Clinical and cost-effectiveness of first contact physiotherapy for musculoskeletal disorders in primary care: the FRONTIER, mixed method realist evaluation
Bibliographic record
Abstract
Background: First-contact physiotherapists assess and diagnose patients with musculoskeletal disorders, determining the best course of management without prior general practitioner consultation. Objectives: The primary aim was to determine the clinical and cost-effectiveness of first-contact physiotherapists compared with general practitioner-led models of care. Design: Mixed-method realist evaluation of effectiveness and costs, comprising three main phases: A United Kingdom-wide survey of first contact physiotherapists. Rapid realist review of first contact physiotherapists to determine programme theories. A mixed-method case study evaluation of 46 general practices across the United Kingdom, grouped as three service delivery models: General practitioner: general practitioner-led models of care (no first contact physiotherapists). First-contact physiotherapists standard provision: standard first-contact physiotherapist-led model of care. First-contact physiotherapists with additional qualifications: first-contact physiotherapists with additional qualifications to enable them to inject and/or prescribe. Setting: United Kingdom general practice. Participants: A total of 46 sites participated in the case study evaluation and 426 patients were recruited; 80 staff and patients were interviewed. Main outcome measures: Short Form 36 physical outcome component score and costs of treatment. Results: No statistically significant difference in the primary outcome Short Form 36 physical component score measure at 6-month primary end point between general practitioner-led, first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models of care. A greater number of patients who had first-contact physiotherapist standard provision (72.4%) and first-contact physiotherapist with additional qualifications (66.4%) showed an improvement at 3 months compared with general practitioner-led care (54.7%). No statistically significant differences were found between the study arms in other secondary outcome measures, including the EuroQol-5 Dimensions, five-level version. Some 6.3% of participants were lost to follow-up at 3 months; a further 1.9% were lost to follow-up after 3 months and before 6 months. Service-use analysis data were available for 348 participants (81.7%) at 6 months. Inspecting the entire 6 months of the study, a statistically significant difference in total cost was seen between the three service models, irrespective of whether inpatient costs were included or excluded from the calculation. In both instances, the general practitioner service model was found to be significantly costlier, with a median total cost of £105.50 versus £41.00 for first-contact physiotherapist standard provision and £44.00 for first-contact physiotherapists with additional qualifications. Base-case analysis used band 7 for first-contact physiotherapist groups. A sensitivity analysis was undertaken at band 8a for first-contact physiotherapists with additional qualifications; the general practitioner-led model of care remained significantly costlier. Qualitative investigation highlighted key issues to support implementation: understanding role remit, integrating and supporting staff including full information technology access and extended appointment times. Limitations: Services were significantly impacted by COVID-19 treatment restrictions, and recruitment was hampered by additional pressures in primary care. A further limitation was the lack of diversity within the sample. Conclusions: First-contact physiotherapists and general practitioner models of care are equally clinically effective for people with musculoskeletal disorders. Analysis showed the general practitioner-led model of care is costlier than both the first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models. Implementation is supported by raising awareness of the first-contact physiotherapist role, retention of extended appointment times, and employment models that provide first-contact physiotherapists with professional support. Future research: Determining whether shifting workforce impacts physiotherapy provision and outcomes across the musculoskeletal pathway. Study registration: The study is registered as Research Registry UIN researchregistry5033. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 49. See the NIHR Funding and Awards website for further award information.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.035 | 0.064 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.005 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".