Characteristics of participants
i) PPs and case sites
Seven matched pairs of sites, (3 podiatry and 4 physiotherapy) were recruited. Sites were based across 8 Academic Health Science Networks in England (https://www.ahsnnetwork.com/) , provided adult services, a mixed range of settings, including private practice (n=2), primary care (n=6), secondary care (n=6), social enterprise (n=2) and were well matched by professional role, care setting and agenda for change banding (see Table 2). All physiotherapist and podiatrist independent prescribers had been qualified for at least 12 months prior to data collection. A total of 488 patients were recruited: 243 across the PP-IP sites with 245 across the NP-PP sites.
Table 2: Characteristics of the sites and Physiotherapists and Podiatrists
Pair
|
Case study site
|
No. Patients
Recruited
|
Type of PP
|
Job Title
|
Setting
|
Location in England *
|
Age
|
Salary band
|
Full or part time <30 hrs in practice
|
Education highest
|
Single or
multi-professional team
|
Patient questionnaire 1
|
Follow up- Patient Questionnaire2
|
Prescriptions
|
1
|
1
|
49
|
PO-IP
|
General/Private
|
Private
|
London
|
71
|
8a
|
Full time
|
Doctorate
|
single
|
40
|
N/A
|
0
|
2
|
46
|
PO-NP
|
General/Private
|
Private
|
London
|
47
|
12
|
Full time
|
Masters
|
single
|
35
|
N/A
|
n/a
|
2
|
3
|
33
|
PO-IP
|
Specialist
|
Secondary care, NHS
In/outpatient
|
Wessex
|
41
|
7
|
Full time
|
Masters
|
multi-professional
|
22
|
19
|
6
|
8
|
37
|
PO-NP
|
Specialist
|
NHS primary & secondary (& private)
|
Kent, Surrey, Sussex
|
39
|
6
|
Full-time
|
Degree
|
single
|
25
|
22
|
n/a
|
3
|
10
|
51
|
PO-IP
|
Surgeon/consultant
|
NHS secondary (& private)
|
Oxford
|
59
|
9
|
Full time
|
Masters
|
multi-professional
|
32
|
38
|
3
|
6
|
42
|
PO-NP
|
Surgeon/consultant
|
NHS secondary
|
North East &
North Cumbria
|
47
|
9
|
Part-time
|
Masters
|
multi-professional
|
26
|
23
|
n/a
|
4
|
7
|
6
|
PT-IP
|
Specialist
|
Community
|
London
|
31
|
7
|
Part-time
|
Masters
|
multi-professional
|
25
|
N/A
|
0
|
4
|
11
|
PT-NP
|
Specialist
|
NHS Primary, Community care
|
Kent, Surrey, Sussex
|
47
|
8a
|
Full time
|
Masters
|
multi-professional
|
25
|
N/A
|
n/a
|
5
|
9
|
42
|
PT-IP
|
Specialist
|
Primary, community
Social enterprise
|
Kent, Surrey, Sussex
|
46
|
8a
|
Full time
|
Diploma
|
multi-professional
|
2
|
2
|
3
|
5
|
38
|
PT-NP
|
Surgeon/consultant
|
Tier 2 NHS ESP
assessment service
|
Wessex
|
42
|
8a
|
Part-time
|
Doctorate
|
multi-professional
|
6
|
3
|
n/a
|
6
|
11
|
41
|
PT-IP
|
Specialist
|
Acute Foundation Trust
|
Northwest coast
|
58
|
8a
|
Full time
|
Masters
|
multi-professional
|
27
|
29
|
0
|
12
|
35
|
PT-NP
|
Surgeon/consultant
|
NHS secondary care
|
Kent, Surrey, Sussex
|
48
|
8c
|
Full time
|
Masters
|
multi-professional
|
19
|
23
|
n/a
|
7
|
13
|
21
|
PT-IP
|
Specialist
|
NHS primary & community
Social enterprise
|
Kent, Surrey, Sussex
|
52
|
8a
|
Full time
|
Masters
|
multi-professional
|
8
|
16
|
3
|
14
|
36
|
PT-NP
|
Specialist
|
Primary & community
Social enterprise
|
Kent, Surrey, Sussex
|
38
|
8a
|
Full time
|
Masters
|
multi-professional
|
23
|
20
|
n/a
|
Totals
|
|
488
|
|
|
|
|
|
|
|
|
|
315
|
195
|
15
|
PO-IP: Podiatrist independent prescriber PO-NP: Podiatrist non-prescriber PT-IP: Physiotherapist independent prescriber PT-NP: Physiotherapist non-prescriber
Job title: Surgeon/Consultant (consultant physiotherapists, consultant podiatric surgeons) General/Private (physiotherapists practitioners, physiotherapists, podiatrists)
Specialist (e.g. Clinical specialist physiotherapists, extended scope physiotherapist clinical specialist podiatrists, clinical lead or senior podiatrists)
Nearly all consultations (n=474), both independent prescribers and to non-prescribers, were face to face (n=473, 99.8%), duration 2-203 minutes. There was considerable variation in the location of services: 39.2% (n=186) of consultations were provided in NHS hospital outpatients, 25.1% (n=119) NHS community clinics, 20.3% (n=96) private practice, 9.7% (n=46) general practice, 4.4% (n=21) social enterprise and 1.3% (n=6) community service. Of the observed consultations 112 (23.6%) included a medicine related activity, where either a new medication, repeat medication (same dosage) or repeat medication with a change to dosage was required, with patients requiring a total of 124 items of medicine (see Table 3).
Almost all medicines related activity within physiotherapy sites, both independent prescribers and non-prescribers, was related to pain and movement control, either via pain medication or through injection therapy. There was one incident where a patient was advised to alter contraception use following surgery by an independent prescriber. A wider range of medication types were used by podiatrists, both independent prescribers and to non-prescribers, the most common being anti-microbial/anti-fungal topical creams, antibiotics and pain medication. Patients requiring medicines recommended by non-prescribers, both podiatrists and physiotherapists, were subsequently referred to a medical doctor in the usual way.
Table 3: Consultations with medicines related activity
Number of observed consultations
|
Physiotherapist IP
|
Number of items
|
Physiotherapist NP
|
Number of items
|
Podiatrist IP
|
Number of items
|
Podiatrist NP
|
Number of items
|
n=107
|
n=37
|
n=115
|
n=29
|
n=128
|
n=45
|
n=124
|
n=13
|
Consultations with no medicines related activity
|
75
|
n/a
|
87
|
n/a
|
93
|
n/a
|
114
|
|
Consultations with medicines activity
|
|
|
|
|
|
|
|
|
New medication
|
23
|
21 x 1
2 x 2
3 x 1
|
27
|
26 x 1
1 x 2
|
31
|
27 x 1
3 x 2
1 x 4
|
10
|
7 x 1
3 x 2
|
Repeat medication (same dosage)
|
9
|
9 x 1
|
1
|
1
|
2
|
2x 2
|
0
|
0
|
Repeat medication (dosage changed)
|
0
|
0
|
0
|
0
|
2
|
2 x 2
|
0
|
0
|
Total number of consultations with medicines related activity
|
n=32
|
n/a
|
n=28
|
n/a
|
n=35
|
n/a
|
n=10
|
n/a
|
ii) Patients
Demographic data (see table 4) were collected from 315/ 468 (67.3%) patients who consented to and returned patient questionnaire 1: 49.5% (n=156) were from prescribing and 50.5% (n=159) from non-prescribing sites. A lack of benchmark data with which to compare the patient data means it is not possible to confirm how representative our sample is with respect to the larger population. However, the samples, from the prescribing and non-prescribing group in this study were similar in terms of age, employment status, level of formal education, and ethnic group (p>0.05).
Table 4: Patient characteristics
|
Physiotherapy
n (%)
|
Podiatry
n (%)
|
Total
n=number of responses
|
% of total sample
|
Professional group
|
|
|
|
|
Which professional consulted
|
135 (42.86%)
|
180 (57.14%)
|
315
|
100%
|
Gender
|
|
|
n=254
|
|
Male
|
34 (30.4%)
|
55 (38.7%)
|
89
|
35%
|
Female
|
78 (69.6%)
|
87 (61.3%)
|
165
|
65%
|
Age
|
|
|
|
Physiotherapy group: n= 111, mean 59.7, SD 16.6, (range 17.6-100.98)
|
Podiatry group: n=139, mean 67.1, SD 16.16, (range 16.17-94.32)
|
Total: n=250, mean 63.8, SD 16.7
|
Living arrangements
|
|
|
n=257
|
|
Live alone
|
19 (17.4%)
|
32 (21.6%)
|
51
|
19.8%
|
Live with other adult(s)
|
90 (82.6%)
|
94 (63.5)
|
184
|
71.6%
|
Care home resident
|
0
|
22 (14.9%)
|
22
|
8.6%
|
Type of accommodation
|
|
|
n=276
|
|
Owner occupied house/flat
|
97 (82.2%)
|
104 (65.8%)
|
201
|
72.8%
|
Privately rented house/flat
|
12 (1.02%)
|
12 (7.6%)
|
24
|
8.7%
|
Local authority/housing association/cooperative
|
9 (7.6%)
|
13 (8.2%)
|
22
|
8%
|
Residential or care home, hospice
|
0
|
29 (18.4%)
|
29
|
1.05%
|
Employment group
|
|
|
n=262
|
|
In paid or voluntary employment
|
46 (41.1%)
|
40 (26.7%)
|
86
|
32.8%
|
Unemployed/student/at home/sick
|
15 (13.4%)
|
12 (8%)
|
27
|
10.3%
|
Retired
|
51 (45.5%)
|
98 (65.3%)
|
149
|
56.9%
|
Educated beyond 18 years
|
|
|
n=274
|
|
Yes
|
32 (27.4%)
|
51 (32.5%)
|
83
|
30.3%
|
No
|
85 (72.6%)
|
106 (67.5%)
|
191
|
69.7%
|
Ethnic group
|
|
|
n=283
|
|
White
|
117 (96.7%)
|
160 (98.8%)
|
277
|
97.9%
|
Other
|
4 (3.3%)
|
2 (1.2%)
|
6
|
2.1%
|
Follow up questionnaire 2: A response rate of 73.7% (197/267) was obtained for questionnaire 2. This sample excluded the 175 participants from the first 4 sites (Sites 1, 2, 4, 7) (see Table 2). Of the remaining 313 participants, 285 consented to follow-up, however contact details were incorrect or missing for 18 participants, leaving 267 eligible to participate.
iii) Patient outcomes
a) Satisfaction and access to services
The majority of patients (75.9%, n=239) agreed that physiotherapists and podiatrists should be able to prescribe medicines for patients, however 23.2% (n=73) would prefer a doctor to prescribe. Levels of satisfaction for the sample as a total were high, with over 60% positive agreement on all items other than ability to contact the service in an emergency (n=144, 44.4%). Satisfaction with 17 specified aspects of the consultation and services provided by physiotherapists and podiatrists indicated a significantly higher level of satisfaction among the patients of physiotherapist and podiatrist independent prescribers than those of non-prescribers in 8 instances (table 5).
With respect to service access, patients of podiatrist independent prescribers were more satisfied with ‘the ease of making an appointment’ and ‘the ability to contact the service by phone or in times of emergency’ (see table 5) than patients of the non-prescribing podiatrists, with no notable difference evident in patients attending physiotherapist prescribers compared to patients of non-prescribing physiotherapists.
There was no effect on the remaining four items reporting on ease of access on the acceptability of: i) waiting time to obtain an appointment; ii) obtaining an appointment on a convenient day or hour; iii) waiting time or iv) seeing the physiotherapist or podiatrist at the appointed time between patients attending a physiotherapist or podiatrist independent prescriber when compared to those attending a non-prescribing physiotherapist or podiatrist.
Table 5 Patient views and experience of satisfaction with care received from physiotherapist or podiatrist
Patient views and experience of consultation with physiotherapist or podiatrist
(R) indicates reverse score item
|
Physiotherapist Independent
Prescriber (n=62)
|
Physiotherapist
Non-prescriber
(n=73)
|
Mann-
Whitney
U-test
|
Podiatrist
Independent Prescriber (n=94)
|
Podiatrist
Non-prescriber
(n=86)
|
|
Total
n=315
|
Strongly Agree/Agree
(compared with strongly disagree/disagree/no opinion)
|
Strongly Agree/Agree
(compared with strongly disagree/disagree/no opinion)
|
Strongly Agree/Agree
|
n
|
% sample
|
n
|
%
sample
|
p*
|
n
|
%
Sample
|
n
|
%
sample
|
P *
|
n
|
%
|
1. Overall I was satisfied with the consultation from this physiotherapist or podiatrist
|
59
|
95.1%
|
67
|
91.2%
|
0.280
|
85
|
90.4%
|
80
|
93.0%
|
0.281
|
291
|
92.4%
|
2.The physiotherapist or podiatrist was very careful to check everything when carrying out my care
|
60
|
96.8%
|
69
|
94.5%
|
0.092
|
82
|
87.2%
|
77
|
89.5%
|
0.367
|
288
|
91.4%
|
3.I will follow the advice of this physiotherapist or podiatrist because I think she/he is right
|
59
|
95.1%
|
64
|
87.7%
|
0.021
|
81
|
86.2%
|
75
|
87.2%
|
0.020
|
279
|
88.6%
|
4.The time I was able to spend with the physiotherapist or podiatrist was a bit too short (R)
|
46
|
74.2 %
|
61
|
83.6%
|
0.807
|
68
|
81.0%
|
59
|
68.6 %
|
0.333
|
234
|
74.3%
|
5.The physiotherapist or podiatrist explained the reasons for the advice given
|
56
|
90.3%
|
67
|
91.2%
|
0.150
|
79
|
94.0%
|
72
|
83.7%
|
0.711
|
274
|
87.0%
|
6.Some things about the consultation with the physiotherapist or podiatrist could have been better (R)
|
46
|
74.2 %
|
53
|
63.0 %
|
0.166
|
68
|
72.3%
|
60
|
69.8%
|
0.120
|
227
|
72.1%
|
7.The physiotherapist or podiatrist listened very carefully to what I had to say
|
57
|
91.2%
|
68
|
93.2%
|
0.344
|
79
|
94.0%
|
74
|
86.0%
|
0.330
|
278
|
88.3%
|
8.I understand my treatment much better after seeing this The physiotherapist or podiatrist
|
54
|
87.1%
|
54
|
74.0%
|
0.025
|
68
|
72.3%
|
61
|
70.9%
|
0.164
|
237
|
75.2%
|
9.The physiotherapist or podiatrist was interested in me as a person not just my illness
|
50
|
80.1%
|
56
|
76.7%
|
0.033
|
77
|
81.9%
|
65
|
75.6%
|
0.152
|
248
|
78.7%
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Patient views and experience of consultation with physiotherapist or podiatrist
(R) indicates reverse score item
|
Physiotherapist Independent
Prescriber (n=62)
|
Physiotherapist
Non-prescriber
(n=73)
|
Mann-
Whitney
U-test
|
Podiatrist
Independent Prescriber (n=94)
|
Podiatrist
Non-prescriber
(n=86)
|
|
Total
n=315
|
Strongly Agree/Agree
(compared with strongly disagree/disagree/no opinion)
|
Strongly Agree/Agree
(compared with strongly disagree/disagree/no opinion)
|
|
Strongly Agree/Agree
|
n
|
% sample
|
n
|
%
sample
|
P*
|
n
|
%
sample
|
n
|
%
sample
|
P *
|
n
|
%
sample
|
10.I am NOT completely satisfied with the advice received from this physiotherapist or podiatrist (R)
|
56
|
90.3%
|
61
|
83.6%
|
0.019
|
75
|
79.8%
|
67
|
78.0 %
|
0.455
|
249
|
79.0%
|
11.It was easy to make an appointment with the physiotherapist or podiatrist
|
35
|
56.5%
|
49
|
67.1%
|
0.900
|
74
|
78.7%
|
60
|
69.8%
|
0.028
|
218
|
69.2%
|
12.There was an acceptable time lapse to obtain an appointment
|
30
|
48.4%
|
43
|
58.9%
|
0.759
|
67
|
71.3%
|
57
|
66.3%
|
0.378
|
197
|
62.5%
|
13.It was possible to obtain an appointment on a convenient day or hour
|
40
|
64.5%
|
49
|
67.1%
|
0.695
|
70
|
74.5%
|
62
|
72.1%
|
0.067
|
221
|
70.2%
|
14.I can contact someone in the service by phone for help or advice in case of problem
|
38
|
61.2%
|
47
|
64.4%
|
0.881
|
70
|
74.5%
|
56
|
65.1%
|
0.020
|
211
|
67.0%
|
15.In an emergency I can get a quick appointment/consultation at this service
|
19
|
30.6%
|
25
|
34.2%
|
0.177
|
60
|
63.8%
|
36
|
41.9%
|
0.001
|
140
|
44.4%
|
16.I saw the physiotherapist or podiatrist at the appointed time
|
42
|
67.7%
|
62
|
84.9%
|
0.111
|
74
|
78.7%
|
73
|
84.9%
|
0.952
|
251
|
79.7%
|
17.The waiting time was acceptable
|
45
|
72.5%
|
64
|
87.7%
|
0.088
|
80
|
85.1%
|
71
|
82.6%
|
0.494
|
260
|
82.5%
|
* p based on Mann Whitney U test using 5-point Likert Scale; for ease of interpretation, the table only displays for each item the number of patients who indicated a positive response (i.e. Strongly Agree/Agree or Strongly Disagree/Disagree for negatively paraphrased items (R) ) – all corresponding percentages relate to the entire subgroup at the top of the column i.e. interpreting no response to the specific item as a lack of a positive response.
Patients of a physiotherapist or podiatrist independent prescribers were more likely to receive medicines information or advice during the consultation (58 out of 146 (39.7%) vs 37 out of 151 non-prescribing physiotherapist or podiatrist patients (24.5%); p=0.005), with varying levels of satisfaction reported (see table 6). Compared to patients of non-prescribing physiotherapist or podiatrists, patients of physiotherapist or podiatrist independent prescribers were significantly more likely to: ‘be told when’ and ‘how often’ to take their medicine, ‘intend to take their medicines’ and ‘find it easier to follow the physiotherapists’ advice’ (p≤ 0.05).
Table 6 Patient views and experience of medicines management advice and information provided by physiotherapist or podiatrist
Patient views and experience of medicines management advice and information provided by physiotherapist or podiatrist
|
|
Physiotherapist Independent
Prescriber
(n=27)
|
Physiotherapist
Non-prescriber
(n=24)
|
Mann-
Whitney
U-test
|
Podiatrist
Independent Prescriber
(n=31)
|
Podiatrist
Non-prescriber
(n=13)
|
Mann-
Whitney
U-test
|
Total
|
|
Strongly Agree/Agree
|
Strongly Agree/Agree
|
Strongly Agree/Agree
|
N
(excluding not applicable^ )
|
n
|
%
|
n
|
%
|
p*
|
n
|
%
|
n
|
%
|
p*
|
n
|
%
|
- The physiotherapist or podiatrist gave me time to clarify questions I may have had about my medicine
|
84
|
24
|
96.0%
|
19
|
86.4%
|
0.627
|
21
|
84.0%
|
11
|
91.7%
|
0.901
|
75
|
89.3%
|
- The physiotherapist or podiatrist told me when to take my medicine
|
64
|
11
|
73.3%
|
6
|
40.0%
|
0.030
|
19
|
82.6%
|
9
|
81.8%
|
0.719
|
45
|
70.3%
|
- The physiotherapist or podiatrist told me how often I should take my medicine
|
61
|
12
|
85.7%
|
5
|
35.6%
|
0.002
|
19
|
86.4%
|
9
|
81.8%
|
0.835
|
43
|
70.5%
|
- The physiotherapist or podiatrist provided me with information on the purpose of my medicine
|
75
|
16
|
73.7%
|
14
|
70.0%
|
0.547
|
19
|
82.6%
|
11
|
84.6%
|
0.549
|
60
|
80.0%
|
- The physiotherapist or podiatrist provided me with information on how to use my medicine
|
59
|
11
|
73.3%
|
5
|
45.5%
|
0.062
|
16
|
80.0%
|
10
|
91.0%
|
0.608
|
42
|
71.2%
|
- I expect that it will be easy to follow the physiotherapist's or podiatrist's advice about my medicine
|
68
|
12
|
75.0%
|
10
|
66.7%
|
0.181
|
22
|
91.7%
|
11
|
84.6%
|
0.346
|
57
|
83.8%
|
- The physiotherapist or podiatrist told me the name of my medicine
|
71
|
17
|
85.0%
|
9
|
60.0%
|
0.178
|
18
|
75.0%
|
9
|
75.0%
|
0.354
|
53
|
74.6%
|
Patient views and experience of medicines management advice and information provided by physiotherapist or podiatrist
|
|
Physiotherapist Independent
Prescriber
|
Physiotherapist
Non-prescriber
|
Podiatrist
Independent Prescriber
|
Podiatrist
Non-prescriber
|
|
Total
|
|
Strongly Agree/Agree
|
|
Strongly Agree/Agree
|
|
Strongly Agree/Agree
|
N (excluding not applicable^)
|
n
|
%
|
n
|
%
|
p*
|
n
|
%
|
n
|
%
|
p*
|
n
|
%
|
- The physiotherapist or podiatrist explained the side effects of my medicine
|
63
|
11
|
68.8%
|
12
|
70.6%
|
0.578
|
13
|
59.1%
|
5
|
50.0%
|
0.443
|
41
|
65.0%
|
- I would have liked to have received more information about my medicine from the physiotherapist or podiatrist #
|
73
|
3
|
13.6%
|
3
|
17.6%
|
0.438
|
0
|
0.0%
|
3
|
25.0%
|
0.288
|
9
|
12.3%
|
- The physiotherapist or podiatrist provided me with information on what to do if I missed a dose of my medicine
|
48
|
3
|
25.0%
|
3
|
27.3%
|
0.795
|
3
|
21.4%
|
1
|
9.1%
|
0.274
|
10
|
20.8%
|
- It may be difficult for me to do exactly what the physiotherapist or podiatrist told me to do in relation to my medicine #
|
56
|
0
|
0.0%
|
1
|
9.1%
|
0.038
|
5
|
23.8%
|
1
|
9.1%
|
0.832
|
7
|
12.5%
|
- I'm not sure it will be worth the trouble to take the medicine advised by the physiotherapist or podiatrist #
|
62
|
2
|
13.3%
|
1
|
8.3%
|
0.298
|
1
|
6.7%
|
1
|
8.3%
|
0.570
|
5
|
8.1%
|
- Receiving a prescription for medicine from my physiotherapist or podiatrist reduced my waiting time today
|
40
|
4
|
30.8%
|
1
|
16.6%
|
0.919
|
6
|
46.1%
|
6
|
75.0%
|
0.446
|
17
|
42.5%
|
- I am likely to take the medicine prescribed for me today
|
47
|
7
|
36.8%
|
2
|
28.5%
|
0.022
|
13
|
72.2%
|
11
|
100.0%
|
0.204
|
33
|
70.2%
|
^ those patients who did not respond “Yes” to the preceding question “During the consultation today, did the physiotherapist or podiatrist prescribe and/or give you advice and information about medicines(s) ?”.
*p-value based on Mann Whitney U test utilising the original 5 point Likert scale; for ease of interpretation, the table only displays for each item the number of patients who responded Strongly Agree/Agree.
b) Quality of life- EQ-5D-L
Indications at baseline were that patients who saw physiotherapist independent prescribers had lower generic quality of life than those seeing the non-prescribing physiotherapists, due to lower scores on the mobility dimension. However, there was no statistically significant difference between physiotherapist or podiatrist independent prescribers and non-prescribing physiotherapist or podiatrist groups on either individual items or overall EQ-5D-5Lscore (p≥0.05) (Table 7, individual dimension scores not shown).
Quality of life overall scores in both physiotherapist and podiatrist independent prescribers and non-prescribing groups improved significantly between baseline and follow-up. Differences in change scores between the physiotherapist and podiatrist independent prescribers and non-prescribing physiotherapist or podiatrists, however, were not statistically significant (Table 7). The sample for which data at both time points were available was limited (n=116).
Table 7: Overall EQ5D index score: baseline and follow-up
|
From the 129 completers
|
Baseline for 116 with EQ5D in BOTH data sets only
|
Follow-Up for 116 with EQ5D in BOTH data sets only
|
|
|
|
Number of patients completing BOTH sets of EQ5D questions
|
EQ5D-5L
Mean (SD)
|
EQ5D-5L
Mean (SD)
|
Change from Baseline (95% CI)*
|
Paired
t-test
p-value
|
PT IP
|
25
|
0.56 (0.31)
|
0.64 (0.27)
|
0.08 (-0.04 to 0.19)
|
0.194
|
PT NP
|
28
|
0.73 (0.19)
|
0.73 (0.22)
|
0.001 (-0.07 to 0.07)
|
0.973
|
PO IP
|
33
|
0.70 (0.26)
|
0.78 (0.20)
|
0.08 (0.003 to 0.16)
|
0.042
|
PO NP
|
30
|
0.66 (0.26)
|
0.76 (0.28)
|
0.10 (0.03 to 0.16)
|
0.004
|
All IP
|
58
|
0.64 (0.29)
|
0.72 (0.24)
|
0.08 (0.01 to 0.14)
|
0.019
|
All NP
|
58
|
0.69 (0.23)
|
0.75 (0.25)
|
0.05 (0.003 to 0.10)
|
0.036
|
All PT
|
53
|
0.65 (0.26)
|
0.69 (0.25)
|
0.04 (-0.03 to 0.10)
|
0.266
|
All PO
|
63
|
0.68 (0.26)
|
0.77 (0.24)
|
0.09 (0.04 to 0.14)
|
0.001
|
*[Positive change indicates mean improvement in health at Follow-Up]
iv. Economic analysis
Amongst physiotherapists, the independent prescribers had significantly longer consultation duration than non-prescribers (27.6 vs 20.8 minutes) (Table 8). Amongst podiatrists, the frequency with which medications i.e. a new medication, repeat medication (same dosage), or repeat medication (dosage changed) and tests were ordered were significantly higher in independent prescribers than non-prescribers (Table 8). There was a trend for consultation duration to be longer for independent prescribers (23.4 vs 19.9 minutes) (Table 8).
Comparing physiotherapists and podiatrists, planning of follow up consultations was higher by podiatrist independent prescribers than physiotherapist independent prescribers, but no significant differences were found between independent prescribers and non-prescribers within the professions. After removing unplanned consultations in the two months after the original consultation that were considered (by two independent reviewers) to be unamenable to treatment delivered in the index consultation, only four items of unplanned service utilisation remained across the whole sample of patients of physiotherapists and podiatrists, all of which were related to pain relief (Table 8).
Costs of consultations: Difference in costs of consultation duration of independent prescribers compared to non-prescribers for physiotherapist and podiatrist groups were based on Agenda for Change (AfC) band 8a, which was the most frequent grade of physiotherapist and podiatrist independent prescribers in the study, i.e. £70 per hour 65. Compared to the cost of a non-prescriber consultation, the independent prescriber consultation was, on average, more costly by £7.95 for physiotherapists (£24.30 vs £32.25) and £8.62 (£19.69 vs £28.31) for podiatrists. The salary of a grade 9 professional is twice that of grade 8a, so at that higher level, the differences in the cost of consultations between independent prescribers and non-prescribers would be doubled. Use of grade 7 instead of grade 8a would reduce the differences between independent prescribers and non-prescriber by about £1.20 per consultation. Amongst the podiatrists, the independent prescribers were at band 7 (advanced / team leader), 8a (principal) and 9 (consultant); two of the non-prescribers were band 9 and the third was band 6 (specialist). Participating physiotherapists were all band 8a, except one non-prescriber (grade 8c), and one independent prescriber (grade 7).
Costs could not be estimated for the other elements of activity that might differ between independent prescribers and non-prescribers due to data availability problems. Information on tests ordered were drawn from a small sample of records (n=max 15 per site) in each site (the audit); reporting of the type and dose of new medications, referrals and frequency of planned follow up was incomplete.
Table 8 Comparison of independent prescribers and non-prescribers, by profession, on variables used in the cost analysis
Professional group
|
Prescribing status
|
|
Number of medications required
(Observation Q6)
|
Number of tests requested / patient
(Sample audit)
|
Consultation time in minutes / patient
(Observation Q1)
|
Discussions with colleagues in minutes/ per patient (Observation Q9,10)
|
x
|
Patients receiving referral (not for tests) (Observation Q11)
|
Patients with planned follow up (Observation Q15)
|
Patients reporting verified unplanned consultations within 2 months (Patient questionnaire)
|
PHYSIO-
THERAPY
|
Independent prescriber (IP)
|
N
|
107
|
42
|
107
|
107
|
N
|
107
|
107
|
47
|
Missing
|
9
|
74
|
9
|
9
|
Yes N
|
32
|
54 (8 by phone)
|
1
|
N, % of zeros
|
75, 70.1%
|
32, 76.2%
|
0
|
88, 82.2%
|
Yes %
|
29.9%
|
50.5%
|
2.1%
|
Mean
|
0.327
|
0.262
|
27.64
|
1.802
|
|
|
|
|
SD
|
0.546
|
0.497
|
14.10
|
5.585
|
|
|
|
|
Median
|
0
|
0
|
24
|
0
|
|
|
|
|
IQR
|
0 to 1
|
0 to 0.25
|
18 to 34
|
0 to 0
|
|
|
|
|
Non prescriber (NP)
|
N
|
115
|
44
|
115
|
115
|
N
|
115
|
115
|
46
|
Missing
|
7
|
78
|
7
|
7
|
Yes N
|
34
|
51 (1 by phone)
|
2
|
N, % of zeros
|
87, 75.7%
|
33, 75.0%
|
0
|
114, 99.1%
|
Yes %
|
29.6%
|
44.3%
|
4.3%
|
Mean
|
0.252
|
0.250
|
20.83
|
0~
|
|
|
|
|
SD
|
0.456
|
0.438
|
10.46
|
0~
|
|
|
|
|
Median
|
0
|
0
|
19
|
0
|
|
|
|
|
IQR
|
0 to 0
|
0 to 0.75
|
14 to 28
|
0 to 0
|
|
|
|
|
Significant difference (p)
|
MWU 0.336
|
MWU 0.949
|
MWU <0.0005
|
MWU <0.0005
|
|
Chi Sq 0.956
|
Chi Sq 0.361
|
FE 0.617
|
|
|
|
|
|
|
|
|
|
|
|
PODIATRY
|
Independent prescriber (IP)
|
N
|
128
|
24
|
128
|
128
|
N
|
128
|
128
|
57
|
Missing
|
5
|
109
|
5
|
5
|
Yes N
|
17
|
110 (0 by phone)
|
0
|
N, % of zeros
|
93, 72.7%
|
17, 70.8%
|
0
|
109, 85.2%
|
Yes %
|
13.3%
|
85.9%
|
0%
|
Mean
|
0.328
|
0.375
|
24.27
|
0.976
|
|
|
|
|
SD
|
0.616
|
0.647
|
24.32
|
2.682
|
|
|
|
|
Median
|
0
|
0
|
16
|
0
|
|
|
|
|
IQR
|
0 to 1
|
0 to 1
|
11 to 27.75
|
0 to 0
|
|
|
|
|
Non prescriber (NP)
|
N
|
124
|
32
|
123
|
124
|
N
|
124
|
124
|
47
|
Missing
|
3
|
95
|
4
|
3
|
Yes N
|
6
|
111 (7 by phone)
|
1
|
N, % of zeros
|
114, 91.9%
|
32, 100%
|
0
|
111, 89.5%
|
Yes %
|
4.8%
|
89.5%
|
2.1%
|
Mean
|
0.105
|
0
|
16.88
|
0.726
|
|
|
|
|
SD
|
0.379
|
0
|
9.86
|
2.867
|
|
|
|
|
Median
|
0
|
0
|
16
|
0
|
|
|
|
|
IQR
|
0 to 0
|
0 to 0
|
10 to 23
|
0 to 0
|
|
|
|
|
Significant difference (p)
|
MWU 0.001
|
MWU <0.0005
|
MWU 0.073
|
MWU 0.349
|
|
Chi Sq 0.20
|
Chi Sq 0.387
|
FE 0.452
|
Number of medications required= new medication + repeat medication (same dosage) + repeat medication (dosage changed)
Discussions with colleagues: The independent prescribers in the physiotherapist group consulted colleagues about patients significantly more often than the non-prescribers (17.8% vs 0.9% of consultations), and most discussions were with medical colleagues, averaging 9.5 minutes per discussion (Table 9).
Podiatrists held discussions with colleagues for >10% of consultations (14.8% IPs, 10.5% NPs, (Table 9)), for around 7 minutes. Independent prescribers discussed a higher proportion of patients with medical colleagues, than a colleague from the same profession, thereby likely to be incurring higher costs. However, information on colleagues consulted was not precise, so calculations were indicative only. Some podiatrists were band 9 (consultant), so reporting discussions with ‘same’ professional would imply higher costs than are indicated in the table, which are based on AfC band 8a.
Table 9 Discussion with colleagues about patient
Professional group
|
Prescribing status
|
Number and % of all patients seen for whom discussion occurred with colleague
|
Mean (SD) minutes in discussions with colleague
per patient
|
Discussion with same
professional
n, mean (SD) minutes
|
Same colleague
cost / discussion*
(£, 2015)
|
Discussion with
medical professional
n, mean(SD)
minutes
|
Medical colleague cost / discussion*
(£, 2015)
|
PHYSIOTHERAPY
|
Independent prescriber
|
19 (17.8%)
|
10.61 (9.68)
|
3, 19.5 (14.8)
|
£22.75
|
16, 9.5 (8.9)
|
£21.69
|
|
Non prescriber
|
1 (0.9%)
|
0 (n/a)
|
1, time missing
|
Not known
|
0, n/a
|
0
|
|
Significant difference
|
p<0.0005#
|
n/a
|
|
|
|
|
|
|
|
|
|
|
|
|
PODIATRY
|
Independent prescriber
|
19 (14.8%)
|
6.89 (3.20)
|
11, 6.8 (3.6)
|
£7.93
|
8, 7.0 (2.8)
|
£15.98
|
|
Non prescriber
|
13 (10.5%)
|
6.92 (6.14)
|
12, 7.3 (6.3)
|
£8.52
|
1, 3.0 (0.0)
|
£6.85
|
|
Significant difference
|
p=0.299~
|
p=0.493^
|
|
|
|
|
# Fishers Exact test; ~ Chi squared test; ^ Mann Whitney U test
|
* Unit costs of health and social care 2015 (Curtis and Burns 2015), pro rata based on £70/ hour for same professional i.e. AfC band 8a, as in Ec2 above, and £137/ hour for medical consultant
|
Cost implications: The available data suggest that for both physiotherapists and podiatrists in this study, care delivery by independent prescribers is more resource intensive and costly than non-prescribers due to longer consultations for physiotherapists and taking more time of colleagues to discuss patients. Whilst not costed, podiatrist independent prescribers had higher frequency of ordering medications and tests than non-prescribing podiatrists. Analysis of the changes in self-reported health status between baseline and 2 months follow up using EQ-5D-5L found no difference in change scores of independent prescribers and non-prescribers for either physiotherapists or podiatrists, but these data were only available for a small sample of participants.