1. Senior Research Fellow
The MRC PhysioDirect trial: A pragmatic RCT of 'PhysioDirect' telephone assessment and advice services versus usual care for musculoskeletal problems
Dr Annette Bishop
Senior Research Fellow
Keele University

2. The MRC PhysioDirect Trial was a collaboration between
University of Bristol
and
Keele University
NHS physiotherapy departments in Bristol, Somerset, Stoke-on-Trent, Central and East Cheshire
Recruited July-December 2009

3. Background
Healthcare systems challenge of meeting demand within limited resources
Burden of musculoskeletal conditions
Telephone based approaches had been introduced to assess and advise patients with a wide range of problems in primary care, although have rarely been rigorously evaluated
Telephone based approaches may be particularly appropriate for musculoskeletal conditions

4. Design
Pragmatic individually randomised controlled trial, incorporating economic analysis and a nested qualitative interview
Comparing PhysioDirect approach and Usual Care
Designed to assess equivalence between the 2 arms in the primary clinical outcome

5. Setting Conducted in 4 typical community physiotherapy services
Included patients from 94 general practices
Covering a range of geographical areas and population demographics

6. Patients Inclusion criteria Exclusion criteria
Adults referred to physiotherapy from GP or self referred with musculoskeletal disorders
Exclusion criteria
Very urgent cases; unable to speak English; consultant referrals; needing domiciliary physiotherapy; unable to contact

7. Follow-up at 6 weeks and 6 months
PhysioDirect trial
Usual care: Wait for appointment for face-to-face care
PhysioDirect
2256 patients with MSK conditions
Patients randomised in 2:1 ratio to PhysioDirect or Usual care,
minimised by age-group, gender, presenting complaint, PCT
Our sample size calculation was based on
95% power to detect equivalence (2 points on SF36 PCS)
And we needed to recruit 2143 patients, allowing for 30% loss to follow-up
We recruited 2256 patients
Follow-up at 6 weeks and 6 months

8. PhysioDirect intervention
Participants allocated to PhysioDirect invited to telephone senior physiotherapist
Assessment of whether patient needs face-to-face treatment, and how urgently
Provision of telephone advice and written advice about self- management and exercise
Telephone follow-up generally offered
Those not improving advised to phone back, given face-to-face consultation or signposted to other services
Computerised assessment templates and training provided by physiotherapy team in Huntingdonshire

9. Clinical Outcomes Primary Secondary SF36 Physical Component Summary
Generic measure of physical health status, applicable to wide range of musculoskeletal conditions
Secondary
MYMOP Quality of life (EQ5D)
Waiting times Time lost from work
Satisfaction DNA rates
Overall rating of improvement Costs

10. Results

11. GP referrals to physiotherapy
Flow of participants
GP referrals to physiotherapy
6870
Eligible
4523 (66%)
Randomised
2256 (50%)
PhysioDirect
1513 (67%)
6 week response
1341 (89%)
6 month response
1287 (85%)
Usual Care
743 (33%)
657 (88%)
634 (85%)
98% referred by GPs

12. Patient Baseline Characteristics
Randomised Patients
n=2,249 (100%)
Usual Care
n=743 (33%)
PhysioDirect n=1,506 (67%)
Gender
Female
58.9
59.5
Age
Years
48.2
48.3
Referral problem %
Cervical 12
Thoracic 2
Lumbar 27
Upper limb 23
Lower limb 30
Widespread pain 1
Multiple MSK 4
Other MSK
Preference %
Usual care 33 31
PhysioDirect 35 36
No preference 32 34

13. Adjusted difference in means
Primary outcome SF36 PCS
Usual Care n=743
PhysioDirect n=1506
Adjusted difference in means
95% CI p
Baseline
37.72
36.81
6 weeks
41.81
41.57
0.42
-0.42, 1.12
0.24
6 months
44.18
43.5
-0.01
-0.80, 0.79
0.99
Value are means
*Regression analysis adjusted for PCS at baseline, gender, age, referral problem, PCT
Robust to sensitivity analyses taking account of baseline imbalance, missing data, clustering by PCT and practice

14. Economic analysis Mean cost of physiotherapy Mean total NHS costs
£4.28 (-£1.12 to £9.69) greater in PhysioDirect than usual care
Phone consultations only slightly shorter (29mins phone versus 34mins face to face)
Cost per hour of phone consultation time was higher because of non-contact time and physiotherapists were on higher bandings
Mean total NHS costs
£7.24 greater in PhysioDirect than usual care

15. Economic analysis QALYs Higher in the PhysioDirect group by 0.009
Equates to about 3.3 extra days of full health over a year
Small extra cost of caring for patients in PhysioDirect arm compensated by the extra QALY gain
Incremental cost per QALY gained was £2889

16. Other outcomes
Patient satisfaction: Overall satisfaction very slightly higher for Usual Care (0.19 points on a 6 point scale)
Waiting times: 7 days to first assessment for PhysioDirect vs 34 for Usual Care
Number of consultations: 2.87 in PhysioDirect vs 3.25 in Usual Care
Patients managed by telephone alone = 47%
DNA rate (of all face to face appointments booked):
PhysioDirect 10%
Usual care 11%
No adverse events identified

17. Qualitative research – ‘headlines’
Patients
Patients described the PhysioDirect telecare service as quick, efficient, convenient and preferable to the long waits for physiotherapy face-to-face care
But
Some found it impersonal and difficult to communicate the complexities of pain by telephone
Evidence of trade-offs

18. Physiotherapists
Need to adapt the way of working using visualisation and enhanced communication skills
Generalised rather than individualised treatment
Effective at providing self-management
Impact on the physiotherapist - patient relationship
Impairs continuity of care
Professional identity and skills

19. General practitioners
General ambivalence about PhysioDirect
Perception of physiotherapy as a face-to-face service
Commissioning perspective
Importance of waiting time as a quality indicator
Relative priority given to physiotherapy services
Assumption that PhysioDirect would be cheaper

20. Conclusions
With respect to patient outcomes at 6 weeks and 6 months, PhysioDirect is equivalent to usual care
PhysioDirect
Reduces the number of consultations
Provides faster access to advice
Is safe (there were NO adverse events)
Broadly acceptable, but patients are not more satisfied with ‘improved’ access
Is slightly more costly than usual care but QALY gain makes it cost-effective

21. Conclusions Safe and equivalent service Provides patient choice
Combined with self-referral the benefits of initial telephone assessment and advice may be greater

22. Acknowledgements
This research was funded by the MRC and managed by the NIHR on behalf of the MRC-NIHR partnership. The views expressed in this presentation are those of the authors and not necessarily those of the MRC, NHS, NIHR or the Department of Health.
Supported by the Arthritis Research UK Primary Care Centre
now

23. Publications Protocol
Salisbury C, Foster NE, Bishop A et al. 'PhysioDirect' telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial. BMC Health Serv Res 2009;9:136
Main results
Salisbury C, Montgomery AA, Hollinghurst S, Hopper C, Bishop A, Franchini A, Kaur S, Coast J, Hall J, Grove S, Foster NE. Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems: pragmatic randomised controlled trial. BMJ 2013 Jan 29:346:f43. doi: /bmj.f43
HTA report
C Salisbury, NE Foster, C Hopper, A Bishop, S Hollinghurst et al. Pragmatic cluster randomised trial of PhysioDirect telephone assessment and advice services for physiotherapy. Health Technol Assess 2013;17(2)
Training and support for physiotherapists
Bishop A, Gamlin J, Hall J, Hopper C, Foster NE. PhysioDirect: Supporting physiotherapists to deliver telephone assessment and advice services within the context of a randomised trial. Physiotherapy (2013) 113–118
Health economics
Hollinghurst S, Coast J, Busby J, et al. A pragmatic randomised controlled trial of ‘PhysioDirect’ telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation. BMJ Open 2013;3:e doi: /bmjopen