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Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems
  1. Chris Salisbury1,
  2. Alan A Montgomery2,
  3. Sandra Hollinghurst1,
  4. Cherida Hopper1,
  5. Annette Bishop3,
  6. Angelo Franchini2,
  7. Surinder Kaur1,
  8. Joanna Coast4,
  9. Jeanette Hall5,
  10. Sean Grove5,
  11. Nadine E Foster3
  1. 1Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
  2. 2Bristol Randomised Controlled Trials Collaboration, University of Bristol, UK
  3. 3Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK
  4. 4Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
  5. 5Musculoskeletal Outpatient Department, Bristol Community Health, Bristol, UK
  1. Correspondence to: C Salisbury; c.salisbury{at}bristol.ac.uk

Abstract

STUDY QUESTION Are PhysioDirect services, based on initial telephone assessment and advice from a physiotherapist, as effective as usual care involving patients waiting for a face-to-face appointment?

SUMMARY ANSWER Patients allocated to PhysioDirect received treatment more quickly than those allocated to usual care, and had equivalent clinical outcomes.

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Design

We conducted a pragmatic randomised controlled trial to assess equivalence in clinical effectiveness between PhysioDirect and usual care. Patients allocated to PhysioDirect were invited to telephone a physiotherapist for initial assessment and advice, followed by face-to-face physiotherapy if necessary. Patients allocated to usual care joined a waiting list for face-to-face treatment. Patients were individually randomised 2:1 to PhysioDirect or usual care using an automated remote system. Outcomes were collected blind to group allocation.

Participants and setting

Adults referred by general practitioners or self referred for musculoskeletal physiotherapy to one of four physiotherapy services in England.

Primary outcome(s)

Primary outcome was the SF-36v2 physical component score (PCS) at six month follow-up (equivalence was prespecified as a between group difference of ≤2 in PCS). Secondary outcomes included four other measures of health outcome, number of appointments, waiting time for treatment, rates of non-attended appointments, time lost from work, and patient satisfaction and preference.

Main results and the role of chance

Of 1506 patients allocated to PhysioDirect and 743 to usual care, 85% provided primary outcome data at six months (1283 and 629 patients, respectively). PhysioDirect patients had fewer face-to-face appointments than usual care patients (mean 1.91 v 3.11; incidence rate ratio 0.59 (95% confidence interval 0.53 to 0.65)), a shorter waiting time (median 7 days v 34 days; arm time ratio 0.32 (0.29 to 0.35)), and lower rates of non-attendance (incidence rate ratio 0.55 (0.41 to 0.73)). At six months' follow-up, the SF-36v2 PCS was equivalent between groups (adjusted difference in means −0.01 (−0.80 to 0.79)). All measures of health outcome suggested a trend towards slightly greater improvement in the PhysioDirect arm at six weeks' follow-up and no difference at six months. There was no difference in time lost from work. Patients offered PhysioDirect were no more satisfied with access to physiotherapy than those offered usual care, but were slightly less satisfied with the service overall at six months (difference in satisfaction −3.8% (−7.3% to −0.3%; P=0.031). PhysioDirect patients were more likely than usual care patients to prefer PhysioDirect in future. We did not detect any adverse events or other harms.

Between group differences in SF-36v2 PCS

Bias, confounding, and other reasons for caution

The few differences observed between groups were small and might not be clinically meaningful. Only 50% of eligible patients chose to take part in the study. Questions about satisfaction were only completed by patients who had contacted a physiotherapist.

Generalisability to other populations

Broad eligibility criteria meant that the results were generalisable to the types of patients likely to be offered PhysioDirect. Some people could have declined participation in the trial because they did not think PhysioDirect was suitable, so the findings might only be generalisable if PhysioDirect is offered to patients as a choice.

Footnotes

  • This is a summary of a paper that was published on bmj.com as BMJ 2013;346:f43