Background
Methods
1 | The first step is the development of relevant criteria. The criteria should be clearly defined and must relate to the overall purpose of the decision process. The objective in the development of criteria is to include all considerations relevant to the decision that has to be made and to provide sufficient clarity to ensure consistency in the translation of information about the alternatives into ratings. |
2 | The second step is the identification of the possible alternatives. In this case, the alternatives are the most common physiotherapy services. Each alternative [or in this case set of services] must be accompanied by the information required to assess it on the basis of the established criteria. |
3 | The third step is the formal evaluation of each possible alternative. This is done by rating each alternative on each criterion and calculating a composite score. Because the same criteria are used with all alternatives, the scores are comparable across all alternatives. |
4 | The final step is the formulation of recommendations. First, each composite score is validated to ensure that no process errors took place. Once that is done, each alternative can be ranked in relation to all others. Funding recommendations are then based on this ranking. |
Resource impact | Impact on system-wide resource use |
Quality of Life | This criterion deals with the absolute change in quality of life, i.e. a service that has a limited impact on quality of life could not rate to the top of the scale on this criterion. |
Patient/ provider satisfaction | Deals with benefits of the service other than the direct impact on the underlying condition, for example, a service that is very personalized will rate higher here because, presumably, the provider would be able to allow to a greater extent for the client’s preferences [for example, regarding the nature of the activities, the location, the timing, the setting- group or alone]. |
Integration | This criterion is about the continuum of care [and goes beyond the health care system]. Does the service address a gap in the continuum of care that facilitates the clients’ transition from one program or service to another? |
Access | This criterion measures the impact of the provision of a given service on the current utilization of other services, thereby possibly making these other services more accessible. For example, if a given service results in fewer hours per week of home care being required, then this service has freed up those hours for someone else to use. Some services will free up resources that way and some won’t. |
Equity | Impact of the service on the health status of groups where there is an avoidable, unfair, and remediable health status gap. |
Effectiveness | This is about the absolute effectiveness of the service. Just because a service is the best that can be done for an underlying condition does not mean that it is highly effective. Also effectiveness is measured with respect to the impact on the underlying condition itself or the impact on the consequences of the underlying condition. |
Appropriateness | This criterion deals with the high level degree of match between a given service and the overall needs of the population, defined as the combination of the number of persons with the underlying condition and the impact of the underlying condition on quality of life. We should also consider here the availability of possible alternatives. Alternatives to be considered here can be privately provided services but also different services that are publicly funded. We are getting at the idea of the possibility of substitution with this criterion. |
Acceptability | This deals with the relative ‘displeasure’ associated with the service delivery- amount of pain, discomfort |
Implementation challenges | Risks associated with the implementation of given service change [for example, increased volume] but also degree of support- this would be measured, amongst other considerations, by the extent of public pressure in favour of a service. |
Impact on future use of health care services [3+years] | This criterion is about the extent to which the provision of a physiotherapy service now is likely to affect the overall use of health care services down the road [at least three years from now]. |
1. | Physiotherapy interventions for musculoskeletal conditions |
2. | Physiotherapy interventions for low back pain |
3. | Rehabilitation services in the intensive care unit |
4. | Physiotherapy interventions for chronic disease management |
5. | Rehabilitation services for chronic lung disease |
6. | Rehabilitation services for cardiovascular disease |
7. | Rehabilitation services following joint arthroplasty |
8. | Rehabilitation services following stroke |
9. | Physiotherapy services in the emergency department |
10. | Home based rehabilitation services |
11. | Rehabilitation services for falls |
12. | Rehabilitation services for pediatrics |
Results: Key findings by service areas
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 | 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 |