More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment.

BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.

Service Utilization and Costs of Patients at a Cash-Based Physical Therapy Clinic.

Cash-based physical therapy, a model in which the clinicians do not accept insurance payments and accept only direct payment, is quickly becoming an enticing option for clinicians who own their own practice. The purpose of this study was to describe service utilization for a single cash-based physical therapy clinic. Forty-eight charts of patients who had been discharged between 2013 and 2016 were randomly selected. The data were deidentified prior to the researchers gaining access. Chronic diagnoses were predominately prevalent (n = 28). The lumbo/pelvic region of diagnoses (39.6%) and knee/leg region of diagnoses (29.2%) encompassed the majority of the diagnoses. The mean physical therapy utilization for the cohort per episode of care was 8.0 ± 8.1 visits per episode of care, total cost of $780.19 ± 530.30 per episode of care, and $97.52 per visit. This study is the first to present data regarding costs, utilization, and patient demographics for a cash-based physical therapy clinic.

Using cost-analyses to inform health professions education - The economic cost of pre-clinical failure.

BACKGROUND: Student failure creates additional economic costs. Knowing the cost of failure helps to frame its economic burden relative to other educational issues, providing an evidence-base to guide priority setting and allocation of resources. The Ingredients Method is a cost-analysis approach which has been previously applied to health professions education research. In this study, the Ingredients Method is introduced, and applied to a case study, investigating the cost of pre-clinical student failure. METHODS: The four step Ingredients Method was introduced and applied: (1) identify and specify resource items, (2) measure volume of resources in natural units, (3) assign monetary prices to resource items, and (4) analyze and report costs. Calculations were based on a physiotherapy program at an Australian university. RESULTS: The cost of failure was £5991 per failing student, distributed across students (70%), the government (21%), and the university (8%). If the cost of failure and attrition is distributed among the remaining continuing cohort, the cost per continuing student educated increases from £9923 to £11,391 per semester. CONCLUSIONS: The economics of health professions education is complex. Researchers should consider both accuracy and feasibility in their costing approach, toward the goal of better informing cost-conscious decision-making.

Economic evaluation of a brief education, self-management and upper limb exercise training in people with rheumatoid arthritis (EXTRA) programme: a trial-based analysis.

OBJECTIVE: The aim of this study was to conduct a cost-utility analysis of the Education, Self-management and Upper Limb Exercise Training in People with RA (EXTRA) programme compared with usual care. METHODS: A within-trial incremental cost-utility analysis was conducted with 108 participants randomized to either the EXTRA programme (n = 52) or usual care (n = 56). A health care perspective was assumed for the primary analysis with a 36 week follow-up. Resource use information was collected on interventions, medication, primary and secondary care contacts, private health care and social care costs. Quality-adjusted life years (QALYs) were calculated from the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire responses at baseline, 12 and 36 weeks. RESULTS: Compared with usual care, total QALYs gained were higher in the EXTRA programme, leading to an increase of 0.0296 QALYs. The mean National Health Service (NHS) costs per participant were slightly higher in the EXTRA programme (by £82), resulting in an incremental cost-effectiveness ratio of £2770 per additional QALY gained. Thus the EXTRA programme was cost effective from an NHS perspective when assessed against the threshold of £20 000-£30 000/QALY gained. Overall, costs were lower in the EXTRA programme compared with usual care, suggesting it was the dominant treatment option from a societal perspective. At a willingness-to-pay of £20 000/QALY gained, there was a 65% probability that the EXTRA programme was the most cost-effective option. These results were robust to sensitivity analyses accounting for missing data, changing the cost perspective and removing cost outliers. CONCLUSION: The physiotherapist-led EXTRA programme represents a cost-effective use of resources compared with usual care and leads to lower health care costs and work absence. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number Register; http://www.controlled-trials.com/isrctn/ (ISRCTN14268051).

Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review.

BACKGROUND: The convergence of rising health care costs and physician shortages have made health care transformation a priority in many countries resulting in the emergence of new models of care that often involve the extension of the scope of practice for allied health professionals. Physiotherapists in advanced practice/extended scope roles have emerged as key providers in such new models, especially in settings providing services to patients with musculoskeletal disorders. However, evidence of the systematic evaluation of advance physiotherapy practice (APP) models of care is scarce. A systematic review was done to update the evaluation of physiotherapists in APP roles in the management of patients with musculoskeletal disorders. METHODS: Structured literature search was conducted in 3 databases (Medline, Cinahl and Embase) for articles published between 1980 and 2011. Included studies needed to present original quantitative data that addressed the impact or the effect of APP care. A total of 16 studies met all inclusion criteria and were included. Pairs of raters used four structured quality appraisal methodological tools depending on design of studies to analyse included studies. RESULTS: Included studies varied in designs and objectives and could be categorized in four areas: diagnostic agreement or accuracy compared to medical providers, treatment effectiveness, economic efficiency or patient satisfaction. There was a wide range in the quality of studies (from 25% to 93%), with only 43% of papers reaching or exceeding a score of 70% on the methodological quality rating scales. Their findings are however consistent and suggest that APP care may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. CONCLUSIONS: The emerging evidence suggests that physiotherapists in APP roles provide equal or better usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. There is a need for more methodologically sound studies to evaluate the effectiveness APP care.

Addition of telephone coaching to a physiotherapist-delivered physical activity program in people with knee osteoarthritis: a randomised controlled trial protocol.

BACKGROUND: Knee osteoarthritis (OA) is one of the most common and costly chronic musculoskeletal conditions world-wide and is associated with substantial pain and disability. Many people with knee OA also experience co-morbidities that further add to the OA burden. Uptake of and adherence to physical activity recommendations is suboptimal in this patient population, leading to poorer OA outcomes and greater impact of associated co-morbidities. This pragmatic randomised controlled trial will investigate the clinical- and cost-effectiveness of adding telephone coaching to a physiotherapist-delivered physical activity intervention for people with knee OA. METHODS/DESIGN: 168 people with clinically diagnosed knee OA will be recruited from the community in metropolitan and regional areas and randomly allocated to physiotherapy only, or physiotherapy plus nurse-delivered telephone coaching. Physiotherapy involves five treatment sessions over 6 months, incorporating a home exercise program of 4-6 exercises (targeting knee extensor and hip abductor strength) and advice to increase daily physical activity. Telephone coaching comprises 6-12 telephone calls over 6 months by health practitioners trained in applying the Health Change Australia (HCA) Model of Health Change to provide behaviour change support. The telephone coaching intervention aims to maximise adherence to the physiotherapy program, as well as facilitate increased levels of participation in general physical activity. The primary outcomes are pain measured by an 11-point numeric rating scale and self-reported physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale after 6 months. Secondary outcomes include physical activity levels, quality-of-life, and potential moderators and mediators of outcomes including self-efficacy, pain coping and depression. Relative cost-effectiveness will be determined from health service usage and outcome data. Follow-up assessments will also occur at 12 and 18 months. DISCUSSION: The findings will help determine whether the addition of telephone coaching sessions can improve sustainability of outcomes from a physiotherapist-delivered physical activity intervention in people with knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12612000308897.

Examining the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors.

BACKGROUND AND PURPOSE: There is a growing consensus among healthcare researchers that, within the field of family caregiving, cost-effectiveness research is needed to determine which programs have the greatest benefit for family members. This study examines the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors. METHOD: Cost data from the CAReS study were analyzed to determine the cost of the intervention per caregiver. RESULTS: The cost of the intervention per caregiver was $2,500 at the 2009 median wage estimate. It was $1,700 at the 2009 10 percentile wage estimate and $3,500 at the 2009 90 percentile wage estimate. CONCLUSIONS: This study provides a prototype cost analysis from which researchers can build. In future analyses, costs should be tracked at a participant level so uncertainty can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate cost-effectiveness acceptability curves, enabling cost-effectiveness comparisons between interventions.

Effect of extended scope physiotherapists assessments in orthopaedic diagnostic setting: a systematic review.

BACKGROUND: Patients with musculoskeletal diseases can potentially be assessed by an extended scope physiotherapist (ESP) instead of by an orthopaedic surgeon (OS). OBJECTIVES: To evaluate the effectiveness of the diagnostic musculoskeletal assessment performed by ESP compared to OS. DATA SOURCES: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PEDro and reference lists of included studies and previous reviews were searched in November 2015. ELIGIBILITY CRITERIA: Studies were included if they evaluated adults with a musculoskeletal disease referred to an outpatient orthopaedic clinic where a diagnostic assessment had been conducted by an ESP. DATA EXTRACTION: Data were extracted using a customised data extraction sheet. Two reviewers using checklists evaluated methodological independently. RESULTS: We included one randomised controlled trial and 31 observational studies. Diagnostic agreement between ESPs and OSs was 65 to 100% across studies. Health care cost savings for diagnostic assessments performed by ESPs were 27 to 49% compared to OSs. Overall, 77 to 100% of the patients were satisfied with the ESP assessment. Results were comparable on diagnostic agreement, cost and satisfaction in studies with high, moderate and low risk of bias. LIMITATIONS: Risk of bias in the included studies. CONCLUSION AND IMPLICATION OF KEY FINDINGS: Diagnostic assessments performed by ESP may be as beneficial as or even better than assessment performed by OSs in terms diagnostic agreement, costs and satisfaction. However, the methodological quality was generally too low to determine the clear effectiveness of ESP assessment, and more high quality studies are needed. Systematic review registration number: PROSPERO CRD42014014229.

The Debt Burden of Entry-Level Physical Therapists.

BACKGROUND: The growing student debt of physical therapists entering the workforce, coupled with the growth in projected need, raises concerns about where and how entry-level physical therapists will practice and if these choices will be affected by their debt burden. OBJECTIVE: The purpose of this study was to identify the debt profile of entry-level physical therapists and explore relationships between student debt and clinical practice setting choices. METHODS: This study utilized a cross-sectional survey design to identify debt profiles and explore relationships between student debt and the clinical practice choices of entry-level physical therapists. RESULTS: The mean debt-to-income ratio based on the total reported educational debt was 197% (93%). The most frequently reported debt range for doctor of physical therapy (DPT) debt and total educational debt was $100,000 to $124,999. Despite the setting itself being rated as the most important factor (83%), 28% of participants reported debt as a barrier to their desired practice setting. In addition, when considering job choice overall, 57% of the participants reported that their student debt has had an effect on their decision. LIMITATIONS: This study is limited by its small sample size, originating from 1 state, and being taken by convenience from a special interest group. Data were collected via an anonymous survey, which increases the risk of selection bias. In addition, there are further personal, family, and institutional characteristics that were not collected in this study, which may influence the interaction between student debt and clinical practice choices. CONCLUSION: The results of this study suggest that practice setting choice may be affected by physical therapist student debt, and student debt may be a barrier overall to practice and career choices in physical therapy.

Value-Based Care for Musculoskeletal Pain: Are Physical Therapists Ready to Deliver?

Early physical therapy models hold great promise for delivering high-value care for individuals with musculoskeletal pain. However, existing physical therapist practice and research standards are misaligned with value-based principles, which limits the potential for growth and sustainability of these models. This Perspective describes how the value proposition of early physical therapy can be improved by redefining harm, embracing a prognostic approach to clinical decision making, and advocating for system-wide guideline-adherent pain care. It also outlines the need to adopt a common language to describe these models and embrace new, rigorous study designs and analytical approaches to better understand where and how early physical therapy delivers value. The goal is to define a clear path forward to ensure physical therapists are aligned within health care systems to deliver on the American Physical Therapy Association's vision of high-value care in a rapidly changing health care environment.

At-risk advertising by Australian chiropractors and physiotherapists.

Background: Society expects professionals to promote their businesses in an ethical manner, refraining from misleading or deceptive marketing due to the potential to harm members of the community. In Australia this expectation resides in the Australian registration board advertising guidelines or the Health Practitioner Regulation National Law. Registration board data indicate there are many health care professionals failing to meet these expectations. The aims of this research were to determine the frequency, type and nature of at-risk advertising by Australian chiropractors and physiotherapists and whether there is a correlation between professional association membership and advertising guideline compliance. Method: A cross sectional audit examining practitioner advertising was performed on representative samples of Australian chiropractors and physiotherapists. Two auditors examined advertising by 380 physiotherapists and 359 chiropractors for material potentially in breach of the regulatory authorities' advertising guidelines. The advertising appeared on practitioner websites and linked Facebook pages. Results: Two-hundred and fifty-eight (72%) audited chiropractors and 231 (61%) audited physiotherapists had breaches of the Advertising Guidelines on their websites and linked Facebook pages. The frequency of breaches by chiropractors was higher. The type and nature of the breaches by chiropractors was potentially more harmful. Membership in a professional association influenced neither the frequency nor the severity of breaches with chiropractors. Discussion: Advertising breaches were common in both samples even though regulators and professional associations provide practitioners with explicit information on how to comply with advertising guidelines. Breaches by chiropractors were more numerous and more serious due to their greater potential to lead consumers to make inappropriate and potentially harmful healthcare decisions.Stronger enforcement strategies may have a positive effect on compliance.

Caregiver impact and health service use in high and low severity Dravet syndrome: A multinational cohort study.

PURPOSE: To estimate costs associated with the current management of Dravet syndrome (DS), explore psychosocial aspects of the disease in caregivers and siblings, and identify patient characteristics associated with higher costs in a large, predominantly European survey cohort of patients and their caregivers conducted in 2016. METHODS: Health and social care resource use, productivity and quality of life (QoL) data were summarised. Costs for European five (EU5) countries (France, Germany, Italy, Spain and UK) were calculated and patients with high and low current seizure burden compared. Direct healthcare costs and out-of-pocket costs were calculated using literature reported health service costs and participant reported costs, respectively. RESULTS: Direct annual costs of management of non-seizure-related symptoms ($7929) contributed to approximately 50% of all costs (including medication). Excluding medication, non-seizure-related costs dominated costs of care. Cost for patients with high seizure burden were higher for seizure-related healthcare use and physiotherapy, but lower for other therapies. Most (80%) caregivers reported an influence on their career choices and 28% of those in work had missed over three working days in the past four weeks for emergency or routine needs of their child. Caregivers had little free time, relied on family members for support and respite, and experienced emotional stress and uncertainty about their child's future healthcare needs. CONCLUSION: Families caring for a DS patient manage considerable social and financial impacts. Total direct costs of DS patients (excluding drugs) are driven by non-seizure-related healthcare use and high seizure burden is associated with higher healthcare costs.

Advanced musculoskeletal physiotherapists in post arthroplasty review clinics: a state wide implementation program evaluation.

OBJECTIVE: To evaluate outcomes following a state-wide implementation of post arthroplasty review (PAR) clinics for patients following total hip and knee arthroplasty, led by advanced musculoskeletal physiotherapists in collaboration with orthopaedic specialists. DESIGN AND SETTING: A prospective observational study analysed data collected by 10 implementation sites (five metropolitan and five regional/rural centres) between September 2014 and June 2015. MAIN OUTCOME MEASURES: The Victorian Innovation and Reform Impact Assessment Framework was used to assess efficiency, effectiveness (access to care, safety and quality, workforce capacity, utilisation of skill sets, patient and workforce satisfaction) and sustainability (stakeholder engagement, succession planning and availability of ongoing funding). RESULTS: 2362 planned occasions of service (OOS) were provided for 2057 patients. Reduced patient wait times from referral to appointment were recorded and no adverse events occurred. Average cost savings across 10 sites was AUD$38 per OOS (Baseline $63, PAR clinic $35), representing a reduced pathway cost of 44%. Average annual predicted total value of increased orthopaedic specialist capacity was $11,950 per PAR clinic (range $6149 to $23,400). The Australian Orthopaedic Association review guidelines were met (8/10 sites, 80%) and patient-reported outcome measures were introduced as routine clinical care. High workforce and patient satisfaction were expressed. Eighteen physiotherapists were trained creating a sustainable workforce. Eight sites secured ongoing funding. CONCLUSIONS: The PAR clinics delivered a safe, cost-efficient model of care that improved patient access and quality of care compared to traditional specialist-led workforce models.

A short, structured skills training course for critical care physiotherapists in a lower-middle income country.

OBJECTIVES: The aim of this article is to describe the delivery and acceptability of a short, structured training course for critical care physiotherapy and its effects on the knowledge and skills of the participants in Sri Lanka, a lower-middle income country. METHODS: The two-day program combining short didactic sessions with small group workshops and skills stations was developed and delivered by local facilitators in partnership with an overseas specialist physiotherapist trainer. The impact was assessed using pre/post-course self-assessment, pre/post-course multiple-choice-question (MCQ) papers, and an end-of-course feedback questionnaire. RESULTS: Fifty-six physiotherapists (26% of critical care physiotherapists in Sri Lanka) participated. Overall confidence in common critical care physiotherapy skills improved from 11.6% to 59.2% in pre/post-training self-assessments, respectively. Post-course MCQ scores (mean score = 63.2) and percentage of passes (87.5%) were higher than pre-course scores (mean score = 36.6; percentage of passes = 12.5%). Overall feedback was very positive as 75% of the participants were highly satisfied with the course's contribution to improved critical care knowledge. CONCLUSIONS: This short, structured, critical care focused physiotherapy training has potential benefit to participating physiotherapists. Further, it provides an evidence that collaborative program can be planned and conducted successfully in a resource poor setting. This sustainable short course model may be adaptable to other resource-limited settings.

Allied health weekend service provision in Australian rehabilitation units.

OBJECTIVES: To determine current Australian allied health rehabilitation weekend service provision and to identify perceived barriers to and facilitators of weekend service provision. METHODS: Senior physiotherapists from Australian rehabilitation units completed an online cross-sectional survey exploring current service provision, staffing, perceived outcomes, and barriers and facilitators to weekend service provision. RESULTS: A total of 179 (83%) eligible units responded, with 94 facilities (53%) providing weekend therapy. A Saturday service was the most common (97%) with the most frequent service providers being physiotherapists (90%). Rehabilitation weekend service was perceived to increase patient/family satisfaction (66%) and achieve faster goal attainment (55%). Common barriers were budgetary restraints (66%) and staffing availability (54%), with facilitators including organisational support (76%), staff availability (62%) and staff support (61%). CONCLUSION: Despite increasing evidence of effectiveness, only half of Australian rehabilitation facilities provide weekend services. Further efforts are required to translate evidence from clinical trials into feasible service delivery models.

Substitution of doctors with physiotherapists in the management of common musculoskeletal disorders: a systematic review.

BACKGROUND: There is large variation in models-of-care involving the professional substitution of doctors with physiotherapists. OBJECTIVE: To establish the impact upon patients and health services, of substituting doctors with physiotherapists in the management of common musculoskeletal disorders. DATA SOURCES: Medline, CINAHL and ABI Complete databases, and hand-searching of related studies. STUDY SELECTION: Randomised and non-randomised clinical trials, inter-rater reliability and comparative studies comparing the outcomes of usual care from doctors, with outcomes when the doctor was substituted with a physiotherapist. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers evaluated all studies using the Downs and Black Instrument. Meta-analysis was not possible due to study heterogeneity. A descriptive review was undertaken. RESULTS: 14 studies of moderate to low quality met the inclusion criteria. Professional substitution with a physiotherapist causes no significant change to health outcomes and inconsistent variation in the use of healthcare resources. There is insufficient health economic data to determine overall efficiency. In the selected presentations studied, physiotherapists made similar diagnostic and management decisions to orthopaedic surgeons and patients are as, or more satisfied with a physiotherapist. LIMITATIONS: Further high quality health and economic research is needed, in less selective patient populations, to determine the optimal role for physiotherapists. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Physiotherapists provide a professional alternative to doctors for musculoskeletal disorders but the health economic implications of this model are presently unclear. Systematic Review Registration Number PROSPERO (Registration number CRD42015027671).

The economic value of an investment in physiotherapy education: a net present value analysis.

QUESTIONS: What is the economic value for an individual to invest in physiotherapy undergraduate education in Australia? How is this affected by increased education costs or decreased wages? DESIGN: A cost-benefit analysis using a net present value (NPV) approach was conducted and reported in Australian dollars. In relation to physiotherapy education, the NPV represents future earnings as a physiotherapist minus the direct and indirect costs in obtaining the degree. Sensitivity analyses were conducted to consider varying levels of experience, public versus private sector, and domestic versus international student fees. Comparable calculations were made for educational investments in medicine and nursing/midwifery. RESULTS: Assuming an expected discount rate of 9.675%, investment in education by domestic students with approximately 34 years of average work experience yields a NPV estimated at $784,000 for public sector physiotherapists and $815,000 for private sector therapists. In relation to international students, the NPV results for an investment and career as a physiotherapist is estimated at $705,000 in the public sector and $736,000 in the private sector. CONCLUSION: With an approximate payback period of 4 years, coupled with strong and positive NPV values, physiotherapy education in Australia is a financially attractive prospect and a viable value proposition for those considering a career in this field.

US hospital-based direct access with radiology referral: an administrative case report.

BACKGROUND AND PURPOSE: Legislative gains in the US allow physical therapists to function in expanded scopes of practice including direct access and referral to specialists. The combination of direct access with privileges to order imaging studies directly offers a desirable practice status for many physical therapists, especially in musculoskeletal focused settings. Although direct access is legal in all US jurisdictions, institutional-based physical therapy settings have not embraced these practices. Barriers cited to implementing direct access with advanced practice are concerns over medical and administrative opposition, institutional policies, provider qualifications and reimbursement. This administrative case report describes the process taken to allow therapists to see patients without a referral and to order diagnostic imaging studies at an academic medical center. Nine-month implementation results show 66 patients seen via direct access with 15% referred for imaging studies. Claims submitted to 20 different insurance providers were reimbursed at 100%. DISCUSSION: While institutional regulations and reimbursement are reported as barriers to direct access, this report highlights the process one academic medical center used to implement direct access and advanced practice radiology referral by updating policies and procedures, identifying advanced competencies and communicating with necessary stakeholder groups. Favorable reimbursement for services is documented.

Community group exercise versus physiotherapist-led home-based physical activity program: barriers, enablers and preferences in middle-aged adults.

BACKGROUND/PURPOSE: Barriers and enablers of physical activity have been investigated, but it remains unclear what middle-aged adults' physical activity preferences are. Two physical activity interventions were compared to determine barriers, enablers and preferences for physical activity format in sedentary, community-dwelling 50- to 65-year-olds. METHODS: Using mixed methods, 37 Physical Activity at Home (PAAH) participants took part in focus groups at the end of the intervention period and completed the Active Australia Survey (AAS). Participants were divided into three sub-groups: (1) group exercise attendees (GA, n = 14); (2) group exercise non-attendees (GNA, n = 9); and (3) physiotherapist-led home-based physical activity program attendees (HB, n = 14). Focus groups were audio-taped, transcribed, coded and analysed using an inductive thematic approach. Thirty-seven exit telephone calls with GNA were included in the analysis. RESULTS: Cost, self-efficacy, work and carer commitments were major themes identified for GA and GNA. HB participants reported fewer barriers and a number of enablers, including flexibility of the program and physiotherapist instruction. HB and GNA were younger than GA (p< 0.05), more likely to be in paid employment and GNA participants were insufficiently active (p ≤ 0.01). All participants preferred some home-based physical activity, although a variety of formats was indicated. CONCLUSION: The barriers, enablers and preferences indicate that the physiotherapist-led home-based physical activity program with initial face-to-face contact and telephone support may increase the adoption and maintenance of physical activity in middle-aged adults, particularly for those not interested in, or unable to attend, group exercise.