Clinical Course of Patients Receiving Physiotherapy Services in Primary Health Care

The primary aim of the FYSIOPRIM project is to build a database by systematically collecting data from baseline throughout the intervention period and beyond, including both patient-reported outcome measures, the patients' and PTs' goals and plans for intervention, and their evaluation thereof. This will enable description of patients receiving physiotherapy services, of goal-setting and type of interventions and how general health, physical function and relevant clinical factors change throughout and after a treatment period. Secondly, the investigators want to study associations and interaction effects between and among clinical characteristics, interventions and change as well as perform health-economic evaluations. The investigators will also examine how physiotherapy practice is affected by using the system for systematic registration of clinical data and effects of such registration. Moreover, the investigators will be able to compare patients receiving physiotherapy services with information from national patient registries. In addition, elderly participants' physical fitness, balance and walking ability will be examined to study associations between these aspects of physical functioning and health-related quality of life, self-reported physical and psychological functioning as well as response to physical fitness tests. The investigators will compare data from this group of elderly with data from other patients with musculoskeletal complaints who receive physiotherapy treatment, and with similar data from large population-based studies in Norway. Finally, this project enables methodological studies to validate clinical tests and questionnaires.

Design and setting This is a longitudinal observational project following patients through physiotherapy treatment periods in primary health care in Norway and until one year after baseline. The project involves both private practice and municipally employed PTs working in primary health care in eight municipalities of Norway; Lørenskog, Ski, Nedre Eiker, Lillehammer, Stavanger, Bergen, Trondheim and Alta. All five health regions of Norway are represented. The Norwegian Health care system is publicly funded. PTs working as private practitioners have an agreement with the municipality. Hence, they are partly paid by the municipality (as a financial support for practice) and partly paid per visit by the Norwegian Health Economics Administration (HELFO) and the patient's charge (maximum around 200 Euro per patient per calendar year). Patients seeking physiotherapy services in private practice will normally meet at the PT's clinic.

Municipally employed PTs are on fixed salary. They work in an out-patient setting, and their patients receive physiotherapy services in their usual daily environment, i.e. for children at home, in kindergarten or in school, and for elderly patients often in their own home. There are no clear guidelines for which patients that should receive physiotherapy from a private practice or a municipally employed PT. The choice can be based on previous personal experiences with physiotherapy, the possibility to visit a clinic, evaluation of need and/or benefit of treating the patients in their own setting.

Characteristics of participants

The participants are recruited to three different parts of the project depending on age and whether they are referred to a private practice PT or to a municipally employed PT (in this project, these PTs are from Trondheim). The three parts of the project are:

1. Adults seeking physiotherapy services in private practice This part of the project started data collection in June 2015, and data collection is planned to continue through June 2020. From January 2016 through December 2017, data were collected from a total of 2754 patients above the age of 18 years seeking physiotherapy treatment from 111 PTs in eight municipalities in different parts of Norway, including 536 patients already in treatment. Among the 111 PTs, 78 (70.3%) are general PTs, 20 (18.0%) are manual therapists and13 (11.7%) are PTs with special education in psychomotor physiotherapy. Seventy-seven (69.4%) of the PTs are working in Trondheim.
2. Adults and elderly receiving physiotherapy services in Trondheim Municipality This part of the project collected data from the beginning of May 2016 to the end of May 2018. From January 2016 until the end of September 2017, data were collected from 684 adults and elderly patients receiving physiotherapy services from approximately 55 PTs working with adults and elderly in the municipality of Trondheim in Norway. Adults and elderly may be referred from general practitioners, occupational therapists, health professionals at health care centers, rehabilitation centers or hospitals, or by proxy. The physiotherapy services to adults and elderly include early intervention, activities of daily living (ADL) rehabilitation and ordinary physiotherapy, all of which are typically delivered in a home setting. Early intervention is a collaboration between health and welfare centers and units for physiotherapy and occupational services and is offered to patients in need of limited services who are referred to municipality health care services for the first time. ADL rehabilitation are offered to patients in risk of functional deterioration who are receiving home based services, while ordinary physiotherapy is offered to patients in need of more specific physiotherapy services.
3. Children receiving physiotherapy services in Trondheim Municipality This part of the project collected data from May 2016 through April 2017. During this period, data were collected from 165 children aged 0-18 years receiving physiotherapy services from approximately 25 PTs working with children in the municipality of Trondheim in Norway. For children, physiotherapy may be initiated on referral from parents, personnel at kindergarten or in school, general practitioners, occupational therapists, and health professionals at primary health care centers or hospitals. The children typically receive physiotherapy services at the primary health care centers, in their own home or in kindergarten or at school, depending on the child's usual primary location and condition.

Data collection Patients are asked to participate at their first time encounter with a physiotherapist in primary health care. Project information and consent forms are available in Norwegian and English. The investigators collect baseline data in two steps. First, the therapist and the participant together fill in information about the main problem, and jointly agree on goals for treatment and a treatment plan. The therapist also asks the participant for their own specific functional problem using the Patient-Specific Functional Scale (PSFS). The therapist provides information about the referral, diagnosis and whether any disease-specific questionnaires should be used for this participant. Secondly, the participant completes questionnaires themselves, either using an e-tablet or through a web-link sent by e-mail. A set of outcome data are common to all, and in addition disease-specific outcome measures are included for some common patient groups.

Approximately 1 month after baseline (for participants seeking PTs in private practice), or 2-3 months after baseline (for participants receiving physiotherapy from municipally employed PTs), the therapist and the participant together evaluate goal achievement and fulfilment of the treatment plan so far. They also adjust these when needed and the participant recompletes the PSFS. Three months (for private practice) or six months after baseline (for participants receiving physiotherapy from municipally employed PTs), the PT and the participant again evaluate goal achievement and fulfilments of the treatment plan. The participant then completes the same standardized questionnaires as at baseline. The same questionnaires are also completed 6 and 12 months after baseline by participants treated by PTs in private practice using a web-link sent by smartphone or e-mail. All participants treated by PTs in private practice receive reminders once a week, up to three times, by sms and e-mail if they have not answered the questionnaires.

All data are collected electronically using an application run on a tablet or through a web-link. The software is provided by Infopad AS (www.infopad.no). Immediately after the completion of the questionnaires all data are transferred to a backend secure server with in-memory encryption. The PTs have access to their own participants' data either through a web-site and/or by importing data into their electronic medical journal. The journal number of the participant is used as the study identifier to enable data flow between the electronic medical journal and the secure backend server. The data from all participants are copied to a secure server at the University of Oslo set up for research purposes (Services for Sensitive Data). Data management is done according to the quality assurance system of the University of Oslo. The investigators have prepared for linkage between data from FYSIOPRIM and data from national patient registers. This will be done by use of the participant's journal number to access their unique 11-digit Norwegian personal number.

All the data are collected electronically, thereby avoiding the possibility of mistakes when transferring data from paper forms to electronic data. Data management is performed using STATA 15 (Stata Corp., College Station, Texas, USA). The raw data are stored in a secure database where only researchers associated with the project have access. Before data can be used for analyses a range of automated procedures for data preparation and quality checking are performed using standardized, written scripts in STATA. Examples are to check, i) patterns of missing data, ii) values outside the possible range of a variable (e.g., age>120 years), iii) conflicting answers (e.g., pregnancy and male) and iv) unexpected frequency distributions for categorical variables. The investigators will explore each variable graphically using histograms and plots to evaluate the data distribution. Descriptive statistics will be used to describe the patient populations using parametric or non-parametric statistics according to the data distribution. Detailed descriptions of all the statistical analyses planned are beyond the length of this paper. Thus, specific analyses related to investigation of associations between variables, prognosis and clinical course will be described in future publications.