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. 2023 Sep 14;18(9):e0277369. doi: 10.1371/journal.pone.0277369

Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: Protocol for an economic evaluation

Rose Gagnon 1,2, Luc J Hébert 1,2,3, Jason R Guertin 4,5, Simon Berthelot 5,6,7, François Desmeules 8,9, Kadija Perreault 1,2,*
Editor: Joshua Robert Zadro10
PMCID: PMC10501643  PMID: 37708179

Abstract

Objectives

1) To compare the average cost of an emergency department (ED) visit for various minor musculoskeletal disorders between two models of care (physiotherapist and ED physician or ED physician alone); 2) To evaluate the incremental cost-effectiveness ratio (ICER) of these two models of care over a 3-month period post-initial visit; and 3) To estimate the ICER of three ED models of care (physiotherapist and ED physician, ED physician alone, physiotherapist alone) over a two-year period.

Methods

Obj.1: The costs incurred by participants in the two groups during their ED visit will be calculated using the Time-Driven Activity-Based Costing (TDABC) method. These costs will be compared using generalized linear models. Obj. 2: The ICER of the two models will be evaluated over three months via a cost-utility analysis that will combine costs and effectiveness data (quality-adjusted life years) using both Health system and Societal perspectives (patient + health system costs). Obj. 3: The 2-year ICER of the three above-mentioned models will be estimated using a mathematical model including a decision tree (0–3 months post-visit) and a Markov model (3–24 months post-visit), also using both Health system and Societal perspectives. Data to answer the three objectives will come from data collected during a randomized clinical trial (n = 78, CHU de Québec)which will be supplemented with data obtained via some of the CHU de Québec administrative databases (nominative data; SIURGE (ED management software), Cristal-Net (patient electronic record), and the ED’s pharmacy transactions directory; administrative data: drug costs repository), the literature, and public cost repositories.

Conclusion

This study will help to determine which model of care is most efficient for the management of individuals who come to the ED with minor musculoskeletal disorders. The increased involvement of various health professionals in the management of patients in the ED paves the way for the development of new avenues of practice and more efficient organization of services.

Introduction

The emergency department (ED) serves as the main gateway and the preferred resource when primary care services are not available, for example in cases of lack of affiliation with a primary care source or inability to see a physician within a reasonable time frame [1–5]. Although pain conditions for which patients decide to go to the ED are varied, they are oftentimes related to a musculoskeletal disorder (MSKD) [6–8].

According to the World Health Organization, MSKDs are characterized by "pain (often persistent) and limitations in mobility, dexterity and general functioning" [9]. MSKDs can affect joints, bones, muscles, spine and multiple regions of the body [9, 10]. The prevalence of these disorders is reported to be significantly higher in women, older people and people with low socio-economic status [11–15]. When they do not receive timely and appropriate care, people with MSKDs tend to make greater use of health care services and resources [16–22]. MSKDs account for up to 12.6% of a country’s total health care costs each year [15] and this figure is expected to rise with the increase in obesity, physical inactivity and the aging of the population [11, 23]. It is therefore essential to study the costs and clinical effectiveness of interventions aimed at managing MSKDs in order to choose the most efficient ones, including in the ED.

Various models of care have been implemented in the ED and studied in recent years to optimize the management of people presenting with MSKDs. These models of care aim to optimize the flow of patients to and in the ED in three distinct phases: "input" (i.e., flow of patients deciding to come to the ED), "throughput" (i.e., flow of patients while in the ED), and "output" (i.e., flow of patients upon discharge from the ED) [24]. Such models of care include for instance fast-track corridors for patients with minor injuries or rapid assessment teams [25]. Some models include the addition of ED nurse practitioners and a variety of health professionals with a usual or extended scope of practice, such as the primary contact physiotherapist or advanced practice physiotherapist [25].

The addition of primary contact physiotherapists in the ED is an emerging model of care that aims to optimize patient flow while in the ED [25]. Several studies conducted in recent years have shown that this model of care is associated with reduced time waited before receiving care, and reduced length of stay in the ED, as well as fewer unnecessary consultations with various health professionals, and less prescriptions of imaging tests and medication, including opioids, and over-the-counter medication [8, 26–29]. In addition, this model of care was associated with fewer repeat visits to the ED for a similar condition for up to one month after the initial ED visit [29]. Thus, management by a primary contact physiotherapist appears to be associated with decreased service and resource use, both at the ED and up to several weeks later. However, very few studies having investigated primary contact physiotherapist care in the ED have looked at its cost-effectiveness.

Indeed, despite evidence of clinical benefits associated with the presence of a primary contact physiotherapist in the ED (effectiveness), scientific evidence remains rather scarce regarding the cost-effectiveness of this model of care. Two studies conducted in primary care settings (primary care clinic and private clinic) report that primary contact physiotherapist management is associated with a slight increase in health-related quality of life and a decrease in total costs compared to usual management by a family physician [30, 31]. In addition, early physiotherapy management was associated with a decrease in total MSKD-related costs for up to two years after initial management [17, 19, 32]. Two cost-minimization studies conducted in Great Britain looked specifically at the costs associated with the integration of a primary contact physiotherapist in the ED compared to usual management by an emergency physician. According to the study by Richardson et al. (2005, n = 766 patients with non-fracture MSKDs), the presence of a primary contact physiotherapist in the ED results in costs equivalent to usual management (emergency physician) [33]. Similarly, according to McClellan et al. (2013, n = 372 patients >16 years of age with a peripheral MSKD), management by a primary contact physiotherapist results in costs at least as high as usual management (emergency physician) [34]. Nevertheless, in addition to having been conducted exclusively in Great Britain several years ago, these two studies only measured the costs of the two models of care compared and not their effectiveness, the authors assuming that the two models compared were equivalent in terms of clinical effectiveness. These studies are thus not considered to be formal economic evaluation according to current guidelines, but rather a costing exercise, in that a cost-effectiveness analysis accounts for the uncertainty associated with the effects of the interventions being compared [35]. To our knowledge, no other study has examined the cost-effectiveness of primary contact physiotherapy in the ED. Furthermore, no study has assessed whether involving primary contact physiotherapists in the ED have a long-term impact on use of health system services and resources for persons with minor MSKDs. Consequently, further evidence is needed on the efficiency of integrating a primary contact physiotherapist in the ED compared to usual management by an emergency physician.

Therefore, the general objective of this project is to evaluate the efficiency of different models of care for the management of minor MSKDs in the ED. More specifically, the objectives are to:

  1. Compare the average costs of an ED consultation and care for various MSKDs, according to two models of care:
    1. Usual management by an emergency physician
    2. Primary contact physiotherapist management + emergency physician management

  2. Evaluate the incremental cost-effectiveness ratio (ICER), from both Health system and Societal perspectives, of these two ED models of care for the management of MSKDs over a three-month period post-initial ED visit.

  3. Estimate the ICER between three ED models of care for MSKD management over a two-year period from both Health system and Societal perspectives:
    1. Usual management by an emergency physician
    2. Primary contact physiotherapist management + emergency physician management
    3. Primary contact physiotherapist management alone

Materials and methods

Study design and costing approaches

This study is composed of three distinct designs, one per objective. The costing approach used for Objective 1 will be Time-Driven Activity-Based Costing (TDABC), which involves determining the per-minute costs associated with each care process included in a care pathway by multiplying the cost per minute of each care process by its duration. Details on this costing approach and its application to the ED have been described by one of the authors elsewhere [36]. Objective 2 will be achieved through a cost-utility analysis approach in which health care costs at the ED visit and those reported at the 1- and 3-month follow-ups will be compiled and combined with the utility scores obtained at the same measurement times, from both Health system and Societal perspectives. Cost-utility analysis is favored in Canada since it uses a generic outcome measure allowing comparison of the health gains associated with several different interventions, such as different models of care [35].

The ICER between the three ED models of care for the management of MSKDs over a two-year period (Objective 3) will be estimated using a cost-effectiveness analysis via a hybrid mathematical model. This model will consist of a decision tree covering the period from the initial ED visit up to three months post-initial visit, and a Markov model starting three months post-initial ED visit and ending 24 months (two years) after the ED visit. The decision tree provides a simple and clear illustration of a patient’s possible short-term care pathways following a new intervention [35, 37]. In addition to reporting the different interventions used, the decision tree also allows for the inclusion of adverse events following the initial intervention, such as a new ED visit for the same condition, and for repeating an intervention over time as needed (e.g., new visit in the ED a few days after the initial visit and then a new visit two months later for the same condition) [35, 37]. It also permits to determine the proportion of disability associated with each of the three ED models of care.

Several considerations guided the choice of the time horizon for the Markov model. First of all, to be considered chronic, a musculoskeletal disorder must be present for at least three months [38]. Moreover, approximately 30% of people presenting with MSKDs report pain and functional disability lasting more than 12 months after the onset of their condition. Furthermore, studies on MSKD care in primary care or the ED have had follow-up periods ranging from six to 24 months (e.g. [26, 39–42]). Thus, the Markov model will cover a 24-month period. It will include two-week cycles in order to capture the clinical evolution of the patients included.

Population of interest

Inclusion and exclusion criteria for the population of interest are described in Box 1. The population targeted covers persons with a peripheral or spinal MSKD, a P3, P4 or P5 triage category at the ED (Canadian Triage and Acuity Scale [43]), and that are aged between 18 and 80. Having a major MSKD, red flag or associated unstable condition are criteria for exclusion.

Box 1. Inclusion and exclusion criteria for the population of interest.

Box 1

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Data collection

Objectives 1, 2 and 3 will be achieved in part using data collected through a two-arm pilot pragmatic randomized clinical trial (RCT) conducted in the ED of the CHUL, one of the five sites of the CHU de Québec—Université Laval (UL) (Quebec City, Canada) from September 2018 to March 2019 (n = 78). This trial aimed to compare the effects of management by a primary contact physiotherapist to usual care provided by an emergency physician for persons presenting with a minor MSKD on their clinical course (pain and pain interference) and the use of resources at ED discharge and after 1 and 3 months post-visit [29]. Two groups of participants were compared: one group managed by a primary contact physiotherapist and an emergency physician and one group managed by an emergency physician alone.

Data were collected at the initial ED visit and at the one- and three-month post-visit follow-ups. While more details of the data collection procedures can be found in our previous paper [29], any person presenting to the ED who met the inclusion and exclusion criteria was seen by a member of the research team who confirmed eligibility, obtained informed consent, and ensured completion of baseline questionnaires. The participant was then randomized to either study group: primary contact physiotherapist + emergency physician management or usual management by the emergency physician alone. After the ED visit was completed, participants were contacted at 1 and 3 months either by phone or email to complete post-visit follow-ups. The supplementary data needed to meet the three Objectives will come from some of the CHU de Québec—UL administrative databases (nominative data: SIURGE (ED management software), Cristal-Net (patient electronic record), and the CHUL’s ED pharmacy transactions directory; administrative data: prescription and over-the-counter drug costs repository), the scientific literature, and public cost repositories (e.g., salaries of general practitioners and specialists, see https://www.msss.gouv.qc.ca/inc/documents/ministere/acces_info/seance-publique/etude-credits-2018-2019/Reponses-aux-questions-generales-et-particulieres-RAMQ.pdf; laboratory analysis costs, see https://publications.msss.gouv.qc.ca/msss/fichiers/2017/17-922-05W.pdf).

Of note, the study population for the model of care consisting of primary contact physiotherapist management and discharge from the ED was not observed at all during the pilot pragmatic RCT. Consequently, this model of care will have to be modeled, and therefore cannot be studied in the context of Objectives 1 and 2, which are based on RCT data. All the parameters needed to represent this care model within Objective 3 (probabilities, costs, measures of effectiveness) will be taken from a literature review, an approach regularly used in economic evaluation [44]. However, the studies from which the metrics will be derived will need to have a sample that meets the same inclusion criteria as those presented in Box 1. Data extracted from the literature will be validated with members of the research team and with experts in the field of emergency medicine, MSKDs and rehabilitation if necessary during the construction of the hybrid model [35].

Study outcomes

Primary outcomes used to measure the average cost of an ED visit (Objective 1) will be the costs of care processes and the time associated with each care process. This method of costing is routinely used by some members of the research team [36, 45, 46]. The costs related to ED management (medical and non-medical staff, imaging, medication, consumables, maintenance, etc.) were obtained via a formal request made by a member of the research team to the CHU de Québec–UL Finance Department. The time associated with each care process was calculated by a member of the research team using estimates provided by the CHUL medical and non-medical staff that were validated during an observation period in the ED [36, 45]. Uncertainty in measured times will allow the variability of ED costs to be considered, and to derive a distribution of possible costs at baseline for each participant.

As part of the cost-utility analysis (Objective 2) and hybrid mathematical model (Objective 3), the efficiency of the ED models of care will be assessed using an incremental cost-effectiveness ratio (ICER). The resulting ICER will be reported in terms of incremental cost per quality-adjusted life years (QALY) gained, between the models of care. The follow-up costs of each participant recorded via the self-administered follow-up questionnaires completed at 1 and 3 months during the pilot pragmatic RCT will be added to the distribution of ED visit costs for each individual obtained under Objective 1. Once all costs have been added, an average will be calculated to obtain an average cost per participant at 3 months, for each model of care (Objective 2 & 3 –decision tree). The questionnaires provided data on resources used by each participant during follow-up such as ED re-visits for the same condition, number of consultations with other health professionals in the public and private sector, imaging tests used, etc. The costs of all resources used in the public healthcare system will be drawn from public cost repositories data from the Régie de l’assurance-maladie du Québec (RAMQ) (costs related to the emergency physician and other physicians consulted, drugs, laboratory analysis, imaging tests) [47]. Hourly rates for the primary contact physiotherapist and other health professionals consulted (e.g., massage therapist, chiropractor, osteopath) will be derived from a search of the grey literature and will be based on rates in effect within the private healthcare system, since the majority of these professionals work within this system [47]. Costs related to the use of technical aids (e.g., cane, crutches, walker) will also come from a grey literature search. It should be noted that the salary data available from human resources for all healthcare professionals (physicians and allied health professionals) considered will not allow for variability in hourly costs. The only source of variability considered for the purpose of these analyses will be that related to the time required for ED processes. Utility scores were obtained at the initial visit [48] and at 1 and 3 months using the EQ-5D-5L, a generic standardized questionnaire designed to measure health status in an economic and clinical evaluation [49]. The EQ-5D-5L has been found to be reliable, valid, and sensitive to change [50, 51]. The difference in utility scores between the 3-month follow-up and baseline will be calculated for each participant using area-under-the-curve analyses. Once the difference in utility scores will be calculated for each participant, the differences will be averaged to obtain the average gain or loss in utility scores per ED care model. The mean gain or loss in utility scores will then be transformed into QALYs. The efficiency values and the costs from 3 to 24 months required to run the Markov model (Objective 3) for the three models of care will be taken from the literature.

Data analysis and interpretation of results

As part of Objective 1, a mapping of the care pathways encountered will be completed for each type of MSKD encountered in our study population (i.e., low back pain, neck pain, upper limb, lower limb) (Fig 1). The unit cost of each of the resources, consumables and indirect costs required in each process of care of the care pathway will be calculated and multiplied by the duration of each process to obtain the cost related to each process of care present in the care pathway. The costs associated with each process will be summed to obtain the total cost of the ED care pathway specific to each MSKD and each model of care (i.e., emergency physician or primary contact physiotherapist and emergency physician management). A generalized linear model with a Gamma distribution and log link will be used to test whether there is a significant difference in the costs of managing equivalent MSKDs between the two models of care [52, 53].

Fig 1. Mapping of a hypothetical care pathway in the ED using the Time-Driven Activity-Based Costing.

Fig 1

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The decision tree (Objective 3) will be created to reflect the results of the RCT as closely as possible and will therefore include all possible interventions and services used by a participant following the initial visit to the ED for each model of care considered (Fig 2). The pruning of each terminal node containing less than 5% of the participants will be determined based on discussions with a panel of experts. The conditional probability of ending up in each of the remaining terminal nodes of the decision tree will be used to calculate the proportion of disability associated with each care model (Fig 2). The disability proportions obtained for each model of care will be used to determine the number of individuals in each state at entry in the Markov model (Fig 3). The Markov model will then be used to calculate the long-term costs and effectiveness over 2 years of each of the model of care based on the level of disability estimated in the decision tree [35, 37].

Fig 2. Hypothetical decision tree covering the period from ED visit to three months post initial ED visit.

Fig 2

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Fig 3. Projected Markov model covering the period from three to 24 months post initial ED visit.

Fig 3

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Both the cost-utility analysis (Objective 2) and the hybrid mathematical model (Objective 3) will be conducted from a Health system and a Societal perspective. Results obtained via the EQ-5D-5L at 1 and 3 months (Objective 2 & 3 –decision tree) will be converted to utility scores using the Canadian conversion algorithm developed by Xie et al. [54]. As the 3-month retention rate for the pilot pragmatic trial was 80% [29], some participants’ data are missing (service and resource use, costs, utility scores). Missing data will be imputed using the Missing not at random (MNAR) multiple imputation method [55]. Patient characteristics believed to have influenced loss to follow-up at 1 and 3 months (e.g., socioeconomic status; level of pain and level of catastrophizing at the ED visit) will be examined to identify if they are indeed predictors of loss to follow-up. Characteristics shown to influence follow-up will be used within multiple imputations and within sensitivity analyses regarding these variables. Uncertainty in cost and effectiveness measures for the cost-utility analysis (Objective 2) will be obtained using non-parametric bootstrap resampling with replacement. Uncertainty in the hybrid model parameters (probabilities, costs, and efficiency) (Objective 3) will be obtained via a probabilistic sensitivity analysis performed using a Monte Carlo simulation. Three scenarios will be considered in the probabilistic sensitivity analyses. The first will assume that all participants with missing follow-up data in the control group will have utility scores at 3 months corresponding to those of the 95th percentile, while all those missing in the intervention group will have scores corresponding to those of the 5th percentile. For the second scenario, we will re-analyze all parameters included in the model, excluding outliers. Finally, in the third and last scenario, the different states of the Markov Model will be based not on the level of pain, but on the level of interference of pain on daily activities. Both uncertainties will be represented visually using a cost-effectiveness diagram, cost-effectiveness acceptability curve, and cost-effectiveness acceptability frontier [35]. As there are significant differences between men and women in the strategies used to cope with pain, and the use of health system services and resources during a painful episode (e.g., [56, 57]), subgroup analyses of men and women will be performed for both objectives (p < .05). Subgroup analyses will also be performed according to MSKD category (spine, upper extremity, and lower extremity) for both objectives (p < .05). All the statistical analyses carried out as part of this project and their detailed reporting in scientific publications will adhere to the CHEERS 2022 standard [58].

Ethical considerations and data management

This project and all of its components (conduct of the RCT, three-month participants’ follow-up, access to nominative and administrative databases) were approved by the CHU de Québec–UL’s Ethical review board (approval number: MP-20-2019-4307). The randomized clinical trial was also registered with the US National Institutes of Health (#NCT04009369). Each participant signed a written consent form prior to participation. All data collected will be kept in a secure repository and destroyed thereafter. All members of the research team signed a confidentiality agreement.

Discussion

The overall aim of this project is to evaluate the costs of different models of care for the management of MSKDs in the ED. This will be achieved through three specific objectives: 1) to compare the average costs of an ED consultation and care for various MSKDs; 2) to evaluate the incremental cost-effectiveness ratio (ICER) of two ED models of care for the management of MSKDs over a three-month period post-initial ED visit; and 3) to estimate the ICER between ED models of care for the management of MSKDs over a two-year period.

Until now, there has been no formal economic evaluation of the inclusion of a primary contact physiotherapist in the ED compared with usual practice (emergency physician). The only studies that have been done on the subject have assumed that the effectiveness of the primary contact physiotherapist’s management in the ED is equivalent to that of usual care by the emergency physician. However, several studies have reported that primary contact physiotherapist management can reduce the use of services and resources during the ED stay [8, 26–29, 59]. This research project will fill an important need in the literature by providing an in-depth analysis of the costs and efficiency of the considered models of care. Indeed, this project will help identify the most efficient ED model of care. These models of care also have the potential to improve the quality of services offered to people with MSKDs, their clinical evolution and their quality of life. The increased use of various health professionals in the management of patients in contexts such as the ED can pave the way for the development of new avenues of practice and potentially more efficient organization of services that will benefit the population.

This study is associated with some potential limitations. First of all, the data needed to carry out Objectives 1 and 2 will partly be based on results from a pilot pragmatic RCT. Therefore, the results obtained should be interpreted with caution. The small sample size (n = 78) could possibly limit analyses on the number of plausible branches in the final decision tree as well as the amount of subgroup analysis that will be performed. In addition, although high, the retention rate at the 3-month follow-up of the RCT was 80% [29], which implies that some data related to the use of services and resources, costs and health-related quality of life will be missing. However, this limitation will be mitigated using multiple imputation methods [55]. Sensitivity analyses will also be performed to assess the robustness of the results obtained. Finally, it may be difficult to obtain some of the data on medium- and long-term costs and measures of effectiveness for the ED models of care studied in Objective 3 from the scientific literature. Nevertheless, estimates can be obtained by soliciting the opinions of experts in the fields of MSKD management and emergency medicine, as this method is regularly used in modeling [35].

As for knowledge translation, following the project, formal presentations will be made to all key stakeholders at the CHU (emergency physicians, physiotherapists, nurses, orderlies, patient representatives and administrators) on site or remotely to present the results of the study and discuss lessons learned and future avenues. The results of this project will also be shared with provincial stakeholders (professional associations, patient associations and governments). They will also be disseminated at national and international scientific conferences on economics, health services organization and emergency services. Four manuscripts will be published in peer-reviewed journals. If successful, this project will help guide economic evaluations for a large-scale, multi-center trial aiming to improve the management of people presenting with a MKSD in the ED.

Acknowledgments

The authors would like to thank the following persons for their contributions: project participants, Antony Barabé, PT, physiotherapist at the Centre Hospitalier de l’Université Laval (CHUL), the entire team of managers at the Direction des services multidisciplinaires of the CHU de Québec–Université Laval (Marie-Christine Laroche, Catherine Van Neste, Marie-Claude Brodeur and Stéphane Tremblay) for their support throughout the implementation of the project and its realization.

Data Availability

No datasets were generated or analyzed during the current study. All relevant data from this study will be made available upon study completion.

Funding Statement

Part of the data that will be used in this study were acquired during a randomized clinical trial that was supported by the CHU de Québec – Université Laval, subsidies from LJH and KP, and a clinical research scholarship awarded to one of the CHU de Québec collaborators by the Fondation du CHU de Québec for the multidisciplinary council of the CHU de Québec – Université Laval. RG received scholarships from the Canadian Institute of Health Research (CIHR #491913; https://cihr-irsc.gc.ca/e/193.html), the Fonds de recherche du Québec – Santé (FRQ-S; https://frq.gouv.qc.ca/sante/), the Unité de Soutien SSA – Québec (https://ssaquebec.ca/), the Ordre professionnel de la physiothérapie du Québec (OPPQ; https://oppq.qc.ca/), the Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris; https://www.cirris.ulaval.ca/) and Université Laval (https://www.fmed.ulaval.ca/). There was no additional external funding received for this study. JRG, SB and FD are FRQ-S Research Scholars. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Joshua Robert Zadro

9 Jun 2023

PONE-D-22-27339Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: Protocol for an economic evaluationPLOS ONE

Dear Dr. Gagnon,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Academic Editor

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2. We note that you will be accessing administrative databases for data collection for your study. Please clarify which databases will be accessed and whether you have obtained the necessary ethics approval or permission to access these databases. Furthermore, please clarify whether these databases are anonymized.

3. Thank you for stating in your Funding Statement:

“Part of the data that will be used in this study were acquired during a project that was supported by the CHU de Québec – Université Laval, subsidies from LJH and KP and a clinical research scholarship awarded to one of the CHU de Québec collaborators by the Fondation du CHU de Québec for the multidisciplinary council of the CHU de Québec – Université Laval . RG received scholarships from the Canadian Institute of Health Research (CIHR; https://cihr-irsc.gc.ca/e/193.html), the Fonds de recherche du Québec – Santé (FRQ-S; https://frq.gouv.qc.ca/sante/), the Unité de Soutien SSA – Québec (https://ssaquebec.ca/), the Ordre professionnel de la physiothérapie du Québec (OPPQ; https://oppq.qc.ca/), the Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris; https://www.cirris.ulaval.ca/) and Université Laval (https://www.fmed.ulaval.ca/). JRG, SB and FD are FRQ-S Research Scholars. The funders had and will not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Please provide an amended statement that declares *all* the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now.  Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement.

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Additional Editor Comments (if provided):

Thank you for your patience Rose and apologies again for the delay. The reviewers are generally positive about the protocol but there is more detailed needed in numerous places. Please pay careful attention to the reviewers comments when revising your paper.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This work has three objectives: to compare the average cost, to evaluate the ICER, and to estimate the ICER of the models of interest, which would be the combinations of physiotherapist and ED physician, ED physician alone, or physiotherapist alone.

1. Why only objective 3 consider the model with the group of primary contact physiotherapist management alone?

2. Authors propose to use decision tree for objective 2. However, tree is well-known to be overfitting. Please provide the information how this will be avoided in the analysis plan.

3. Authors argued to impute data using the Missing not at random approach. Please be specific how this will be implemented, especially if it’s not at random, what assumptions the authors will make? And whether it is reasonable in practice?

Reviewer #2: Just clarify if the total sample size is 78 or as read in lign 49-50 that data are collected during a randomized clinical trial (n=78) as well from CHU Québec administrative databases .Are they the same

Do you have an estimate of the number of men and women for the subgroup analyses.What about the lack of power if a group is too small?

Reviewer #3: Thank you for the opportunity to review this interesting work examining the cost-effectiveness of an physiotherapy led intervention in the emergency department setting. The ability to conduct an economic evaluation using clinical trial data associated with an allied healthcare intervention in the emergency department is not that common in the literature as outlined in the introduction of the paper. The structure of the paper is well organized however further clarification is required and along with the provision of more details about the methods prior to being suitable for publication.

Major comments

1. Although the manuscript describes a protocol for an economic evaluation, it would be of benefit to follow the CHEERS 2022 reporting guidance for economic evaluations. This is primarily applicable to the items outlined in the checklist associated with reporting of Methods (items 4-21).

Husereau, D., Drummond, M., Augustovski, F., et al. & CHEERS 2022 ISPOR Good Research Practices Task Force (2022). Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMJ (Clinical research ed.), 376, e067975. https://doi.org/10.1136/bmj-2021-067975

2. Further description in the methods is needed to outline how the costing will be completed associated with the Recommendation and use of services and resources at baseline and 1- and 3-month follow-up visits as outlined in Table 3 of your published clinical trial paper pg. 854. How will uncertainty associated with these costs be addressed in the model? Also from Table 3 are any of the consultation with other professional further physiotherapy appointments with outpatient public or private healthcare providers? How will these visits be costed out?

3. With respect to Objective 3 in the manuscript please expand on the rationale for considering how a short-term ED physiotherapist intervention is to have a clinical impact and effect an individual’s healthcare resource utilization and costs over a two-year period. It is stated in the manuscript that follow-up for studies with similar interventions have had follow-up periods up to 2 years. What are some of the findings of these papers and their limitations that need to be considered associated with your utilization of a 2-year time horizon for the economic evaluation.

4. Please justify further why only a societal perspective was used for the analysis. It would seem to be important for this evaluation to provide the perspective of the health system (i.e. the hospital and the provincial payers) as well as just the patient perspective for out of pocket expenses and potential time off work.

5. Please provide further details regarding which specific CHU de Quebec – UL administrative dataases will be used and which public databases will be used. Do you have permission for the study to use hospital level administrative inpatient and outpatient reporting systems?

6. Further details regarding the calculation of dis-utility from baseline to 1 month and 3 months is required. It states in the manuscript that mean-utility scores will be used. Will you be determining the utility values using Area Under the Curve analysis for each patient? Using just the calculated mean values at each time point may not reflect the within patient changes in quality of life.

Minor comments

1. Please provide updated Figures 2 and 3. They did not upload appropriately in the pdf image and are not readable.

2. What is the cycle length associated with the Markov Model?

3. Further description of the anticipated sensitivity analyses.

4. Consider discussing the challenges faced so far with the development of the protocol and analysis plan.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: James Bowen

**********

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PLoS One. 2023 Sep 14;18(9):e0277369. doi: 10.1371/journal.pone.0277369.r002

Author response to Decision Letter 0

21 Jul 2023

Manuscript ID PONE-D-22-27339 / Plos One

“Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: Protocol for an economic evaluation”

POINT-BY-POINT RESPONSE TO THE REVIEWERS’ COMMENTS

We very much appreciate the reviewers’ comments and suggestions, which certainly have helped us improve the manuscript.

Editor’s comments to the Author

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

Author’s response:

Thank you for bringing this to our attention. We made the following changes to ensure that the manuscript meets PLOS ONE’s style requirements:

- Removal of the capitalized words in the title and subtitle

- Removal of the abbreviations in the affiliations

- Removal of all bold words throughout the abstract and the text

- Moving of the references before the punctuation marks

We note that you will be accessing administrative databases for data collection for your study. Please clarify which databases will be accessed and whether you have obtained the necessary ethics approval or permission to access these databases. Furthermore, please clarify whether these databases are anonymized.

Author’s response:

Details have been added to the abstract and the body of the manuscript (Pages 9-10, Lines 198-207) on the various CHU de Québec - Université Laval databases that will be used. Details have also been added as to whether these databases are nominative or not. Finally, the "Ethical considerations and data management" subsection has been modified and now begins as follows: “This project and all of its components (conduct of the RCT, three-month participants’ follow-up, access to nominative and administrative databases) were approved by…” (Page 15, Lines 333-335).

Thank you for stating in your Funding Statement:

“Part of the data that will be used in this study were acquired during a project that was supported by the CHU de Québec – Université Laval, subsidies from LJH and KP and a clinical research scholarship awarded to one of the CHU de Québec collaborators by the Fondation du CHU de Québec for the multidisciplinary council of the CHU de Québec – Université Laval . RG received scholarships from the Canadian Institute of Health Research (CIHR; https://cihr-irsc.gc.ca/e/193.html), the Fonds de recherche du Québec – Santé (FRQ-S; https://frq.gouv.qc.ca/sante/), the Unité de Soutien SSA – Québec (https://ssaquebec.ca/), the Ordre professionnel de la physiothérapie du Québec (OPPQ; https://oppq.qc.ca/), the Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris; https://www.cirris.ulaval.ca/) and Université Laval (https://www.fmed.ulaval.ca/). JRG, SB and FD are FRQ-S Research Scholars. The funders had and will not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Please provide an amended statement that declares *all* the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement.

Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf.

Author’s response:

Thank you for your comment. We included a modified funding statement in the cover letter. We hopefully provided clearer information regarding funding sources. As the sources of funding received are nominative and/or are not grants received from funding agencies, they do not have a specific grant number, except for the CIHR scholarship.

We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Author’s response:

As this manuscript is a Study protocol, this clause does not apply. This is what is stated in the manuscript’s data availability statement.

Thank you for your patience Rose and apologies again for the delay. The reviewers are generally positive about the protocol but there is more detailed needed in numerous places. Please pay careful attention to the reviewers’ comments when revising your paper.

Author’s response:

Thank you to the Editor for working so hard to provide us with a quality peer review process. We have carefully read the reviewers' comments and used them to make significant changes to the manuscript.

Reviewer 1

This work has three objectives: to compare the average cost, to evaluate the ICER, and to estimate the ICER of the models of interest, which would be the combinations of physiotherapist and ED physician, ED physician alone, or physiotherapist alone.

Why only objective 3 consider the model with the group of primary contact physiotherapist management alone?

Author’s response:

Thank you for this relevant question. It is true that this choice is not clearly explained in the manuscript. We have added clarification to this effect in the "Data collection" subsection of the "Materials and Methods" section of the manuscript. The text now reads as follows: “Of note, the study population for the model of care consisting of primary contact physiotherapist management and discharge from the ED was not observed at all during the pilot pragmatic RCT. Consequently, this model of care will have to be modeled, and therefore cannot be studied in the context of Objectives 1 and 2, which are based on RCT data. All the parameters needed to represent this care model within Objective 3…” (Page 10, Lines 208-214).

Authors propose to use decision tree for objective 2. However, tree is well-known to be overfitting. Please provide the information how this will be avoided in the analysis plan.

Author’s response:

Thank you for highlighting this point with which we agree. Details have been added to the analysis plan, which now reads as follows: “The decision tree (Objective 3) will be created to reflect the results of the RCT as closely as possible and will therefore include all possible interventions and services used by a participant following the initial visit to the ED for each model of care considered (Fig 2). The pruning of each terminal node containing less than 5% of the participants will be determined based on discussions with a panel of experts. The conditional…” (Page 13, Lines 283-289)

Authors argued to impute data using the Missing not at random approach. Please be specific how this will be implemented, especially if it’s not at random, what assumptions the authors will make? And whether it is reasonable in practice?

Author’s response:

Thank you for your relevant comment. Based on the results obtained in the pilot randomized clinical trial, it will be assumed that some characteristics, such as those listed below, may put participants at greater risk of having been lost to follow-up at 1 and 3 months:

- Low socioeconomic status

- Level of pain at the time of the emergency visit

- Level of catastrophizing related to pain experience at ED visit.

Missing follow-up data will therefore be imputed using the Missing not at random technique, and sensitivity analyses will be performed on the chosen hypotheses. All necessary variables have already been collected during the randomized clinical trial.

Following this comment, details on the assumptions used have been added to the manuscript on Page 14, Lines 306 to 311.

Reviewer 2

Just clarify if the total sample size is 78 or as read in lign 49-50 that data are collected during a randomized clinical trial (n=78) as well from CHU Québec administrative databases. Are they the same

Author’s response:

We apologize for any confusion. Details have been added in the abstract on lines 51 and 52, as well as in the manuscript through the "Data collection" sub-section of the "Materials and Methods" section.

Do you have an estimate of the number of men and women for the subgroup analyses. What about the lack of power if a group is too small?

Author’s response:

We would like to thank the reviewer for this interesting comment.

We would like to note to the reviewer that statistical power considerations are not routinely considered within economic evaluations as their power depends, at least in part, on the willingness-to-pay threshold of the analysis. As this parameter is considered to be undefined, at least in Canada, the study’s power will also be undefined [Textbook of Pharmacoepidemiology, 2006].

Nonetheless, in Canada, the organization responsible for overseeing economic evaluation and issuing the various guidelines informing the work of health economists is the Canadian Agency for Drugs and Technologies in Health (CADTH). In their latest guidelines, issued in 2017, they state:

“The economic evaluation should reflect the entire target population as defined by the decision problem. Researchers should, however, examine any potential sources of heterogeneity that may lead to differences in parameter-input values across distinct subgroups. Note that heterogeneity may result from differences in the natural history of the disease, effectiveness of the interventions, health state preferences, or costs of the interventions. Heterogeneity may result in different decisions with respect to cost-effectiveness among different subgroups. The responsibility of the researcher, therefore, is to establish whether important heterogeneity exits in parameter estimates. A stratified analysis will allow decision-makers to identify any differential results across subgroups.”

[Guidelines for the Economic Evaluation of Health Technologies: Canada – 4th Edition, March 2017]

Considering the potential differences between men and women in the physiological mechanisms of pain, in the experience of pain and in the use of health system services and resources in the context of pain [e.g., Fullerton et al., 2018; Mills et al., 2019], it is important to carry out sub-group analyses based on sex and to report these results.

Reviewer 3

Thank you for the opportunity to review this interesting work examining the cost-effectiveness of a physiotherapy led intervention in the emergency department setting. The ability to conduct an economic evaluation using clinical trial data associated with an allied healthcare intervention in the emergency department is not that common in the literature as outlined in the introduction of the paper. The structure of the paper is well organized however further clarification is required and along with the provision of more details about the methods prior to being suitable for publication.

Although the manuscript describes a protocol for an economic evaluation, it would be of benefit to follow the CHEERS 2022 reporting guidance for economic evaluations. This is primarily applicable to the items outlined in the checklist associated with reporting of Methods (items 4-21).

Husereau, D., Drummond, M., Augustovski, F., et al. & CHEERS 2022 ISPOR Good Research Practices Task Force (2022). Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMJ (Clinical research ed.), 376, e067975. https://doi.org/10.1136/bmj-2021-067975

Author’s response:

We thank the reviewer for his very pertinent comment. Details have been added in the "Data analysis and interpretation of results" sub-section of the "Materials and Methods" section of the manuscript. The text now reads as follows: “All the statistical analyses carried out as part of this project and their detailed reporting in scientific publications will adhere to the CHEERS 2022 standard [58].” (Page 15, Lines 329-331)

Further description in the methods is needed to outline how the costing will be completed associated with the Recommendation and use of services and resources at baseline and 1- and 3-month follow-up visits as outlined in Table 3 of your published clinical trial paper pg. 854. How will uncertainty associated with these costs be addressed in the model? Also from Table 3 are any of the consultation with other professional further physiotherapy appointments with outpatient public or private healthcare providers? How will these visits be costed out?

Author’s response :

The reviewer makes important points that deserved further clarification in the manuscript. The "Study outcomes" sub-section of the "Materials and Methods" section has been substantially modified to reflect the essence of this commentary. The changes can be found on Pages 11-12, Lines 228 to 256.

With respect to Objective 3 in the manuscript please expand on the rationale for considering how a short-term ED physiotherapist intervention is to have a clinical impact and effect an individual’s healthcare resource utilization and costs over a two-year period. It is stated in the manuscript that follow-up for studies with similar interventions have had follow-up periods up to 2 years. What are some of the findings of these papers and their limitations that need to be considered associated with your utilization of a 2-year time horizon for the economic evaluation.

Author’s response:

Thank you for this comment, which we believe deserves a detailed response as found below. The reviewer will find further explanations between lines 88 and 124 of the manuscript.

To start, between 25 to 30% of all emergency department visits are for musculoskeletal disorders. A significant proportion of people with a minor musculoskeletal disorder will present pain related to this disorder more than a year after its onset. Currently, 18.9% of the Canadian population suffers from persistent pain [Schopflocher et al., 2011]. The presence of persistent pain is associated with greater use of health system services and resources, such as medication and consultations with various health professionals. Hence, the impacts of such musculoskeletal disorders can manifest in the long term and require assessment in the long term.

Also, in response to the reviewer’s comment, previous research supports the potential for long term benefits of a brief physiotherapy intervention. Indeed, early treatment by a physiotherapist is associated with a reduction in pain levels, psychological symptoms and the risk of developing persistent pain. Other studies have reported that early management by a physiotherapist in a primary care setting is also associated with a reduction in costs and a slight increase in health-related quality of life up to two years after initial treatment compared to usual management by a family physician [Bornhöft et al, 2019; Denninger et al, 2017]. However, no study has measured the long-term effects of this kind of management in the ED.

The results of our previous RCT [Gagnon et al, 2021] support the favorable clinical outcomes of the integration of physiotherapy in the ED compared to usual medical practice 3 months after the ED visit. Analysing outcomes up to two years will allow to provide new results to inform the implementation of ED models for the management of musculoskeletal disorders.

Please justify further why only a societal perspective was used for the analysis. It would seem to be important for this evaluation to provide the perspective of the health system (i.e. the hospital and the provincial payers) as well as just the patient perspective for out of pocket expenses and potential time off work.

Author’s response:

We thank the reviewer for his comments, with which we agree. The abstract and manuscript have been modified to reflect that we will be studying two different perspectives, the Health system perspective and the Societal perspective.

Please provide further details regarding which specific CHU de Quebec – UL administrative dataases will be used and which public databases will be used. Do you have permission for the study to use hospital level administrative inpatient and outpatient reporting systems?

Author’s response:

This comment has already been addressed previously. The reviewer will be able to find the information on the databases and Ethics approval on Lines 198 to 207 and 333-335.

Further details regarding the calculation of dis-utility from baseline to 1 month and 3 months is required. It states in the manuscript that mean-utility scores will be used. Will you be determining the utility values using Area Under the Curve analysis for each patient? Using just the calculated mean values at each time point may not reflect the within patient changes in quality of life.

Author’s response:

The requested clarifications have been added to the manuscript, which now reads as follows: “The difference in utility scores between the 3-month follow-up and baseline will be calculated for each participant using area-under-the-curve analyses. Once the difference in utility scores will be calculated for each participant, the differences will be averaged to obtain the average gain or loss in utility scores per ED care model. The mean gain or loss in utility scores will then be transformed into QALYs. The efficiency values…” (Page 12, Lines 260-264).

Please provide updated Figures 2 and 3. They did not upload appropriately in the pdf image and are not readable.

Author’s response:

We apologize for the inconvenience. Figures 2 and 3 have been updated to appear correctly on the journal submission platform.

What is the cycle length associated with the Markov Model?

Author's response:

This precision can be found in the manuscript on Page 8, Lines 170 to 172. The text reads as follows: “Thus, the Markov model will cover a 24-month period. It will include two-week cycles in order to capture the clinical evolution of the patients included.”

Further description of the anticipated sensitivity analyses.

Author's response:

We thank the reviewer for his relevant comment and have added the requested specifications to the "Data analysis and interpretation of results" sub-section of the "Materials and Methods" section. The text now reads as follows: “Uncertainty in the hybrid model parameters (probabilities, costs, and efficiency) (Objective 3) will be obtained via a probabilistic sensitivity analysis performed using a Monte Carlo simulation. Three scenarios will be considered in the probabilistic sensitivity analyses. The first will assume that all participants with missing follow-up data in the control group will have utility scores at 3 months corresponding to those of the 95th percentile, while all those missing in the intervention group will have scores corresponding to those of the 5th percentile. For the the second scenario, we will re-analyze all parameters included in the model, excluding outliers. Finally, in the third and last scenario, the different states of the Markov Model will be based not on the level of pain, but on the level of interference of pain on daily activities. Both uncertainties…” (Page 14 and 15, Lines 313-322).

Consider discussing the challenges faced so far with the development of the protocol and analysis plan.

Author's response:

We thank the reviewer for his insightful comment. This suggestion is highly appropriate, but it might be premature to initiate this discussion at this stage of the project. The project's post-mortem will enable us to identify the challenges encountered and the lessons learned which will be discussed thoroughly in the four manuscripts that we intend to publish in peer-reviewed journals, as well as in the first author’s doctoral thesis.

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Decision Letter 1

Joshua Robert Zadro

29 Aug 2023

Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: protocol for an economic evaluation

PONE-D-22-27339R1

Dear Dr. Gagnon,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Joshua Robert Zadro, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #3: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: thanks for the response. all comments have been successfully addressed and I have no further comments.

Reviewer #3: Thank you for addressing the comments of the reviewers. The methodology associated with the economic evaluation are more fully described in the revised manuscript.

**********

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Reviewer #1: No

Reviewer #3: Yes: James M. Bowen

**********

Acceptance letter

Joshua Robert Zadro

1 Sep 2023

PONE-D-22-27339R1

Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: protocol for an economic evaluation

Dear Dr. Gagnon:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Kind regards,

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on behalf of

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Academic Editor

PLOS ONE

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