrics Getting right programs in place early can make a lifelong difference in health outcomes and lead to very significant savings Movement is freedom; for children who have difficulty getting involved in activities, these services open opportunity for participation Physiotherapist is the health care professional in closest contact with the patient and his/her family; relationship that develops is potentially unlike any other health care profession; very personal in nature; physiotherapists best understand the child’s disability and so can relate very well; becomes very strong advocates for the patient and family The service definitely addresses a gap; if this service was not in place, by the time the child reached adulthood they would be so far behind in their development they could never catch up Some surgery avoidance; some reduction in GP visits Many disadvantaged groups do not typically go to the hospital for services; if rehab services are in the community and/or school or community centre, access to health care is more likely: practitioners will often see individuals who have not accessed any other service in the system Many studies have shown effectiveness; studies are typically small, but results are consistent across conditions Children do not respond as well in adult facilities Typically, very well received Baseline services are not a challenge - new grads can do this Early intervention has significant impact on reducing future utilization of services, including prevention of secondary surgeries