Implementation of a primary care model that integrates physiotherapists within primary care for people with musculoskeletal conditions: Two process evaluations

Background: Integrating physiotherapists within primary care teams for people with musculoskeletal conditions has been proposed as a way to provide more integrated, continuous, and accessible care; however, there is a need for more rigorous literature about how models of primary care that integrate physiotherapists are being implemented. The two cluster trial process evaluations within this presentation aimed to evaluate the implementation of a physiotherapist-led primary care model for people with low back pain (LBP, study 1) and hip or knee pain (study 2) in comparison to usual physician led care (usual care).

 

Approach: Two process evaluations were embedded within two cluster randomized trials to assess how the PT-led primary care model, in which a physiotherapist is integrated within a primary care team and made available as the first point of contact for people with LBP and hip/knee pain, were implemented in comparison to usual care.

 

We extracted data from all relevant primary care encounters from the electronic health records of enrolled participants over a one-year period following enrollment. Implementation outcomes were identified a priori by a research team comprised of health service researchers, patients, and health professionals and included: medications prescribed, exercises provided, education offered, diagnostic images ordered, and specialist referrals made.

 

Results: A total of 739 and 647 participants were recruited for the cluster trials for LBP and hip/knee pain, respectively. In both cohorts, >75% of participants in the PT-led groups received exercise as part of their intervention, compared to <20% with usual care. Approximately 6% more participants received physical activity education in the PT-led groups. There were minimal differences in medication prescription patterns between the cohorts. In both trials, diagnostic images were ordered less frequently in the PT-led arm (43% vs. 65% LBP and 29% vs. 39% hip/knee pain for PT-led and usual care groups, respectively). Fewer participants in the PT-led arms received a referral to a physician specialist (15% vs. 27% back pain and 21% vs. 28% hip/knee pain for PT-led and usual care groups, respectively).

 

Implications: Participants enrolled in the PT-led model of care were more likely than those in usual care to receive exercise prescription and physical activity education. They also had fewer specialist referrals and diagnostic images ordered. The results of this process evaluation provide valuable implementation evidence to help interpret cluster trial findings and to understand how the model of care may influence health service delivery and healthcare utilization if this model is implemented more widely.