Musculoskeletal complaints in primary care: Constraining healthcare costs, rethinking the deployment of healthcare professionals

Worldwide policy makers are challenged to account for rising healthcare costs and increased healthcare demand. Also, in the Netherlands there is a growing concern how to maintain high-quality and accessible care while keeping costs in check. Access to care is under pressure as the demand for care is rising fast, due to an aging population and an increasing number of chronically ill people. Not only at the policy level, but also in clinical practice challenges exist. The workload in the health care sector is high, causing health workers, such as general practitioners (GPs), to leave this sector. To keep costs in check available resources need be allocated as efficiently as possible. A good starting point for evaluating healthcare costs may be assessing large patient groups that are responsible for high resource use and costs, such as patients with musculoskeletal conditions treated in general practice. Another point may be identifying prognostic factors for higher healthcare costs. Besides lowering costs, it is also of importance to keep GP care accessible by lowering GPs’ workload. One of the ways to address GPs’ high workload is task reallocation. Internationally, positive effects have been found for an Advanced Physiotherapy Practitioner (APP) model of care, in which APPs take over tasks from a physician in the care for patients with musculoskeletal conditions. This model of care could potentially be of value in reducing the workload of Dutch GPs and keeping GP care accessible. Besides lowering healthcare cost and decreasing GPs’ workload maintaining good quality care is essential. One of the most widely used Patient Reported Outcome Measures (PROMs) in assessing quality of healthcare is the EQ-5D, a preference-based measurement instrument that measures health related quality of life and is used to estimate utility values that represent the preferences of the general population of a country for given health states. These utility values are needed for estimating Quality-Adjusted Life-Years (QALYs) in cost effectiveness analysis. However, quality-of-life measurements are generally not available when data are collected for clinical purposes, such as data from GP electronic medical records. Therefore, researchers are exploring ways to estimate EQ-5D based utility values by means of outcomes on other available health related outcome measures. This thesis aimed to explore some of the challenges in Dutch primary care by evaluating 1) healthcare utilization and associated cost of GP-guided care in patients with musculoskeletal complaints, 2) the introduction of an APP model of care, and 3) different approaches to estimate missing EQ-5D based utility values.