A pragmatic randomised controlled trial of PhysioDirect telephone assessment and advice services for physiotherapy

Lead Research Organisation: University of Bristol
Department Name: Community-Based Medicine

Abstract

Muscular and joint problems are a major cause of illness, and lead to a large number of consultations with GPs. Many of these patients are referred to physiotherapy, with more than 4 million new referrals each year. The NHS has always struggled to meet the demand for physiotherapy, with waiting times of several months in many areas. During this time patients experience pain and disability and may be off work. However physiotherapy is not always helpful, so some patients experience long waits for treatment which is unlikely to be effective, while others wait for treatment which would have been more effective if delivered earlier.

In an attempt to overcome these problems, several areas have introduced telephone assessment and advice services for physiotherapy. Following the telephone assessment, patients are sent written advice by post and invited for face-to-face treatment only when necessary. These services, often known as PhysioDirect, have received awards from NHS organisations, but evidence about their costs and benefits is lacking. Good research is needed before PhysioDirect services become widespread.

This proposal is for a trial which compares PhysioDirect and usual waiting-list based care. We want to test the idea that PhysioDirect is at least as effective and provides equally good results at lower cost compared with usual face-to-face care, while also providing faster access to care and greater patient satisfaction. PhysioDirect services will be established in four PCT areas, each serving at least 25 general practices. When patients are referred by GPs for physiotherapy we will invite them to take part. Those that agree will be randomly allocated to receive either PhysioDirect or usual care. We will compare the two types of service in terms of whether patients? symptoms improved, the cost of the services, waiting times for advice or treatment, time lost from work or usual activities, satisfaction with care and which type of care patients prefer.

Using interviews with patients and staff we will examine factors associated with the success (or failure) of the service, the acceptability of PhysioDirect to patients and staff, and ways in which the service could be improved.

This trial will provide evidence to support or refute the widespread introduction of PhysioDirect. If it achieves the benefits in terms of improved effectiveness and efficiency, as well as improved convenience and satisfaction for patients, which are claimed by early PhysioDirect sites then the potential advantages for patients and the NHS are considerable.

Technical Summary

Musculoskeletal problems are a major cause of morbidity in the population and a leading cause of days lost from work. They account for 15% of all consultations with GPs. Many of these patients are referred to physiotherapy, with more than 4 million new referrals to physiotherapy each year. Providing timely access to physiotherapy is a long-standing problem for the NHS, with waiting times of several months in many areas. During this time patients experience pain and disability and may be unable to return to work. The value of physiotherapy varies for different conditions, so some patients experience long waits for treatment which is unlikely to be effective, while others wait for treatment which would have been more effective if delivered earlier.

In an attempt to overcome these problems, several areas have introduced telephone assessment and advice services for physiotherapy, based on computerised algorithms. Following the telephone assessment, patients are sent tailored written advice by post and invited for face-to-face treatment only when necessary. These services, often known as PhysioDirect, have been commended by NHS bodies but evidence about effectiveness, cost-effectiveness and acceptability are lacking. Robust research is needed before PhysioDirect services become widespread.

This proposal is for a pragmatic individually randomised trial comparing PhysioDirect with usual waiting-list based care. The hypothesis is that PhysioDirect will be equally effective and more cost-effective than usual care, while also providing faster access to care and greater patient satisfaction. PhysioDirect services will be newly established in four PCT areas, each serving at least 25 general practices. We will recruit patients referred by GPs for physiotherapy and randomise them individually, stratified by physiotherapy service, age and presenting problem. The primary outcome is clinical improvement; secondary outcomes include cost, waiting times, time lost from work and usual activities, patient satisfaction and preference. We will explore the impact of PhysioDirect on patients in different age-groups and with different conditions.

Using qualitative methods we will examine factors associated with the success or failure of the service, the acceptability of PhysioDirect to patients and staff, and ways in which the service could be improved.

This trial will provide evidence to support or refute the widespread introduction of PhysioDirect throughout the NHS. If it achieves the benefits in terms of improved effectiveness and efficiency, as well as improved access and satisfaction for patients, which are claimed by early PhysioDirect sites then the potential advantages for patients and the NHS are considerable.

Publications

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Description INfluence on clinical practice
Geographic Reach UK 
Policy Influence Type Influenced training of practitioners or researchers
Impact Two of the areas which set up new services as part of this research have continued this new way of working after the research has finished. I also receive regular emails and telephone calls from managers and commissioners of services keen to hear early findings to inform their decisions about future planning of services
 
Description NIHR School for Primary Care Research (NSPCR)
Amount £31,810 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 03/2011 
 
Description NIHR Senior Investigator Award
Amount £75,000 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 04/2017 
End 03/2022
 
Title 1) Physiotherapy patient satisfaction questionnaire, and 2) Postal version of MYMOP questionnaire 
Description 1) One-page physiotherapy patient satisfaction questionnaire 2) Adaptation of the MYMOP questionnaire for postal use 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact Too early to report 
 
Description Bristol CCG 
Organisation NHS Bristol CCG
Country United Kingdom 
Sector Public 
PI Contribution Bristol CCG hosts this project, and we conduct the research on their behalf.
Collaborator Contribution We undertake the research; the CCG provides the links into the NHS
Impact All of the papers from the various projects conducted with the partnership with the CCG have been possible because the research was facilitated by the CCG
Start Year 2014
 
Description Bristol-Keele 
Organisation Keele University
Department Research Institute for Primary Care and Health Sciences
Country United Kingdom 
Sector Academic/University 
PI Contribution We have experience in pragmatic trials of new forms of delivery of primary care to improve access and quality
Collaborator Contribution They have great experience and expertise in musculoskeletal research which complements our experience in evaluation of new forms of care
Impact 20. Salisbury C, Foster NE, Bishop A, Calnan M, Coast J, Hall J et al. 'PhysioDirect' telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial. BMC Health Services Research 2009; 9:136.
Start Year 2008
 
Title A pragmatic RCT of Physiodirect 
Description Telephone assessment and advice from a physiotherapist for patients with musculoskeletal problems referred by GPs 
Type Health and Social Care Services
Current Stage Of Development Late clinical evaluation
Year Development Stage Completed 2012
Development Status Closed
Clinical Trial? Yes
Impact The PhysioDirect service is now being used in a number of areas of the UK 
 
Description BRTC Poster 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? Yes
Primary Audience Health professionals
Results and Impact Presentation to the BRTC group of the issues in designing/running the trial

Increased knowledge of the issues faced when running trials within a primary care service.
Year(s) Of Engagement Activity 2009
 
Description News Article 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Primary Audience Health professionals
Results and Impact Article about the trial in the the physiotherapy journal Frontline (Autumn 2008); Also Jan 2009 issue of GP News, and PCRN SW Newsletter.

Raised awareness of the trial amongst physiotherapists; also amongst GPs in the SW region, some of whose patients were to be invited to take part in the trial.
Year(s) Of Engagement Activity 2008,2009