How Much Allied Health Therapy Care Is Enough? An Evidence Scan

Abstract

Purpose: Pressure to eliminate low-value health care is increasing internationally. This pressure has produced an urgent need to identify evidence-based methods to determine the value of allied health (AH) care, particularly to recognize when additional AH care adds no further benefits. This article reports on the published methods of determining the value of AH care. Method: We systematically scanned PubMed, MEDLINE, AMED, CINAHL, PsycINFO, and the Grey Literature Review database from inception until July 2018 for peer-reviewed English-language literature. Hierarchy of evidence and information on study design and the methods or measures used to determine the value of AH care were extracted. Results: Of 189 articles, 30 were potentially relevant; after the full text was read, all were included. Of these, 24 reported on ways of determining the value of AH care, and 6 described the optimal provision of AH episodes of care. No methods were reported that could be applied to establish when enough AH therapy had been provided. Conclusion: This review found a variety of attributes of value in AH care, but no standard value measure or methods to determine what constituted enough AH care. Repeated measurement of the standard attributes of value and costs is required throughout episodes of AH care to better understand the impact of AH care from the different stakeholders’ perspectives.

Allied health (AH) consists of non-medical, non-nursing, or non-dentistry health disciplines, and those who work in these disciplines are broadly classified as therapists or scientists.^1–3 AH professionals work across the primary, secondary, and tertiary sectors, in private and public practice, and across the lifespan, commonly working to optimize function; quality of life (QOL); and physical, psychological, cognitive, and social independence.^2,3 AH therapies traditionally consist of physiotherapy, occupational therapy, speech pathology, clinical nutrition, and podiatry; more recently, they have included chiropractic, osteopathy, exercise physiology, and other complementary medical practices.^1,2 To provide care for specific conditions, therapists generally have multiple contacts with patients, each contact termed an occasion of service (OoS), delivered within an overarching bundle or episode of care (EoC).^4,5

Discussions about the value of AH care have been occurring for more than 30 years, but there is no agreed-on method of determining this value or identifying when care is of low value. In Australia, long before the evidence-based practice movement had an impact on AH, health insurers interpreted the New South Wales Workers Compensation Act 1987 to outline the principles of “reasonably necessary treatment” for injured workers.^6–8 These principles continue to form the basis on which health insurers assess individual claims to determine the type and amount of AH services required to address claimants’ needs. However, AH therapists, managers, and patients have not yet developed standard ways of determining the value of care, nor can they identify when enough AH care has been provided on a case-by-case basis. Moreover, different stakeholders may have different notions of value.^7–9

Health care systems are increasingly seeking innovative ways to improve individual and population-based health outcomes with limited health budgets.⁹ Consequently, how to value an AH EoC is of growing interest to health facility managers, therapists, referrers, researchers, policy-makers, funders, and patients. The question that resonates across all stakeholders is “What amount of AH care provides the best health outcome when resources are constrained?”

The Oxford Dictionary defines value as “the regard that something is held to deserve; the importance, usefulness or worth of something.”¹⁰ Although the notion of value might be readily attributed and understood when related to tangible goods such as furniture or services (such as a restaurant meal), it is not as readily applied to health care or health outcomes. Porter defined value in health as outcomes relative to costs.¹¹ He indicated that placing a value on health care is complex because different stakeholders have different views of value, including “access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction”^11(p.2477)

Porter’s definition of value combines the concepts of outcomes and costs.¹¹ This is in line with the World Economic Forum’s notion of health system optimization which seeks full value for every health dollar spent.¹² Optimization is constrained by system inefficiencies that “can result from misalignment of incentives, interests, strategies, and behaviours of parties engaged in healthcare delivery.”^12(p.1) Culyer, however, describes value, in dollar and preference terms, as “the maximum amount that an individual is willing to pay for a good or service rather than go without it.”^{13(p. 640)}

Given the usual AH therapy EoC service delivery model, a critical value question relates to the number of OoS sessions delivered within an EoC. Underlying this is the tension among the evidence for the effectiveness of AH care for the condition being treated;^7,8 the number of OoS sessions required to produce optimum health benefits;^{11,12 the patient’s willingness to pay for each additional OoS session;13 and the alignment of patient and therapist expectations, incentives, interests, and behaviours.12–15 Thus, the number of OoS sessions involved in an EoC may be influenced not just by patients’ health needs and clinical decisions but also by non-clinical factors such as local work practices; the true cost of services (vs. what the market will bear); patients’ expectations, knowledge, and beliefs; therapists’ location, workload, incentives to provide more (or fewer) OoS sessions; and terms of employment.7,8,11–17}

The global Choosing Wisely initiative is shining a light on quality of health care, value for money, and informed choices.^11,18,19 This movement began as a Physician Charter that outlined a set of professional responsibilities for medical practice.^18,19 The broader goal of this movement was to reduce treatment burden or harm while improving health care quality, and professional associations and individual health care providers have been encouraged to identify practices that are of low value and to consider de-prescribing them (i.e., reducing or stopping care that may no longer be of benefit or may be causing harm).¹⁹ After extensive consultation with their membership, the Canadian Physiotherapy Association and the Australian Physiotherapy Association reported de-prescribing strategies that supported the Choosing Wisely initiative.^20,21

Evidence-based and expert consensus guidelines prompt AH disciplines to consider the value of their care decisions by considering the strength of the evidence underpinning them. However, difficulties in making defensible evidence-based decisions have been noted, reflecting the lack of robust information with which to guide the determination of value, the lack of information on how to determine how much AH care is enough, and the lack of indicators for when to stop providing AH care because optimum outcomes have been reached.^4,15–22

Economic evaluation principles suggest that AH care should be underpinned by value statements.^{11–13,21,22} Economic evaluation indicators of effectiveness may include improved health outcomes, QOL, cost effectiveness (which combines measures of costs and benefits), and the effect of cost savings on the health care budget.^13,21,22 The notion of utility also applies.^11–13 Utility indicates the strength of stakeholder preference for AH care and how it may change over time (in increments of utility). This utility is balanced by the cost of providing each additional OoS.¹³ Increments of AH utility may reflect the changes in health outcome, or QOL, that can be attributed to each OoS and the cost increments of each additional OoS relative to resource constraints.^{11–13,21–22} However, none of these measures provides guidance to individual therapists, patients, health care managers, or policy-makers when determining, on a case-by-case basis, when enough AH care has been provided, funded, or consumed.

The rising prevalence of chronic diseases, and the important roles that AH therapies could play in preventing and managing them, means that it is increasingly urgent to estimate the value of AH therapies and thereby ensure wise allocation of scant resources.²³ A practical example of the challenges of determining value-based AH care is observed in the 2005 Australian Medicare Chronic Disease Management (MCDM) initiatives.²⁴ The MCDM provides many Australians with previously unavailable access to AH care and raises the profile of AH therapy in the community.²⁴ However, the MCDM AH funding provides for only five AH therapy OoSs per patient per calendar year, despite different chronic disease profiles and needs.

There is also no guidance for general practitioners (GPs) regarding which AH therapies they can refer patients to, using the MCDM initiative, and no measure of outcome that is collected in a standard fashion. Thus, GPs may refer patients to five AH disciplines for one OoS per discipline or, conversely, they may refer them to one AH discipline to receive five OoSs. Moreover, there is no measure of accountability required from either a GP or an AH practitioner. The lack of value-based referral, treatment, or evaluation methods in the MCDM initiatives can mean that, for some patients, the AH care they receive represents under-servicing because they received insufficient care from any AH provider to obtain a significant health outcome. For other patients, however, multiple contacts with one AH provider may represent over-servicing because the optimum health outcome may have been achieved in one or two OoS sessions. A further example of the need for value-based care decisions is highlighted in a systematic review of chiropractic services,²⁵ which noted that providing unnecessary preventive care was a key barrier to expanding chiropractic coverage.

This article aims to identify the published methods used to determine (1) what represented value in AH care and (2) when enough AH care was provided.

Methods

Design

We undertook a systematic evidence scan – a rapid systematic collation of empirical research, the intent of which is to report on what is known, with a view toward identifying gaps and determining future priorities and next steps.²⁶

Review questions

We had two questions: What methods have been reported to determine the value of AH care and what methods are used to determine when enough AH care has been delivered?

Search strategy

We applied a PIO approach, in which P = any patient with any condition, I = AH therapy described as OoS or EoC, and O = outcome related to any measure of value or enough care. The Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses was used to ensure the rigour of our search.²⁷ Because an evidence scan does not answer a focused question, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for systematic literature reviews was not relevant.²⁸

Broad search terms and the search approach, using the exemplar search strategy in MEDLINE, are presented in Table 1. Search terms with similar meanings or intent were connected by OR. The bracketed group was connected to other bracketed groups by AND to build the filter around the search. Search terms were applied as appropriate to the database searched: PubMed, MEDLINE, CINAHL, PsycINFO (all searches undertaken from database inception until July 2018), and the Grey Literature Report (searched from database inception until it was discontinued in 2016).

Table 1.

Example Search of the MEDLINE Database

Query no.	Query	No. of results
1	allied health OR	102,032
	physiotherapy OR
	occupational therapy OR
	chiropractic OR
	osteopathy OR speech
	pathology OR podiatry
2	occasions of service OR	486,678
	episode of care OR contact OR consultations
3	1 and 2	29,068
4	worth OR value OR price	2,214,031
	OR reimbursement OR
	expenditure OR
	incremental benefit OR
	cost effectiveness OR
	ICER OR incremental cost
	OR cost benefit OR
	marginal gains
5	satisfaction OR treatment	1,275,012
	end OR health outcome
	OR quality of life OR
	social benefit OR access
	OR equity OR safety
6	methods OR calculation	6,527,120
	OR estimation OR
	procedures
7	6 and 3 and 4	1,065
8	5 and 7	257

ICER = incremental cost-effectiveness ratio.

Full text, peer-reviewed, English-language articles of any research design were included if they addressed either review question. The research team discussed the inclusion of each potentially relevant article and what aspects of the article should be extracted and how.

Hierarchy of evidence

The included literature was classified, where appropriate, using the Australian National Health and Medical Research Council (NHMRC) evidence hierarchy.²⁹

Critical appraisal, data extraction, and analysis

Critical appraisal of included articles is not required for an evidence scan. Information was extracted from each article on its study design, definitions or attributes of AH value, and the methods or measures used to determine AH value. Qualitative thematic descriptive analysis was applied to summarize the extracted data.

Results

Of the 189 articles identified in the search, 30 were potentially relevant and, after a full-text reading, all were included in the review. No new articles were found from the grey literature search. Of the potential articles, 24 reported on the approaches required, variables needed, or both to determine the value of AH care. Six articles discussed the need to determine how much AH care was enough, with 3 discussing the optimal provision of AH care value. Four articles reported findings from randomized controlled trials (RCTs;^30–33 NHMRC level II), 3 reported prospective observational studies^4,34,35 (NHMRC level III-1), 2 reported cross-sectional studies^36,37 (NHMRC III-2), 11 reported retrospective studies^38–48 (NHMRC Levels III-3), 1 reported a mixed-methods study,⁴⁹ and 9 provided commentary or opinion^{11,14,50–56} (NHMRC level IV). The articles and their purpose are summarized in Table 2.

Table 2.

Calculating How Much AH Care Is Enough: Summary of Findings

		Value in AH care
		Methods†					Toward enough AH care
Reference	Level of evidence*	a	b	c	Described value	Value in EoC	Provided no. of OoSs	Provided the process
GAPS Group30	II	✓					✓
Clarke et al.31	II	✓					✓
Clarke et al.32	II	✓					✓
Neumann et al.33	II					✓	✓
Fortinsky et al.34	III-1	✓					✓
Neumann et al.35	III-1	✓					✓
Grimmer et al.4	III-1					✓	✓
Grimmer et al.36	III-2			✓				✓
Axen et al.37	III-2			✓				✓
Franklin et al.38	III-3	✓
Haas et al.39	III-3	✓
Harding et al.40	III-3	✓
Homeming et al.41	III-3	✓
Bonanno et al.42	III-3	✓
Chetty43	III-3	✓					✓
Meade et al.44	III-3	✓
Liliedahl et al.45	III-3		✓
Smith & Stano46	III-3		✓
Jette & Delitto47	III-3		✓
Scott et al.48	III-3		✓
Myburgh et al.49	Mixed methods			✓				✓
Porter11	IV				✓
Scott & Duckett14	IV				✓
Scott et al.50	IV			✓
Scott51	IV				✓
Lizarondo et al.52	IV				✓
Ubel & Asch53	IV				✓
Lizarondo et al.54	IV				✓
Hussey et al.55	IV					✓
Hussey et al.56	IV					✓
Total	30	12	4	4	6	4	8	3

^*Based on the Australian National Health and Medical Research Council evidence hierarchy.

^†a = incremental-oriented methods; b = claims or payment-oriented methods; c = patient-clinician-oriented methods or concepts.

AH = allied health; EoC = episode of care; OoS = occasion of service (contact or encounter with an allied health therapist).

Methods of determining the value of AH care

The articles reported on three discrete approaches: incremental-oriented methods, claims or payment-oriented methods, and patient- and clinician-oriented methods or concepts.

Incremental-oriented methods

This category was addressed in 12 studies (3 RCTs,^30–32 3 prospective studies,^4,34,35 and 6 retrospective studies).^38–42,44 They described the effectiveness of AH encounters by duration of AH contact,³⁰ number of contacts,^{31–32,33,34} health outcomes or QOL,^{30–32,34,35} health care cost,³⁵ or the impact of AH service delivery.^38–44,57 Health care performance measures included waiting time, emergency admissions, length of stay or patient flow,^38–43 health outcomes,^39,44,57 and patient satisfaction and cost.³⁸

Claims or payment-oriented methods

Four retrospective studies reported this approach, two describing the impact of AH EoC on insurance or Medicare claims,^45,46 one describing the impact of the methods of AH payments on resource use or modality of care,⁴⁷ and one describing the impact of AH payment on health outcome.⁴⁸

Patient- and clinician-oriented methods or concepts

Four retrospective, mixed-methods, or opinion-based studies were identified; they reported on the expectations of patients or clinicians after the first contact with AH care,^{36,37,49–50} recovery after four visits to AH care,³⁷ or the perceived utility of the AH contact.⁴⁹ Scott and colleagues also explored the notion of low-value care, finding that cognitive biases in decision making can constrain clinicians from reconciling the evidence of service overuse with ingrained prior beliefs.⁵⁰

Discussions on the value of care

Six opinion articles described the need for care to be valued without reporting on the methods used for doing so or how to determine when enough AH care had been provided.^11,14,51–⁵⁴

Porter published on attributes of value in health. These broad principles of estimating value were relevant to AH OoS.¹¹ He noted that value measures should be patient centred and suggested that “the creation of value for patients should determine the rewards for all other actors in the system.”^11(p.2477) He identified the main challenge in measuring value as shifting the focus from measuring health processes to measuring health outcomes because reducing the costs of service delivery must consider the impact on outcomes. Scott and Duckett discussed the challenges of decreasing the delivery of low-value care in the presence of insufficient evidence to guide individual clinical decisions.¹⁴ They suggested that, in the absence of research, policy interventions should support professional consensus on what constitutes low-value care and the best means for reducing it.

Scott outlined 10 strategies for maximizing the value of Australian health care.⁵¹ Five strategies were immediately relevant to AH: discontinuing practices that provide little benefit or cause harm, deferring the use of unproven interventions, selecting care options according to comparative cost effectiveness, actively involving patients in shared decision making and self-management, and advocating for integrated systems of care that maximize value.

Lizarondo and colleagues proposed multiple elements of high-quality AH care, including multidisciplinary care; evidence-based treatment decisions; sensitive outcome measures; reflection on, and audit of, practice; and patient engagement.⁵² Ubel and Asch⁵³ proposed the notion of “de-innovation” of practices – meaning stopping any usual practices that have little value. These authors noted that this was more challenging than adopting new practices. Lizarondo and colleagues presented an evidence-informed opinion article on AH examples in response to the Scott strategies.^51,54

Determining the value of care in an EoC

Two opinion pieces described how value might be determined throughout an EoC when multiple health care providers were engaged.^55,56 These articles proposed capturing metrics, such as health process and outcome measures, and how these changed over the EoC; how long a patient’s health had been less than optimal; and how the outcome of care in one OoS depended on outcomes from the previous OoS. The authors concluded that these metrics were generally unavailable in many health care settings (including the AH sector) and that efforts should be made to routinely collect them.

Two articles reported the specific number of OoS sessions during an EoC as a measure of value.^33,35 However, Grimmer and colleagues highlighted the difficulty of flagging the beginning and end of an EoC because AH providers often use different ways to define and record them.⁴ Neuman and colleagues reported a dose–response relationship (albeit with diminishing marginal improvements) between the number of OoS sessions provided and good continence outcomes.^33,35 This research found that women responded well to pelvic floor training, irrespective of their history of incontinence. Women with longer standing incontinence simply required more OoS sessions in an EoC to achieve the same health outcomes than women with a shorter history.³⁵

How much AH care is enough?

Seven studies considered the quantity of AH encounters;^30–35,43 however, none provided a methodology to determine, on a case-by-case basis, when care could be discontinued. Neumann and colleagues’ studies reported a positive dose–response relationship with diminishing returns between the number of OoS sessions provided and continence outcomes, finding that 64% of patients were completely cured within four to six specialist physiotherapy OoS sessions.^33,35 Three studies reported patient-oriented processes using self-reported recovery status as a way of determining when enough AH care had been received.^36,37,49

Axen and colleagues used patients’ self-reports of “definitely improved” at the fourth visit to chiropractic care.³⁷ Grimmer and colleagues and Myburgh and colleagues used patients’ self-reported expectations for contact with AH clinicians or their motivation for attending subsequent OoS.^36,49 These value measures took into account only the patients’ perspectives of benefits and did not consider other stakeholders’ perspectives. They also did not consider the potential for diminishing utility with additional OoSs in an EoC or perverse incentives for continuing AH care even if the benefit was marginal.

Discussion

This evidence scan highlighted the fact that the issues of measuring value in health care are not just concerns for AH.¹¹ Our review found a significant gap in knowledge that requires urgent attention, because providing demonstrable evidence of high-value health care is essential in an international climate of health resource constraints.^11,12,18,19 High-value health care has the potential to generate significant health benefit returns – for the resources invested and for individuals, communities, and countries^11,14 – whereas low-value health care delivers little or no health benefit for a significant investment of resources; it can even lead to harm.^1,14,50,51 To provide the requisite evidence to all stakeholders of the value of their care, and thereby retain and enhance their role in the current and future health markets, AH professionals must be proactive.

The 30 articles included in this review reported on a variety of measures of value in health care that are relevant to AH. None described methods for establishing how much AH care is enough (or how to determine the point within an EoC beyond which further care becomes ineffective). However, the articles reported on many elements of value that could routinely be collected to provide data that would assist in determining when AH care should cease. These elements included repeated measures of patients’ needs and goals; health outcomes, including QOL; research evidence of expected effects of care; and clinically reasoned decisions about the benefits for each additional OoS.

What are the health outcome measures relevant to AH?

Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.⁵⁸ AH therapies claim to improve QOL,^2–4 and QOL measures can be used as measures of the impact of altered health states on an individual within the family and society.^{14,51,59–60} QOL measures can be generic (e.g., the 36-item Short Form Health Survey), preference based (e.g., the EuroQol-5D), rank based (e.g., Patient Generated Index), or disease specific (e.g., the World Health Organization Quality of Life – Pain scale).^59,61–63 However, there is no agreed-on way to measure QOL that best demonstrates the impact of any AH intervention, and there is no routine commitment to measuring QOL in any AH therapy.^14,64–66

Thus, it seems that a first step for AH in establishing the value of care is to establish agreement on the systematic, regular, and rigorous recording of outcomes that comprehensively reflect patients’ values and health states. In theory, “enough AH care” could be identified as the number of sequential OoSs that optimize a patient’s overall health and QOL. AH care could viably cease when it is determined that one additional OoS would not add significantly to incremental health benefits and when ceasing AH care would have no deleterious effects. To calculate this assumes that a change in health state can be measured regularly throughout an EoC. Figure 1 shows three scenarios of determining what is enough AH care by measuring the diminishing marginal utility (health outcome) from an AH intervention against the alternative to AH (the comparator),^11–13 using the EoC (made up of a number of OoS sessions) as an example.

Figure 1.

Three representations of the marginal utility achieved from consuming additional OoS in an EoC:¹³ (a) the health outcome from an AH intervention is lower for the level of contact below Cx; (b) AH performs better than the comparator; (c) AH performs better than the comparator for the level of contact below Cy.

OoS = occasion of service; EoC = episode of care; Hx = the utility achieved from the EoC (Cx); Hy = the utility achieved from the EoC(Cy); Cx (or Cy) = the number of contacts (or sessions); AH = allied health.

In Figure 1a, the health outcome from an AH intervention is lower for the number of OoSs below Cx. Hx and Hy represent the utility derived from the EoC with Cx and Cy OoS sessions, respectively. When the number of OoS sessions is higher than Cx (i.e., Cy), AH produces a higher level of health benefit than the comparator. If the treatment stops at Cx, the effectiveness of an AH intervention is clearly ruled out. The question is, is it cost effective to increase the level of contact to Cy? Indeed, stopping care at Cx hinders the information that would help finance AH for the number of treatments required for the EoC (Cy) if it were cost effective.

In Figure 1b, AH performs better than the comparator. One can ask whether it would be cost effective to increase the number of OoS sessions past Cx to Cy. In Figure 1c, AH performs better than the comparator for the number of OoS sessions below Cx. AH care is therefore potentially more cost effective up to this level, but further OoS sessions are unlikely to provide improvements in health outcomes that warrant further funding.

Evidence-based decisions about value

Evidence-based practice presents the notion of intersecting circles of research evidence, clinical knowledge and experience, and patient choices, all in the usual environments.^66–67 However, there are few tested examples of the mechanisms by which AH patients and therapists make evidence-based care decisions. This particularly affects how best to determine the value of each additional OoS within an AH therapy EoC.^52,56

Evidence of effective interventions is generally considered to be provided by high-quality RCTs. However, all too often this evidence is unconvincing in clinical settings and difficult to generalize because it is often constrained by sampling limitations and strict intervention protocols. The Evidence Based Medicine Renaissance Group has questioned the relevance of elegant RCTs in ensuring that effective interventions are translated to individual patients.⁶⁸ This group suggests revisiting the notion of evidence-based practice to address the increasing disconnect between research elegance and the pragmatics of translating evidence into individual patient care.^47,48 By reconsidering the relevance of research designs to value-based AH decisions, better information may be gained on how to estimate when enough AH therapy has been provided.

The elegance required of an AH RCT usually means that AH interventions are delivered in a pre-prescribed EoC – for example, “six treatments delivered once a week for 6 weeks.”^37,69,70 Most AH therapy RCTs provide little justification for the chosen number of OoSs or the frequency with which care is delivered; this could raise the question of whether providing a different therapy (more OoSs, or different frequencies of OoS delivery) might produce different outcomes.⁴⁹ Although the template for intervention description and replication (TIDier) checklist will assist future AH RCTs to better describe their interventions,⁷¹ the rationale for the chosen number and frequency of OoSs in an RCT remains unaddressed. For instance, TIDier Item 8 says, “Describe the number of times the intervention was delivered and over what period of time including the number of sessions, their schedule, and their duration, intensity, or dose,” but it does not seek the rationale for why the intervention was delivered in that manner.

An example of alternative ways in which generalizable evidence of service delivery could be obtained was provided by Neumann and colleagues in an Australia-wide prospective observational study involving women with stress urinary incontinence.^33,35 At each clinical contact, health outcome measures were collected. As noted earlier, this study reported an incremental dose–response relationship between OoS and outcomes. If this study had been conducted as an elegant RCT, it is probable that women with a long history of incontinence would have been excluded to ensure sample homogeneity or that a specific number of OoSs would have been prescribed. Such a study would potentially have provided different findings and would thus have had limited relevance to women with chronic incontinence problems.

Analyzing information about AH OoSs and EoCs obtained from big datasets (e.g., insurance claims data) provides important insights into AH EOCs and variability in AH service delivery in real life.⁷² However, these large datasets do not often include information on health or QOL outcomes, and they usually provide only the dates on which treatment ended and patients returned to work. Cessation of claims from AH providers appears to be a default marker that claimants have achieved significant health improvement; however, this is a large assumption, and it has not been tested. In addition, big dataset analysis may not provide sufficient evidence of the real EoC outcome or cost because patients may have multiple concurrent encounters with many AH professionals whose treatment may have an impact on the effectiveness of care provided by others. In most big datasets, there is no integrated system of collecting multiple AH OoS data and thus no way of “unpicking” specific AH discipline effects.

Patient need and service funding

The demand for AH services is often dictated by referral (self-referral or referral by medical doctors). Patients have been shown to balance their perspectives of the need for AH care against its availability, affordability, and accessibility.³⁶ AH services can be funded by personal health insurance, some limited public funding such as the Australian Medicare Enhanced Primary Care initiative, or simply by a patient paying out of pocket.²⁴ Patients who pay out of pocket may find themselves trapped with an affordability problem whereby they require AH care but cannot afford it, and in this context their health condition could deteriorate.

This could also happen when patients need AH services that are not available in their area, or there is a long waiting list to access them. Maintaining waiting lists is a common way in which demand for service is controlled or rationed. Patients who wait a long time for a service could experience a deterioration in their condition.⁷³ If we knew more about how much was enough AH care, unnecessary (or low value) additional OoSs could be restricted, once patients had achieved the optimal health gain for dollars spent (see Figure 1). Thus, reducing low-value care may have the effect of decreasing waiting time for care, and thus may minimize a deterioration in a patient’s health or QOL.

An AH EOC that includes repeated measures of health, or QOL, outcomes could become the norm for developing innovative evidence-informed AH funding models.^32,34,38 If this information were collected electronically from public and private providers, it would enable funding bodies to determine the optimal number of OoSs in an EoC for different conditions. This would assist them in efficiently allocating AH resources to optimize patients’ health outcomes.^58,74,75 In reality, however, many funding bodies have already decided how much AH care is enough by establishing the quantity of AH care for which they are prepared to pay. How they have defined the cap on the quantity of AH services in relation to patients’ health outcomes is unclear, however, and it is unlikely that they have made this decision on the basis of research evidence of cost-effective AH care because the research evidence is scant. Moreover, there is no evidence that these cost constraint approaches support value for money because they might be supporting under-servicing or over-servicing.⁷⁶

A limitation of this review was that we were only able to review articles that were freely available and published in the English language. Whether there is a significant body of literature on the value of AH care in the non-English literature is therefore unknown.

Conclusion

Robust and agreed-on methods for estimating AH value, and how much AH therapy is enough, are lacking. There is, however, a range of data items that could routinely be collected to inform a calculation of overall AH value. Some of these measures could also be used to determine when there is no further value in consuming additional AH therapy. The health care system urgently requires methods of expressing these data items as value statements; these statements would underpin an evidence-based consumption of scarce AH resources and demonstrate AH value.

Key Messages

What is already known on this topic

In the face of dwindling resources, health service systems are under increasing pressure internationally to eliminate low-value health care. This pressure has produced an urgent need to identify evidence-based methods to determine the value of allied health (AH) care, particularly to recognize when additional AH care adds no further benefit. Given the usual AH therapy service delivery model, a critical value question relates to the number of occasions of service delivered within an episode of care

What this study adds

We identified 30 articles that reported on value in AH care. Overall, the value in AH care has been reported variably in the literature, with no standard value measure or methods of determining sufficiency of AH care presented. This limits the capacity to differentiate low-value from high-value care. Repeated measurement of the standard attributes of value and costs is required throughout episodes of AH care to better understand the impact of AH care from the perspective of different stakeholders.