Chapitre 3 Résultats 50
3.1. Article 50
3.1.1. Résumé 52
Objectifs : Des contraintes d’accessibilité aux services de physiothérapie en clinique externe ont été rapportées dans les établissements publics de plusieurs pays à travers le monde. Différentes stratégies ont été proposées afin de gérer les listes d’attente, mais leur impact sur le temps d’attente est peu étudié à ce jour, notamment dans le contexte des services de physiothérapie au Québec. Les objectifs de cette étude étaient de documenter l’accessibilité aux services de physiothérapie en clinique externe pour les personnes souffrant de troubles musculosquelettiques dans les centres hospitaliers au Québec et d’explorer l’association entre les caractéristiques organisationnelles et le temps d’attente. Méthodes : Une enquête a été réalisée dans les centres hospitaliers publics du Québec offrant des services de physiothérapie en clinique externe pour des adultes souffrant de troubles musculosquelettiques.
Résultats : Des données ont été obtenues auprès de 97 (99%) centres hospitaliers québécois. Le temps d’attente médian était de plus de six mois dans 41% des centres hospitaliers. Les stratégies de gestion de listes d’attente les plus utilisées étaient des politiques en cas d’annulation ou d’absence (99,0%) et la priorisation des demandes (95,9%). Selon les résultats des analyses multivariées, la procédure de priorisation impliquant une rencontre d’évaluation et une intervention initiale était associée à un temps d’attente plus court (p=0.008).
Conclusion : Les résultats de cette étude démontrent qu’une grande quantité de personnes sont inscrites sur les listes d’attente des services de physiothérapie et que le temps d’attente peut être très élevé. D’après nos résultats, l’implantation d’une méthode de priorisation incluant une évaluation et une intervention pourrait permettre d’améliorer l’accès en temps opportun aux services de physiothérapie.
3.1.2.
Abstract
Purpose: Problems with access to outpatient physiotherapy services have been reported in publicly funded healthcare systems worldwide. A few studies have reported strategies aimed at managing extensive waiting lists, but their association with waiting times is not fully understood. The purpose of this study was to document access to outpatient physiotherapy services in publicly funded hospitals and explore organizational characteristics associated with waiting times.
Methods: We surveyed outpatient physiotherapy clinics offering services for adults with musculoskeletal disorders in publicly funded hospitals in the province of Quebec.
Results: A total of 97 sites responded (99%) to the survey. The median waiting time was more than six months in 41% of outpatient physiotherapy services. The waiting list management strategies most frequently used were attendance and cancellation policies (99.0%) and referral prioritization (95.9%). Based on the results of multivariate analyses, the use of a prioritization process with an initial evaluation and intervention was associated with shorter waiting times (p = 0.008).
Conclusions: Our findings provide evidence that a large number of persons are on waiting lists for publicly funded physiotherapy services in Quebec and that waiting times can be very long. Based on our results, the implementation of a prioritization process including an initial evaluation and an intervention could help improve timely access to outpatient physiotherapy services.
3.1.3.
Background
Musculoskeletal disorders are highly prevalent [30-33] and are a major source of pain and physical disability [39]. Every year, more than 20% of the population consults a physician for this type of condition in Canada, in the UK and in other countries around the world [39, 198, 199]. The prevalence of activity limitations related to musculoskeletal disorders is also high and is expected to increase in years to come because of population ageing and the increasing prevalence of chronic conditions [33, 40, 41].
Physiotherapists are frequently involved in the treatment and management of musculoskeletal disorders [4]. They have a high degree of knowledge in the management of musculoskeletal disorders and provide safe and cost-effective care [45]. Outpatient physiotherapy services are provided in different publicly funded healthcare settings, including hospitals, and the majority of their clientele seek help for musculoskeletal disorders [10-13]. The benefits of physiotherapy have been demonstrated for multiple musculoskeletal conditions such as low back pain [1], knee pain [2] and neck pain [200]. Furthermore, early active physiotherapy intervention is associated with reduced pain and reduced psychosocial symptoms and could decrease the risk of developing chronic pain [56, 92, 201]. Based on previous work, patients with low back pain who have prompt access to physiotherapy services have significantly less pain and need fewer medical consultations and interventions (i.e. injections, surgery, medication, advanced imaging diagnostic tests) than those who experience delayed physiotherapy [56-58].
However, problems with access to physical rehabilitation services, including outpatient physiotherapy, have been reported in Canada and in other countries [7, 10, 15, 21, 103, 106, 202]. Delaurier et al. [15] conducted a study examining waiting time for outpatient physiotherapy services for persons with arthritis in the province of Quebec (Canada) and found that 13% of the healthcare facilities offered an appointment within 6 to 12 months, 24 % within more than 12 months, while 22% systematically refused the referral. In
Ontario, the most populous province of Canada, Passalent et al. [14] reported that the demand for publicly funded outpatient physiotherapy services exceeds the resources available. The limited access to outpatient physiotherapy services translates into extensive waiting times, especially for persons with chronic conditions [22, 64], but also results in the exclusion of certain persons from receiving services. In Ontario, the restriction of the eligibility criteria to access publicly funded outpatient physiotherapy services in designated clinics had a significant impact on patients’ self-reported health status. Those who remained eligible for services were 10 times more likely to report a very good or excellent health status than patients who were no longer entitled to receive services [91].
Because of the limited access to services in the publicly funded health sector, many persons with pain and disability turn to the private sector. However, paying for physiotherapy services may not be possible for persons with limited insurance coverage or low income. Yet, these persons are also at higher risk of suffering pain and disability [19, 20 p.76-8]. This situation leads to inequity regarding access to services and raises serious ethical issues [203, 204].
Different waiting list management strategies have been put forward to tackle the problem of delayed access to healthcare services. Prioritization of referrals is a common practice, but questions remain about its effectiveness to reduce waiting time [23, 24, 28, 111]. There is moderate evidence that providing an initial treatment “at the point of triage” can reduce waiting time in different healthcare settings [23]. Other examples of waiting list management strategies include regular audits of the waiting list, targets for maximum waiting time, caseload quotas for clinicians and group interventions [21, 22, 28, 29, 106]. Few studies have reported management strategies aimed at reducing extensive waiting lists for outpatient physiotherapy services, and the association between these strategies and waiting times is not fully understood.
Overall, prompt access to publicly funded outpatient physiotherapy services is a crucial issue for persons with musculoskeletal disorders. Although problems regarding access to publicly funded physiotherapy services have been reported in other provinces of Canada, little is known on the subject in the province of Quebec, Canada’s second most populous province. The main objective of this study was to document access to outpatient physiotherapy services for persons with musculoskeletal disorders in publicly funded hospitals. More specifically, we 1) described waiting times and organizational characteristics (including waiting list management strategies) and 2) explored organizational characteristics associated with waiting time.
3.1.4.
Methods
This study used a descriptive-correlational design. We conducted a cross-sectional survey of all publicly funded hospitals offering outpatient musculoskeletal physiotherapy services in Quebec. Approval for conducting the project was obtained from the Ethics Committee of the Institut de réadaptation en déficience physique de Québec.
3.1.4.1. Selection criteria and recruitment procedure
An initial list of potentially eligible hospitals was identified through the website of the Ministry of Health and Social Services of the province of Quebec [63]. Eligible hospitals had to: 1) be publicly funded and 2) offer outpatient physiotherapy services with the majority of their patients being adults (≥ 18 years old) with musculoskeletal disorders. Hospitals offering physiotherapy only through multidisciplinary rehabilitation services were excluded, since their waiting time could not be exclusively attributed to the physiotherapy waiting list. We contacted the targeted hospitals by telephone and asked to speak to the outpatient physiotherapy waiting list manager, who was the key respondent for the survey. During this first contact, we explained the project and verified the eligibility criteria. Eligible
and interested respondents were sent an email that gave them access to further information on the project.
3.1.4.2. Data collection
Survey data were collected via a self-administered Internet questionnaire followed by a subsequent telephone interview that served to gather data on more complex questions relating to the waiting list (e.g. median waiting times, time waited before receiving services) [186 p.133-4].
The survey questionnaire was composed of 32 questions covering the characteristics of the hospitals (e.g. number of clinicians, student placements offered), delivery of physiotherapy services (e.g. clientele accepted, direct access to services), waiting list management strategies (e.g. maximum waiting time targets, group interventions) and waiting times. We developed the questionnaire based on the framework conceptualized by Lamarche et al. [170] regarding organizational dimensions of healthcare services that include the vision, environment, organizational structure (e.g. management strategies and policies), available resources (e.g. human or financial resources), practices implemented in the organization and outcomes (e.g. timely access to services). This framework was used in previous studies to examine access and organizational characteristics of healthcare services [173, 174]. Furthermore, principles of survey methods [176, 180, 185, 205] and other studies on waiting times for rehabilitation services guided the survey design [13, 21, 106, 111, 183]. The questionnaire was analyzed for content validity by an expert in waiting lists management and two survey methods experts, before being pretested by three respondents outside of our study population. Various modifications to the questionnaire were applied at each of these steps such as reformulating questions, combining multiple-choice items in a single question, reordering questions and reducing the total number of questions. The final version of the survey questionnaire was integrated
to the Limesurvey™ (v2.05+) platform [179] and the link to access the questionnaire was provided to the respondents in the initial email.
3.1.4.3. Variables
Main variables pertained to organizational characteristics (including waiting list management strategies) and waiting times. Waiting time was defined as the number of days between the reception of the referral and the date of the telephone interview [106]. This variable represents a measure of the time waiting (i.e. the duration of wait for the patients on the list at a specific moment) [28]. This measurement method is easily accessible to waiting list managers and considers every patient on the waiting list, including those who would potentially never receive services [16]. Data were collected for minimum, median and maximum waiting time. Minimum waiting time was obtained by calculating the mean waiting time of the three high-priority patients who would be the next ones to receive services. The median waiting time was obtained as that of the patient exactly in the middle of the waiting list (if odd number of patients on list) or the mean of the waiting time of the two patients in the middle of the ordered-list (if even number on list). The median waiting time was collected instead of the mean, as it is less sensitive to extreme values [85, 182]. Moreover, when measuring waiting time, the mean is usually expected to be higher than the median [16]. Maximum waiting time was calculated as the mean of the waiting time of the three patients who had been waiting the longest time at the time the questionnaire was completed. Another measure of waiting that we used was the time waited, which represents the time waited by the majority of patients who ultimately received services during the last 12 months, as estimated by the respondents.
3.1.4.4. Data analyses
Data were extracted from Limesurvey™ into Excel™ and SPSS™. Descriptive statistics were used to analyze organizational characteristics and waiting times (objective 1). Main
were defined as values with a standardized score (z score) of more than 3.0 [190, 191]. Correlational analyses were performed to explore the association between the median waiting time (dependent variable) and the organizational characteristics, which included the characteristics of the hospitals (e.g. demographic area, number of physiotherapists and services offered) and the waiting list management strategies (e.g. targets for maximum waiting time, group interventions) (objective 2). Bivariate correlations were first carried out. Because the distribution of the dependent variable was non-normal, Spearman’s rank-correlations (ρ) were used with ordinal or continuous independent variables, while point-biserial correlations (rpb) were used with dichotomous independent variables [175, 191]. Variables associated with the median waiting time at a p-value < 0.10 were entered in a generalized linear model of gamma distribution (log link function), as recommended for positively skewed dependent variables [192, 193]. The finite sample corrected Aikake Information Criterion (AICC) was used to assess the goodness of fit of the model [192-194]. Pairwise comparisons of estimated marginal means of the median waiting time were also analyzed based on the sequential Bonferroni significance level. Glass’s delta was used to calculate effect size, as recommended by Ellis [195]. Statistical analyses were computed with SPSS Statistics™ v23.0 [196].
3.1.5.
Results
3.1.5.1. Sample of hospitals
Of the 145 hospitals included in our initial list, we excluded two paediatric hospitals and contacted 143 hospitals between June and November 2015. Based on our selection criteria, 101 hospitals were eligible. Five of these hospitals had a centralized waiting list (a group of three hospitals and another pair of hospitals), which means they shared the same waiting list. Therefore, only two of these five hospitals were surveyed (one per group), for a total of 98 eligible hospitals retained for the study. Proportion of participation was 99.0%, as 97 out of the 98 waiting list managers responded to the survey.
3.1.5.2. Characteristics regarding outpatient physiotherapy in Quebec's hospitals
The hospitals surveyed covered 17 out of Quebec’s 18 health regions; 30.9% were located in a rural area (population < 10,000 inhabitants), 44.3% in a semi-urban area (10,000- 100,000 inhabitants) and 24.7% in an urban area (> 100,000 inhabitants) [20]. Characteristics regarding outpatient physiotherapy in Quebec’s hospitals are found in table 1. There were an average of 2.82 physiotherapists (standard deviation [SD]=2.39) and 1.52 physical rehabilitation therapists (SD=1.52) who delivered outpatient physiotherapy services in the surveyed hospitals. These services were offered for a variety of conditions, the great majority of hospitals (99.0%) offering services for orthopedics conditions (post- surgery/post-fracture), and 71.1% for persons with chronic pain. Services were offered for patients who were covered under the Workers’ Compensation Board (56.7%) and the Automobile Insurance Society (22.7%). A minority of hospitals (4.1%) offered direct access to outpatient physiotherapy services (i.e. they did not require a medical referral by a doctor). Only two hospitals (2.1%) did not have a waiting list and were able to schedule patients immediately. Approximately two thirds of hospitals (68.0%) had a computerized waiting list.
Table 1. Characteristics regarding outpatient physiotherapy in Quebec's hospitals (n=97)
Demographic areaa n hospitals (%) Mean (SDb) Missing n (%)
Rural 30 (30.9)
Semi-urban 43 (44.3)
Urban 24 (24.7)
Staffing
Physiotherapist (FTEc) 2.82 (2.39)
Physical rehabilitation therapistsd (FTE) 1.52 (1.52) 5 (5.2)
Physiotherapy aides 52 (53.6) 12 (12.4)
Vacant clinician position 7 (7.2) Student placement offered (college or university
Table 1. Characteristics regarding outpatient physiotherapy in Quebec's hospitals (n=97)
(Continued)
Services offered
Services offered in following domains:
Cardiorespiratory 29 (29.9) 2 (2.1)
Chronic pain 69 (71.1) 1 (1.0)
Neurological 79 (81.4)
Orthopaedics (post-surgical and post-fracture) 96 (99.0)
Orthopaedics (other) and rheumatology 90 (92.8) 1 (1.0)
Loss of independence 69 (71.1) 2 (2.1)
Burn and wound care 70 (72.2) 1 (1.0)
Amputee rehabilitation 30 (30.9) 6 (6.2)
Perineal rehabilitation 12 (12.4) 7 (7.2) Vestibular rehabilitation 56 (57.7) 3 (3.1) Oncology or palliative care 42 (43.3) 5 (5.2)
Clientele accepted:
Children 0-4 years 62 (63.9) 4 (4.1)
Children 5-17 years 79 (81.4) 1 (1.0)
Adults 18-64 years 97 (100)
Seniors ≥65 years 92 (94.8) 3 (3.1)
Insurance coverage accepted:
Workers' Compensation Board 55 (56.7) 1 (1.0) Automobile Insurance Society 22 (22.7) 1 (1.0)
Source of referral
Physicians/other clinicians within your facility 95 (97.9) Physicians/other clinicians outside of your facility 83 (85.6)
Patients/families (direct access referral) 4 (4.1) 1 (1.0)
Waiting list
Computerized waiting list 66 (68) 2 (2.1)
Lowest-priority patients can access services: 3 (3.1) After a target waiting time 11 (11.3)
If there are no higher-priority patients on the list 61 (62.9)
Other 22 (22.7)
a Rural had a population < 10,000 inhabitants; Semi-urban between 10,000-100,000; Urban > 100,000. [20] b SD = standard deviation
c FTE = full-time equivalent
While more than half (56.7%) of respondents reported an increase in physiotherapy referrals over the previous three years, 36.1% reported a decrease in physiotherapy staff. Over one third of respondents (38.1%) noticed a reduction of overall access to these services in the same time period. Other perceived and anticipated changes in access to services are presented in table 2.
Table 2. Perceived and anticipated changes in access to services
Changes noticed over the previous three years Increase n (%) No change n (%) Decrease n (%) Missing n (%) Number of clinicians 18 (18.6) 42 (43.3) 35 (36.1) 2 (2.1) Types of clientele receiving services 37 (38.1) 43 (44.3) 15 (15.5) 2 (2.1) Number of referrals received 55 (56.7) 21 (21.6) 9 (9.3) 12 (12.4) Number of patients who received services 43 (44.3) 18 (18.6) 23 (23.7) 13 (13.4) Waiting time 50 (51.5) 16 (16.5) 24 (24.7) 7 (7.2) Access in general 30 (30.9) 22 (22.7) 37 (38.1) 8 (8.2)
Changes anticipated in the following year
Number of clinicians 5 (5.2) 65 (67.0) 10 (10.3) 17 (17.5) Types of clientele receiving services 11 (11.3) 61 (62.9) 6 (6.2) 19 (19.6) Waiting time 23 (23.7) 45 (46.4) 13 (13.4) 16 (16.5) Access in general 12 (12.4) 50 (51.5) 21 (21.6) 14 (14.4)
3.1.5.3. Characteristics of the waiting list
There was a mean of 192.1 patients (SD = 176.6) on the waiting list per hospital, for a total of 18,245 patients on waiting lists for outpatient physiotherapy services at the time of the survey. Minimum, median and maximum waiting times are presented in table 3. The maximum waiting time (median = 15.6 months; range 0-155.6) was more than 12 months in 57.3% of hospitals. Median waiting time was available for 83 of the 97 participating hospitals; missing values were evenly spread between rural, urban and semi-urban areas. The median waiting time ranged from 0 to 77.4 months and the mean was 7.6 months (SD = 11.2 months; median = 4.6 months). Moreover, 41.0% of the 83 hospitals had a median waiting time of more than six months (figure 1). In contrast, the most frequent waiting time
for the patients that received services was less than one month in 47.9% of the hospitals (figure 2).
Table 3. Waiting lists for outpatient physiotherapy services (n=97)a
Waiting list Mean (SDb) Median Range Missing n (%)
Number of patients waiting 192.1 (176.6) 149 0-941 2 (2.1) Minimum waiting time (months)c 1.3 (2.0) 0.7 0-12.4 6 (6.2)
Median waiting time (months)d 7.6 (11.2) 4.6 0-77.4 14 (14.4)
Maximum waiting time (months)e 22.3 (25.8) 15.6 0-155.6 1 (1.0)
a For the two hospitals that had no waiting list (could offer services for new referrals immediately), the value for
waiting time and number of patients waiting was 0.
b SD = standard deviation
c Mean waiting time of the three patients who would be next to receive services (highest priority on the list). d Waiting time from the one or two patient(s) in the middle of the waiting list (depending on whether the number of
patients on the list was odd or even).
e Mean waiting time of the three patients who had been waiting the longest time.
Figure 1. Median waiting time for patients waiting for outpatient physiotherapy services
(n=83)
Median waiting time was obtained as that of the one or two patient(s) in the middle of the waiting list (depending on whether the number of patients on the list was odd or even).
Figure 2. Most frequent time waited for patients who received services (n=94)
This variable represents the most frequent delay waited by the patients who received services during the previous 12 months, as estimated by the respondents.
3.1.5.4. Waiting list management strategies
Strategies used to manage waiting lists for the physiotherapy services are presented in table 4. The strategies most frequently used were administrative strategies: attendance and cancellation policies (99.0%), referral prioritization (95.9%) and redirecting patients towards another setting (86.6%). Approximately one third (35.1%) of hospitals used maximum waiting time targets. Other strategies relating to clinical practice, such as offering group interventions (39.2%) or using formal criteria for discharge (29.9%), were less frequently used.
To prioritize patients on their waiting list, 74.2% of the hospitals used a formal prioritization tool. Many respondents (61.9%) reported using an initial evaluation for prioritization that included an intervention, but only 25.8% systematically used it for every patient.
Table 4. Waiting list management strategies for outpatient physiotherapy services (n=97)
Administrative strategies n (%) Missing n (%)
Attendance policies 96 (99.0) 1 (1.0) Redirection of clients towards another setting 84 (86.6) 1 (1.0) Audit of the waiting list (i.e. verify if services are still required) 72 (74.2)
Systematic follow-up of the waiting list 66 (68.0) 1 (1.0) Maximum waiting time targets 34 (35.1) 1 (1.0)
Prioritization processes used
Formal process 93 (95.9) 1 (1.0)
Formal tool (e.g. a form, a list of criteria) 72 (74.2) 3 (3.1) Initial evaluation without an intervention 4 (4.1)
Always 4 (4.1)
Often 10 (10.3)
Sometimes 20 (20.6)
Never 59 (60.8)
Initial evaluation including an intervention 4 (4.1)
Always 25 (25.8)
Often 17 (17.5)
Sometimes 18 (18.6)
Never 33 (34.0)
Strategies related to clinical practice
Education about self-management strategies during
rehabilitation 68 (70.1) 5 (5.2)
Group interventions 38 (39.2)
Maximum number of treatment sessions per patient 37 (38.1)
Quotas for clinicians for taking up new patients 37 (38.1) 1 (1.0) Formal criteria for discharge 29 (29.9) 2 (2.1) Information/education sessions for patients on the waiting list 28 (28.9)
3.1.5.5. Organizational characteristics associated with waiting time
Two outliers (z score > 3.0) were identified for the dependent variable (median waiting time) and their values of 54.8 and 77.4 months were given the value equivalent to a z score of 3.0 (41.3 months) to reduce their impact on correlational analysis [190, 191]. The
same variables were significant in bivariate and multivariate analyses by applying this correction or not. Hence, we present the corrected data.