Clinical Course and Prognostic Factors of Patients Receiving Physiotherapy Services in Primary Health Care in Norway (FYSIOPRIM)
Clinical Course and Prognostic Factors of Patients Receiving Physiotherapy Services in Primary Health Care in Norway (FYSIOPRIM)
Background: Physiotherapists (PTs) in primary health care manage patients with a large variation in medical diagnosis, age, functional status, disability and prognosis. Lack of knowledge and systematically collected data about patients treated by PTs in primary health care has prompted this longitudinal observational physiotherapy project in Norway. This paper aims to describe a method for developing a database of patients managed by PTs in primary health care to study patients' characteristics, treatment courses and prognostic factors.
The study is a longitudinal observational project, following patients through physiotherapy treatment periods in primary health care in Norway and until one year after inclusion. The project involves both private practice and municipally employed PTs working in primary health care in eight municipalities in Norway. The participants are recruited to three different parts of the project depending on age and whether they are referred to a private practice or a municipally employed PT. All data are recorded electronically, transferred and stored securely. All patients complete extensive questionnaires providing information about demographics, disability and function, pain related variables, treatment and evaluation of treatment as well as clinical tests. The PTs have access to their own patients' data. The investigators have also prepared for linkage to national patient registers and population-based studies to be able to gather further important data.
This project will have important implications for physiotherapy services in primary health care. The database already contains almost 3000 patients, and data collection is ongoing. Preliminary analyses suggest that the patients included so far are representative of the larger population of patients treated by private practice or municipally employed PTs in Norway. This large scale prospective physiotherapy project will provide knowledge about the patient groups treated, treatment given as well as short and long term outcome of the patients.
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:
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.
Inclusion Criteria:
Exclusion Criteria: