Organizing the flow of physiotherapy services: agreement between clinical perception and a referral protocol

Introduction: Protocols to organize the flow of treatment between primary and secondary healthcare levels help physiotherapists working in Primary Health Care (PHC) determine which cases will remain at the primary level and which should be referred to the secondary level for specialized treatment. Objective: Assess the agreement between the clinical perception of physiotherapists and the protocol in organizing the flow of physiotherapy patients. Methods: This is a methodological cross-sectional study based on the analysis of secondary data, recorded on a service spreadsheet, with respect to the clinical perception of 4 physiotherapists working in PHC and the protocol they apply to determine the urgency for referral to the secondary care level, considering physiotherapy specialties. Assessment was expressed as the percentage agreement, magnitude and significance according to the Kappa test, with > 0.80 considered perfect agreement. Analyses were conducted using SPSS 21.0 statistical software at a significance level of α = 0.05. Results: In 619 of 715 referrals, the perception of physiotherapists corroborated with the protocol in terms of patient referral to the secondary service. The percentage agreement for urgency classification in the total sample was 71% and the Weighted Kappa index 0.3710 (CI95% 0.3029-0.4391). The instrument exhibited high agreement in the areas of musculoskeletal physiotherapy (94.7%) and gerontology (98.2%), and low in urogynecology (27.6%). Conclusion: The protocol showed a high percentage of agreement and may be an important instrument in organizing the flow of physiotherapy services and could be enhanced for use in other specialties.


Introduction
The Ministry of Health described Health Care Networks (HCN) as a strategy to restructure the Brazilian National Health System (SUS), which aims to provide effective and efficient services. 1 HCNs are polyarchy organizations of health services, consisting of primary, secondary and tertiary healthcare levels. Their objective is to provide continuous comprehensive care to the population and are coordinated by Primary Health Care (PHC), which is the patients' initial contact and entry point to the health system. 1,2 Physiotherapy services were long excluded from PHC, possibly due to the initial nature of the profession, whose focus was primarily curative and rehabilitative. Before its inclusion PHC, patients only had access to physiotherapy when referred to specialized secondary care and tertiary hospitals, which hindered the access of the general population. 3 Physiotherapy practices can be developed in different healthcare specialties and its field of action is quite broad, encompassing musculoskeletal, adult and child neurofunctional, cardiac rehabilitation, dermatofunctional, gerontological, pulmonary rehabilitation, and urogynecological specialties, among others.
Physiotherapists have ample knowledge to act in all levels of care, given that PHC is a more generalist field. 4 Knowledge inherent to physiotherapy may contribute to preventing disease and sequelae in addition to promoting health and preventing disorders. Including physiotherapy in PHC reduces the need for referrals to other HCN levels due to the demand for physiotherapy services, thereby lowering public expenditures and contributing to changing the healthcare model. 5,6 Physiotherapists in PHC must use their resolution capacity to individually or collectively determine which cases are a priority and should be referred to the secondary level. To that end, they must be armed with the knowledge and tools needed during the assessment process. 7 In this respect, referral protocols have been developed, which are both management and healthcare tools, since they not only guide the decisions of the professionals, but are also a reference during assessment. 8,9 Silva et al. 10

Methods
This is a methodological cross-sectional study to assess the agreement between a referral protocol 10 The public physiotherapy service of the municipality employs four physiotherapists in PHC to give support to 20 BHUs, five for each professional. They treat individuals, groups, or patients at home, in addition to applying the protocol to organize the flow and determine those who will remain in PHC or be referred to the secondary level. Before the protocol was implemented, there was no standardization and most cases were referred, creating long waiting lists, overloading the second level and hindering patient access. 10 The second level consists of the teaching clinic of a public university, whose treatment is divided into the following specialties: musculoskeletal, adult and child neurofunctional, cardiac and pulmonary rehabilitation, dermato-functional, urogynecological, aquatic physiotherapy and gerontology.
At the time the protocol was implemented in the public physiotherapy system, a survey of the number of referrals on a waiting list for PHC treatment resulted in a total of 1524 individuals, potential targets for application. The protocol has become part of the work routine of physiotherapists and after its application, the patient is given one of the following directives: remain in PHC for individual or group treatment, or referred to the secondary level, according to the nature of the urgency. 10 The four physiotherapists were trained to apply the protocol and include it in their work routine by order of municipal authorities. The patients whose referrals had accumulated were screened by the protocol (Figure 1).
After the protocol is applied, the physiotherapist is allowed to refer patients to the secondary service and define urgency based on the protocol score, but also on their practical experience and knowledge, that is,

Survey of study data
The data used in the present study were obtained from the spreadsheet filled out by the physiotherapist to organize the patients referred to the specialized service.
The professional responsible for the information on the municipal spreadsheet gave written permission for the researchers to access the data. The information recorded In cases with no variability between the possible protocol answers and/or professional perception,  (13) Cardiac rehabilitation 0.90 (6) the Kappa statistic could not be calculated. 11 The significance of the Kappa coefficient was assessed by the 95% confidence interval.
Analyses were conducted using the SPSS statistical package, version 21.0 at a significance level of α = 0.05.

Results
A total of 715 individuals referred to the secondary physiotherapy service were registered on the standardized spreadsheet. In order to assess agreement regarding urgency criteria, 96 patients were excluded because, according to the protocol, they should remain in PHC, leaving 619 individuals.
All the data on the referred patients were extracted from the spreadsheet. The most common referrals were for musculoskeletal disorders (44.9%) and the least for cardiac rehabilitation (0.90%).
The percentage agreement between referrals based on the protocol and the clinical perception of the physiotherapists is presented in Table 2, for the total sample and each specialty.

Discussion
The aim of the present study was to assess the agreement between the protocol score and the clinical Adults, mainly women, predominated in the sample of referred patients in this study. Women typically represent a majority of patients treated by public health services, including physiotherapy. This is due to their longer life expectancy, greater concern with health, more exposure to the risk factors for disease due to the roles they play and the predominance of health policies aimed primarily at women. Men seek health services less frequently due to embarrassment and anxiety. 23  the low participation in Brazil may be due to a lack of medical indication, few available patients and the popular belief that cardiac rehabilitation is not necessary. Ribeiro et al. 30 and Buys et al. 28 also corroborate these results and underscore that a number of personal factors may also lead to low demand, such as transport problems and perceived tiredness.
Study limitations include not monitoring patients who remained in PHC and considering only those that were referred and included on the spreadsheet, which precluded comparing the clinical perception of physiotherapists and the protocol in terms of non-referral to the secondary level. As strong points, the study is the first to compare the clinical perception of physiotherapists and a protocol for screening at physiotherapy services, underscoring that these protocols may reflect real patient needs and help manage flow.
The practical application of the results of the present study is the importance of including a protocol in the daily routine of PHC physiotherapists and that it can reflect their conduct. Objective instruments like the one described here help standardize patient-oriented decisions and organize demands, thereby ensuring more equitable access to specialized services. Physiotherapists and healthcare managers should encourage the use of this tool, in order to better organize demand, which will reflect in patient satisfaction.