Skip to main content
  • Review article
  • Open access
  • Published:

The quality of physiotherapy care: the development and application of quality indicators using scientific evidence and routinely collected data embedded in the process of clinical reasoning

Abstract

Quality improvement has become a central tenet of physiotherapy care. Quality indicators (QIs) as measurable elements of care have been used over the past 25 years to analyze and evaluate the quality of physiotherapy care. The aim of this article is to describe the state of the art regarding the development and application of QIs in physiotherapy primary care when embedded in a clinical reasoning process. In contrast to international clinical practice guidelines, Dutch physiotherapy clinical practice guidelines are generally based on the clinical reasoning process in combination with best available evidence. Information required to develop QIs is preferably derived by combining available systematic review-based scientific evidence, guideline-based recommendations, and routinely collected data with clinical evidence, professional expertise and standards, and patient perspectives. A set of QIs (n=28) in patients with whiplash-associated disorders was developed and embedded per step of the clinical reasoning process in physiotherapy care: (a) administration (n=2); (b) history taking (n=7); (c) objectives of examination (n=1); (d) clinical examination (n=4); (e) analysis and conclusion (n=2); (f) treatment plan (n=3); (g) treatment (n=2); (h) evaluation (n=5); and (i) discharge (n=2). The use of QIs represents a useful tool for measuring the (improvement of) quality of physiotherapy primary care, as many evidentiary gaps still exist in terms of diagnostics, prognostics, and treatment, and concerning patient-related outcome measurements in different patient groups such as patients with musculoskeletal pain. The recommended set of QIs embedded in the clinical reasoning process for patients with whiplash-associated disorders can be used as a starting point for the development of a general set of QIs that measure the (improvement of) quality of primary care physiotherapy.

References

  1. World Confederation for Physical Therapy (WCPT). Description physical therapy. Available at: http://www.wcpt.org/policy/ps-descriptionPT. [Assessed January 29, 2019].

  2. Braspenning J, Campbell S, Grol R. Measuring changes in patient care: development and use of indicators. In: Grol R, Wensing M, Eccles M, eds. Improving patient care. The implementation of change in clinical practice. Edinburgh: Elsevier Butterworth Heineman; 2005. 222–234

    Google Scholar 

  3. Lawrence M, Olesen F. Indicators of quality health care. Eur J Gen Pract 1997; 3:103–108.

    Google Scholar 

  4. Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 2003; 15:523–530.

    PubMed  Google Scholar 

  5. Grimmer K, Dibden M. Clinical indicators for physiotherapists. Aust J Physiother 1993; 39:81–85.

    CAS  PubMed  Google Scholar 

  6. Scholte M, Neeleman-van der Steen CWM, Hendriks HJM, Nijhuis-van der Sanden MWG, Braspenning J. Evaluating quality indicators for physical therapy in primary care, Int J Qual Health Care 2014; 26:261–270.

    PubMed  Google Scholar 

  7. Campbell S, Braspenning J, Hutchinson A, Marshall M. Research methods used in developing and applying quality indicators in primary care. In: Grol R, Baker R, Moss F, eds. Quality improvement research. Understanding the science of change in health care. London: BMJ Publishing Group 2004. 6–28

    Google Scholar 

  8. Hoque DME, Kumari V, Hoque M, Ruseckaite R, Romero L, Evans SM. Impact of clinical registries on quality of patient care and clinical outcomes: a systematic review. PLoS One 2017; 12:e0183667.

    PubMed  PubMed Central  Google Scholar 

  9. Moore A, Jackson A, Jordan J, Hammersley S, Hill J, Mercer C, et al. Clinical guidelines for the physiotherapy management of Whiplash Associated Disorder (WAD). London: Chartered Society of Physiotherapy; 2005.

    Google Scholar 

  10. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976) 2001; 26:2504–2513.

    Google Scholar 

  11. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008; 33(4 Suppl):S123–S152.

    Google Scholar 

  12. Meerhoff G, Heijblom K, Knoop J. Methodology for developing/updating and implementing KNGF guidelines. Amersfoort, the Netherlands: The Royal Dutch Society for Physical Therapy (KNGF); 2006.

    Google Scholar 

  13. Staal JB, Hendriks EJM, Heijmans M, Kiers H, Lutgers-Boomsma AM, Rutten G, et al. KNGF Clinical practice guideline for physical therapy in patients with low back pain. KNGF Clinical Practice Guideline for Physical Therapy in patients with low back pain. Amersfoort, The Netherlands: Royal Dutch Society for Physical Therapy (KNGF); 2013.

    Google Scholar 

  14. Bier JD, Scholten-Peeters GGM, Staal JB, Pool J, van Tulder M, Beekman E, et al. KNGF Clinical Practice Guideline for Physical Therapy in patients with neck pain. Amersfoort, The Netherlands: Royal Dutch Society for Physical Therapy (KNGF); 2017.

    Google Scholar 

  15. Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical reasoning in the health professions. Edinburgh: Butterworth Heinemann 2008. 3–18

    Google Scholar 

  16. Jones MA, Rivett DA, eds. Clinical reasoning for manual therapists. Edinburgh: Butterworth Heinemann 2004. 1–24

    Google Scholar 

  17. Chia-Chien H, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval 2007; 12:1–8.

    Google Scholar 

  18. Jansen MJ, Hendriks EJ, Oostendorp RA, Dekker J, De Bie RA. Quality indicators indicate good adherence to the clinical practice guideline on ‘Osteoarthritis of the hip and knee’ and few prognostic factors influence outcome indicators: a prospective cohort study. Eur J Phys Rehabil Med 2010; 46:337–345.

    CAS  PubMed  Google Scholar 

  19. Peter WF, Hurkmans EJ, van der Wees P, Hendriks E, van Bodegom-Vos L, Vliet Vlieland TP. Healthcare quality indicators for physiotherapy management in hip and knee osteoarthritis and rheumatoid arthritis: a Delphi study. Musculoskelet Care 2016; 14:219–232.

    CAS  Google Scholar 

  20. Gijsbers HJ, Lauret GJ, van Hofwegen A, van Dockum TA, Teijink JA, Hendriks HJ. Development of quality indicators for physiotherapy for patients with PAOD in the Netherlands: a Delphi study. Physiotherapy 2016; 102:196–201.

    CAS  PubMed  Google Scholar 

  21. Rutten GM, Harting J, Bartholomew LK, Schlief A, Oostendorp RA, de Vries NK. Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study. BMC Health Serv Res 2013; 13:194.

    PubMed  PubMed Central  Google Scholar 

  22. Oostendorp RA, Rutten GM, Dommerholt J, Nijhuis-van der Sanden MW, Harting J. Guideline-based development and practice test of quality indicators for physiotherapy care in patients with neck pain. J Eval Clin Pract 2013; 19:1044–1053.

    Google Scholar 

  23. Oostendorp RA, Elvers H, van Trijffel E, Rutten GM, Scholten-Peeters GG, Heijmans M, et al. Has the quality of physiotherapy care in patients with Whiplash-associated disorders (WAD) improved over time? A retrospective study using routinely collected data and quality indicators. Patient Prefer Adherence 2018; 12:2291–2308.

    PubMed  PubMed Central  Google Scholar 

  24. Scholte M. Developing and implementing quality indicators for physical therapy: lessons learned [Academic Thesis]. Nijmegen, The Netherlands: Radboud University, 2014.

    Google Scholar 

  25. Scholten RJPM, Tuut MK, Kremer LCM, Assendelft WJJ. Beoordelen van de kwaliteit van medisch-wetenschappelijk onderzoek. In: Van Everdingen JJE, Burgers JS, Assendelft WJJ, Swinkels JA, Van Barneveld TA, Van de Klundert JLM, eds. Evidence-based Richtlijnontwikkeling. Houten: Bohn Stafleu Van Loghum; 2004. 158–171.

    Google Scholar 

  26. WHO. International classification of functioning, disability and health. Geneva: WHO; 2001.

    Google Scholar 

  27. Bekkering GE, Hendriks HJM, Lanser K, Oostendorp RAB, Peeters GGM, Verhagen AP, van der Windt DA. KNGF-richtlijn Whiplash. Ned Tijdschr Fysiother 2001; 111(3 Suppl):S1–S25.

    Google Scholar 

  28. Scholten-Peeters GG, Bekkering GE, Verhagen AP, van der Windt DA, Lanser K, Hendriks EJ, Oostendorp RA. Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders. Spine (Phila Pa 1976) 2002; 27:412–422.

    Google Scholar 

  29. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining ‘whiplash’ and its management. Spine (Phila Pa 1976) 1995; 20(8 Suppl):1S–73S.

    CAS  Google Scholar 

  30. Rothstein JM, Echternach JL. Hypothesis-oriented algorithm for clinicians. A method for evaluation and treatment planning. Phys Ther 1986; 66:1388–1394.

    CAS  PubMed  Google Scholar 

  31. Rothstein JM, Echternach JL, Riddle DL. The hypothesis-oriented algorithm for clinicians II (HOAC II): a guide for patient management. Phys Ther 2003; 83:455–470.

    PubMed  Google Scholar 

  32. Allet L, Bürge E, Monnin D. ICF: clinical relevance for physiotherapy? A critical review. Adv Physiother 2008; 10:127–137.

    Google Scholar 

  33. Groves M, Dick ML, McColl G, Bilszta J. Analysing clinical reasoning characteristics using a combined methods approach. BMC Med Educ 2013; 13:144.

    PubMed  PubMed Central  Google Scholar 

  34. Nazim SM, Talati JJ, Pinjani S, Biyabani SR, Ather MH, Norcini JJ. Assessing clinical reasoning skills using Script Concordance Test (SCT) and extended matching questions (EMQs): a pilot for urology trainees. J Adv Med Educ Prof 2019; 7:7–13.

    PubMed  PubMed Central  Google Scholar 

  35. Cooke S, Lemay JF, Beran T. Evolutions in clinical reasoning assessment: The Evolving Script Concordance Test. Med Teach 2017; 39:828–835.

    PubMed  Google Scholar 

  36. Maissan F, Pool J, de Raaij E, Mollema J, Ostelo R, Wittink H. The clinical reasoning process in randomized clinical trials with patients with nonspecific neck pain is incomplete: A systematic review. Musculoskelet Sci Pract 2018; 35:8–17.

    PubMed  Google Scholar 

  37. Smith J, Bolton PS. What are the clinical criteria justifying spinal manipulative therapy for neck pain? A systematic review of randomized controlled trials. Pain Med 2013; 14:460–468.

    PubMed  Google Scholar 

  38. Gerstein HC, McMurray J, Holman RR. Real-world studies no substitute for RCTs in establishing efficacy. Lancet 2019; 393:210–211.

    PubMed  Google Scholar 

  39. Scholte M, van Dulmen SA, Neeleman-Van der Steen CW, van der Wees PJ, Nijhuis-van der Sanden MW, Braspenning J. Data extraction from electronic health records (EHRs) for quality measurement of the physical therapy process: comparison between EHR-data and survey data. BMC Med Inform Decis Mak 2016; 16:141.

    PubMed  PubMed Central  Google Scholar 

  40. Jorm L. Routinely collected data as a strategic resource for research: priorities for methods and workforce. Public Health Res Pract 2015; 25: e2541540.

    PubMed  Google Scholar 

  41. Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies conducted using observational routinely-collected health data (RECORD) statement. PLoS Med 2015; 12:e 1001885.

    Google Scholar 

  42. Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. Improving the reporting of studies using routinely collected health data in physical therapy. J Orthop Sports Phys Ther 2016; 46:126–127.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Rob A.B. Oostendorp Prof. Rob A.B. Oostendorp, PhD, PT, MPT.

Additional information

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Oostendorp, R., Hans Elvers, J. & van Trijffel, E. The quality of physiotherapy care: the development and application of quality indicators using scientific evidence and routinely collected data embedded in the process of clinical reasoning. Bull Fac Phys Ther 24, 113–120 (2019). https://doi.org/10.4103/bfpt.bfpt_4_19

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/bfpt.bfpt_4_19

Keywords