Ilse Swinkels

Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands: cross sectional analyses of data from three clinical databases.

BackgroundMany assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands.MethodsCross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands.ResultsAge, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands.ConclusionThe current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.

Patients with shoulder syndromes in general and physiotherapy practice: an observational study

BackgroundShoulder complaints are commonly seen in general practice and physiotherapy practice. The only complaints for which general practitioners (GPs) refer more patients to the physiotherapist are back and neck pain. However, a substantial group have persistent symptoms. The first goal of this study is to document current health care use and the treatment process for patients with shoulder syndromes in both general practice and physiotherapy practice. The second goal is to detect whether there are differences between patients with shoulder syndromes who are treated by their GP, those who are treated by both GP and physiotherapist and those who access physiotherapy directly.MethodsObservational study using data from the Netherlands Information Network of General Practice and the National Information Service for Allied Health Care. These registration networks collect healthcare-related information on patient contacts including diagnoses, prescriptions, referrals, treatment and evaluation on an ongoing basis.ResultsMany patients develop symptoms gradually and 35% of patients with shoulder syndromes waited more than three months before visiting a physiotherapist. In 64% of all patients, treatment goals are fully reached at the end of physiotherapy treatment. In general practice, around one third of the patients return after the referral for physiotherapy. Patients with shoulder syndromes who are referred for physiotherapy have more consultations with their GP and are prescribed less medication than patients without a referral. Often, this referral is made at the first consultation. In physiotherapy practice, referred patients differ from self-referrals. Self-referrals are younger, they more often have recurrent complaints and their complaints are more often related to sports and leisure activities.ConclusionsThere is a fairly large group of patients with persistent symptoms. Early referral by a GP is not advised under current guidelines. However, in many patients, symptoms develop gradually and a wait-and-see policy means more valuable time may pass before physiotherapy intervention takes place. Meanwhile a long duration of complaints is a predictor for poor outcome. Therefore, future research into early referral is required. As physiotherapists, we should develop a way of educating patients to avoid lengthy waiting periods before seeking help. To prevent high costs, physiotherapists could consider a classification of pain and limitations and wait-and-see policy as used by GPs. With early detection, a once-off consultation might be sufficient.

An Overview of 5 Years of Patient Self-Referral for Physical Therapy in the Netherlands

Background Self-referral for physical therapy was introduced in 2006 in the Netherlands. Internationally, debate on self-referral is still ongoing. Objective The aim of this study was to evaluate the effects of self-referral for physical therapy in the Netherlands, focusing on volume of general practice and physical therapy care (incidence rates and utilization of services). Design The study was based on monitoring data from existing data sources. Methods Longitudinal electronic medical record data from general practitioners (GPs) and physical therapists participating in the NIVEL Primary Care Database were used, as well as public data from Statistics Netherlands. Descriptive statistics and Poisson multilevel regression analyses were used for analyzing the data. Results Incidence rates of back (including low back), shoulder, and neck pain in general practice declined slightly from 2004 to 2009. No linear trends were found for number of contacts in GP care for back (including low back) and neck pain. The number of patients visiting physical therapists and the proportion of self-referrers are growing. Self-referrers receive treatment less often after initial intake than referred patients, and the mean number of visits is lower. Limitations This study was based on data of various patient populations from existing data sources. Conclusions The current study indicates that self-referral in the Netherlands has fulfilled most expectations held prior to its introduction, although no changes to the workload of GP care have been found. Use of physical therapy grew, but due to population aging and increasing prevalence of chronic diseases, it remains unclear whether self-referral affects health care utilization. Therefore, cost-benefit analyses are recommended.

Direct Access to Physical Therapy for Patients With Low Back Pain in the Netherlands: Prevalence and Predictors

Background In the Netherlands, direct access to physical therapy was introduced in 2006. Although many patients with back pain visit physical therapists through direct access, the frequency and characteristics of episodes of care are unknown. Objective The purposes of this study were: (1) to investigate the prevalence of direct access to physical therapy for patients with low back pain in the Netherlands from 2006 to 2009, (2) to examine associations between mode of access (direct versus referral) and patient characteristics, and (3) to describe the severity of the back complaints at the beginning and end of treatment for direct access and referral-based physical therapy. Design A cross-sectional study was conducted using registration data of physical therapists obtained from a longitudinal study. Method Data were used from the National Information Service for Allied Health Care, a registration network of Dutch physical therapists. Mode of access (direct or referral) was registered for each episode of physical therapy care due to back pain from 2006 to 2009. Logistic regression analysis was used to explore associations between mode of access and patient/clinical characteristics. Results The percentage of episodes of care for which patients with back pain directly accessed a physical therapist increased from 28.9% in 2006 to 52.1% in 2009. Characteristics associated with direct access were: middle or higher education level (odds ratio [OR]=1.3 and 2.0, respectively), previous physical therapy care (OR=1.7), recurrent back pain (OR=1.7), duration of back pain <7 days (OR=4.2), and age >55 years (OR=0.6). Limitations The study could not compare outcomes of physical therapy care by mode of access because this information was not registered from the beginning of data collection and, therefore, was missing for too many cases. Conclusions Direct access was used for an increasing percentage of episodes of physical therapy care in the years 2006 to 2009. Patient/clinical characteristics associated with the mode of access were education level, recurrent back pain, previous physical therapy sessions, and age.

Pain intensity, neck pain and longer duration of complaints predict poorer outcome in patients with shoulder pain--a systematic review.

BackgroundShoulder complaints are common and have an unfavourable prognosis in many patients. Prognostic information is helpful for both patients and clinicians in managing the complaints. The research question was which factors have prognostic value on (un)favourable outcome in patients with shoulder complaints in primary care, secondary care and occupational settings.MethodsUpdate of a systematic review in primary care, secondary care and occupational settings.ResultsNine articles were published since the original review in 2004. Six were of high quality covering a wide variety of prognostic factors and outcome measures. Four studies were conducted in primary care settings. A best evidence synthesis, including the results of the previous systematic review on this topic shows that there is strong evidence that higher shoulder pain intensity, concomitant neck pain and a longer duration of symptoms predict poorer outcome in primary care settings. In secondary care populations, strong evidence was found for the association between greater disability and poorer outcome and between the existence of previous shoulder pain and poorer outcome.ConclusionClinicians may take these factors into account in the management of their patients. Those with a worse prognosis may be monitored more frequently and the treatment plan modified if complaints persist.

Overweight and obese adults have low intentions of seeking weight-related care: a cross-sectional survey

BackgroundThe prevalence of obesity is growing worldwide. Obesity guidelines recommend increasing the level of weight-related care for persons with elevated levels of weight-related health risk (WRHR). However, there seems to be a discrepancy between need for and use of weight-related care. The primary aim of this study is to examine predisposing factors that may influence readiness to lose weight and intention to use weight-related care in an overweight population.MethodsA population-based, cross-sectional survey was conducted. Data were collected using an online self-administered questionnaire sent to a population-representative sample of 1,500 Dutch adults on the Health Care Consumer Panel (n = 861 responded). Data were used from individuals (n = 445) with a mildly, moderately or severely elevated level of WRHR. WRHR status was based on self-reported data on Body Mass Index, risk assessment for diabetes mellitus type 2 (DM2) and cardiovascular disease (CVD), or co-morbidities.Results55.1% of persons with increased WRHR were ready to lose weight (n = 245). Depending on level of WRHR; educational level, marital status, individuals with an accurate perception of their weight and better perceptions and expectations of dietitians were significantly related to readiness to lose weight. Most of them preferred individual weight-loss methods (82.0% of n = 245). 11% (n = 26 of n = 245) intended to use weight-related care. Weight-related care seeking was higher for those with moderate or severe WRHR. Expectations and trust in dietitians did not seem to influence care seeking.ConclusionsMany Dutch adults who are medically in need of weight-related care are ready to lose weight. Most intend to lose weight individually, and only a few intend to use weight-related care. Therefore, obesity prevention initiatives should focus on monitoring weight change and weight-loss plans, and timely referral to obesity management. However, many people are not ready to lose weight. For this group, strategies for behaviour change may depend on WRHR, perceptions of weight and dietitians, educational level and marital status. Obesity prevention initiatives should focus on increasing the awareness of the seriousness of their condition and offering individually appropriate weight management programmes.

Dutch General Practitioners’ weight management policy for overweight and obese patients

BackgroundGeneral practitioners (GPs) can play an important role in both the prevention and management of overweight and obesity. Current general practice guidelines in the Netherlands allow room for GPs to execute their own weight management policy.ObjectiveTo examine GPs’ current weight management policy and the factors associated with this policy.Methods800 Dutch GPs were asked to complete a questionnaire in December 2012. The questionnaire items were based on the Dutch Obesity Standard for GPs. The data were analyzed by means of descriptive statistics and multiple linear regression analyses in 2013.ResultsIn total, 307 GPs (39.0%) responded. Most respondents (82.9%) considered weight management as part of their responsibility for providing care. GPs aged <48 years discussed weight less frequent. Next, weight is less frequently discussed with patients without weight-related comorbidities or with moderately overweight patients compared to obese patients. On average, 47.7% of the GPs reported to refer obese patients to a weight management professional, preferably a dietitian (98.3%). GPs with a BMI ≥ 25 kg/m2 were less likely to refer obese patients. In addition, GPs who had frequent contact with a dietitian were more likely to refer obese patients.ConclusionsIn the context of General Practice and preventive medicine, GPs’ discussion of weight and the variety of obesity-determinants with their moderately overweight patients deserves more attention, especially from younger GPs. Strengthening interdisciplinary collaboration between GPs and dietitians could increase the referral percentage for dietary treatment.

Factors associated with referral to secondary care in patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy.

We introduced a stepped‐care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of high‐quality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS.

Huisartsenzorg bij overgewicht en obesitas

SamenvattingKloek CJJ, Tol J, Veenhof C, Van der Wulp I, Swinkels ICS. Huisartsenzorg bij overgewicht en obesitas. Huisarts Wet 2015;58(2):66-9.InleidingHuisartsen kunnen een belangrijke rol spelen bij de preventie en behandeling van overgewicht en obesitas. De NHG-Standaard Obesitas geeft de huisarts vrijheid in het uitvoeren van zijn of haar behandelbeleid bij deze doelgroep. Met dit onderzoek wilden we inzicht krijgen in het behandelbeleid van huisartsen bij patiënten met overgewicht en obesitas, en in de factoren, zoals persoonskenmerken of persoonlijke visie op dieetzorg, die gerelateerd zijn aan dit beleid.MethodenIn 2012 hebben we 800 huisartsen benaderd om een schriftelijke vragenlijst in te vullen. De vragen waren gebaseerd op de NHG-Standaard Obesitas. Door middel van beschrijvende statistiek en meervoudige lineaire regressieanalyses hebben we de factoren gerelateerd aan het bespreken van het gewicht en het verwijsbeleid voor voedings- en/of dieetadvies in kaart gebracht.ResultatenVan de 307 respondenten (netto respons 39,0%) vond 82,9% het bevorderen van een gezond gewicht een belangrijk onderdeel van de huisartsenzorg. Huisartsen jonger dan 48 jaar brachten het gewicht minder vaak ter sprake bij zwaarlijvige patiënten dan hun oudere collega’s. Daarnaast bespraken ze het gewicht minder vaak met patiënten met overgewicht of obesitas als er geen sprake was van een daaraan gerelateerde klacht. De huisartsen verwijzen bijna de helft van de patiënten met obesitas naar een professional, bij voorkeur een diëtist (98,3%). Huisartsen die frequent interdisciplinair contact met een diëtist hadden en huisartsen met een gezond gewicht stuurden hun patiënt met obesitas vaker door.BeschouwingIn het kader van de preventie van (ernstig) overgewicht vraagt het bespreken van gewicht en aan het gewicht gerelateerde onderwerpen bij patiënten met beginnend overgewicht vooral bij de jongere huisartsen om meer aandacht. Daarnaast blijken er tussen huisartsen verschillen te zijn in het verwijspercentage naar zorgverleners voor voedings- en/of dieetadvies.

Exploring physiotherapists' personality traits that may influence treatment outcome in patients with chronic diseases: a cohort study

BackgroundDuring treatment of patients with Chronic Diseases (CD) the therapist-patient interaction is often intense, and the strategies used during treatment require physiotherapists to assume a coaching role. Uncovering therapist factors that explain inter-therapist variation might provide tools to improve treatment outcome and to train future therapists. The purpose of this study was to explore the so-called ‘therapist-effect’, by looking at the influence of intrinsic therapist factors, specifically personality traits, on treatment outcome in patients with CD.MethodsA cohort study was performed using data from the NIVEL Primary Care Database (NPCD) in 2011–2012 and an additional questionnaire. Patients with CD (n = 393) treated by Dutch physiotherapists working in outpatient practices (n = 39) were included. Patient and treatment outcome variables were extracted from NPCD. The course of complaint was measured using the Numeric Rating Scale. Therapist variables were measured using a questionnaire consisting of demographics and the Big Five traits: Extraversion, Neuroticism, Agreeableness, Conscientiousness and Openness to experiences. Data were analysed using multilevel linear regression.ResultsOnly Neuroticism was found to be significant (Neuroticism F = 0.71, P = 0.01; therapist gender F = 0.72, P = 0.03; life events F = −0.54, P = 0.09; patient gender F = −0.43, P = 0.10; patient age F = 0.01, P = 0.27). Subgroup analyses of 180 patients with Osteoarthritis and 30 therapists showed similar results.ConclusionsThere are indications that patients with CD who are treated by therapists who tend to be calmer, more relaxed, secure and resilient have a greater reduction in severity of complaints compared to patients treated by therapists who show less of these traits. Being a male therapist and having experienced life events influence outcome positively. However, more extensive research is needed to validate the current findings.