Development of quality indicators for physiotherapy for patients with PAOD in the Netherlands: a Delphi study

Improved quality of physiotherapy care in patients with Whiplash-Associated Disorders: Results based on 16 years of routinely collected data

Quality improvement is now a central tenet in physiotherapy care, and quality indicators (QIs), as measurable elements of care, have been applied to analyze and evaluate the quality of physiotherapy care over the past two decades. QIs, based on Donabedian's model of quality of care, provide a foundation for measuring (improvements in) quality of physiotherapy care, providing insight into the many remaining evidentiary gaps concerning diagnostics, prognostics and treatment, as well as patient-related outcome measures. In this overview we provide a synthesis of four recently published articles from our project group on the topic of quantitative measures of quality improvement in physiotherapy care, in this context specifically focused on patients with WAD in primary care physiotherapy. A set of process and outcome QIs (n = 28) was developed for patients with WAD and linked to a database consisting of routinely collected data (RCD) on patients with WAD collected over a 16-year period. The QIs were then embedded per step of the clinical reasoning process: (a) administration (n = 2); (b) history taking (n = 7); (c) objectives of examination (n = 1); (d) clinical examination (n = 5); (e) analysis and conclusion (n = 1); (f) treatment plan (n = 3); (g) treatment (n = 2); (h) evaluation (n = 5); and (i) discharge (n = 2). QIs were expressed as percentages, allowing target performance levels to be defined ≥70% or ≤30%, depending on whether the desired performance required an initially high or low QI score. Using RCD data on primary care patients with WAD (N = 810) and a set of QIs, we found that the quality of physiotherapy care has improved substantially over a 16-year period. This conclusion was based on QIs meeting predetermined performance targets of ≥70% or ≤30%. Twenty-three indicators met the target criterium of ≥70% and three indicators ≤30%. Our recommended set of QIs, embedded in a clinical reasoning process for patients with WAD, can now be used as a basis for the development of a validated QI set that effectively measures quality (improvement) of primary care physiotherapy in patients with WAD.

Implementation of a Personalized, Cost-Effective Physical Therapy Approach (Coach2Move) for Older Adults: Barriers and Facilitators

Background and Purpose:

This article reports on a recent randomized clinical trial that showed a personalized approach to physical therapy (Coach2Move) by a physical therapist specialized in geriatrics (PTG) to be more cost-effective than usual physical therapy care in people with mobility problems (n = 130, mean age = 78 years).

Methods:

We used an explanatory mixed-methods sequential design alongside the randomized clinical trial to gain insight into (a) the contrast between the 2 interventions, (b) the fidelity of the Coach2Move delivery; (c) PTGs' experiences of Coach2Move; and (d) possible barriers and facilitators for future implementation. The study included 13 PTGs educated in the strategy and 13 physical therapists with expertise in geriatrics delivering the usual care. In total, 106 medical records were available for assessment: 57 (85%) Coach2Move, 49 (75%) usual care. Quantitative process indicators were used to analyze electronic medical records to determine contrasts in the phases of clinical reasoning. The fidelity of the delivery was tested using indicator scores focusing on 4 key elements of Coach2Move. In-depth interviews with Coach2Move therapists were thematically analyzed to explore experiences and facilitators/barriers related to implementation.

Results and Discussion:

Indicator scores showed significant and clinically relevant contrasts in all phases of clinical reasoning, with consistently higher scores among PTGs, except for the treatment plan. Moreover, the fidelity of Coach2Move delivery was more than 70% in all phases, except the evaluation phase (53%). Experiences of Coach2Move were positive. In particular, extended intake allowing motivational interviewing, physical examination and an in-depth problem analysis, and shared goal setting were considered valuable. Facilitators for implementation were the addition of a Coach2Move medical record, frequent coaching by the researcher, and readiness to change in the therapist. Barriers were (1) having to use 2 parallel electronic medical record systems, (2) having to clear the calendar to schedule an intake of 90 minutes, (3) fear of losing income, (4) the sense that patients do not want to change their lifestyle, and (5) not acknowledging that increasing physical activity is an important goal for older adults with mobility problems.

Conclusions:

Physical therapy based on the Coach2Move strategy is substantially different from usual care. Future implementation should focus on increasing regular evaluation and feedback, taking into account individuals' contextual factors, and improving organizational facilities while mitigating income loss.

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care

BACKGROUND

Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle.

AIM

To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD.

MATERIALS AND METHODS

Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05).

RESULTS

In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables.

CONCLUSION

The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

Has the quality of physiotherapy care in patients with Whiplash-associated disorders (WAD) improved over time? A retrospective study using routinely collected data and quality indicators

PURPOSE

To develop valid quality indicators (QIs) for physiotherapy care based on best available evidence, and to use these QIs to explore trends in the quality of physiotherapy care of patients with Whiplash-associated disorders (WAD) using guideline-based routinely collected data (RCD) gathered between 1996 and 2011.

MATERIALS AND METHODS

The study consisted of two phases: 1) development of QIs and 2) analysis of patient records. A set of QIs was developed based on recommendations in the scientific literature and the Dutch Clinical Practice Guideline (CPG) "Physiotherapy Management and WAD". QIs were expressed as percentages, allowing target performance levels to be defined (≥80% or ≤30% depending on whether desired performance required a high or low score on a QI). We then analyzed WAD patient data (N = 810) collected over a period of 16 years in two physiotherapy practices, separating patients into two groups defined as before (Group A 1996-2002; n = 353) and after (Group B 2003-2011; n = 457) implementation and transition to the Dutch CPG "Physiotherapy Management and WAD".

RESULTS

Using an iterative process and input from both experts and users, 28 QIs were developed and subsequently classified per step of the clinical reasoning process for physiotherapy care. Based on 16 years of RCD, we found that the clinical reasoning process differed significantly (P ≤ 0.05) between the groups, in favor of Group B. Twelve of the 25 indicators (48.0%) in Group A and 19 of 26 indicators (73.1%) in Group B met predetermined performance targets. The number of target indicators also differed significantly between groups, favoring Group B (P ≤ 0.05).

CONCLUSION

A preliminary set of novel QIs was developed. Using RCD and these QIs, we conclude that physiotherapy care in our study setting improved over the period 1996-2011. Furthermore, the QIs met the performance targets set for the clinical reasoning process after the transition to the Dutch CPG "Physiotherapy Management and WAD".