Discussion
The findings from this study demonstrate a stepped reduction of approximately 10%, in the rates of GP consultations for MSK conditions in Norway primary care, associated with the introduction of a direct access physiotherapy model of care in 2018. The introduction of this model of care was not associated with a change in rates of physiotherapy consultations for MSK conditions, nor the rates of specialist consultations or surgery for spinal conditions. Exploratory analysis of subgroups indicated an associated reduction in the quarterly rates of physiotherapy MSK consultations for those in the lower and intermediate education groups following the introduction of the direct access to physiotherapy model. Additionally, a stepped reduction of spinal operations was observed in those aged between 40 and 60 years, 6 months after the introduction of the model of care. We did not observe any association between the introduction of the direct access to physiotherapy model of care and primary outcome measures for different MSK conditions (back, neck, shoulder and knee).
The demonstration of an immediate reduction in the number of GP consultations associated with the introduction of a direct access to physiotherapy model, is a novel finding. While no previous research has used an interrupted time series design to evaluate the impact of introducing this intervention at a specific time point, at a healthcare system level, there is evidence that direct access to physiotherapy can reduce GP MSK workload. A national 1-year trial, conducted across 26 clinics in Scotland, observed those who directly accessed physiotherapy spent 50% less time consulting with GPs compared with those who first consulted with their GP.38 While not directly comparable to our results, the authors extrapolated this would equate to 400 weeks of freed GP appointment time in Scotland each year, based on an estimated 22% of patients self-referring directly to physio for MSK management. In contrast, a 5-year longitudinal evaluation of the national introduction of direct access physiotherapy model of care in the Netherlands, did not report a reduction in GP workload.19 However, the evaluation did not investigate total GP MSK consultations prior to the introduction of the service, relying on incidence rates of the top five MSK conditions as an indication of GP workload. One proposed mechanism by which direct access physiotherapy can reduce GP workload is through a reduction in repeat visits to GPs.38 Not including this may have led to an under-reporting on the impact of direct access physiotherapy on GP workload following the introduction of this pathway in the Netherlands.
A concern raised in opposition to direct access physiotherapy models of care is the prospect of an overwhelming increase in physiotherapy consultations following the removal of the GP gatekeeper role. Results of the current study do not support this. The data showed a steady declining rate of consultations with physiotherapist in Norway that remained unaffected by the introduction of direct access to physiotherapy care in 2018. This finding was also reported following Scotland’s national trial, and in the 1-year follow-up of the national introduction of direct access physiotherapy in the Netherlands, where overall physiotherapy consultations did not increase after the introduction of the new model of care.30 38
It is plausible that introducing a direct access pathway to physiotherapy care in Norway, simply removed the unnecessary step of having to see the GP first (prior to referral), resulting in a drop in GP consultations for those who self-referred to a physiotherapist. This may also partly explain why physiotherapy consultations did not increase. Rather than a new group of patients accessing physiotherapy care, it could be hypothesised that consultations consisted of those who were referred by GPs and those who self-referred (who would previously been referred by their GP).30
In addition, direct access physiotherapy was not associated with a change in the rates of specialist consultations or surgical procedures for spinal conditions. While little is known about the impact on rates of surgery associated with this model in primary care, previous evaluation of direct triage to physiotherapy services, at a clinic level, has demonstrated a reduction in specialist referrals associated with physiotherapy led care.15 18 Non-experimental studies conducted in primary care in Sweden and the UK observed a 61%15 reduction in specialist referrals (ie, rheumatologists, orthopaedics, pain physicians, neurologists) and up to 64%18 reduction in orthopaedic referrals, respectively, when patients initiated care with a physiotherapist compared with a GP. The contrasting findings between these results, and the findings observed in the current study, might be explained by a smaller percentage of those whose who used the direct access pathway. Unlike these service evaluations, the direct access model of care in Norway permits patients to choose their initial provider. While the numbers of those self-referring to physiotherapy were not measured in the current study, the estimated 10% decrease in GP consultations would suggest a significant proportion of patients still initiated care with their GP, potentially reducing the impact on specialist referral rates. Supporting this idea, Holdsworth et al38 observed that rates of specialist referrals were doubled for those patients who started care with their GP compared with those who self-referred to physiotherapy. These results underline the importance of uptake of this direct access service by self-referrers, and perhaps emphasise the need for public awareness and education to support this model of care.30 39
We found exploratory evidence to suggest that the introduction of direct access physiotherapy model was associated with a reduction in physiotherapy consultations in the intermediate and lower education groups. The differences in characteristics of patients self-referring for physiotherapy compared with those who use GP-led care, provides a possible explanation for this finding. Although this study did not collect patient level characteristics, recent systematic reviews suggest those who access physiotherapy directly may be more educated (younger and with a short duration of symptoms) than those who use GP-led care.13 40 It is possible that a higher proportion of physiotherapy consultations were used by those more highly educated patients who self-directed to physiotherapy following the introduction of this service, reducing the availability for those in lower educations groups who might be more likely to rely on a GP referral.
The associated reduction in spinal surgery for those aged 40–60 years is intriguing. While age-standardised rates of spinal surgery in Norway are typically highest in those aged 60–74 years, spinal surgery for those aged 40–60 years typically accounts for the largest proportion of procedures performed.41 With surgical procedures lowest in those aged 18–39 years, and older patients often preferring to see their GP to initiate care,30 it is perhaps surgical rates in the ‘middle-age’ bracket that are likely to reflect divergent treatment pathways affected by GPs and physiotherapists as initial care providers. For example, sciatic pain, with an incidence highest in this age group,42 is frequently managed surgically, though evidence suggests it can be adequately managed with conservative care.43 It is possible that direct access to physiotherapy in this subgroup of patients might offer improved earlier management of symptoms, reducing the need for escalated care (eg, surgery). An alternate mechanism of effect might be altered referral patterns, with physiotherapists less frequently referring for surgical consultations when managing patients with sciatic symptoms compared with GPs. The lack of participant-level data collected in this study, and the exploratory nature of the subgroup analysis (using separate segmented regressions for each group), precludes strong conclusions being interpreted from subgroup findings.
Strengths and limitations
The main strengths of the current study are the longitudinal analysis, large patient sample broadly representative of Norwegian population, and the use of routinely collected registry data to evaluate time series trends in healthcare utilisation, associated with the nationwide introduction of direct access physiotherapy in Norway. Although variability in MSK and diagnostic coding is a limitation of registry based studies, it is not expected this changed systematically across the time period analysed. Interrupted time series analyses are susceptible to time-varying confounders, and the variability seen in GP consultations after 2020 might reflect consultation changes with the impact of COVID-19. In Norway, stringent measures were introduced in March 2020 to control the spread of the COVID-19 pandemic including the closure of schools, universities and reduction in sporting events which may have impacted primary care consultation rates. Mean daily number of healthcare contacts for common MSK injuries (ie, dislocations, sprains and strains) reduced by 55% during the lockdown period between 13 March and 2 April, compared with the preceding month.44 While there are several explanations for this reduction in healthcare contacts (eg, reduced injury exposure or redistribution of healthcare resources limiting access to care), it appears trends normalised by June 2020. Similarly, a 50% reduction in GP consultations for MSK conditions reported between March and May in 2020 in Norway, reduced to an 8% difference by November 2020, compared with the referenced 5-year average.45 These findings suggest the lower rates of GP MSK consultations we observed in the first two quarters of 2020 might partly reflect changes in COVID-19-related healthcare use. What is less clear is how this might have influenced the following time period and potential increased usage of primary care services because of delayed access to care. Nonetheless, sensitivity analysis excluding years affected by COVID-19 disease did not meaningfully alter our results.
It is acknowledged that differences in the time frames of when surveys were administered may introduce selection bias if there are systemic differences in the cohort of participants responding to the early versus later surveys. However, baseline statistics across the three surveys demonstrated that characteristics were balanced for measured variables, and visual exploration of outcomes stratified by early survey responders (Ullensaker study) through to the late survey responders (The HUNT4 Survey) did not demonstrate differences in healthcare utilisation rates over the analysed time period. A further limitation of this study is the lack of patient-level data, preventing strong conclusions explaining healthcare utilisation rates associated with the direct access model of care. Finally, the reliability of the results in this study are based on the underlying assumptions of the segmented regression analyses being met. While Newey-West standard errors provide some accommodation for residual autocorrelation and heteroskedasticity, there was some variability of residuals in the GP regression model after the year 2020. Additionally, a lagged effect for the intervention on surgical procedures was based on field expertise, given a lack of prior evidence in the literature to inform the modelling. However, sensitivity analyses conducted demonstrated that our results were robust to altered assumptions and our conclusions would not be altered.
Clinical and policy implications
This study provides evidence that a nationwide introduction of direct access physiotherapy is associated with a reduction in GP workload. While this change may not be felt at the clinic,46 it may have implications at a healthcare system level. With an estimated 10% reduction in GP MSK consultations, an average GP consultation time in Norway of 18 minutes47 and a conservative total of 1 000 000 MSK consultations nationally,48 this could be extrapolated to represent over 900 weeks of freed GP time in Norway each year, based on an average of 33 hours of direct patient contact time.49 Given direct access was available to manual therapists since 2006, and they accounted for 10% of recorded MSK consultations in this cohort, the impact of GP workload when implementing this model of care, may be more pronounced in healthcare systems without a history of direct access physiotherapy. Current evidence suggests the wider impact of this model of care is largely dependent on the proportion of patients who choose to self-refer,38 39 the level of public awareness/education on how or why to directly access physiotherapy care,30 39 and the availability of physiotherapy services to support the model.50
The context of the healthcare system is also an important consideration. Norway is a high-income country with a well-established healthcare system. In Norway, GP funding is a mixed payment model, constituting payments from the municipality, fee for service and out-of-pocket payments from patients. Patients’ maximum out-of-pocket payments are also capped by the Norwegian government. The effectiveness of direct access physiotherapy in other healthcare systems is likely dependent on service accessibility and reach, funding for primary care service delivery and use, resource availability and population health profile.46 For example, in the absence of publicly funded physiotherapy services or capped out-of-pocket costs, self-referral to physiotherapy services is likely to be low and unlikely to impact GP workloads. In addition, the level of centralisation within healthcare systems is likely to impact widespread policy implementation of a direct access physiotherapy service. While our findings revealed consistent healthcare utilisation rates across geographical regions, it is possible that regional variation (eg, characteristics of the population distribution of primary care services) could influence the generalisability of these results. Collectively, these characteristics might limit the applicability of our findings in middle-income and lower-income countries. Future research evaluating this model of care should employ a broad range of effectiveness measures at a healthcare system level (eg, GP workload, cost-effectiveness), service (eg, medication prescription and imagine referral) and patient level outcomes (eg, pain and function). Consideration of these key factors in the context of other healthcare systems is needed before wider adoption can be promoted .
Conclusion
This is the first study to evaluate the longitudinal impact of the introduction of direct access physiotherapy on healthcare utilisation for MSK conditions, using an interrupted time series design. Results showed a 10% reduction in the rates of GP MSK consultations associated with the introduction of direct access physiotherapy, without an associated change in rates of physiotherapy consultations in Norwegian primary care. No change was observed in the rates of specialist consultations or surgical procedures for spinal pain, in the primary analysis. The associated reduction in GP workload, highlights the potential benefits of optimising healthcare resources and patient access to appropriate care, by offering direct access to physiotherapy at a healthcare system level. These findings build on existing knowledge demonstrating this model of care is safe and effective at a clinic level, strengthening support for the consideration of the implementation of direct access physiotherapy in similar healthcare systems.
