The access randomized clinical trial of public versus private physiotherapy for low back pain

Sarah N Casserley-Feeney, Leslie Daly, Deirdre A Hurley
Spine 2012 January 15, 37 (2): 85-96

STUDY DESIGN: Pragmatic randomized clinical trial.

OBJECTIVE: This study investigated differences in the clinical outcomes of public physiotherapy (public PT) versus private physiotherapy (private PT) for general practitioner-referred patients with acute and chronic low back pain (LBP).

SUMMARY OF BACKGROUND DATA: Health care setting (i.e., public or private) has been found to influence the course and clinical outcome of common diseases. Despite the international burden of LBP, the effect of health care setting on clinical outcomes has not been investigated in this population.

METHODS: One hundred sixty consenting patients, who were referred for physiotherapy for LBP by their general practitioner, completed the Roland Morris Disability Questionnaire (primary outcome), Short-Form 36 v2, Fear Avoidance Beliefs Questionnaire, Back Beliefs Questionnaire, EuroQol EQ5D, and Patient Satisfaction Questionnaires. The patients were stratified (acute LBP: ≤ 3 months, n = 55; chronic LBP: > 3 months, n = 105), randomly allocated to receive public PT (n = 3 hospitals) or private PT (n = 12 clinics), and followed up at 3, 6, and 12 months postrandomization.

RESULTS: Repeated measures analysis of variance showed significant improvement over time for 9 predominantly biomedical outcomes: (i) Roland Morris Disability Questionnaire at 3 and 6 months, (ii) Short-Form 36 v2 Physical Component Score, Bodily Pain, Role Physical, General Health, Vitality, EQ5D visual analogue scale, and weighted health index scores at 3 months, and (iii) the Back Beliefs Questionnaire at 6 months. The remaining 7 biopsychosocial outcomes showed no change over time, and the "between within" repeated measures analysis of variance showed no significant differences between groups over time for any outcome measures (P > 0.05). Independent samples t tests found no significant differences between groups in the mean changes in outcome measures from baseline at 12 months, apart from SF-36 v2 Role Physical (mean difference, 95% CI = 5.64 [0.860-10.428]; t = 2.337; P = 0.021) in favor of the private PT group. There were significantly higher levels of satisfaction with outcome of treatment in the private PT group (median [IQR]: public PT: 5.0 [2.0]; private PT: 6.0 [2.0]; Mann-Whitney U test = 1324.50; P = 0.020), but no differences in satisfaction with treatment or global perceived improvement (P > 0.05). The private PT group had a significantly shorter waiting time (mean difference = 39.79 days; 95% CI: 26.88-52.69; t = 6.121; P < 0.001) and treatment duration (mean difference: 23.48 days; 95% CI: 7.43-39.52; t = 2.909; P = 0.005) than public PT. Participants in both groups were treated with advice/education, manipulative therapy, and exercise therapy, with minimal use of cognitive behavioral approaches in either group. Physiotherapists in the private PT group had significantly more experience and more postgraduate qualifications than the public PT group (P < 0.005).

CONCLUSION: Despite differences between public and private PT regarding waiting times for treatment and therapist experience, there were no significant differences between groups in the majority of clinical outcome measure scores at follow-up, apart from SF-36 Role Physical and satisfaction with treatment outcome in favor of the private PT group.

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