Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care-a randomised controlled pragmatic study

Chan-Mei Ho, Carina A Thorstensson, Lena Nordeman, Chan-Mei Ho, Carina A Thorstensson, Lena Nordeman

Abstract

Background: In Swedish primary care, the healthcare process for patients with knee osteoarthritis (KOA) can be initiated by a physician or physiotherapist assessment. However, it is unclear how the different assessments affect the healthcare processes and patient reported outcomes over time. The purpose of this study was to examine the differences in health-related quality of life (HrQoL), adjusted for pain and physical function, for patients with KOA when the healthcare process is initiated by a physiotherapist assessment compared to a physician assessment in primary care.

Methods: An assessor-blinded randomised controlled pragmatic trial. Using a computer-generated list of random numbers, patients seeking primary care during 2013-2017 with suspected KOA were randomised to either a physiotherapist or physician for primary assessment and treatment. Data was collected before randomisation and at 3, 6, and 12-month follow-ups. Primary outcome was HrQoL using EuroQol 5 dimensions 3 levels questionnaire, index (EQ-5D-3L index) and a visual analogue scale (VAS) (EQ-5D-3L VAS); pain intensity was measured with VAS (0-100) and physical function measured with the 30-s chair stand test. Mixed effect model analyses compared repeated measures of HrQoL between groups. The significance level was p < 0.05 and data was applied with intention-to-treat.

Results: Patients were randomised to either a physiotherapist (n = 35) or physician (n = 34) for primary assessment. All 69 patients were included in the analyses. There were no significant differences in HrQoL for patients assessed by a physiotherapist or a physician as primary assessor (EQ-5D-3L index, p = 0.18; EQ-5D-3L VAS, p = 0.49). We found that HrQoL changed significantly 12 months after baseline assessment for all patients regardless of assessor (EQ-5D-3L index, p < 0.001; EQ-5D-3 L VAS, p = 0.0049). No adverse events or side effects were reported.

Conclusions: There were no differences in HrQoL, when adjusted for pain and physical function, for patients with KOA when the healthcare process was initiated with physiotherapist assessment compared to physician assessment in primary care. Both assessments resulted in significantly higher HrQoL at the 12-month follow-up. The results imply that physiotherapists and physicians in primary care are equally qualified as primary assessors.

Trial registration: Retrospectively registered at http://clinicaltrial.gov , ID: NCT03715764.

Keywords: Delivery of health care; Disease management; Knee; Osteoarthritis; Quality of life; Treatment outcome.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The participant flow
Fig. 2
Fig. 2
Model means for EQ-5D-3L index, Model 2: adjusted model using confounders
Fig. 3
Fig. 3
Model means for EQ-5D-3L VAS, Model 2: adjusted model using confounders

References

    1. Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA, Gabriel S, Hirsch R, Hochberg MC, Hunder GG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26–35. doi: 10.1002/art.23176.
    1. Hubertsson Jenny, Petersson Ingemar F, Thorstensson Carina A, Englund Martin. Risk of sick leave and disability pension in working-age women and men with knee osteoarthritis. Annals of the Rheumatic Diseases. 2012;72(3):401–405. doi: 10.1136/annrheumdis-2012-201472.
    1. Turkiewicz A, Petersson IF, Bjork J, Hawker G, Dahlberg LE, Lohmander LS, Englund M. Current and future impact of osteoarthritis on health care: a population-based study with projections to year 2032. Osteoarthr Cartil. 2014;22(11):1826–1832. doi: 10.1016/j.joca.2014.07.015.
    1. Hunter DJ, McDougall JJ, Keefe FJ. The symptoms of osteoarthritis and the genesis of pain. Med Clin North Am. 2009;93(1):83–100. doi: 10.1016/j.mcna.2008.08.008.
    1. Ferrell BA. Pain management in elderly people. J Am Geriatr Soc. 1991;39(1):64–73. doi: 10.1111/j.1532-5415.1991.tb05908.x.
    1. Picavet HS, Hoeymans N. Health related quality of life in multiple musculoskeletal diseases: SF-36 and EQ-5D in the DMC3 study. Ann Rheum Dis. 2004;63(6):723–729. doi: 10.1136/ard.2003.010769.
    1. Gay C, Guiguet-Auclair C, Mourgues C, Gerbaud L, Coudeyre E. Physical activity level and association with behavioral factors in knee osteoarthritis. Ann Phys Rehabil Med. 2019;62(1):14–20. doi: 10.1016/j.rehab.2018.09.005.
    1. Palazzo C, Ravaud JF, Papelard A, Ravaud P, Poiraudeau S. The burden of musculoskeletal conditions. PLoS One. 2014;9(3):e90633. doi: 10.1371/journal.pone.0090633.
    1. Nuesch E, Dieppe P, Reichenbach S, Williams S, Iff S, Juni P. All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study. BMJ (Clinical research ed) 2011;342:d1165. doi: 10.1136/bmj.d1165.
    1. Barbour KE, Lui LY, Nevitt MC, Murphy LB, Helmick CG, Theis KA, Hochberg MC, Lane NE, Hootman JM, Cauley JA, et al. Hip osteoarthritis and the risk of all-cause and disease-specific mortality in older women: a population-based cohort study. Arthritis Rheumatol. 2015;67(7):1798–1805. doi: 10.1002/art.39113.
    1. Hawker GA, Croxford R, Bierman AS, Harvey PJ, Ravi B, Stanaitis I, Lipscombe LL. All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: a population based cohort study. PLoS One. 2014;9(3):e91286. doi: 10.1371/journal.pone.0091286.
    1. Hoeven TA, Leening MJ, Bindels PJ, Castano-Betancourt M, van Meurs JB, Franco OH, Kavousi M, Hofman A, Ikram MA, Witteman JC, et al. Disability and not osteoarthritis predicts cardiovascular disease: a prospective population-based cohort study. Ann Rheum Dis. 2015;74(4):752–756. doi: 10.1136/annrheumdis-2013-204388.
    1. Varannan svensk har övervikt eller fetma. .
    1. Oliveria SA, Felson DT, Cirillo PA, Reed JI, Walker AM. Body weight, body mass index, and incident symptomatic osteoarthritis of the hand, hip, and knee. Epidemiology (Cambridge, Mass) 1999;10(2):161–166. doi: 10.1097/00001648-199903000-00013.
    1. Turkiewicz A, Petersson IF, Björk J, Dahlberg LE, Englund M. The consultation prevalence of osteoarthritis 2030 may increase by 50%: prognosis for Sweden. Osteoarthr Cartil. 2013;21(Supplement:S160–1).
    1. Fehring TK, Odum SM, Troyer JL, Iorio R, Kurtz SM, Lau EC. Joint replacement access in 2016. J Arthroplast. 2010;25(8):1175–1181. doi: 10.1016/j.arth.2010.07.025.
    1. Holdsworth LK, Webster VS, McFadyen AK. What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial. Phys Ther. 2007;93:3–11.
    1. Ludvigsson ML, Enthoven P. Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Physiotherapy. 2012;98(2):131–137. doi: 10.1016/j.physio.2011.04.354.
    1. Thorn J, Maun A, Bornhoft L, Kornbakk M, Wedham S, Zaffar M, Thanner C. Increased access rate to a primary health-care Centre by introducing a structured patient sorting system developed to make the most efficient use of the personnel: a pilot study. Health Serv Manag Res. 2010;23(4):166–171. doi: 10.1258/hsmr.2010.010005.
    1. Bornhoft L, Larsson ME, Thorn J. Physiotherapy in primary care triage - the effects on utilization of medical services at primary health care clinics by patients and sub-groups of patients with musculoskeletal disorders: a case-control study. Physiother Theory Pract. 2015;31(1):45–52. doi: 10.3109/09593985.2014.932035.
    1. Verbeek J, Sengers MJ, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine. 2004;29(20):2309–2318. doi: 10.1097/01.brs.0000142007.38256.7f.
    1. Stenberg G, Fjellman-Wiklund A, Ahlgren C. “getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. J Rehabil Med. 2012;44(2):163–171. doi: 10.2340/16501977-0912.
    1. Smith TO, Purdy R, Lister S, Salter C, Fleetcroft R, Conaghan PG. Attitudes of people with osteoarthritis towards their conservative management: a systematic review and meta-ethnography. Rheumatol Int. 2014;34(3):299–313. doi: 10.1007/s00296-013-2905-y.
    1. Thorstensson CA, Gooberman-Hill R, Adamson J, Williams S, Dieppe P. Help-seeking behaviour among people living with chronic hip or knee pain in the community. BMC Musculoskelet Disord. 2009;10:153. doi: 10.1186/1471-2474-10-153.
    1. Mann C, Gooberman-Hill R. Health care provision for osteoarthritis: concordance between what patients would like and what health professionals think they should have. Arthritis Care Res (Hoboken) 2011;63(7):963–972. doi: 10.1002/acr.20459.
    1. Sanders C, Donovan JL, Dieppe PA. Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee. Rheumatology (Oxford) 2004;43(3):353–357. doi: 10.1093/rheumatology/keh044.
    1. Victor CR, Ross F, Axford J. Capturing lay perspectives in a randomized control trial of a health promotion intervention for people with osteoarthritis of the knee. J Eval Clin Pract. 2004;10(1):63–70. doi: 10.1111/j.1365-2753.2003.00395.x.
    1. Sakellariou G, Conaghan PG, Zhang W, Bijlsma JWJ, Boyesen P, D'Agostino MA, Doherty M, Fodor D, Kloppenburg M, Miese F, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017;76(9):1484–1494. doi: 10.1136/annrheumdis-2016-210815.
    1. Thorstensson CA, Petersson IF, Jacobsson LT, Boegard TL, Roos EM. Reduced functional performance in the lower extremity predicted radiographic knee osteoarthritis five years later. Ann Rheum Dis. 2004;63(4):402–407. doi: 10.1136/ard.2003.007583.
    1. Thorstensson CA, Andersson ML, Jonsson H, Saxne T, Petersson IF. Natural course of knee osteoarthritis in middle-aged subjects with knee pain: 12-year follow-up using clinical and radiographic criteria. Ann Rheum Dis. 2009;68(12):1890–1893. doi: 10.1136/ard.2008.095158.
    1. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7):1125–1135. doi: 10.1136/annrheumdis-2012-202745.
    1. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil. 2014;22(3):363–388. doi: 10.1016/j.joca.2014.01.003.
    1. Batsis JA, Germain CM, Vasquez E, Zbehlik AJ, Bartels SJ. Physical activity predicts higher physical function in older adults: the osteoarthritis initiative. J Phys Act Health. 2016;13(1):6–16. doi: 10.1123/jpah.2014-0531.
    1. Rausch Osthoff AK, Niedermann K, Braun J, Adams J, Brodin N, Dagfinrud H, Duruoz T, Esbensen BA, Gunther KP, Hurkmans E, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77(9):1251–1260. doi: 10.1136/annrheumdis-2018-213585.
    1. Daker-White G, Carr AJ, Harvey I, Woolhead G, Bannister G, Nelson I, Kammerling M. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health. 1999;53(10):643–650. doi: 10.1136/jech.53.10.643.
    1. Ball ST, Walton K, Hawes S. Do emergency department physiotherapy practitioner's, emergency nurse practitioners and doctors investigate, treat and refer patients with closed musculoskeletal injuries differently? Emerg Med J. 2007;24(3):185–188. doi: 10.1136/emj.2006.039537.
    1. Richardson B, Shepstone L, Poland F, Mugford M, Finlayson B, Clemence N. Randomised controlled trial and cost consequences study comparing initial physiotherapy assessment and management with routine practice for selected patients in an accident and emergency department of an acute hospital. Emerg Med J. 2005;22(2):87–92. doi: 10.1136/emj.2003.012294.
    1. Thorstensson CA, Garellick G, Rystedt H, Dahlberg LE. Better Management of Patients with osteoarthritis: development and Nationwide implementation of an evidence-based supported osteoarthritis self-management Programme. Musculoskeletal Care. 2015;13(2):67–75. doi: 10.1002/msc.1085.
    1. Jonsson T, Ekvall Hansson E, Thorstensson CA, Eek F, Bergman P, Dahlberg LE. The effect of education and supervised exercise on physical activity, pain, quality of life and self-efficacy - an intervention study with a reference group. BMC Musculoskelet Disord. 2018;19(1):198. doi: 10.1186/s12891-018-2098-3.
    1. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy W, Cookie TD, Greenwald R, Hochberg M, et al. Development of criteria for the classification and reporting of osteoarthritis. Arthritis Rheum. 1986;29(8):1039–1049. doi: 10.1002/art.1780290816.
    1. Brazier JE, Harper R, Munro J, Walters SJ, Snaith ML. Generic and condition-specific outcome measures for people with osteoarthritis of the knee. Rheumatology. 1999;38:870–877. doi: 10.1093/rheumatology/38.9.870.
    1. Walters SJ, Brazier JE. Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-36. Qual Life Res. 2005;14:1523–1532. doi: 10.1007/s11136-004-7713-0.
    1. Nationella riktlinjer för rörelseorganens sjukdomar – 2012. Osteoporos, artros, inflammatorisk ryggsjukdom och ankyloserande spondylit, psoriasisartrit och reumatoid artrit. .
    1. The EuroQol Group EuroQol-a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199–208. doi: 10.1016/0168-8510(90)90421-9.
    1. Brooks R. EuroQol: the current state of play. Health Policy. 1996;37(1):53–72. doi: 10.1016/0168-8510(96)00822-6.
    1. Dolan P. Modeling valuations for EuroQol health states. Med Care. 1997;35(11):1095–1108. doi: 10.1097/00005650-199711000-00002.
    1. Fransen M, Edmonds J. Reliability and validity of the EuroQol in patients with osteoarthiritis of the knee. Rheumatology. 1999;38:807–813. doi: 10.1093/rheumatology/38.9.807.
    1. Huskisson EC. Measurement of pain. Lancet. 1974;304(7889):1127–1131. doi: 10.1016/S0140-6736(74)90884-8.
    1. Gill SD, de Morton NA, McBurney H. An investigation of the validity in six measures of physical function in people awaiting joint replacement surgery of the hip or knee. Clin Rehabil. 2012;26(19):945–951. doi: 10.1177/0269215511434993.
    1. Corp. I . IBM SPSS statistics for windows. In., 22.0 edn. Armonk, NY: IBM Corp. ; Released; 2013.
    1. Samsson Karin S., Larsson Maria E.H. Physiotherapy triage assessment of patients referred for orthopaedic consultation – Long-term follow-up of health-related quality of life, pain-related disability and sick leave. Manual Therapy. 2015;20(1):38–45. doi: 10.1016/j.math.2014.06.009.
    1. Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review. BMC Musculoskelet Disord. 2012;13:107. doi: 10.1186/1471-2474-13-107.
    1. Razmjou H, Robarts S, Kennedy D, McKnight C, Macleod AM, Holtby R. Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times. Physiother Can. 2013;65(1):46–55. doi: 10.3138/ptc.2011-56.
    1. Robarts S, Kennedy D, MacLeod AM, Findlay H, Gollish J. A framework for the development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients. Healthcare Q (Toronto, Ont) 2008;11(2):67–75. doi: 10.12927/hcq.2008.19619.
    1. Bath B, Janzen B. Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service. J Multidiscip Healthc. 2012;5:1–15.
    1. Desmeules F, Toliopoulos P, Roy JS, Woodhouse LJ, Lacelle M, Leroux M, Girard S, Feldman DE, Fernandes JC. Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic. BMC Musculoskelet Disord. 2013;14:162. doi: 10.1186/1471-2474-14-162.
    1. Samsson KS, Bernhardsson S, Larsson ME. Perceived quality of physiotherapist-led orthopaedic triage compared with standard practice in primary care: a randomised controlled trial. BMC Musculoskelet Disord. 2016;17:257. doi: 10.1186/s12891-016-1112-x.
    1. Krueger C, Tian L. A comparison of the general linear mixed model and repeated measures ANOVA using a dataset with multiple missing data points. Biol Res Nurs. 2004;6(2):151–157. doi: 10.1177/1099800404267682.
    1. Zuidgeest MGP, Goetz I, Groenwold RHH, Irving E, van Thiel G, Grobbee DE. Series: pragmatic trials and real world evidence: paper 1. Introduction. J Clin Epidemiol. 2017;88:7–13. doi: 10.1016/j.jclinepi.2016.12.023.
    1. Agborsangaya CB, Lahtinen M, Cooke T, Johnson JA. Comparing the EQ-5D 3L and 5L: measurement properties and association with chronic conditions and multimorbidity in the general population. Health Qual Life Outcomes. 2014;12:74. doi: 10.1186/1477-7525-12-74.
    1. Briani RV, Ferreira AS, Pazzinatto MF, Pappas E, De Oliveira Silva D, Azevedo FM. What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials. Br J Sports Med. 2018;52(16):1031–1038. doi: 10.1136/bjsports-2017-098099.
    1. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A randomized, controlled trial of Total knee replacement. N Engl J Med. 2015;373(17):1597–1606. doi: 10.1056/NEJMoa1505467.
    1. Samsson KS, Bernhardsson S, Larsson ME. “Take me seriously and do something!” - a qualitative study exploring patients' perceptions and expectations of an upcoming orthopaedic consultation. BMC Musculoskelet Disord. 2017;18(1):367. doi: 10.1186/s12891-017-1719-6.
    1. Wesseling Janet, Boers Maarten, Viergever Max A, Hilberdink Wim KHA, Lafeber Floris PJG, Dekker Joost, Bijlsma Johannes WJ. Cohort Profile: Cohort Hip and Cohort Knee (CHECK) study. International Journal of Epidemiology. 2014;45(1):36–44. doi: 10.1093/ije/dyu177.
    1. Whiting P, Rutjes AW, Reitsma JB, Glas AS, Bossuyt PM, Kleijnen J. Sources of variation and bias in studies of diagnostic accuracy: a systematic review. Ann Intern Med. 2004;140(3):189–202. doi: 10.7326/0003-4819-140-3-200402030-00010.
    1. Bornhöft Lena, Larsson Maria EH, Nordeman Lena, Eggertsen Robert, Thorn Jörgen. Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial. Therapeutic Advances in Musculoskeletal Disease. 2019;11:1759720X1982750. doi: 10.1177/1759720X19827504.
    1. Frobell RB, Lohmander LS, Roos EM. The challenge of recruiting patients with anterior cruciate ligament injury of the knee into a randomized clinical trial comparing surgical and non-surgical treatment. Contemp Clin Trials. 2007;28(3):295–302. doi: 10.1016/j.cct.2006.10.002.

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