Canadian physiotherapists' views on certification, specialisation, extended role practice, and entry-level training in rheumatology

<p>Abstract</p> <p>Background</p> <p>Since the last decade there has been a gradual change of boundaries of health professions in providing arthritis care. In Canada, some facilities have begun to adopt new arthritis care models, some of which involve physiotherapists (PT) working in extended roles. However, little is known about PTs' interests in these new roles. The primary objective of this survey was to determine the interests among orthopaedic physiotherapists (PTs) in being a certified arthritis therapist, a PT specialized in arthritis, or an extended scope practitioner in rheumatology, and to explore the associated factors, including the coverage of arthritis content in the entry-level physiotherapy training.</p> <p>Methods</p> <p>Six hundred PTs practicing in orthopaedics in Canada were randomly selected to receive a postal survey. The questionnaire covered areas related to clinical practice, perceptions of rheumatology training received, and attitudes toward PT roles in arthritis care. Logistic regression models were developed to explore the associations between PTs' interests in pursuing each of the three extended scope practice designations and the personal/professional/attitudinal variables.</p> <p>Results</p> <p>We received 286 questionnaires (response rate = 47.7%); 258 contained usable data. The average length of time in practice was 15.4 years (SD = 10.4). About 1 in 4 PTs agreed that they were interested in assuming advanced practice roles (being a certified arthritis therapist = 28.9%, being a PT specialized in rheumatology = 23.3%, being a PT practitioner = 20.9%). Having a caseload of ≥ 40% in arthritis, having a positive attitude toward advanced practice roles in arthritis care and toward the formal credentialing process, and recognizing the difference between certification and specialisation were associated with an interest in pursing advanced practice roles.</p> <p>Conclusion</p> <p>Orthopaedic PTs in Canada indicated a fair level of interest in pursuing certification, specialisation and extended scope practice roles in arthritis care. Future research should focus on the effectiveness and cost-effectiveness of the emerging health service delivery models involving certified, specialized or extended scope practice PTs in the management of arthritis.</p

First steps in developing clinical practice guidelines for post-acute rehabilitation after primary total hip and knee arthroplasty

Total hip (THA) and total knee arthroplasty (TKA) are cost-effective interventions for advanced osteoarthritis (OA) of the knee and hip. With the rapidly growing number of these procedures performed annually in Canada and the United States, greater attention needs to be directed to identify rehabilitation practices that optimize outcomes and minimize cost. Currently, there is no consensus on rehabilitation best practice and no evidence-based clinical practice guidelines to inform clinical decision-making on post-acute rehabilitation following THA and TKA. A multi-phase, mixed-method project integrated stakeholder perspectives, research evidence and expert opinion to develop best practice recommendations for THA and TKA rehabilitation. Chapter 2 involved 11 focus groups and eight interviews to identify key themes related from North American patients and health care professionals on rehabilitation practices and outcomes. Chapters 3-4 are Cochrane systematic reviews examining the strength of the evidence for post-acute physiotherapy after THA and TKA. Chapter 5-6 involved two parallel Delphi surveys with consumers, clinicians and researchers to develop consensus on a range of rehabilitation topics to inform best practice for THA and TKA rehabilitation. Chapter 2: Six key themes emerged relating to communication, patient expectations, patient attitude, forms of support, barriers to recovery, and diversity of outcomes. Chapters 3-4: Systematic reviews of THA (n=8) and TKA (n=7) trials revealed limited, low to high quality evidence with mixed findings for various forms of post-acute physiotherapy on pain, function and health-related quality of life. Trial heterogeneity prevented meta-analysis. Chapters 5-6: Consensus (80% agreement) was reached on the need for post-acute rehabilitation, types of interventions, rehabilitation providers, treatment settings, outcomes and outcome measurement. Consensus was not reached regarding timing and dosage of rehabilitation. Sub-group analysis revealed few differences comparing responses by profession, primary role and country. This thesis has taken important first steps in identifying appropriate rehabilitation interventions and health care resources to optimize individuals’ activity, participation and health-related quality of life after THA and TKA. Further, it highlights the need for more high quality research to address the knowledge gaps and inform policy on this important and understudied aspect of arthroplasty surgery.Medicine, Faculty ofGraduat

Patient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis:a focus group study

Background: There is worldwide variation in rehabilitation practices after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and no agreement on which interventions will lead to optimal short and long term patient outcomes. As a first step in the development of clinical practice guidelines for post-acute rehabilitation after THA and TKA, we explored experiences and attitudes about rehabilitation practices and outcomes in groups of individuals identified as key stakeholders. Methods: Separate focus groups and interviews were conducted with patients (THA or TKA within past year) and three health professional groups: allied health professionals (AHPs), orthopaedic surgeons, and other physicians, in Canada and the United States. Pairs of moderators led the focus groups using a standardized discussion guide. Discussions were audiotaped and transcribed verbatim. A content analysis within and across groups identified key themes. Results: Eleven focus groups and eight interviews took place in six sites. Patients (n = 32) varied in age, stage of recovery, and surgical and rehabilitation experiences. Health professionals (n = 44) represented a range of disciplines, practice settings and years of experience. Six key themes emerged: 1) Let's talk (issues related to patient-health professional and inter-professional communication); 2) Expecting the unexpected (observations about unanticipated recovery experiences); 3) It's attitude that counts (the importance of the patient's positive attitude and participation in recovery); 4) It takes all kinds of support (along the continuum of care); 5) Barriers to recovery (at patient, provider and system levels), and 6) Back to normal (reflecting diversity of expected outcomes). Patients offered different, but overlapping views compared to health professionals regarding rehabilitation practices and outcomes following THA and TKA. Conclusion: Results will inform subsequent phases of guideline development and ensure stakeholders' perspectives shape the priorities, content and scope of the guidelines.Medicine, Faculty ofOccupational Science and Occupational Therapy, Department ofOther UBCNon UBCReviewedFacult

A Snapshot of Hip and Knee Replacement Rehabilitation Care Across Canada: A Cross-Sectional Survey Using an Online Clinician Quality Indicator Questionnaire

Purpose: To determine usability, feasibility, and reliability of an online questionnaire to assess clinicians’ adherence to 10 postacute rehabilitation quality indicators (QIs) for total hip (THR) and knee replacement (TKR) and explore current rehabilitation practices across Canada. Method: Following usability testing with clinicians in BC and Quebec, we recruited rehabilitation clinicians across Canada to complete the online survey. Respondents rated adherence (past 3 months), importance, and feasibility for 10 QIs. We resent the survey 2–3 weeks later (test–retest reliability). Results: Based on usability testing, we made minor changes in wording, altered response options, and created a French language version. In total, 238 clinicians completed all or parts of the English ( n = 123) and French ( n = 115) questionnaires. Respondents mostly practiced in the public sector (88%) and outpatient settings (42%). On average, clinicians met (“always” or “often” response) 23.3% (SD 13.7%, 95% CI 21.1, 25.4) of THR and 25.5% (SD 15.1%, 95% CI 23.0, 27.9) of TKR indicators. There were mixed views on the importance and feasibility of the QIs. Varied rehabilitation formats, duration, and dosage were described. Conclusion: Canadian rehabilitation clinicians report low overall adherence to THR and TKR rehabilitation QIs and differing rehabilitation approaches and models of care. </jats:sec

Emerging Role of Quality Indicators in Physical Therapist Practice and Health Service Delivery

Quality-based care is a hallmark of physical therapy. Treatment effectiveness must be evident to patients, managers, employers, and funders. Quality indicators (QIs) are tools that specify the minimum acceptable standard of practice. They are used to measure health care processes, organizational structures, and outcomes that relate to aspects of high-quality care of patients. Physical therapists can use QIs to guide clinical decision making, implement guideline recommendations, and evaluate and report treatment effectiveness to key stakeholders, including third-party payers and patients. Rehabilitation managers and senior decision makers can use QIs to assess care gaps and achievement of benchmarks as well as to guide quality improvement initiatives and strategic planning. This article introduces the value and use of QIs to guide clinical practice and health service delivery specific to physical therapy. A framework to develop, select, report, and implement QIs is outlined, with total joint arthroplasty rehabilitation as an example. Current initiatives of Canadian and American physical therapy associations to develop tools to help clinicians report and access point-of-care data on patient progress, treatment effectiveness, and practice strengths for the purpose of demonstrating the value of physical therapy to patients, decision makers, and payers are discussed. Suggestions on how physical therapists can participate in QI initiatives and integrate a quality-of-care approach in clinical practice are made.</jats:p

Total joint arthroplasty: practice variation of physiotherapy across the continuum of care in Alberta

Abstract Background Comprehensive and timely rehabilitation for total joint arthroplasty (TJA) is needed to maximize recovery from this elective surgical procedure for hip and knee arthritis. Administrative data do not capture the variation of treatment for rehabilitation across the continuum of care for TJA, so we conducted a survey for physiotherapists to report practice for TJA across the continuum of care. The primary objective was to describe the reported practice of physiotherapy for TJA across the continuum of care within the context of a provincial TJA clinical pathway and highlight possible gaps in care. Method A cross-sectional on-line survey was accessible to licensed physiotherapists in Alberta, Canada for 11 weeks. Physiotherapists who treated at least five patients with TJA annually were asked to complete the survey. The survey consisted of 58 questions grouped into pre-operative, acute care and post-acute rehabilitation. Variation of practice was described in terms of number, duration and type of visits along with goals of care and program delivery methods. Results Of the 80 respondents, 26 (33 %) stated they worked in small centres or rural settings in Alberta with the remaining respondents working in two large urban sites. The primary treatment goal differed for each phase across the continuum of care in that pre-operative phase was directed at improving muscle strength, functional activities were commonly reported for acute care, and post-acute phase was directed at improving joint range-of-motion. Proportionally, more physiotherapists from rural areas treated patients in out-patient hospital departments (59 %), whereas a higher proportion in urban physiotherapists saw patients in private clinics (48 %). Across the continuum of care, treatment was primarily delivered on an individual basis rather than in a group format. Conclusions Variation of practice reported with pre-and post-operative care in the community will stimulate dialogue within the profession as to what is the minimal standard of care to provide patients undergoing TJA