Reaching for high value care
High value care is a concept bandied around by researchers, policy wonks and bureaucrats but it’s also something that all physiotherapists can strive to provide to their patients.
High value care is currently a much-discussed concept in healthcare, especially in health economics and policy, where it forms a key platform for reform.
But what actually is high value care?
The following definition, from one of the background reports for the Western Australian Department of Health’s recent Sustainable Health Review (Western Australian Department of Health 2019) states that:
High value healthcare means that consumers receive safe and high quality services and effective care based on clinical evidence, whilst also addressing system waste by directing resources to where they are most needed.
It’s a nice broad statement but doesn’t do much to tell the clinician—whether they are a physiotherapist, doctor or other health professional—if they are delivering high value care or not.
In fact, much of the discussion about what constitutes high level care focuses on the big picture at the policy and system level rather than looking at how individual clinicians can provide high value care.
From a policy and advocacy perspective, the focus is on reshaping the healthcare system to provide patients with the best and most cost-effective care.
It’s an area in which the APA’s policy team has been quite active over the past few years, arguing that physiotherapy provides a cost-effective high value approach to the treatment of musculoskeletal disorders, which at $14 billion have the highest health spend of any disease, condition or injury in Australia and should be better integrated into the primary healthcare system as an essential service (Australian Physiotherapy Association 2023), allowing physiotherapists to work to their full scope of practice.
The APA’s recent Future of Physiotherapy in Australia white paper (Australian Physiotherapy Association 2022) notes that high healthcare spending doesn’t always translate to high value care.
Outcome measurements focus on improvements to safety and mortality but often fail to capture important quality-of-life benefits for patients (Nous Group 2020).
‘Physiotherapy holds the potential to reshape the healthcare system towards faster treatment, better outcomes and lower costs,’ says Simon Tatz, APA General Manager, Policy and Government Relations.
‘The system needs to be redesigned around patient needs and towards experience-based design and measurement of effective outcomes.
‘Key requirements for advancing health equity and access include integrated care and support through transitions of care.’
But the picture is much less clear at ground level.
While piecemeal efforts have been made to define high value care and pathways for treatment of specific conditions, policymakers often focus on what comprises low value care without addressing high value care beyond its cost-effectiveness.
‘What we experience as clinicians is that these terms get thrown around quite loosely.
‘For the everyday clinician, it’s hard to know how to actually put that into practice,’ says Connor Gleadhill APAM, a physiotherapist and researcher at the University of Newcastle.
The clinicians’ consensus
Connor Gleadhill started RIPN to facilitate translation of evidence into practice.
A recent paper published in BMJ Open by Connor and colleagues from the Research in Practice Network (RIPN, see below) aims to define high value care for physiotherapists treating musculoskeletal conditions (Gleadhill et al 2023a).
The paper outlines the process used by RIPN to reach a consensus on what high value care means at a practitioner level when applied to physiotherapy and musculoskeletal conditions.
‘We wanted to provide some clarity to the everyday clinician.
‘As we went further into that, we found that in the eyes of clinicians, high value care is a multidimensional concept that revolves around the process of delivering care and also takes into account the outcomes,’ Connor says.
To create its consensus statement, RIPN started with a rapid literature review.
A working group within the network developed definitions, themes and a model based on the identified themes.
‘This was then distributed to the wider network for feedback.
‘We were asking does this model and do these themes make sense to you based on your clinical experience,’ Connor says.
The feedback was analysed and the definitions, themes and model updated to reflect it.
Then a meeting was held to reach a consensus on what represents high value care.
The result is a consensus statement consisting of three definitions (see below), a model (see Figure 1 below) and 15 statements related to the application of the themes and definitions for high value care.
Taken together, it all forms a framework for high value care that gives physiotherapists a basis for their own practice.
Andrew Delbridge says the high value care model developed by the RIPN team gives physios a model to consider in their practice.
Co-author and co-founder of RIPN Andrew Delbridge APAM MACP says he is very happy with the resulting model for high value care.
‘It covered more than I had initially thought about,’ Andrew says.
‘The consensus statement gives people a model to consider in their practice.
‘Do I meet those domains? Does my practice reflect those domains?
‘It’s certainly not exhaustive or necessarily the only model but I think it is a good one.’
The paper’s authors see the consensus as a guide to help clinicians improve their care as much as possible by aligning their practice with the themes and domains identified in the model.
‘You might not ever land in high value care.
‘What you might be doing is trying to achieve care that’s of higher value than previous care or higher value as you grow as a clinician,’ Connor says.
He says that while cost-effectiveness is popular from a policy perspective, value consists of much more than that and pushing the economics can lead to lower value care.
One aspect of high value care that Connor says is often missed is the patient perspective.
Patients often have expectations of receiving a certain kind of care for their condition, regardless of whether the evidence points to that care being optimal.
For example, a patient might expect hands-on treatment, while the clinician might be pushing exercise as the best path for improvement, based on the current evidence for best practice.
‘A patient may have preferences and expectations that lead them to not consider exercise a high priority in care.
If a physio delivers exercise only, that may be of lower value to the patient.
A higher value approach might be a collaborative discussion about what exercise might be beneficial and the reasons why it might be better than other treatments that they may have a higher preference for,’ Connor says.
‘Value is determined by the patient.
‘The clinician might see certain things as being more valuable for their patient than the patient believes they are.
‘Likewise, there might be a system overlaying the clinician–patient interaction that looks at the cost-benefit analysis.
‘It’s about being aware of these perspectives.
‘The cornerstone for everyone needs to be a conversation about what is most valuable for the patient.’
In fact, the next step in the high value care project is to look at the patient perspective.
Michael Corrigan says he is interested in the difference between what clinicians believe is high value care and what patients believe.
Co-author Michael Corrigan APAM, another RIPN member, says he is interested in the difference between what clinicians believe is high value care and what patients believe.
‘If you consider the recently published paper to be the first step, the patient perspective is the second.
‘I think the third step is to reflect on the two,’ Michael says.
The paper has largely been well received, says Connor, although he stresses that people should read it as one group’s ideas about what high value care looks like rather than the definitive answer.
‘We’re saying that this is the perspective of a network of clinicians that gives policymakers and other clinicians and, ultimately, our patients some insight into what can be valuable about the care experience,’ he says.
Connor is quick to note that the consensus framework was developed by a specific group of clinicians and therefore may not be fully applicable to all physiotherapists and practices.
But he believes the paper can be used as a jumping-off point for others around the country to start working together to improve the quality of care.
Musculoskeletal national group chair Adnan Asger Ali says the high value care model promotes evidence-based practice.
APA Musculoskeletal national group chair Adnan Asger Ali APAM MACP agrees.
‘I really liked the emphasis that high value care is, at its core, about what the patient considers high value care,’ Adnan says.
‘It didn’t demonise specific treatment modalities; it promoted evidence-based practice.’
For Priti Kharel, a public health researcher and PhD student at the University of Sydney, the paper provides a welcome positive view.
‘My research focuses on low value care in physiotherapy—what it is and how to replace it with high value care.
‘I found it interesting how the paper sums up the definition of high value care, because often when I search for definitions of high or low value care, there are different perspectives from different researchers or different medical fields.
‘However, this paper focuses on physiotherapists and it’s drawn from their experience,’ she says.
Priti Kharel has been looking at the barriers that prevent physios from adopting high value care practices.
One of Priti’s research projects examined barriers to adopting high value care in physiotherapy.
In particular, she looked at the Choosing Wisely recommendations developed with the support of the APA in 2015 (Choosing Wisely Australia 2016, Kharel et al 2021) and explored the reasons why many physiotherapists did not adopt them (Kharel et al 2022).
Ranking high among the barriers she has identified is the influence of the private practice culture, particularly when clinicians are incentivised to attend to a high volume of patients.
Another important barrier is patient expectations of specific care such as imaging, even in situations when it wasn’t considered best practice.
‘It will also be very interesting to see from a patient’s viewpoint what they consider high value care,’ Priti says.
Putting it into practice
For Connor, the consensus has clarified his approach to practice, making him more mindful of avoiding non-evidence-based, lower value care.
‘When you have a valuable care experience with someone, it’s a real partnership where you’ve been able to work together towards the result that is best for them.
‘Ultimately, everyone is striving for the best patient outcome,’ Connor says.
‘It boils down to good communication and working to empower the patient to reach their ideal health outcome.
‘And with a lot of patients it may not be the thing they initially say to you—“I want you to fix my knee pain.”
‘There is an element of really listening well, translating and sharing information and getting them to a place where they have the tools and they feel like you’ve given them a large portion of their life back or expanded their options.’
Michael says that while he hasn’t felt the need to overhaul the way he practises, the process of defining high value care has refined how he approaches his work, particularly in the provision of effective and accountable care.
‘I’m more conscious of considering what the patient’s goals are and making sure that the treatment approach is specific to the person, not just applying research broadly across groups,’ he says.
Within his practice, clinicians have always had informal chats about patient care but they are now looking at ways to more formally structure peer review—a process he says is easier to do in larger private clinics than in small or sole practitioner settings or in the public system.
Andrew says that it can be difficult to work out what part of the process he needs to own compared to the patient.
‘That can be hard if you’re striving to deliver the best care you can and it doesn’t work out for someone.
‘The first thing I do is question whether I could have done something better.
‘What could I have done differently to make a difference to that person?’ he says.
Accountability is an important part of high value care.
Andrew notes that when working with the younger physiotherapists in his practice, he encourages them to raise a case with more senior clinicians if they feel that there hasn’t been any change in the patient’s condition within a certain period of time.
‘We get them to examine their clinical reasoning from the perspective of delivering care that makes a difference.
‘If you’re not making a difference, you need to question your hypothesis.
‘Is there something else I’m not seeing?
‘Is there a medical reason for this problem rather than a musculoskeletal reason?
‘Where else could I refer this person to get care that might help them?’ he says.
Nicole Mandell says the model encourages physios to really listen to what their patients are saying.
Nicole Manvell APAM MACP, who has just taken on the role of chair for RIPN, says it’s important for physiotherapists to really listen to what their patients are telling them.
‘It’s the thing that frustrates me the most when I am working with other physios.
‘The patient comes in and tells them a story but the physio cuts them off—they don’t listen; they don’t hear what’s happening,’ Nicole says.
Consistency is another important aspect of high value care, says Nicole.
‘A patient with a single problem could visit 10 different physios and get 10 different diagnoses, 10 different treatment plans, and that boils my blood.
‘One of my big missions at RIPN is to try to change that,’ Nicole says.
‘I would love for physiotherapists to be a bit more consistent in their ability to diagnose things and to educate their patients about what’s wrong.
‘To know when to connect with certain specialists and when to do certain imaging and whether their patient needs surgery or not.
‘There’s so much variation in care, leading to errors, misinformation and loss of reputation.
‘This inconsistency in our care just undermines everything.’
Ultimately, says Connor, the work that RIPN has done to define high value care provides a framework that is applicable to all areas of physiotherapy, not just musculoskeletal practice.
‘It’s about going the extra mile to truly understand and work with the patient to get what’s best for them.’
The Research in Practice Network
The Research in Practice Network (RIPN) is a network of physiotherapists, physiotherapy researchers and other stakeholders in the greater Newcastle region, with the goal of driving clinically relevant research.
It was established by sports physiotherapist Connor Gleadhill in 2020 as part of his PhD research project, with funding from NSW Regional Health Partners, a NSW organisation that supports partnerships between the academic and healthcare sectors to facilitate translation of evidence into practice and address the health needs of regional and rural New South Wales (Gleadhill et al 2023b).
‘I wanted to create a network that would have practical benefit for the clinicians and help the researchers find problems to work on that would have a real impact on patient outcomes.
‘A network has the potential to address many problems with care delivery and continuously improve care quality in a learning system.
‘And establishing this network demonstrates a demand within physiotherapy, and in turn the profession can lead other allied health and primary care professionals to do the same,’ says Connor.
RIPN’s founding membership came from 19 musculoskeletal and sports clinics across the greater Newcastle region, clinicians and researchers from the Local Health District, and researchers from the University of Newcastle.
Its members range from recent graduates to physiotherapists with decades of experience.
RIPN has now grown to a network of over 120 members from over 50 clinics.
Andrew Delbridge APAM MACP, who until recently was the co-chair of RIPN alongside Connor, was a founding member.
Andrew had previously set up a professional development group with Nicole Manvell to bring together clinicians to discuss difficult cases, and could see the value in clinicians and researchers working together.
‘I hoped this might be a conduit for clinicians to get closer to research, understand it and learn how to integrate it into their practice,’ Andrew says.
The network has come up with three main priority areas:
- understanding patients’ perception of musculoskeletal conditions and effective treatments to manage them
- tackling the poor quality of care for musculoskeletal conditions
- tackling the lack of preventive focus from the healthcare system.
Nicole Manvell APAM MACP has recently taken over as chair of the RIPN.
She says that a key task for the future will be to link physiotherapists with researchers and find the funding to get some clinical research projects off the ground.
‘My role is to connect people. The more people who are involved and interested, the more questions we can answer and the bigger impact we can have,’ says Nicole.
Head to researchinpracticenetwork.com.au for more information.
High value care definitions and model
The BMJ Open paper includes the following consensus definitions:
High value care
Care that delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care.
Within high value care there are four contributing domains: high quality care; patient values; cost- effectiveness; reducing waste.
Evidence-based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems (connected).
Low value care
Care that is not patient-centred, or aligned with the patient’s goals, and is ineffective and/or unnecessary.
More information can be found in the paper (Gleadhill et al 2023a).
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