Low Value Healthcare

Neil - Doctor of PhysiotherapyBlog, Health, Physiotherapy0 Comments

*This* is why we’re so passionate about NOT signing people up to lengthy periods of treatment that they do not need.

Published only a few days ago (Feb 28): Traeger AC, et al. Wise choices: making physiotherapy care more valuable. J Physiother. (2017)

➡️ Low-value healthcare broadly refers to the use of medical tests, diagnoses and treatments that provide patients with little-to-no benefit or cause harm [nocebo is also considered harm]. It also relates to over-diagnosis and over-treatment.

“The problem is highly relevant to Physiotherapy”

➡️ Scoliosis, Scheuermann’s disease, a leg length difference, a forward head posture or poke neck, rounded shoulders, pelvic tilts would all be considered examples of ‘over-diagnosis’.

➡️ In one study referenced here, 61% of Physiotherapists (from 559 interviewed) advocated treatments that do not work, such as ultrasound and traction.

➡️ Low back pain [ ] has considerable evidence to suggest that its management is permeated by low-value care.

➡️ There is a growing evidence base suggesting that low-value medical care is prevalent in health problems commonly seen by physiotherapists.

➡️ Physiotherapists frequently influence decisions about imaging, medication and surgery by the advice they provide to their patient or by their referrals. 80% of people with low back pain will have at least one red flag (they’re considered to be a bad thing), yet less than 1% will have a serious spinal pathology.

➡️ Some well-known examples of low-value practices were referral for x-rays without the use of a validated decision tool, electrotherapy for low back pain, and ongoing manual therapy for frozen shoulder.

➡️ Professional and *commercial factors* were identified as drivers for providing low-value care.

➡️ Early treatment for low back pain is over-medicalisation. Acute low back pain simply doesn’t need to be ‘treated’; the suggestion by a clinician to a patient that it’s necessary and helpful is tantamount to daylight robbery. The STarT Back questionnaire is a useful indictor of whether someone with acute LBP would benefit from seeing a Physiotherapist (that doesn’t mean laying down on a table and receiving some form of manual ‘treatment’).

➡️ Imaging for back, shoulder and knee pain runs the risk of diagnosing and then subsequently treating clinically insignificant ‘abnormalities’ that are highly prevalent in the asymptomatic population.

➡️ Many practitioners order tests as a matter of habit. Others do so because they find it difficult to do nothing, have fear of litigation if serious disease is missed, or feel pressured by their patients.
In general, consumers of healthcare can find it difficult to accept uncertainty. Fears and concerns about illness also drive people to consult more often. There are widespread beliefs that more care is better care and that early detection of disease is always best. ‘False feedback loops’, where patients and practitioners wrongly ascribe improvements in a mild condition to the treatment given, also fuel overtreatment.

➡️ The solution is not simply to stop providing low-value care, but rather that high-value healthcare requires the replacement of inappropriate care with appropriate care.

➡️ Emotional distress appears to be an important driver of health services overuse; physiotherapy trainees should be taught the importance of reducing distress through effective *reassurance*. Brief and structured patient *education*, for example, has high-quality evidence for its reassuring effects in patients with back pain and is a promising alternative to unnecessary diagnostic tests.

Conclusion
➡️ Eliminating low-value services from physiotherapy care altogether will be difficult. Some clinicians and patients will find it hard to break old habits and new low-value habits will likely emerge. Others will find it hard to accept that some treatments and tests are simply not beneficial.

➡️ In addition to the Traeger paper, and in a similar vein, Researchers at the George Institute for Global Health in Sydney and the University of Queensland found that a half-hour advice session with a physiotherapist works just as well as an intensive 12-week course of 20 personal physiotherapy visits for chronic whiplash patients.

Contact us at info@pride.physio if you would like a copy of the Traeger paper and cannot access it yourself.

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