Clinician's Commentary on Lineker et al.

To adequately meet future health care needs, we need to explore alternative workforce models and evolved provider roles. The introduction of a new expanded or extended role for a provider group can be based on intuitive, theoretical, or practical rationales; most often, however, the justifications cited for introducing these roles relate to the demands of the local or national health care system.2 Yet evidence in support of implementing these roles in care settings, in the form of actual quantitative client or system outcomes data, is often not available, and the implementation planning often does not include a systematic approach to enabling the collection of evidence. Lineker and colleagues1 are a notable exception. It can be argued that isolating and understanding clinicians' behavioural changes in practice as a result of extended-role training is a critical precursor to understanding system changes created by the introduction of new roles. The article by Lineker and colleagues marks an initial attempt to compare the roles of extended-role occupational therapists and physiotherapists in the assessment and management of clients with inflammatory arthritis with those of experienced therapists who have not received such training. Through a retrospective chart review of practice variables related to documented physical findings, client goals, investigations, interventions, and outcomes measured, Lineker and colleagues investigated the behavioural practice variances between these two groups. Their exploratory study is a significant contribution to the ongoing discussion of available frameworks for evaluating practice changes resulting from extended scope education. Of the findings reported by Lineker and colleagues, two are particularly noteworthy in terms of future research. First, documentation by the extended-role practitioner group indicated a greater use of outcome measures than in the experienced practitioner group. That outcome measures were more routinely used by this group, albeit commonly only at the impairment level, suggests an opportunity for targeted proactive inclusion of other measures in future research. Second, the extended-role practitioners' enhanced collaboration with general practitioners and other primary care providers also creates a platform from which systemic impacts can be evaluated in the future. As the authors note, the data extracted from the chart audits may represent behaviours actually undertaken more often than they were documented by the experienced group. As reported, however, the latter finding is interesting, as it supports the need for further investigation into the potential differences in inter-professional practice and client advocacy that may be inherent outcomes of the extended-role training. Both these activities are arguably gaining increasing importance as elements of effective care delivery. Further, the findings of Lineker and colleagues' study should provoke an important reflective exercise for all clinicians currently working with adult clients with inflammatory arthritis. Their study is useful not only as preliminary insight into the efficacy of extended-role practitioner interventions but also as a reflective tool for insight into baseline practice of experienced clinicians. As the authors note, further studies are required to examine patient-, organization-, and system-level outcomes for new models of care and/or extended scope of practice roles. Some recent studies have highlighted effective methodologies and frameworks for evaluating roles and models of care at the organization or system levels.3–7 In these studies, the outcomes referenced or evaluated related to system objectives such as wait times, service capacity, enhanced inter-professional practice, patient satisfaction, and/or quality of care. Other studies, however, have highlighted the challenges of organization- or system level-evaluation, particularly for advanced practice roles.8,9 Within the limitations of their study design, Lineker and colleagues were able to observe practice differences between the extended-role and experienced practitioner groups. While variances were identified, the absence of reported predetermined goals or targets of those practice parameters for either group makes the interpretation of the results only speculative. Arguably, the authors could, by adopting an expanded evaluation framework for their study, have made some additional exploratory observations relating to broader organizational or system objectives that might have supported the rationale for the initial inclusion of these extended-role practitioners within the Arthritis Society. Despite the inherent limitations of a descriptive methodology, however, the findings of this study are a significant stepping stone for hypothesis generation and for the design and planning of future research. Lineker and colleagues have brought to light new considerations in the ongoing development of frameworks for the evaluation of new or expanded health care provider roles. Their study highlights the need for exploratory research into changes in practice patterns, which can inform later research aimed at correlating practice pattern changes with metrics that empirically measure outcomes of client and health care system change.

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