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  • Title: Clinical and cost-effectiveness of first contact physiotherapy for musculoskeletal disorders in primary care: the FRONTIER, mixed method realist evaluation.
    Author: Walsh NE, Berry A, Halls S, Thomas R, Stott H, Liddiard C, Anchors Z, Cramp F, Cupples ME, Williams P, Gage H, Jackson D, Kersten P, Foster D, Jagosh J.
    Journal: Health Soc Care Deliv Res; 2024 Dec; 12(49):1-187. PubMed ID: 39707910.
    Abstract:
    BACKGROUND: First-contact physiotherapists assess and diagnose patients with musculoskeletal disorders, determining the best course of management without prior general practitioner consultation. OBJECTIVES: The primary aim was to determine the clinical and cost-effectiveness of first-contact physiotherapists compared with general practitioner-led models of care. DESIGN: Mixed-method realist evaluation of effectiveness and costs, comprising three main phases: A United Kingdom-wide survey of first contact physiotherapists. Rapid realist review of first contact physiotherapists to determine programme theories. A mixed-method case study evaluation of 46 general practices across the United Kingdom, grouped as three service delivery models: General practitioner: general practitioner-led models of care (no first contact physiotherapists). First-contact physiotherapists standard provision: standard first-contact physiotherapist-led model of care. First-contact physiotherapists with additional qualifications: first-contact physiotherapists with additional qualifications to enable them to inject and/or prescribe. SETTING: United Kingdom general practice. PARTICIPANTS: A total of 46 sites participated in the case study evaluation and 426 patients were recruited; 80 staff and patients were interviewed. MAIN OUTCOME MEASURES: Short Form 36 physical outcome component score and costs of treatment. RESULTS: No statistically significant difference in the primary outcome Short Form 36 physical component score measure at 6-month primary end point between general practitioner-led, first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models of care. A greater number of patients who had first-contact physiotherapist standard provision (72.4%) and first-contact physiotherapist with additional qualifications (66.4%) showed an improvement at 3 months compared with general practitioner-led care (54.7%). No statistically significant differences were found between the study arms in other secondary outcome measures, including the EuroQol-5 Dimensions, five-level version. Some 6.3% of participants were lost to follow-up at 3 months; a further 1.9% were lost to follow-up after 3 months and before 6 months. Service-use analysis data were available for 348 participants (81.7%) at 6 months. Inspecting the entire 6 months of the study, a statistically significant difference in total cost was seen between the three service models, irrespective of whether inpatient costs were included or excluded from the calculation. In both instances, the general practitioner service model was found to be significantly costlier, with a median total cost of £105.50 versus £41.00 for first-contact physiotherapist standard provision and £44.00 for first-contact physiotherapists with additional qualifications. Base-case analysis used band 7 for first-contact physiotherapist groups. A sensitivity analysis was undertaken at band 8a for first-contact physiotherapists with additional qualifications; the general practitioner-led model of care remained significantly costlier. Qualitative investigation highlighted key issues to support implementation: understanding role remit, integrating and supporting staff including full information technology access and extended appointment times. LIMITATIONS: Services were significantly impacted by COVID-19 treatment restrictions, and recruitment was hampered by additional pressures in primary care. A further limitation was the lack of diversity within the sample. CONCLUSIONS: First-contact physiotherapists and general practitioner models of care are equally clinically effective for people with musculoskeletal disorders. Analysis showed the general practitioner-led model of care is costlier than both the first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models. Implementation is supported by raising awareness of the first-contact physiotherapist role, retention of extended appointment times, and employment models that provide first-contact physiotherapists with professional support. FUTURE RESEARCH: Determining whether shifting workforce impacts physiotherapy provision and outcomes across the musculoskeletal pathway. STUDY REGISTRATION: The study is registered as Research Registry UIN researchregistry5033. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 49. See the NIHR Funding and Awards website for further award information. Millions of people experience pain and consult their general practitioner because of conditions that affect the bones, joints and muscles – these are known as musculoskeletal disorders. This costs the National Health Service a lot and takes up many general practitioner appointments. We therefore must establish better ways to manage people who need support with their musculoskeletal disorder. First-contact physiotherapists are experts in managing musculoskeletal disorders and see patients without them having to first consult with a general practitioner. We recruited 46 general practices across the United Kingdom who provided three different models of care: (1) general practices without a first-contact physiotherapist; (2) general practices with a first-contact physiotherapist who could not inject and/or prescribe and (3) general practices with a first-contact physiotherapist who could inject and/or prescribe. We recruited 426 patients to the study and conducted 80 interviews with patients and staff involved in the delivery of first-contact physiotherapy. When we looked at the effectiveness of first-contact physiotherapy compared with general practitioner-led approaches, we found that it did not matter whether the patient consulted a general practitioner or a first-contact physiotherapist, they would all achieve the same outcome after 6 months, but when we looked at data at 3 months, a greater proportion of patients who saw first-contact physiotherapists seemed to improve more quickly than if they saw a general practitioner and, in some cases, had fewer days off work. Overall, it was about 2.5 times less costly for the National Health Service to have a first-contact physiotherapist than it was to have a general practitioner-led model of care. When we spoke to practice staff and patients about the first-contact physiotherapist service, the key areas that helped first-contact physiotherapist work in practice were patients knowing about the role, longer appointment times with first-contact physiotherapists, and ensuring that first-contact physiotherapists were supported in their role and had full access to patient records. When we consider the cost to the National Health Service, it may be better to have a first-contact physiotherapist-led model of care for musculoskeletal disorders rather than a general practitioner-led model.
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