One in six physiotherapy practices in primary care offer musculoskeletal ultrasound - an explorative survey

BACKGROUND

The first aim of this research was to investigate the current prevalence of musculoskeletal ultrasound in Dutch physiotherapy practices. The second aim was to explore experiences of physiotherapists with musculoskeletal ultrasound in a primary care setting with patients presenting with shoulder complaints.

METHODS

A random sample of 1000 owners of primary care physiotherapy practices was sent a questionnaire to investigate the prevalence of musculoskeletal ultrasound. A second questionnaire was sent to physiotherapists using musculoskeletal ultrasound to explore experiences with it in patients with shoulder complaints.

RESULTS

The net response rate of the first questionnaire was 57.7%. In 18% of the physiotherapy practices musculoskeletal ultrasound was offered. Sixty-nine physiotherapists returned the second questionnaire. Physiotherapists indicated they most often used musculoskeletal ultrasound in patients with shoulder complaints, mainly for suspected tissue damage (83.7%), followed by making a diagnosis (63.3%) and for determining the choice of treatment (36.7%). Physiotherapists reported the biggest advantage was that they were better able to diagnose presenting shoulder complaints. The most frequently mentioned disadvantage of the use of musculoskeletal ultrasound was that assessment is difficult and that there is a risk that findings may not be sufficiently linked to history and physical examination.

CONCLUSION

One in six physiotherapy practices in the Netherlands offer musculoskeletal ultrasound. It is mainly used for patients with shoulder complaints, with an emphasis on detecting tissue damage and as an aid for diagnosis. Physiotherapists trained to work with musculoskeletal ultrasound seem enthusiastic and are at the same time aware of its disadvantages.

Do project management and network governance contribute to inter-organisational collaboration in primary care? A mixed methods study

Background

The need for organisational development in primary care has increased as it is accepted as a means of curbing rising costs and responding to demographic transitions. It is only within such inter-organisational networks that small-scale practices can offer treatment to complex patients and continuity of care. The aim of this paper is to explore, through the experience of professionals and patients, whether, and how, project management and network governance can improve the outcomes of projects which promote inter-organisational collaboration in primary care.

Methods

This paper describes a study of projects aimed at improving inter-organisational collaboration in Dutch primary care. The projects' success in project management and network governance was monitored by interviewing project leaders and board members on the one hand, and improvement in the collaboration by surveying professionals and patients on the other. Both qualitative and quantitative methods were applied to assess the projects. These were analysed, finally, using multi-level models in order to account for the variation in the projects, professionals and patients.

Results

Successful network governance was associated positively with the professionals’ satisfaction with the collaboration; but not with improvements in the quality of care as experienced by patients. Neither patients nor professionals perceived successful project management as associated with the outcomes of the collaboration projects.

Conclusions

This study shows that network governance in particular makes a difference to the outcomes of inter-organisational collaboration in primary care. However, project management is not a predictor for successful inter-organisational collaboration in primary care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3169-8) contains supplementary material, which is available to authorized users.

SMS text messaging to measure working time: the design of a time use study among general practitioners

Background

Measuring the working hours of general practitioners (GPs) is an important but complex task due to the effects of bias related to self-reporting, recall, and stress. In this paper we describe the deployment, feasibility, and implementation of an innovative method for measuring, in real time, GPs’ working time, plus the response to the study.

Methods

A Short Message Service (SMS) application was developed which sent messages at random to GPs during their working week. Approximately nineteen GPs participated each week during a period of 57 weeks. The text messages asked if GPs were doing activities related to patients, directly, indirectly, or not at all, at the moment of sending. Participants were requested to reply by SMS.

Results

Approximately 27,000 messages were sent to 1051 GPs over more than one year. The SMS system was functioning 99.9% of the time. GPs replied to 94% of all the messages sent. Only a few participants dropped out of the study. The data was available in real time enabling the researchers to monitor the response and overall quality of the data each day.

Conclusions

The SMS method offers advantages over other instruments of measurement because it allows a better response, ease of use and avoids recall bias. This makes it a feasible method to collect valid data about GPs working time.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2926-z) contains supplementary material, which is available to authorized users.

Age-related differences in working hours among male and female GPs: an SMS-based time use study

BACKGROUND

In several countries, the number of hours worked by general practitioners (GPs) has decreased, raising concern about current and impending workforce shortages. This shorter working week has been ascribed both to the feminisation of the workforce and to a younger generation of GPs who prefer more flexible working arrangements. There is, however, limited insight into how the impact of these determinants interact. We investigated the relative importance of differences in GPs' working hours in relation to gender, age, and employment position.

METHODS

An analysis was performed on real-time monitoring data collected by sending SMS text messages to 1051 Dutch GPs, who participated during a 1-week time use study. We used descriptive statistics, independent sample t-tests, and one-way ANOVA analysis to compare the working time of different GP groups. A path analysis was conducted to examine the difference in working time by gender, age, employment position, and their combinations.

RESULTS

Female GPs worked significantly fewer hours than their male peers. GPs in their 50s worked the highest number of hours, followed by GPs age 60 and older. GPs younger than 40 worked the lowest number of hours. This relationship between working hours and age was not significantly different for women and men. As shown by path analysis, female GPs consistently worked fewer hours than their male counterparts, regardless of their age and employment position. The relationship between age and working hours was largely influenced by gender and employment position.

CONCLUSIONS

The variation in working hours among GPs can be explained by the combination of gender, age, and employment position. Gender appears to be the most important predictor as the largest part of the variation in working hours is explained by a direct effect of this variable. It has previously been reported that the difference in working hours between male and female GPs had decreased over time. However, our findings suggest that gender remains a critical factor for variation in time use and for policy instruments such as health workforce planning.

Assessing the precision of a time-sampling-based study among GPs: balancing sample size and measurement frequency

BACKGROUND

Our research is based on a technique for time sampling, an innovative method for measuring the working hours of Dutch general practitioners (GPs), which was deployed in an earlier study. In this study, 1051 GPs were questioned about their activities in real time by sending them one SMS text message every 3 h during 1 week. The required sample size for this study is important for health workforce planners to know if they want to apply this method to target groups who are hard to reach or if fewer resources are available. In this time-sampling method, however, standard power analyses is not sufficient for calculating the required sample size as this accounts only for sample fluctuation and not for the fluctuation of measurements taken from every participant. We investigated the impact of the number of participants and frequency of measurements per participant upon the confidence intervals (CIs) for the hours worked per week.

METHODS

Statistical analyses of the time-use data we obtained from GPs were performed. Ninety-five percent CIs were calculated, using equations and simulation techniques, for various different numbers of GPs included in the dataset and for various frequencies of measurements per participant.

RESULTS

Our results showed that the one-tailed CI, including sample and measurement fluctuation, decreased from 21 until 3 h between one and 50 GPs. As a result of the formulas to calculate CIs, the increase of the precision continued and was lower with the same additional number of GPs. Likewise, the analyses showed how the number of participants required decreased if more measurements per participant were taken. For example, one measurement per 3-h time slot during the week requires 300 GPs to achieve a CI of 1 h, while one measurement per hour requires 100 GPs to obtain the same result.

CONCLUSIONS

The sample size needed for time-use research based on a time-sampling technique depends on the design and aim of the study. In this paper, we showed how the precision of the measurement of hours worked each week by GPs strongly varied according to the number of GPs included and the frequency of measurements per GP during the week measured. The best balance between both dimensions will depend upon different circumstances, such as the target group and the budget available.

Contacts of general practitioners with illegal immigrants

Aims: Violence and economic hardship cause many people to go to industrialized countries, often without obtaining a residence permit. The aim of this study is to gain insight into the factors that determine the occurrence of contacts in primary health care with such illegal immigrants. Methods: Data were analysed on contacts with illegal immigrants from a national survey among Dutch general practitioners (GPs) ( n= 1,148; response: 62%). Results: GPs reported that they have on average 0.74 patient contacts with an illegal immigrant per week (95% CI: 0.56-0.92) . This probably includes some over-reporting. Contacts are more likely in practices and communities that comprise more non-Dutch-born people and more (patients with) typically urban health problems. Working experience and demography of the GP are not independently associated with the occurrence of contacts. Conclusions: Contacts of Dutch GPs with illegal immigrants mostly occur in the deprived areas of the big cities.

A Blended Intervention for Patients With Knee and Hip Osteoarthritis in the Physical Therapy Practice: Development and a Pilot Study

Background

Blended care, a combination of online and face-to-face care, is seen as a promising treatment option. However, actual use of blended interventions in practice is disappointing.

Objective

The objective of this study was two folded. The first aim was to develop a blended exercise therapy intervention for patients with knee and hip osteoarthritis that matches the values of the users and that can be implemented in the daily routine of physical therapists. The second aim was to investigate the feasibility through interviews and a pilot study.

Methods

In this paper, we employed the first 3 steps of the CeHRes road map to develop a blended intervention for patients with knee and hip osteoarthritis. We used interviews, a focus group and discussions with stakeholders to explore the needs, values, and requirements with respect to our to-be-developed blended intervention, which we called e-Exercise. The first version of e-Exercise was tested in a pilot study. Feasibility outcomes, including recruitment rates within each practice, website usage (assignments completed and website visits), and user satisfaction, were measured. In addition, therapists and patients from the pilot study were interviewed to investigate users’ experiences.

Results

The study captured important information about stakeholders’ needs and perspectives. Based on our findings, we created a first version and attuned the application’s content, functionality, and structure. Patients and, to lesser extent, physical therapists were satisfied with the e-Exercise intervention. Eight patients were recruited by 8 physical therapists. Of the 8 patients, 6 completed more than 7 of 12 modules.

Conclusions

This study outlines the development and feasibility of a blended exercise therapy intervention for patients with knee and hip osteoarthritis. E-Exercise offers an alternative approach in the physical therapy treatment of knee and hip osteoarthritis. This study provides valuable information to conduct a further trial to evaluate the (cost) effectiveness of e-Exercise compared to usual physical therapy.

Trial Registration

Netherlands Trial Register Number: NTR4224; www.trialregister.nl/trialreg/admin/rctview.asp?TC=4224 (Archived by WebCite at http://www.webcitation.org/6fOK4lrTO).

Pain intensity, neck pain and longer duration of complaints predict poorer outcome in patients with shoulder pain--a systematic review

Background

Shoulder complaints are common and have an unfavourable prognosis in many patients. Prognostic information is helpful for both patients and clinicians in managing the complaints. The research question was which factors have prognostic value on (un)favourable outcome in patients with shoulder complaints in primary care, secondary care and occupational settings.

Methods

Update of a systematic review in primary care, secondary care and occupational settings.

Results

Nine articles were published since the original review in 2004. Six were of high quality covering a wide variety of prognostic factors and outcome measures. Four studies were conducted in primary care settings. A best evidence synthesis, including the results of the previous systematic review on this topic shows that there is strong evidence that higher shoulder pain intensity, concomitant neck pain and a longer duration of symptoms predict poorer outcome in primary care settings. In secondary care populations, strong evidence was found for the association between greater disability and poorer outcome and between the existence of previous shoulder pain and poorer outcome.

Conclusion

Clinicians may take these factors into account in the management of their patients. Those with a worse prognosis may be monitored more frequently and the treatment plan modified if complaints persist.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0738-4) contains supplementary material, which is available to authorized users.

To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: a multilevel study

BACKGROUND

In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas.

METHODS

Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics.

RESULTS

The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts.

CONCLUSIONS

Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care.

Adherence to a web-based physical activity intervention for patients with knee and/or hip osteoarthritis: a mixed method study

Background

Web-based interventions show promise in promoting a healthy lifestyle, but their effectiveness is hampered by high rates of nonusage. Predictors and reasons for (non)usage are not well known. Identifying which factors are related to usage contributes to the recognition of subgroups who benefit most from Web-based interventions and to the development of new strategies to increase usage.

Objective

The aim of this mixed methods study was to explore patient, intervention, and study characteristics that facilitate or impede usage of a Web-based physical activity intervention for patients with knee and/or hip osteoarthritis.

Methods

This study is part of a randomized controlled trial that investigated the effects of Web-based physical activity intervention. A total of 199 participants between 50-75 years of age with knee and/or hip osteoarthritis were randomly assigned to a Web-based intervention (n=100) or a waiting list (n=99). This mixed methods study used only data from the individuals allocated to the intervention group. Patients were defined as users if they completed at least 6 out of 9 modules. Logistic regression analyses with a stepwise backward selection procedure were executed to build a multivariate prediction usage model. For the qualitative part, semistructured interviews were conducted. Both inductive and deductive analyses were used to identify patterns in reported reasons for nonusage.

Results

Of the 100 participants who received a password and username, 46 completed 6 modules or more. Multivariate regression analyses revealed that higher age (OR 0.94, P=.08) and the presence of a comorbidity (OR 0.33, P=.02) predicted nonusage. The sensitivity analysis indicated that the model was robust to changes in the usage parameter. Results from the interviews showed that a lack of personal guidance, insufficient motivation, presence of physical problems, and low mood were reasons for nonusage. In addition, the absence of human involvement was viewed as a disadvantage and it negatively impacted program usage. Factors that influenced usage positively were trust in the program, its reliability, functionality of the intervention, social support from family or friends, and commitment to the research team.

Conclusions

In this mixed methods study, we found patient, intervention, and study factors that were important in the usage and nonusage of a Web-based PA intervention for patients with knee and/or hip osteoarthritis. Although the self-guided components offer several advantages, particularly in relation to costs, reach, and access, we found that older patients and participants with a comorbid condition need a more personal approach. For these groups the integration of Web-based interventions in a health care environment seems to be promising.

Trial Registration

The Netherlands National Trial Register (NTR): NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by Webcite at http://www.webcitation.org/67NqS6Beq).

The usability and preliminary effectiveness of a web-based physical activity intervention in patients with knee and/or hip osteoarthritis

Background

A large proportion of patients with knee and/or hip osteoarthritis (OA) do not meet the recommended levels of physical activity (PA). Therefore, we developed a web-based intervention that provides a tailored PA program for patients with knee and/or hip OA, entitled Join2move. The intervention incorporates core principles of the behaviour graded activity theory (BGA). The aim of this study was to investigate the preliminary effectiveness, feasibility and acceptability of Join2move in patients with knee and/or hip OA.

Methods

A non-randomized pilot study was performed among patients with knee and/or hip OA. Primary outcomes were PA (SQUASH Questionnaire), physical function (HOOS and KOOS questionnaires) and self-perceived effect (7-point Likert scale). Baseline, 6 and 12 week follow-up data were collected via online questionnaires. To assess feasibility and acceptability, program usage (modules completed) and user satisfaction (SUS questionnaire) were measured as secondary outcomes. Participants from the pilot study were invited to be interviewed. The interviews focused on users’ experiences with Join2move. Besides the pilot study we performed two usability tests to determine the feasibility and acceptability of Join2move. In the first usability test, software experts evaluated the website from a list of usability concepts. In the second test, users were asked to verbalize thoughts during the execution of multiple tasks.

Results

Twenty OA patients with knee and/or hip OA between 50 and 80 years of age participated in the pilot study. After six weeks, pain scores increased from 5.3 to 6.6 (p=0.04). After 12 weeks this difference disappeared (p=0.5). Overall, users were enthusiastic about Join2move. In particular, performing exercise at one's own pace without time or travel restrictions was cited as convenient. However, some minor flaws were observed. Users perceived some difficulties in completing the entire introduction module and rated the inability to edit and undo actions as annoying.

Conclusions

This paper outlines the preliminary effectiveness, feasibility and acceptability of a web-based PA intervention. Preliminary results from the pilot study revealed that PA scores increased, although differences were not statistically significant. Interviews and usability tests suggest that the intervention is feasible and acceptable in promoting PA in patients with knee and/or hip OA. The intervention was easy to use and the satisfaction with the program was high.

Trial registration

The Netherlands National Trial Register. Trial number: NTR2483

Patients with shoulder syndromes in general and physiotherapy practice: an observational study

BACKGROUND

Shoulder complaints are commonly seen in general practice and physiotherapy practice. The only complaints for which general practitioners (GPs) refer more patients to the physiotherapist are back and neck pain. However, a substantial group have persistent symptoms. The first goal of this study is to document current health care use and the treatment process for patients with shoulder syndromes in both general practice and physiotherapy practice. The second goal is to detect whether there are differences between patients with shoulder syndromes who are treated by their GP, those who are treated by both GP and physiotherapist and those who access physiotherapy directly.

METHODS

Observational study using data from the Netherlands Information Network of General Practice and the National Information Service for Allied Health Care. These registration networks collect healthcare-related information on patient contacts including diagnoses, prescriptions, referrals, treatment and evaluation on an ongoing basis.

RESULTS

Many patients develop symptoms gradually and 35% of patients with shoulder syndromes waited more than three months before visiting a physiotherapist. In 64% of all patients, treatment goals are fully reached at the end of physiotherapy treatment. In general practice, around one third of the patients return after the referral for physiotherapy. Patients with shoulder syndromes who are referred for physiotherapy have more consultations with their GP and are prescribed less medication than patients without a referral. Often, this referral is made at the first consultation. In physiotherapy practice, referred patients differ from self-referrals. Self-referrals are younger, they more often have recurrent complaints and their complaints are more often related to sports and leisure activities.

CONCLUSIONS

There is a fairly large group of patients with persistent symptoms. Early referral by a GP is not advised under current guidelines. However, in many patients, symptoms develop gradually and a wait-and-see policy means more valuable time may pass before physiotherapy intervention takes place. Meanwhile a long duration of complaints is a predictor for poor outcome. Therefore, future research into early referral is required. As physiotherapists, we should develop a way of educating patients to avoid lengthy waiting periods before seeking help. To prevent high costs, physiotherapists could consider a classification of pain and limitations and wait-and-see policy as used by GPs. With early detection, a once-off consultation might be sufficient.

Physical therapy management of low back pain has changed

BACKGROUND

Since the 1990s, new insights in the physical therapy management of low back pain have been described in guidelines. Furthermore, insurance companies introduced a volume policy to control the costs for physical therapy.

OBJECTIVE

This study aims to establish if developments in knowledge and health policy since the 1990s have resulted in changes in the physical therapy management of patients with low back pain (LBP) in the Netherlands.

METHODS

Data from 3148 patients, referred because of LBP, were selected from the databases of two registration studies (1989-1992 and 2002-2003) of patients treated by physical therapists. Descriptive statistics were used to compare patient characteristics. A multi-level regression analysis was carried out to determine a change in the number of treatment sessions adjusting for patient and disease characteristics, and to control for different levels (patient and physical therapist).

RESULTS

A small decline in the number of treatment sessions was observed. In 2002, exercise therapy was the most frequently applied intervention, while massage and physical modalities were the interventions of first choice in the early 1990s.

CONCLUSION

Our results suggest that since 1990 the management of patients with LBP by physical therapists in the Netherlands has changed. Both quality management by the profession and volume policy by government and insurance companies seem to have been instrumental in bringing about a decline in the number of treatment visits and an increase in the use of evidence-based interventions.

Patient characteristics determine differences in the influenza vaccination rate more so than practice features

BACKGROUND

World-wide each year 30-55% of the target population is vaccinated against influenza. Determinants of successful vaccination programs are not clear. This study was aimed at identifying practice- and patient-related factors that determine differences in vaccination rates.

METHODS

Data on patients of the target population were extracted from the computerized medical record systems of 48 family practices. Information about organizational factors was collected by a questionnaire for GP's. Multilevel logistic regression analyses were used to assess the determinants.

RESULTS

Of all patients at risk (42,426), 76% were vaccinated. The vaccination rate for patients above age 65 was 15% higher when a medical indication was present. Patients with cardiac diseases or diabetes mellitus attained a relatively higher vaccination rate than other groups at risk. Special hours for vaccination led to significantly higher vaccination rates for the elderly and cardiac patients. Patients below 65 years of age were particularly influenced by special information pamphlets.

CONCLUSION

Explanations of differences in uptake rates were found at the patient level. All practices in this study were well organized; nevertheless, subgroup analyses showed that special vaccination hours for elderly people and information pamphlets for young people could improve results further.

Disease prevalence estimations based on contact registrations in general practice

This paper describes how to estimate the prevalence of chronic diseases in a population using data from contact registrations in general practice with a limited time length. Instead of using only total numbers of observed patients adjusted for the length of the observation period, we propose the use of (i) the time of the first contact of patients, (ii) the joint total numbers of patients and contacts, and (iii) the sets of patients in distinct time intervals, to generate prevalence rate estimates. The three new prevalence rate estimators have been developed assuming either a homogeneous or a parameterized heterogeneous patient population. Systematic and stochastic components of the estimators have been analysed by cross-validation for five chronic diseases using data from the Dutch 'Study on Chronic Conditions'. The results show that the first two estimators work well for diseases with a relatively structured visiting behaviour, such as hypertension and diabetes mellitus, assuming a time-constant contact rate and homogeneous patient population. For diseases such as ischaemic heart disease, chronic non-specific respiratory diseases and osteoarthritis, that do not satisfy these assumptions, the methods generally result in underestimations.