Table 3 Implementation outcomes of musculoskeletal programs of care in active military using the implementation research outcomes taxonomy by Proctor et al. [23]
Author(s), year | ||
|---|---|---|
Implementation outcomes | ||
Acceptability | Physicians tested the preprinted documentation form and concluded that the form was easy to use and shortened the time to process patients. Subsequently, primary care physicians readily accepted the use of the new form | Cretin et al., 2001 [32] |
Concept and quality of care acceptable to patient, physician, and PT Patients preferred direct referral to PT | James et al., 1975 [37] | |
The musculoskeletal team has successfully created an environment of systematic collaboration | Kelly et al., 1997 [39] | |
No reported adverse events with the “Physical Therapy First” approach | McGee et al., 2017 [43] | |
Appropriateness | Allows early and accurate diagnosis Allows early and aggressive reconditioning Coordinated care between providers Bridges the gap between primary care and orthopedic surgeons | Brawley et al., 2012 [30] |
Recruits referred earlier in the course of their injuries | Kelly et al., 1997 [39] | |
Appropriate referrals: > 55% actual surgical cases referred to orthopedic surgeons (vs. 10–15% prior to implementing the “Physical Therapy First” approach) | McGee et al., 2017 [43] | |
Costs | LIMDU boards that resulted in PEBs decreased following implementation of the SMART clinic model Significant increases in the number of patient encounters at the sports medicine clinics Decrease in referrals to orthopedic surgeon | Brawley et al., 2012 [30] |
Decreased number of PT sessions required for rehabilitation | Kelly et al., 1997 [39] | |
Savings over 6 months $162.6K USD attributed to proper utilization of the “Physical Therapy First” approach | McGee et al., 2017 [43] | |
Feasibility | Given appropriate staffing levels and adequate space, all PTs and other providers believed the program should be adopted | James et al., 1975 [37] |
Fidelity | Not applicable | |
Penetration | Expanded PT LBP MSK evaluation role gained wide acceptance within the Army Medical Department PTs now provide primary evaluations for the whole spectrum of MSK problems | James et al., 1981 [38] |
Sustainability | “Backs to Work” program with a modified schedule continues at Naval Medical Center, Portsmouth | Campello et al., 2012 [31] |
Continued analysis of LBP CPG implementation | Cretin et al., 2001 [32] | |
MSK screening protocol continued as planned in 1 unit 1 year later | Larsson et al., 2012 [44] | |
Service outcomes | ||
Efficiency | Increased number of patient encounters; decreased referrals to orthopedic surgery clinic; decreased percentage of patients recommended for physical evaluation boards from limited duty periods | Brawley et al., 2012 [30] |
Utilization patterns during 6-week follow-up after CPG implementation: decreased referrals to PT/DC; no effect on specialty referrals | Cretin et al., 2001 [32] | |
CPG adherence was associated with lower health costs | Feuerstein et al., 2006 [33] | |
Total outpatient visits, number of back patient visits, time expended by PT in attending LBP patients, identification of disease and patient categories for evaluation, orthopedist appraisal | James et al., 1975 [37] | |
Less than 4% of active duty patients with MSK complaints first evaluated by the PT subsequently required orthopedic consultations | James et al., 1981 [38] | |
Economical way to treat significant numbers of injured recruits (reduced number of PT sessions required to return an injured recruit to training, decreased total lost time for injuries requiring PT). Saved the Navy millions of dollars in recovered lost training time and retained, return to full training; number of PT sessions needed; recruit attrition; lost duty days of training. | Kelly et al., 1997 [39] | |
Safety | ||
Effectiveness | Duty status | Campello et al., 2012 [31] |
Return to duty | Green et al., 2010 [36] | |
Resumed normal work activities, released from care | Lillie et al., 2010 [40] | |
Disability (proportion of active-duty service members seeking treatment for a work-disabling spine condition that results in the assignment of a first-career limited-duty status decreased), attrition (proportion of individuals assigned a first-career limited-duty status for a work-disabling spine condition who were referred to a Physical Evaluation Board (no observed effect)) | Ziemke et al., 2015 [42] | |
Equity | ||
Patient-centeredness | ||
Timeliness | Sports Medicine and Reconditioning Team SMART clinic improved MSK care access | Brawley et al., 2012 [30] |
Form shortened the time to process patients Timelines of toolkit production improved over time | Cretin et al., 2001 [32] | |
Decreased wait times for LBP patients | James et al., 1975 [37] | |
Duration of evaluation twice as long as non-evaluation PT visits Substantial physician hours saved | James et al., 1981 [38] | |
Client/patient outcomes | ||
Symptomology | Pain, psychological distress at 12 weeks, function, fitness | Campello et al., 2012 [31] |
CPG adherence was associated with improved perceived general health (HCSDB) | Feuerstein et al., 2006 [33] | |
Back-related pain (NRS), global improvement | Goertz et al., 2013 [34] | |
Pain (VAS) | Green et al., 2006 [35] | |
Pain-free (NRS) at 8 weeks | Green et al., 2010 [36] | |
Subjective complaints resolved | Lillie et al., 2010 [40] | |
Function | Participants reported lower disability and pain. All (in both arms) returned to duty at 12 weeks | Campello et al., 2012 [31] |
CPG adherence was associated with functional outcome: released with/without duty limitations, lower levels of disability | Feuerstein et al., 2006 [33] | |
Physical functioning (RMDQ) | Goertz et al., 2013 [34] | |
Disability (RMDQ) | Green et al., 2006 [35] | |
No disability (NDI) at 8 weeks | Green et al., 2010 [36] | |
Reduced premature discharge from training | Larsson et al., 2012 [44] | |
Satisfaction | Satisfaction: 94.2% satisfied with chiropractic care; none dissatisfied Factors associated with lower satisfaction with chiropractic care: older age, presenting complaint of knee pain Referring Physician Feedback Survey: 80.0% satisfied with chiropractic services | Boudreau et al., 2006 [29] |
CPG adherence was associated with higher levels of patient satisfaction | Feuerstein et al., 2006 [33] | |
Higher patient satisfaction in CMT + SMC (mean 8.9/10 vs. 5.4/10 in SMC alone) | Goertz et al., 2013 [34] | |
Job satisfaction, PTs’ self-appraisal of competence, difficulties, professional adequacy; patient satisfaction | James et al.,1975 [37] | |
PTs preferred: expanded role; MSK patients interspersed within overall practice | James et al., 1981 [38] | |
Patient satisfaction was very high (n = 179), median score 5/5 (completely agree or completely satisfied) | Rhon et al., 2017 [41] | |