WHO MAKES THE TREATMENT CHOICE? A RANDOMIZED CONTROLLED TRIAL OF A GERMAN MODEL OF PRIMARY CARE WITH GREATER PHYSIOTHERAPISTS' AUTONOMY

Nast I1, Mischker A2, Repschlaeger U3, Heine M3, Scheermesser M1, Wirz M1, Schämann A11Zurich University of Applied Sciences / Institute of Physiotherapy (ZHAW), School of Health Professions, Winterthur, Switzerland, 2BIG Direkt Gesund, Berlin, Germany, 3Deutscher Bundesverband Selbstständiger Physiotherapeuten IFK e. V., Bochum, GermanyBackground: In Germany, demographic change, physician shortage and rising healthcare expenditures inspire discussions on potentially more efficient care models - such as direct access to physiotherapy. Traditionally, physicians prescribe treatment modality, frequency and duration. A new legislation allows on a trial basis the implementation and evaluation of primary care models, in which physiotherapists decide on these aspects of the treatment plan autonomously.Purpose: This study evaluated the effectiveness of a new model of care, where physiotherapists decided autonomously on their treatment plans.Methods: A randomised controlled trial has been conducted from June 2011 to December 2017 in two regions of Germany. Patients with musculoskeletal conditions of the spine or lower extremities were randomly assigned to either control group (CG) (treatment according to physician's prescription (n=296)) or model group (MG) (physiotherapists' treatment plan (n=334)). The following outcomes were assessed by questionnaires: pain (Visual Anlaogue Scale (VAS)), function (Roland-Morris Disability Questionnaire (RMDQ), Back Performance Scale (BPS), Lower Extremity Functional Scale (LEFS), health related quality of life (EuroQol), and patient satisfaction (ZUF-8). Information on treatment duration and number of treatment units were derived from treatment records.Results: Independent from treatment group, patients reported significant pain reduction (T = 15.122, p < .001), improvement in function (RMDQ: T = 14.563, p < .001; BPS: T = 9.410, p < .001; LEFS: T = -8.233, p < .001) and health related quality of life (T = -15.122, p < .001). Participants in CG and MG did not differ at the end of treatment regarding pain, function, and quality of life, excluding the EuroQol Dimensions “usual activities” and “pain/discomfort”, where patients in the MG reported higher levels of improvement (T = 2.096, p < .05, and T = 2.860, p < .01). Treatment duration was shorter in MG (9.7 weeks ± 13.2) than in CG (11.8 weeks ± 5.4) (T = 2.542, p < .05). Number of treatment units in both groups were comparable (14.7 ± 15.4 units in CG, vs. 15.8 ± 10.6 units in MG; T = -1.030, p = .303). Patient satisfaction was high with 29.4 ± 3.1 points on a scale from 8-32 in both groups (T = -1.381, p = .168).Conclusion(s): Physiotherapy treatment showed beneficial effects regarding pain, function, health related quality of life, irrespective of whether the treatment modalities, duration and frequency was defined by the physician or by the physiotherapist. Thus, the study prove that physiotherapists are able to choose and define effective treatment plans. Physiotherapists guided their treatment even in a slightly shorter period of time, but with a comparable amount of treatment units. Future research should focus on the association between treatment duration and outcomes and on models with even more autonomy, i.e. direct access.Implications: In this model of autonomous, but delegated care, physiotherapists have shown to choose their treatment plans to the patients' benefit and to complete treatment within a shorter period. There is a need to evaluate pilot models on direct access as substitutional care model, to understand its potential for current and future challenges in health care.Keywords: New models of care, direct access, physiotherapyFunding acknowledgements: This evaluation has been funded by the statutory health insurance company BIG direkt gesund.Topic: Service delivery/emerging roles; Professional issues; Professional practice: otherEthics approval required: NoInstitution: German Federal AuthorityEthics committee: German Federal Social Insurance AuthorityReason not required: The responsible German Federal Social Insurance Authority approved this model project and the research concept. All patients provided informed consent.All authors, affiliations and abstracts have been published as submitted.