Making Decisions about Service Provision for Clients with Low Back Pain: Perspectives of Canadian Physiotherapy Professionals

Abstract

Purpose: This study identified the individuals responsible for making decisions about physiotherapy (PT) wait time, frequency of treatment, and treatment duration for persons with low back pain and determined which factors guided these decisions. Method: A cross-sectional survey was sent to Canadian PT professionals treating adult patients with musculoskeletal problems. It included a clinical vignette describing a patient with low back pain. Respondents were asked who made decisions about wait time, treatment frequency, and treatment duration as well as on which factors they based these decisions. Results: Clinicians were most often responsible for making decisions about treatment frequency and duration. Although clinicians and managers or coordinators were mainly responsible for making decisions about wait time, there was more variability depending on sector of care: in the private sector, administrative assistants played a much larger role. Clinical judgment, clinical guidelines, and patients’ demands were the predominant factors influencing wait time and frequency decisions. Treatment duration was related to patients’ goals, clinical progression, patients’ motivation, and patients’ return to work. Conclusions: Decisions about service provision for wait times are made by a range of stakeholders, and a wide variety of factors guide Canadian PT professionals’ decision making. Identifying these factors is essential for informing a discussion of decisions about evidence-based and equitable service delivery so that the actors involved can reach a consensus.

In physiotherapy (PT), clinical factors (patient functional level, pain on the visual analog scale, range of motion, etc.) are among the most important considerations for deciding wait time, treatment frequency, and treatment duration. PT outpatient departments typically assign the highest priority to patients with acute or traumatic conditions^1#x2013;5 and the lowest priority to patients with chronic conditions.^1–3,6 However, non-clinical factors are also taken into consideration;^7–15 patients’ characteristics and support networks play an important role in decisions about service provision: the preferences and objectives of patients, their families, or both;^14,16,17 patients’ personality;^4,18 their co-operation with their treatment;^14,17,19,20 and their ability to navigate the system.^21,22 Yet, it is not clear to what extent these non-clinical factors are related to professional decision making.

Factors related to health professionals, policies, and systems also influence decisions about service provision. Rehabilitation professionals using an evidence-based practice (EBP) approach have been found to use more effective treatments, and the duration of these treatments is shorter.⁷ Reduced costs and better clinical outcomes are strong arguments for physiotherapists to use EBP,²³ yet there is considerable variation in how they adhere to guidelines for managing low back pain, for example.^24,25 Payment systems and institutional policies can also influence the decisions professionals make about service provision.^{9,11,12,17,21,26–36} In Canada, PT professionals may more frequently see patients covered by third-party payers (e.g., a workers compensation board or other insurer) than patients with similar diagnoses who are not covered.³⁷ Moreover, the number of treatments available to workers can be arbitrarily limited by the policies of third-party payers.^38–40

It is critical to have a better understanding of who makes decisions about service delivery and what factors guide their decision making to ensure that these decisions are made using the best available evidence, rather than other considerations (e.g., individual value judgments about different categories of patient), which may lead to inequitable service delivery. Therefore, the purpose of this study was to identify who (e.g., PT professionals, managers, third-party payers) is responsible for making decisions about wait time, frequency of treatments, and treatment duration in Canada and to determine the factors influencing these decisions.

Methods

We conducted a cross-sectional online survey of PT professionals in Canada, using a clinical vignette describing a patient with a case of low back pain. Although any case of musculoskeletal pain could have been used, we opted for low back pain because it is a highly prevalent condition and accounts for a high proportion of PT caseloads.^41,42 More specifically, the vignette described a patient who had had low back pain for the previous 6 years and whose condition had worsened in the previous few months after a fall. The survey was developed after an extensive review of the gray and academic literatures. It was refined using an iterative process within the research team, after which feedback was obtained from five additional experts in PT clinical practice or vignette methodology.

These experts reviewed and provided feedback on the clinical vignette and the related questions. Each version of the questionnaire (English and French) was pretested by four physiotherapists and one PT student, and the vignette was revised on the basis of their feedback to ensure clarity. The pretesting solicited feedback on the realism, clarity, relevance, and length of the vignette as well as ease of navigation through the online survey platform. On the basis of the feedback received, minor adjustments were made.

The survey asked the respondents questions about who would be responsible for making decisions about wait time, frequency of treatments, and total duration of treatment (from the start to the end of treatments, measured in weeks or months) for this patient in their clinical setting. They were also asked on which factors they based these decisions and the importance of each one in the decision-making process. Importance was rated using a four-level categorical scale (very important, important, of little importance, not relevant). The survey also examined possible biases in practice patterns regarding decisions about wait time, frequency of treatments, and treatment duration in relation to the vignette patient; these results have been reported elsewhere.^43,44 Finally, to address potential social desirability bias, we advised the respondents at the beginning of the survey that there was no right or wrong answer and that they should answer the questions according to what they really did in their clinical practice.

From July to November 2014, associations and professional licensing boards sent out invitations through newsletters or in emails to PT professionals in all Canadian provinces and territories (the Canadian Physiotherapy Association advertised the survey in its July 2014 monthly newsletter). The invitations contained a brief project description and a link. The link directed respondents to the pre-survey Web page, which described the study procedures, included the informed consent form, and asked three questions. These questions were designed to filter the respondents on the basis of our inclusion criteria: currently working in Canada (either full time or part time) as a PT professional with adult patients with musculoskeletal problems. Thus, the first question asked the respondents in which province or territory they currently worked. The second asked whether they currently practised as a physiotherapist or as a physical rehabilitation therapist. The last question asked whether they currently practised with an adult musculoskeletal clientele. If respondents entered their email address on the pre-survey Web page and answered yes to all three questions, they met the inclusion criteria and were sent a second personalized link to the survey. If they answered no to one of the questions, they were excluded from the survey and not sent the second link.

The PT professionals who received the invitations consisted of both physiotherapists and physical rehabilitation therapists. Physical rehabilitation therapists are not the equivalent of PT assistants in Canada; they are trained at the community college level (post-secondary diploma) and are members of the professional licensing board in the province of Quebec. In contrast to physiotherapists, physical rehabilitation therapists are not able to make a physiotherapeutic diagnosis and are therefore limited in the range of conditions that they can treat.⁴⁵ To treat certain health conditions that are more complex, a physical rehabilitation therapist needs to have been evaluated by a physician or a physiotherapist. We included physical rehabilitation therapists in our survey because they are able to treat musculoskeletal problems and can make professional decisions about wait times, treatment frequency, and duration.

The study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the Université de Montréal,⁴⁶ and we used SAS statistical software, Version 9.3 (SAS Institute, Cary, NC) to analyze the data. Analysis consisted of descriptive statistics (n [%]) and comparisons between respondents and non-respondents and between those working in the private and the public sectors (χ² analysis). Results are presented separately for respondents working in either the private or the public sector; those who worked in both sectors were excluded.

The Centre for Research in Rehabilitation of Greater Montreal Research Ethics Board approved the project (CRIR-753-0712), and all study respondents completed an electronic informed consent for on the survey Web site before beginning the study.

Results

Demographic information

In 2014, 20,842 physiotherapists and 2,473 physical rehabilitation therapists were licensed to practice in Canada for a total of 23,315 PT professionals.^47,48 Of these, 39.8% of the PT professionals worked with a musculoskeletal clientele, which translates into a predicted pool of 9,279 participants.⁴⁷ A total of 1,292 individuals consented to participate in the online survey using the first link, and 846 were included in the final analysis (9.1% of the predicted respondent pool). Participants were excluded if they did not respond to the survey (n = 430), if they did not meet the inclusion criteria (were not currently working in Canada as a PT professional with adult patients with musculoskeletal problems; n = 3), and if they were duplicates (n = 13). The 846 PT professionals who answered the survey had similar characteristics to the 430 participants who did not respond to the survey (province of work, p = 0.71; role at work, p = 0.66; physiotherapist or physical rehabilitation therapist, p = 0.73). A description of the sample is presented in Table 1.

Table 1 .

Description of the Sample (N = 846)

Variable	No. (%)
Province*
Quebec	368 (43.5)
Atlantic provinces	173 (20.5)
British Columbia	121 (14.3)
Ontario	112 (13.2)
Prairie provinces	68 (8.0)
Territories	4 (0.5)
Role at work
Clinician	644 (76.1)
Manager	25 (3.0)
Both	177 (20.9)
Sector of practice
Private	388 (45.9)
Public	353 (41.7)
Both	105 (12.4)
Training
Physiotherapist	734 (86.8)
Physical rehabilitation therapist	112 (13.2)
Experience, y
< 10	289 (34.2)
11–20	239 (28.3)
21–30	181 (21.4)
> 30	137 (16.2)

Note: Percentages may total more than 100 because of rounding.

^*Atlantic provinces are Prince Edward Island, Nova Scotia, New Brunswick, and Newfoundland and Labrador; Prairie provinces are Alberta, Manitoba, and Saskatchewan; territories are Yukon, Northwest Territories, and Nunavut. They were grouped to ensure confidentiality, given the lower response rate in these regions, and because they had similar characteristics.

Who makes decisions about service provision?

Table 2 presents the types of personnel (e.g., PT professionals, manager or coordinator, administrative assistant, staff members in or outside PT departments, third parties) who make decisions about wait time, treatment frequency, and treatment duration in the public and private sectors. To maximize the accuracy of these responses, we excluded individuals who worked in both the public and the private sectors. Only those who worked in either one or the other sector were included in the analysis.

Table 2 .

Who Makes Decisions about Wait Time, Treatment Frequency and Treatment Duration in the Public and Private Sectors

Sector and decision	No. (%)
	PT treating clinician*	Manager–coordinator†	PT colleague‡	Third party§	Administrative assistant	Staff member in PT department¶	Staff member outside PT department**
Private sector
Wait time (n = 356)	164 (46.1)	117 (32.9)	14 (3.9)	3 (0.8)	52 (14.6)	6 (1.7)	0 (0.0)
Frequency of treatments (n = 380)	355 (93.4)	8 (2.1)	15 (4.0)	0 (0.0)	0 (0.0)	1 (0.3)	1 (0.3)
Duration of treatment (n = 366)	347 (94.8)	3 (0.8)	11 (3.0)	3 (0.8)	0 (0.0)	0 (0.0)	2 (0.6)
Public sector
Wait time (n = 324)	101 (31.2)	97 (29.9)	111 (34.3)	5 (1.5)	4 (1.2)	2 (0.6)	4 (1.2)
Frequency of treatments (n = 342)	314 (91.8)	15 (4.4)	11 (3.2)	1 (0.3)	0 (0.0)	1 (0.3)	0 (0.0)
Duration of treatment (n = 342)	309 (90.4)	17 (5.0)	12 (3.5)	1 (0.3)	0 (0.0)	2 (0.6)	1 (0.3)

Note: Percentages may not total 100 because of rounding.

^*PT professional with clinical responsibilities (e.g., physical rehabilitation therapist, physiotherapist) who is currently treating a patient for whom a decision is being made.

^†Manager or coordinator (PT or non-PT) making a decision.

^‡PT professional colleague (another physiotherapist or physical rehabilitation therapist).

^§Workers’ compensation board or other insurer.

^¶Any staff member (e.g., PT professional, manager, coordinator, secretary) working in the PT department. A decision is made in a group, with > 1 person involved, and the size of the group can vary.

^**Any staff member not directly related to the PT department.

PT = physiotherapy.

Overall, the respondents identified PT treating clinicians (39.0%) and managers or coordinators (31.5%) as those most likely to be in charge of wait time decisions. Another 18.4% identified a PT colleague (another physiotherapist or physical rehabilitation therapist), while 8.2% named administrative assistants. Third-party payers (1.2%) rarely played a primary role in these decisions. In the private sector, clinicians (46.1%) most commonly determined wait times for patients, followed by managers–oordinators (32.9%). According to 14.6% of the private-sector respondents, administrative assistants also had a say in determining wait times. PT colleagues (3.9%), staff members from the PT department (1.7%), and third-party payers (0.8%) were rarely responsible for making these decisions.

In the public sector, decisions about wait times were primarily made by PT colleagues (34.3%), PT treating clinicians (31.2%), and managers–coordinators (29.9%), whereas administrative assistants (1.2%) and third-party payers (1.5%) rarely had a role. The findings indicated that those in charge of making wait time decisions differed between private and public settings (χ² = 91.8434; p < 0.001).

The frequency of treatments was largely determined by PT treating clinicians themselves (92.7% overall; 93.4% in the private sector, 91.8% in the public sector). Decisions about the duration of treatment were also most commonly made by individual PT treating clinicians (92.7% overall; 94.8% in the private sector, 90.4% in the public sector).

What factors are associated with making service provision decisions?

Figure 1 presents the different factors related to making decisions about wait time and their level of importance (presenting, for clarity, only the categories very important and important), according to respondents working in the private sector and respondents working in the public sector. Figure 2 presents the different factors related to treatment frequency, and Figure 3 illustrates the factors related to treatment duration.

Figure 1 .

Importance of factors associated with making decisions about wait time, by respondents working in the private sector and respondents working in the public sector.

Figure 2 .

Importance of factors associated with making decisions about treatment frequency, according to respondents working in either the private or the public sector.

Figure 3 .

Importance of factors associated with making decisions about treatment duration, according to respondents working in either the private or the public sector.

Wait time

Overall, the top four factors (in order) were professional judgment, practice guidelines, patients’ demands, and norms established by third-party payers. In the private sector, the top four factors were professional judgment, patients’ demands, practice guidelines, and patients’ ability to pay. In the public sector, professional judgment, practice guidelines, norms established by third-party payers, and patients’ demands were the top four factors in the public sector.

Treatment frequency

The respondents reported that professional judgment, practice guidelines, treatment approach, patients’ demands, and norms and policies established by third-party payers were important factors in determining the frequency of treatments. Half the respondents answered that patients’ ability to pay was either important or very important; however, 41% thought that this was not applicable or relevant to their situation. In both the private and the public sectors, professional judgment was said to be the most important factor. In the private sector, the second most important factor was patients’ demands, followed by patients’ ability to pay. In the public sector, practice guidelines was the second most important factor, followed by treatment approach. Patients’ ability to pay was considered not important at all in the public sector (83.0% selected “not applicable”).

Treatment duration

In each sector (private and public separately), attainment of patients’ goals and progression/absence of progression (attaining a plateau) in a patient’s condition were considered the most important factors related to treatment duration. In each sector, decisions made by a physician were important or very important for nearly half the respondents. In the public sector, the majority of the respondents answered that a decrease in patients’ motivation was an important factor, as was patients’ return to full-time work. In the private sector, the third most important factor was patients’ ability to pay (86.2% of the respondents said that it was an important or very important factor), followed by a decrease in patients’ motivation. Also, the end of insurance coverage in accordance with norms or policies established by third-party payers was considered an important or very important factor for 81.6% of the private-sector respondents compared with 27.5% of those in the public sector. In the public sector, patients’ ability to pay was not considered an important factor influencing duration of treatment: of the respondents, 86.4% agreed that it was not relevant or not applicable to their context. Most respondents reported that peer opinion or behaviour was of little importance.

Discussion

Service provision decisions can be made by a treating professional, but also by others, such as an administrator or colleague. Our findings show that, in both the private and the public sectors and in all Canadian provinces, clinicians were most often responsible for making decisions about treatment frequency and treatment duration. However, the individual responsible for wait-time decisions was more variable depending on the sector of care.

Our results are consistent with those of recent studies of the practices in Quebec PT outpatient departments, where physiotherapists with managerial responsibilities and administrative staff decide how to prioritize access for people on the waiting list, whereas physiotherapists decide on frequency and duration of treatment for their patients.^1,49

In the public sector, organizational practices that structure a wait list (e.g., prioritizing post-surgery patients over patients with chronic pain waiting longer than a year) can lead to inconsistencies when non-PT health professionals are responsible for making decisions about service provision. Indeed, Harding and colleagues examined patients prioritization and triage decisions in an allied health services context and found that when decisions about wait times were made by clinicians from different disciplines (e.g., physiotherapists and occupational therapists), interrater reliability was low, with greater variability in how similar patients were prioritized.⁵⁰

According to the World Confederation for Physical Therapy, the responsibility for decisions about service provision belongs entirely to the professional involved in a patient’s case.⁵¹ Professionals must be able to justify their decisions and face the consequences if these choices are judged to be inappropriate.⁵² Looking at our data, it is clear that clinicians sometimes have limited control over the decisions about wait time for their own patients and, therefore, might not be fully accountable for these decisions or the resulting outcomes.

Our findings show that clinical judgment, clinical guidelines, and patients’ demands are predominant factors influencing decisions about wait time and treatment frequency in private and public settings. Researchers in Dublin, Ireland, looked at the differences between PT management for patients with low back pain (non-specific) in public and private health care settings.²⁵ They found that in the public sector, there was a significantly higher use of advice and stabilization exercises (treatment approaches recommended by clinical guidelines for low back pain) than in the private sector. Barriers to implementing guidelines are multiple, and challenges related to the feasibility of implementing new treatment approaches with local available resources can be considerable.⁵³

Understandably, given the context of private PT clinics, patients’ ability to pay was found to be an important factor influencing frequency of treatments and duration of treatment. Overall, we found that treatment duration was also related to patients’ goals, clinical progression, patients’ motivation, and patients’ return to work. This is consistent with the position statement of the Canadian Physiotherapy Association that evidence-informed practice in PT should guide decisions about patient care and should integrate “the best available evidence and clinical expertise with the patient’s needs and values to ensure delivery of best practice.”^54(p.1) According to our respondents, financial factors played only a small role in provision decisions in the public sector.

Although third-party payers are not directly responsible for making decisions, their policies do shape the decisions about service provision made by clinicians and managers. Therefore, it is important that these policies align with the values of the profession – that is, that they have a certain flexibility so that clinicians can use their clinical judgment and follow evidence-based clinical guidelines.

This study had several limitations. First, the clinical vignette methodology we used might not have reflected the embodied and relational aspects of a face-to-face clinical encounter,⁵⁵ thereby potentially affecting respondents’ answers about service provision. Second, although the method we used to recruit participants was the same throughout Canada, some provinces and regions were underrepresented (Ontario and the Prairie provinces) and some were overrepresented (Quebec and the Atlantic provinces).⁵⁶ Third, the response rate was somewhat lower (9.1%) than what is normally obtained for similar online surveys (10%–25%),⁵⁷ which could limit the generalisability of the results. In addition, there is a potential selection bias related to recruiting only professionals who accept communications about research through their professional associations or regulatory bodies. Finally, although multiple stakeholders (e.g., PT department, hospital organization, government or health minister) are involved in making decisions about service delivery, this study surveyed only physiotherapist managers and clinicians. Provincial differences in health care systems were also not taken into consideration.

Conclusion

In Canada, decisions about service provision are made by different actors, and a variety of factors guide PT professionals in making their decisions. As a result, it is difficult to ensure that all patients receive equivalent (equitable) access to services and quality of care on the basis of evidence-based decision making. Given this reality, it is essential to assess the organizational model of Canadian PT practice to ensure that decisions about allocating resources are founded on a reliable evidence base and that the choices made to provide access and quality of care are justifiable (i.e., ethically and evidence based). Decisions should also be made through discussion and consensus among the key actors (health professionals, patients, third-party payers, associations, etc.) to ensure greater consistency.

Key Messages

What is already known on this topic

Clinical factors (e.g., patient functional level) and non-clinical factors (e.g., institutional policies and payment systems) influence decisions about wait times, treatment frequency, and treatment duration in physiotherapy (PT) practice.

What this study adds

Decisions about wait time can be made by treating PT clinicians, by managers, and even by colleagues (PT and non-PT professionals). PT clinicians are most often responsible for making decisions about treatment frequency and treatment duration. For wait time and treatment frequency and duration, the factors guiding decision making are variable and differ according to the sector of care. Clinical judgment, clinical guidelines, and patients’ demands are the main factors related to wait time and frequency decisions, whereas treatment duration is related to factors such as patients’ goals, clinical progression, patients’ motivation, and patients’ return to work. In the private sector, patients’ ability to pay plays an important role in service delivery (frequency and duration of treatment).