What prompted the REFORM trial and why was it important to evaluate the cost-effectiveness of remotely delivered physiotherapy? 

The idea for the REFORM trial came from the realisation that there were many people with musculoskeletal (MSK) conditions who did not have timely access to physiotherapy treatment due to long waiting lists in public hospitals or other difficulties in accessing physiotherapy. 

We wanted to test an intervention that decreased reliance on in-person treatment for MSK conditions, so we designed a randomised controlled, non-inferiority trial to compare usual outpatient department care with remotely delivered physiotherapy. 

The results showed that remotely delivered physiotherapy was as good as usual care in a public hospital outpatient setting and it was important to see whether the REFORM intervention was also cost-effective and cost-saving for both the patients and the health system. 

We conducted costminimisation and cost-effectiveness analyses at six weeks from a combined health system and patient perspective. 

The study found remotely delivered physiotherapy to be just as effective as face-to-face care, with lower costs. What does this mean for clinical practice in the public hospital setting? 

Our economic evaluation showed a 98 per cent probability of remotely delivered physiotherapy being cost-saving and non-inferior to face-to-face physiotherapy at six weeks regardless of the perspective taken (patient plus health funder or health funder only). 

The cost-effectiveness analysis also showed that there was an 88 per cent probability that remotely delivered physiotherapy was less costly and more effective. 

These results could mean that patients with MSK conditions could access physiotherapy in less time and have lower out-of-pocket costs without sacrificing improvement in outcomes. 

From a patient perspective, what were the main benefits of the remote model of care? 

Remotely delivered physiotherapy was cheaper for patients, mostly due to lower travel costs and less time taken to attend in-person appointments. 

There is also the potential benefit of increasing access to care for patients who find attending in-person appointments difficult due to work or caregiving responsibilities, location or mobility limitations. 

Were there any challenges in implementing the remote physiotherapy intervention and how might these be addressed if the model were rolled out more widely? 

The main challenges we faced in delivering remote physiotherapy were the attitudes and beliefs held by some patients and physiotherapists that in-person physiotherapy is better than remotely delivered physiotherapy. 

Some patients were also not confident about using technology such as smart devices or apps. 

The barriers to and facilitators of rolling out this intervention have been examined in our process evaluation, which is currently being completed. 

How can physiotherapists determine which patients are best suited to remote versus in-person care? 

Most of the patients who participated in the REFORM trial had chronic MSK conditions. We didn’t include anyone with a postop protocol. 

Our qualitative work also found that physiotherapists need to have experience in assessing and treating MSK conditions to be confident in delivering a remote or hybrid treatment option. 

Patients need to be confident in using technology and happy to do exercises without direct supervision. 

What are the implications of these findings for workforce planning and future models of physiotherapy service delivery in Australia? 

Our findings should give stakeholders confidence that remotely delivered physiotherapy is an effective and cost-effective option for treating patients with MSK conditions similar to those in our study. 

Future models of physiotherapy service delivery in Australia could include a hybrid approach to delivering physiotherapy, giving patients a wider choice of evidence-based options for how they can best access high quality treatment for their conditions. 

Who helped make this happen? 

This economic analysis was completed as part of my PhD and I want to thank my supervisors Professor Alison Hayes, Professor Lisa Harvey and Associate Professor Joanne Glinsky for their help with this paper. 

I would also like to acknowledge our funders— Sydney Health Partners and SIRA—and thank all of our academic and clinical collaborators as well as staff at the sites. 

>>>Hannah Withers APAM has recently completed her PhD at the University of Sydney’s John Walsh Centre for Rehabilitation Research. She is a physiotherapist with over 15 years of clinical experience.