Physiotherapists as primary care practitioners for patients with musculoskeletal disorders

Musculoskeletal (MSK) disorders, such as osteoarthritis, rheumatoid arthritis, osteoporosis and low back pain, represent an important burden in terms of direct and indirect health care costs in western countries. In Canada, pressure on the health care system is rising; the prevalence of MSK disorders is increasing, while access to care declines.

Arthritis is a chronic condition of the joints which affects more than 4.6 million Canadians (Arthritis Society, 2014). There is no cure for arthritis and it can affect any person at any age. Working Towards Wellness

New models of care are needed to improve access and ameliorating care for this population. Mounting evidence supports the use of non-physician health professionals in more autonomous roles to help increase access in primary or secondary care. In these new roles, non-physician health professionals are positioned upstream in the health care system and become primary care providers. Primary care providers typically provide first contact to persons with any undiagnosed disorder.

Physiotherapists are among the health professionals who are expected to play increasingly important roles as primary care providers for the treatment of MSK disorders as they have the competence and skills to diagnose and manage a variety of MSK disorders without any medical involvement.

In Canada, individuals that have a MSK disorders have access to physiotherapy care without a medical referral either in private practice or in publicly funded institutions. In Canada and elsewhere throughout the world, direct access to physiotherapy care has been associated with improved access, equal or better patient outcomes and decreased health care costs.

Source Acceptability of physiotherapists as primary care practitioners and advanced practice physiotherapists for care of patients with musculoskeletal disorders: a survey of a university community within the province of Québec, Desjardins-Charbonneau A, Roy JS et. al., 2016

Models of Care Delivery for People with Arthritis

A number of different models of care have been developed in an attempt to facilitate a seamless system of settings, services, service providers and service levels that meets the needs of clients or defined populations to manage the current and growing burden of arthritis. This report reviews existing models of arthritis care in the context of the continuum of care for people with arthritis.

Key Messages

There are a multitude of potential models. Key models identified include: the traditional primary care physician to specialist referral loop, more recently with many primary care physicians working within team-based practice; specialized arthritis, multi-disciplinary team-based care; models to access care in rural and remote areas through telemedicine and visiting provider mechanisms; triage models of using health care providers working in expanded roles; and, community-based models.

The objective and structure of the models are different:
- in the traditional primary care-specialist referral model, the primary care physicians assume overall responsibility for care whereas the specialist, usually a rheumatologist or orthopaedic surgeon, provide their specialized services with ongoing care managed in primary care; or in a shared-care model where the specialist sees the patient in limited review with ongoing primary care management
- specialized arthritis, multi-disciplinary team-based models provide care to people across the continuum of care and spectrum of disease severity
- remote and rural models rely on local providers to coordinate and provide ongoing management with input from a specialist via technology or infrequent in-person consultation
- triage models use health providers often working in expanded roles to facilitate priority access to a specialist e.g., people with inflammatory arthritis to a rheumatologist or people with osteoarthritis (OA) who need joint replacement to an orthopaedic surgeon
- community-based programs provide services that are limited or not available in the formal health care system with the goal of promoting wellness, self-management and risk reduction
Few of these models address the continuum of care or spectrum of disease severity given their objectives, leaving potential gaps in access and management for some groups
There is limited evaluation data for any of the models, particularly in a Canadian context
These models have varying vulnerabilities related to sustainability due to issues such as need for administrative support, concern about professional boundaries and their funding mechanisms

Source Models of Care in Arthritis, Bone & Joint Disease (MOCA), Aileen M. Davis, Nikhil Kitchlu, et al., 2010

References

Acceptability of physiotherapists as primary care practitioners and advanced practice physiotherapists for care of patients with musculoskeletal disorders: a survey of a university community within the province of Quebec, Desjardins-Charbonneau A, Roy JS, Thibault J, Ciccone VT, Desmeules F. BMC Musculoskelet Disord. 2016 Sep 21;17(1):400. doi: 10.1186/s12891-016-1256-8. Full text

Models of Care in Arthritis, Bone & Joint Disease (MOCA), Prepared by the Models of Care Working Group, Aileen M. Davis, Nikhil Kitchlu, Crystal MacKay, Marvilyn Palaganas and Rose Wong. July 2010, MOCA2010-07/004 University Health Network, Toronto General Hospital, Toronto Western Hospital, Princess Margaret Hospital