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With the increased prevalence of non-communicable diseases and chronic disorders, including musculoskeletal disorders, access to care is limited in many health care systems and new multidisciplinary collaborative models of care have now been implemented in several countries in an effort to improve access to care. The paper aimed to describe the characteristics and present relevant evidence supporting different models of care that integrate physiotherapists as primary or secondary care practitioners for the management of patients with non-communicable diseases or chronic disorders. On the basis of a literature review up to August 2020 in 4 major bibliographical databases, we searched for studies of any design, including systematic reviews with or without meta-analysis and position statements, that were related to direct access physiotherapy and advanced practice physiotherapy models of care. The impact of direct access physiotherapy and advanced practice physiotherapy models of care is presented in terms of clinical outcomes, patient satisfaction, health care resource use and costs. These models appear to provide equal or better outcomes in terms of access to care, quality of care, and patients’ satisfaction. The strength of the evidence is variable, and outcomes vary depending on clinical settings, roles of physiotherapists, and characteristics of patients. This review highlights that these enhanced roles for physiotherapists, such as diagnosing, ordering diagnostic tests, or referring patients to physicians, in both primary and secondary care settings, are beneficial and may help optimize patients’ journey by providing earlier access to effective and efficient services compared with physician-led usual care models.

Abstract Background The interpretability of the six-minute walk test (6MWT) in individuals with knee osteoarthritis (OA) is unclear. We aimed to determine the minimal clinically important difference (MCID) for improvement in 6MWT in persons with knee OA at 12 months after total knee arthroplasty (TKA), and if it differed by baseline walking ability. Methods Participants with knee OA were assessed 1 month pre- and 12 months post-TKA, including completion of 6MWT. At 12 months, participant-perceived change in walking ability was assessed on an 8-point Likert scale ranging from “extremely worse” to “extremely better”. Using logistic regression, ROC curves examined the ability of change in 6MWT distance to discriminate those who perceived walking was improved. MCID was selected overall and then by quartile of baseline 6MWT distance using the Youden method. Results Two hundred seventy-eight participants were included: mean age 67 years (SD 8.5), 65.5% female, mean pre-TKA 6MWT distance 323.1 (SD 104.7) m, and mean 12-mo 6MWT distance 396.0 (SD 111.9) m. The overall MCID was 74.3 m (AUC 0.65). Acceptable model discrimination (AUC > 0.70) was achieved for individuals in the lowest quartiles of baseline 6MWT distance: Quartile 1: MCID 88.63 m (AUC 0.73); Quartile 2: MCID 84.47 m (AUC 0.72). Conclusions In persons with knee OA 12 months post-TKA, 6MWT MCID is dependent on baseline walking ability. Poor model discrimination for those in the highest (best) quartiles of baseline walking ability raise questions about 6MWT use across the full spectrum of walking ability. Further research is needed to better understand use of 6MWT as a performance-based measure of physical function for persons with knee OA.

Objective To assess the relationship between comorbidities and amount of improvement in pain and physical function in recipients of total knee arthroplasty (TKA) for knee osteoarthritis (OA).Design Prospective cohort study.Setting Two provincial central intake hip and knee centres in Alberta, Canada.Participants 1051 participants (278 in 6-minute walk test (6MWT) subset), ≥30 years of age with primary knee OA referred for consultation regarding elective primary TKA; assessed 1 month prior and 12 months after TKA.Primary and secondary outcome measures Pre-post TKA change in knee OA pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), physical function (Knee injury and Osteoarthritis Outcome Score (KOOS) Physical Function Short-Form) and 6MWT walking distance; and the reporting of an acceptable symptom state (Patient Acceptable Symptom State (PASS)) at 12 months after TKA.Results Mean participant age was 67 years (SD 8.8), 59% were female and 85% reported at least one comorbidity. Individuals with a higher number of comorbidities had worse pre-TKA and post-TKA scores for pain, physical function and 6MWT distance. At 12-month follow-up, mean changes in pain, function and 6MWT distance, and proportion reporting a PASS, were similar for those with and without comorbidities. In multivariable regression analysis, adjusted for potential confounders and clustering by surgeon, no specific comorbidities nor total number of comorbidities were associated with less improvement in pain, physical function or 6MWT distance at 12 months after TKA. Patients with diabetes (OR 0.64, 95% CI 0.44 to 0.94) and a higher number of lower extremity troublesome joints (OR 0.85, 95% CI 0.76 to 0.96) had lower odds of reporting a PASS.Conclusion For individuals with knee OA, comorbid conditions do not limit improvement in pain, physical function or walking ability after TKA, and most conditions do not impact achieving an acceptable symptom state.

Abstract Background Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated. Methods We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes. Results We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies. Conclusion The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.