Comparing fly-in fly-out and telehealth models for delivering advanced-practice physiotherapy services in regional Queensland: An audit of outcomes and costs

Abstract

Introduction

Recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities in Queensland, Australia remains a challenge. To overcome this barrier, two different service delivery models (Fly-In, Fly-Out (FIFO), Telehealth) were trialled by one regional facility. This study aims to describe the economic- and service-related outcomes of these two methods of service delivery.

Methods

A retrospective audit was conducted where two nine-week time periods were selected for each service delivery model. Outcomes of interests include patient demographics and case-mix, service utilisation, clinical actions, adverse events and costs. Net financial position for both models was calculated based upon costs incurred and revenue generated by service activity.

Results

A total of 33 appointment slots were recorded for each service delivery model. Patient case-mix was variable, where the Telehealth model predominately involved patients with musculoskeletal spinal conditions managed from a neurosurgical waiting list. Appointment slot utilisation and pattern of referral for further investigations were similar between models. No safety incidents occurred in either service delivery model. An estimated cost-savings of 13% for the Telehealth model could be achieved when compared to the FIFO model.

Discussion

Telehealth is a safe, efficient and viable option when compared to a traditional in-person outreach service, while providing cost-savings. Telehealth should be seen as a service delivery medium in which sustainable recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities can be achieved.

Keywords

Telehealth physiotherapy cost analysis service delivery musculoskeletal

Introduction

Musculoskeletal conditions are the second largest cause of disability worldwide¹ and affect one-third of Australian adults at any given time.² Over the next two decades, the number of Australians with musculoskeletal conditions is projected to increase by 43%,³ and it has been identified that health systems need to adapt to produce effective strategies in response to this universal health burden.¹

In Queensland, the demand on public specialist orthopaedic and neurosurgery outpatient services for patients with musculoskeletal conditions continues to rise.⁴ An initiative adopted in Queensland has been the Neurosurgical & Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Services (N/OPSC & MDS), which is currently operational in 16 hospital facilities. In this model, patients who are referred to specialist medical orthopaedic or neurosurgery outpatient services with non-urgent musculoskeletal conditions are instead managed by a physiotherapist with advanced training (referred hereon as a Clinical Leader). The primary objective of this model of care is for the Clinical Leader to assess, diagnose and case manage the patient’s episode of care. Approximately 70% of patients do not require any specialist medical consultation upon discharge from the N/OPSC & MDS,⁵ and this model of care has been shown to be cost-effective when compared to traditional specialist-led clinics.^6,7

Even with clear evidence-based benefits of this model of care,^8–10 practical implementation in some areas remains challenging. Workforce issues commonly arise in regional and rural healthcare facilities, due to the highly specialised skill set and training required to fulfill the advanced Clinical Leader role. Recruitment issues arose in 2016 for a regional N/OPSC & MDS, where a shortage of local practitioners resulted in the inability to fill this advanced-practice role. This limited the number of patients that could be re-directed to the N/OPSC & MDS at this hospital facility, where instead they remained on lengthy specialist orthopaedic and neurosurgery outpatient waiting lists.

To overcome this barrier of recruitment a Fly-in, Fly-out (FIFO) model of care was trialled in late 2016 where a Clinical Leader, based in metropolitan Brisbane, was employed by the regional N/OPSC & MDS facility to travel fortnightly for a two-day clinic. At the beginning of 2017 the model was altered so that the clinic could be delivered remotely via telehealth. In the Telehealth model, the Clinical Leader conducted the consultation while situated in a metropolitan tertiary hospital, with the patient attending the regional facility. A graduate physiotherapist was present with the patient on the remote end to facilitate the physical assessment under the direct instruction of the Clinical Leader. Studies within the N/OPSC & MDS have demonstrated a high level of agreement for key clinical decision-making when providing musculoskeletal assessment via telehealth compared to face-to-face,¹¹ where similar services in Australia have adopted the same approach.¹²

As recruitment of highly specialised Clinical Leaders into regional N/OPSC & MDS facilities continues to be an issue, alternative ways to overcome these organisational barriers need to be explored. These strategies (FIFO, Telehealth), trialled as a collaboration between two N/OPSC & MDS facilities, presented an opportunity to conduct an audit of the two discrete methods of service delivery. Therefore, the aim of this study was to describe and compare the economic- and service-related characteristics of these two methods of service delivery.

Methods

This study was a retrospective audit of the electronic medical record and scheduling systems of a single regional N/OPSC & MDS facility. The project was approved by institutional Human Research Ethics Committee with exemption of full ethics review on the basis that the project was a quality assurance project (HREC/17/QPCH/309). The FIFO model of care took place between October and December 2016 (nine weeks in total). To replicate the time period that FIFO was conducted, data for the Telehealth model of care was also collected for a nine-week period from June to August 2017. This time period was chosen to ensure that the audit of the Telehealth service reflected an established model of care that was beyond its initial implementation phase.

Participants

Patients who were scheduled for a Clinical Leader consultation (either initial assessment or review consultation) during the aforementioned time periods were included in this audit. These patients, originally referred to the hospital’s orthopaedic or neurosurgery department for a specialist medical consultation, were triaged by the medical team and deemed suitable to be assessed and managed by an advanced-practice physiotherapist (the Clinical Leader). A single Clinical Leader conducted all consultations for both the FIFO and Telehealth models.

Data collection

Clinical and demographic data for all scheduled patient encounters were extracted from both the electronic medical record and scheduling systems by an administration officer who, as part of their standard role, has access to this clinical information. Due to the nature of this clinical service, individual patients may have had more than one scheduled consultation during the allocated time period. Patient safety was considered to be any adverse event that occurred as a direct result of the clinical consultation in which an incident report was submitted via the institutional clinical incident database, which are routinely handled by the service line manager (P.E.).

Costs in 2017 AUD$ incurred by the service during the time periods of both models of care (FIFO, Telehealth) were also calculated. Direct labour costs (+25% on-costs which include overhead costs such as superannuation, leave loading, payroll tax and professional development allowance) were calculated based upon estimates of time spent by clinical and administrative staff and multiplied by their appointed wage rates. Time required for training in the Telehealth model was also included, despite occurring outside the defined Telehealth time period. Travel costs (e.g. airfares, taxi vouchers, meal allowance, accommodation) associated with the FIFO service model were calculated using available invoices and standard Queensland Health allowances for accommodation and meal allowances¹³ and estimated taxi transfer costs.¹⁴ Taxi transfer costs were estimated from a taxi fare generator¹⁴ with lower and upper estimates provided for each fare estimate in 2018 AUD$. These amounts were discounted using the consumer price index to June 2017 for analysis. Travel costs were based on a two-day per fortnight clinic, such that the Clinical Leader travelled from Brisbane to Mackay on four separate occasions over the nine-week time period. For sensitivity analysis, we inflated airfare costs to ±30% for the upper and lower estimates in the analysis. Existing telehealth infrastructure (e.g. computers, web cameras, MOVI software licenses) was already available at both sites, and therefore did not generate any additional expenses. Costs associated with the additional electricity and data usage from the Telehealth service model was considered negligible, and therefore was not considered in this analysis.

Service revenue was calculated by using the weighted activity unit prices associated with the Independent Hospital Pricing Authority Tier 2 Physiotherapy OPD Code (40.09) for FY17–18. Revenue is based on the type of appointment (new, review) and recognises the difference in appointment duration (60 minutes for new, 30 minutes for review). All costs were in 2017 AUD$.

Data analysis

The unit of analysis for this audit was the appointment slot, of which there were 33 for each service delivery model. The clinical, demographic and safety aspects for each service delivery model are presented using descriptive statistics. A cost comparison was undertaken from the health service perspective. The baseline model comprised of analysis of costs for each model of care (FIFO, Telehealth) for the 9-week audit period and an average cost per slot available was calculated. The estimated cost to implement the models of care over a 12-month period was calculated, assuming an average four slots per day and a total of 46 clinic days per year. The net financial position in implementing the models, taking into account the estimated service revenue from the attended clinic appointments, was also calculated . Factors that influence service revenue include (a) the number of attended appointments and (b) the type of appointment (new versus review). For an estimate of attendance rates over a 12-month period, the proportion of patients attending appointments in the audit was used. For an estimate of proportion of new to review appointments, a weighted average of the ratio of new to review appointments was used in the analysis, based on a state-wide average for the N/OPSC & MDS in 2016/2017.⁵ A binomial 95% confidence interval of the upper and lower estimates for the new/review appointment ratio was calculated for sensitivity analysis¹⁵ and a mid-point between these upper and lower estimates was calculated. The net financial position, calculated as the total estimated revenue less total estimated costs, was calculated to estimate the financial impact of each service delivery model to the health service over a 12-month period.

Results

Patient demographics

Patient demographics for both service delivery models are outlined in Table 1. Due to the opportunity for patients to have multiple appointments scheduled within the chosen audit time period, 26 and 18 unique patients were reported on within the Telehealth and FIFO delivery models, respectively.

Table 1.

Patient demographics.

	Telehealth	FIFO
Unique patients (n)	26	18
Age at time of appointment, years (average (SD))	53.8 (11.4)	46.6 (13.8)
Gender, % female	62	83
SOPD referral source:
Orthopaedics	4	17
Neurosurgery	22	1
Referral triage category:
Category 2 (semi-urgent)	5	11
Category 3 (routine)	21	7
Referral: body region, n (%):
Upper limb	0 (0)	6 (33.3)
Lower limb	0 (0)	7 (38.9)
Spinal	26 (100)	5 (27.8)

FIFO: fly-in fly-out; SOPD: specialist medical outpatient department.

Service metrics

A time period of nine weeks was chosen for each service delivery model for auditing purposes. In total 66 appointment slots (both new and review consultation slot types) were allocated with an equal number of 33 appointment slots available for each model of care. Appointment slot utilisation was similar in both service delivery models, as displayed in Figure 1.

Figure 1.

Appointment slot utilisation. (FIFO: fly-in fly-out)

Clinical actions arising from consultation

Six patients (25%) in each service delivery model were referred for further radiology and/or pathology investigations following their new assessment. The Clinical Leader liaised directly with the medical consultant for six patients (25%) managed via Telehealth, and only two patients (8.3%) in the FIFO model.

The consultation outcome from all appointment slots in which the patient attended are described in Table 2. Of the appointment slots in which the patient failed to attend, four (Telehealth = 2; FIFO = 2) patients were rebooked for a future appointment. The remaining appointment slots resulted in the patient (FIFO = 3) being discharged from the N/OPSC & MDS, where one patient was returned and two patients removed, from the specialist medical outpatient department (SOPD) waiting list.

Table 2.

Consultation outcomes of appointment slots where patient attended.

Consultation outcome:	Telehealth (n = 24)	FIFO (n = 24)
Maintain under N/OPSC & MDS (%)	16 (66.7)	21 (87.5)
Referral to allied health treatment team	14	19
No specific treatment plan	2	2
Discharge from N/OPSC & MDS and return to SOPD wait list (%)	3 (12.5)	3 (12.5)
Urgent upgrade to category	2	2
No upgrade to category	1	1
Discharge from N/OPSC & MDS and remove from SOPD waitlist (%)	5 (20.8)	0 (0)

FIFO: fly-in, fly-out; N/OPSC & MDS: Neurosurgical & Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Services; SOPD: specialist medical outpatient department.

Safety

No safety incidents were reported for either service delivery model during the audit time period.

Costs

Total costs for the nine-week audit time period were calculated for both service delivery models (Table 3). As the FIFO clinic was a two-day per fortnight clinic, the Clinical Leader travelled from Brisbane to Mackay on four separate occasions during the FIFO time period. When the estimated costs of running both models for a 12-month period are compared, there is a 13% (10–16%) cost saving, valued at AUD$9865 (F less E, range AUD$7070–12,661), in favour of the Telehealth model.

Table 3.

Baseline cost analysis between service delivery models.

	Telehealth (AUD$)	FIFO (AUD$)
Expenses for audit period:
Staff travel costs, mid-point (lower and upper estimate)	Nil	3225 (2723–3726)^a
Clinic staff (+25% on-costs):
Clinical Leader	5194	6378
Physiotherapist (remote end)	1935	Nil
Training time	366	Nil
Administrative staff (+25% on-costs):	4435	4097
Total expense for audit period	11,930 (A)	13,699 (13,198–14,201) (B)
Average cost per slot available^b	362/slot available (C)	415 (400–430)/slot available (D)
Estimated cost for 12-month period^c	66,518 (E)	76,384 (73,588–79,180) (F)

FIFO: fly-in, fly-out.

^aEstimated cost, presented as mid point (lower and upper estimates).

^bCalculated as A or B/33 slots available.

^cCalculated as C or D × 4 slots per day × 46 clinic days per year.

When the estimated service revenue is taken into consideration (Table 4), both services were loss making for the health service. The estimated net financial position in implementing the models over a 12-month period resulted in the FIFO model costing AUD$31,269 (AUD$28,454–34,084) more per year than the Telehealth model.

Table 4.

Scenario 1: Implementation for 12 months including estimated revenue.

	Telehealth (AUD$)	FIFO (AUD$)
Estimated revenue:
Clinical Leader	21,404^a (21,385^b–21,423^c)	21,404^a (21,385^b–21,423^c)
Physiotherapist	21,404^a (42,767^b–21,423^c)	Nil
Total estimated revenue	42,808^a (42,770^b–42,846^c)	21,404^a (21,385–21,423^c)
Total estimated cost	66,518	76,384^a (73,588^b–79,180^c)
Net financial position	–23,710 (loss)(–23,749 to –23,672)	–54,980 (loss)(–52,203 to –57,757)

FIFO: fly-in, fly-out.

^aMidpoint: proportion of new appointments 54.58%.

^bLower estimate: proportion of new appointments 53.93%.

^cUpper estimate: proportion of new appointments 55.23%.

Discussion

In this study, a retrospective audit was conducted to evaluate and compare the service-related outcomes of two different models of service delivery (Telehealth, FIFO) trialled by a single regional N/OPSC & MDS facility challenged with the sustainable recruitment of an advanced-practice physiotherapist. Results indicate similar service utilisation between models, however some variation with respect to clinical management decisions were found which may be due to the difference in patient case-mix captured during these two audit time periods.

This audit demonstrated that Telehealth costs 13% less than a FIFO service delivery model, and this finding is consistent with previous studies for a variety of specialist outpatient services throughout Australia. Beard et al. demonstrated a 23% cost reduction in favour of telehealth when conducting advanced-practice physiotherapy assessments for patients with chronic spinal pain referred to the Royal Adelaide Hospital in lieu of their established outreach clinic.¹² The magnitude of the cost savings in the current study may be smaller due to the need for an additional clinician in the Telehealth model compared to the FIFO model adopted in our facility, which contrasts to the use of two clinicians in both the outreach and telehealth models in Adelaide.¹² The implementation of a tele-oncology service in northern Queensland resulted in a net saving of 42% by preventing specialists from travelling to satellite facilities for outreach visits, along with rural patients travelling to the specialist tertiary facility to receive care.¹⁶ Similarly, a state-wide paediatric nephrology service demonstrated an average saving of AUD$505 or 79% per consultation when providing specialist consultation via telehealth.¹⁷ The majority of the cost savings in these latter studies^16,17 was due to a reduction in patient travel to attend the face-to-face clinic, which is different to the FIFO model in which the Clinical Leader travels to the patients in the regional facility. This may explain the smaller savings observed in the current study. When the estimated service revenue is considered, the financial cost to the health facility to provide the FIFO model is greater, costing approximately AUD$31,270 more per year than the Telehealth model of care. This is primarily due to additional revenue that is generated by service activity taking place between two separate locations in which there is clinician involvement.¹⁸ During the audit time periods, the Telehealth model would have also been able to generate additional income as a result of the telehealth incentive payments available at that time.¹⁸ As this incentive payment ceased at the commencement of the financial year 2018–2019 for the majority of Queensland’s Hospital and Health Service districts¹⁹ (including the facilities involved in this study), it was explicitly excluded from the analysis to reflect ongoing funding arrangements.

The perceived risk to patient safety continues to be a common barrier that prevents the widespread adoption of telehealth.^20–22 We were not able to find any adverse events recorded for either service delivery model and this is consistent with previous studies^11,12 Interestingly, we found that no patients were discharged from the N/OPSC & MDS and removed from the SOPD waiting list following their FIFO consultation compared to 20.8% of Telehealth cases. This is low compared to previously reported discharge rates for the service⁵ and may be due to the short period of the audit, where patients may require ongoing monitoring prior to a decision regarding discharge being made. Finally, our study demonstrates that slot utilisation was similar between FIFO and Telehealth (both 72.7%). Despite Telehealth being cost-saving when compared to FIFO, neither are sustainable in the long term as they are operating at a net loss. As such, further efficiencies need to be realised to ensure the long-term sustainability of the N/OPSC & MDS, which could be achieved by either increasing revenue through improved slot utilisation, improving attendance rates and/or reducing overall costs.

Chronic musculoskeletal conditions are a leading cause of pain and disability in Australia,¹ where the rates of burden increase with both remoteness and socioeconomic disadvantage.²³ Despite this, statistics from the Australian Institute of Health and Welfare identify that less than 20% of Australia’s registered physiotherapists work outside of a metropolitan region.²⁴ This audit demonstrates two alternative ways in which recruitment of clinicians with advanced skills to regional and rural facilities may be achieved. While FIFO, or outreach, service delivery models have been in operation throughout Australia for many decades, the advancement of technology and Internet availability now provides an alternative method of healthcare delivery. As suggested by this audit, telehealth provides similar service and safety measures, for a lower cost when compared to traditional FIFO service delivery models. A recent publication also demonstrated a high level of agreement for key clinical decision-making when providing an advanced-practice physiotherapy musculoskeletal assessment via telehealth when compared to face-to-face.¹¹ Therefore, this service model may be suitable for regional and rural areas that face the ongoing challenges in recruiting skilled practitioners to work in advanced-practice roles, such as required in the N/OPSC & MDS model of care. The Telehealth model used in this scenario also has the additional long-term potential to upskill and mentor regional physiotherapists, providing another avenue to sustainable recruitment of advanced-practice clinicians to regional facilities. However, for those facilities in which a remote clinician cannot be made available, similar clinical management decisions can be achieved via telehealth in the absence of a remote physiotherapist,¹¹ and therefore may not be essential when considering a telehealth service delivery model.

There are both strengths and limitations to this study. The retrospective nature of this study, along with the small sample size, is acknowledged as a limitation, however this was dictated by the timeframe in which the FIFO model was trialled. The small sample size is not however expected to affect the costing of individual appointments, as all patients, regardless of their specific musculoskeletal condition, have identical appointment times and requirements. Consultations for both service delivery models were completed by a single Clinical Leader, minimising any bias that may have arisen between models with regards to clinical management decisions. There was also an apparent difference in the patient-case mix for each service delivery model, due to the recent expansion of the N/OPSC & MDS facility to accept patients from the neurosurgical specialist outpatient waiting list. This expansion resulted in the Telehealth audit capturing patients predominately from the Neurosurgical waitlist, and all of which were referred for spinal conditions. Whilst this difference in patient-case mix may have accounted for some of the differences in consultation outcomes and actions, the primary focus of this audit was on service utilisation and economic outcomes. However, as neither model reported any adverse events, outcomes may support the wider generalisability of these models of service delivery for the assessment of patients referred to the N/OPSC & MDS.

Recruitment of specialised healthcare professionals to regional services is an ongoing challenge, which is traditionally mitigated through FIFO outreach services. This audit demonstrates that Telehealth, as an alternative method of recruiting advanced-practice physiotherapists, can provide similar service outcomes but with significant cost-savings to the healthcare service when compared to the FIFO model. To date, the Telehealth service delivery model remains in operation as a solution to maintain stable Clinical Leader staffing levels within the regional N/OPSC & MDS facility.

Footnotes

Acknowledgements

We gratefully acknowledge the staff of the Mackay Base Hospital N/OPSC & MDS for their assistance in data collection.

Declaration of conflicting interests

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

Exemption from ethics approval was granted for this project (HREC/17/QPCH/309).

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Vos

Barber

Bell

, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386(9995): 743–800.

Australian Institute of Health and Welfare. Australia’s Health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: Australian Institute of Health & Welfare, 2016.

Arthritis and Osteoporosis Victoria. A Problem Worth Solving. Elsternwick: Arthritis and Osteoporosis Victoria, 2013.

Queensland Health. Queensland Reporting Hospitals: Specialists Outpatients, http://www.performance.health.qld.gov.au/hospitalperformance/op-main.aspx?hospital=99999 (2017, accessed 22 June 2017).

Neurosurgical & Orthopaedic Physiotherapy Screening Clinic (N/OPSC) and Orthopaedic Screening in Primary Care (OSiP) State-wide Activity Benchmarking Report 2016/17. Brisbane: Metro North Hospital and Health Service, 2017.

Comans

Raymer

O’Leary

, et al. Cost-effectiveness of a physiotherapist-led service for orthopaedic outpatients. J Health Serv Res Pol 2014; 19(4): 216–223.

Comans

Chang

Standfield

, et al. The development and practical application of a simulation model to inform musculoskeletal service delivery in an Australian public health service. Op Res Health Care 2017; 1(15): 13–18.

MacKay

Davis

Mahomed

, et al. Expanding roles in orthopaedic care: A comparison of physiotherapist and orthopaedic surgeon recommendations for triage. J Eval Clin Pract 2009; 15(1): 178–183.

Napier

McCormack

Hunt

, et al. A physiotherapy triage service for orthopaedic surgery: An effective strategy for reducing wait times. Physiother Can 2013; 65(4): 358–363.

10.

Daker-White

Carr

Harvey

, et al. A randomised controlled trial: Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Comm Health 1999; 53(10): 643–650.

11.

Cottrell

O’Leary

Swete Kelly

, et al. Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic. Musculoskelet Sci Pract 2018; 38: 99–105.

12.

Beard

Orlando

J and

Kumar

Overcoming the tyranny of distance: an audit of process and outcomes from a pilot telehealth spinal assessment clinic.

J Telemed Telecare 2016; 23(8): 733–739.

13.

Queensland Government. Domestic Travelling and Relieving Expenses (Directive 09/11), https://www.forgov.qld.gov.au/documents/directive/0911/domestic-travelling-and-relieving-expenses (2017, accessed 22 Aug 2018).

14.

Taxi Fare Calculator, https://www.taxifare.com.au/ (accessed 8 Aug 2018).

15.

StatPages. Exact binomial and Poisson confidence intervals, http://statpages.info/confint.html. (2009, accessed 24 Jan 2019).

16.

Thaker

Monypenny

Olver

, et al. Cost savings from a telemedicine model of care in northern Queensland, Australia. Med J Aust 2013; 199: 414–417.

17.

Trnka

White

Renton

, et al. A retrospective review of telehealth services for children referred to a paediatric nephrologist. BMC Nephrol 2015; 16(125). doi: 10.1186/s12882-015-0127-0.

18.

Queensland Health. Specification Sheet: Purchasing: Telehealth FY17-18 – Healthcare Purchasing and System Performance, https://qheps.health.qld.gov.au/__data/assets/pdf_file/0032/2049863/1718-telehealth.pdf. (2017, accessed 7 July 2018).

19.

Queensland Health. Specification Sheet: Purchasing: Telehealth FY18-19-Brisbane: Queensland Health, https://qheps.health.qld.gov.au/__data/assets/pdf_file/0015/2209020/1819-telehealth.pdf (2018, accessed 19 Feb 2019).

20.

Mair

Finch

May

, et al. Perceptions of risk as a barrier to the use of telemedicine. J Telemed Telecare. 2007; 13(1): 38–39

21.

Shulver

Killington

Crotty

‘Massive potential’ or ‘safety risk’? Health worker views on telehealth in the care of older people and implications for successful normalization.

BMC Med Inform Dec Mak 2016; 16(1): 131.

22.

Brewster

Mountain

Wessels

, et al. Factors affecting frontline staff acceptance of telehealth technologies: A mixed-method systematic review. J Adv Nurs 2013; 70(1): 21–33.

23.

Australian Institute of Health and Welfare. The Burden of Musculoskeletal Conditions in Australia: A detailed analysis of the Australian Burden of Disease Study 2011. Australian Burden of Disease Study Series no. 13. BOD 14. Canberra: AIHW, 2017.

24.

Australian Institute of Health and Welfare. Allied Health Workforce 2012. National Health Workforce Series no. 5. Canberra: Australian Institute of Health & Welfare, 2013.