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154 APPENDICES Physiotherapy KCE reports vol.40 It is relatively common to treat psychological and gait disorders with other conditions, especially with musculoskeletal and neurological disorders. Oldest people are mainly treated for cardiovascular, neurological, gait disorders as well as for the presence of orthopaedic joints implants. Youngest people are mainly treated for psychological, endocrine/metabolic/nutritional, pregnancy/childbearing disorders. A higher prevalence of females is found in the pathology categories that mainly affect older people presumably due to their higher life expectancy. Pathologies usually treated in physiotherapists office are musculoskeletal, psychological and urological disorders. On the contrary, neurological and respiratory disorders are mainly treated in patients home. Almost no sessions are allocated for written report. A high prevalence of common pathologies is observed in musculoskeletal and urological disorders. Heavy pathologies are generally encountered in neurological and cardiovascular disorders. Perinatal pathologies logically concern pregnancy/childbearing conditions. Pathologies of acute FA list mainly refer to the presence of orthopaedic joint implants and injuries such as fractures or sprain/strain of knee. Finally, pathologies of chronic FB list primarily concern psychological and gait disorders. Although the two classifications lead to the same results, the ICPC-2 seems easier and more adequate than the ICD-10 to classify the reasons of physiotherapeutic consultation. First, the ICPC-2 classification has a more basic but easier structure than the more complicated ICD-10 classification. The ICPC-2 has 17 chapters, mainly based on body systems (e.g., digestive, cardiovascular, musculoskeletal etc.) with an additional chapter for broad, non-disease conditions (e.g., feeling tired, general ill feeling etc.), another for psychological problems and one for social problems. Each condition classified in a given chapter may also be specified according to seven components (i.e., process codes such as physical function test or consultation, symptoms/complaints, infections, neoplasms, injuries, congenital anomalies, and other diagnoses). The ICPC-2 is small to handle, having less than 700 condition rubrics. On the contrary, the ICD-10 has much more condition rubrics (more than 5000). Thus, it allows a higher precision to document all individual patients diagnoses to be obtained but cannot be realistically used in the context of an everyday routine. Second, the ICD-10 classification has 21 chapters that are sometimes based on body systems (chapters III, IV, V, VI, VII, VIII, IX, X, XI, XIII and XIV), sometimes on aetiology (chapters I, II, XVII, XIX, XX), or sometimes on other general status (chapters XV, XVI, XVIII, XXI). This mixture creates confusion since diagnostic entities can, with equal logic, be classified in more than one chapter. Instead of conforming to this format, the ICPC chapters are all based on body systems, following the principle that localization has precedence over aetiology. The ICPC-2 includes only one general and unspecified rubric for the most common conditions managed in general ambulatory practice. The less common conditions are place into ragbag codes such as other musculoskeletal diseases or other neurological diseases . As a result, every condition has only one logical place in the ICPC-2. Examples: 1) Acromial plastic surgery following a rotator cuff rupture may be classified in the ICD-10 as follow-up care involving plastic surgery of upper extremity in the factors influencing health status and contact with health services chapter or as injury of tendon of the rotator cuff of shoulder in the injury, poisoning and certain other consequences of external causes chapter. On the contrary, it is easily classified as shoulder syndrome in the ICPC-2 musculoskeletal chapter. 2) Neoplasm of the central nervous system responsible to an hemiplegia may be classified in the ICD-10 as neoplasm of uncertain or unknown behaviour of brain, unspecified in the neoplasms chapter or as hemiplegia in the diseases of the nervous system chapter. In such situation, the condition is classified in two different ICD-10 chapters. This occurs because ICD-10 chapters are based on both the body systems and the aetiology. The biaxial structure of the ICPC-2 (i.e., 17 chapters based on body systems and 7 inside-components) avoids this problem. Indeed, the condition would be classified in the ICPC-2 as Neoplasm nervous system unspecified in the neurological chapter, that is, in the same chapter than if hemiplegia was encoded.
KCE reports vol. 40 APPENDICES Physiotherapy 155 Third, conditions treated by ambulatory physiotherapists are sometimes vague, are not necessarily related to an underlying disease or can sometimes only be diagnosed in terms of symptoms/complaints. Classification of such conditions was easier to be performed with the ICPC-2, a classification essentially based on the high prevalence of common diagnoses in ambulatory practice. On the contrary, a certain number of symptoms/complaints and non-disease conditions recorded in the survey were hardly classified using the ICD- 10 classification. Indeed, the ICD-10 is a disease-oriented classification that is mainly based on the aetiology, pathology, and morphology of the wide range of known diagnoses. Therefore, it lacks sufficient rubrics for the symptoms and non-disease conditions managed in ambulatory physiotherapy. Examples: 1) It was difficult to classify visceral problem or heel complaint with the ICD-10 because these conditions were too vague. On the contrary, visceral problem was easily classified using the ICPC-2 as digestive symptom/complaint other in the digestive chapter and heel complaints as foot/toe symptom/complaint in the musculoskeletal chapter. 2) Non-disease conditions such as delayed milestone , pre-/post-natal physiotherapy, or impaired mobility have been classified under broad general headings of the ICD-10 that have little relationship with the natural language of clinicians. Delayed milestone has been classified in general symptoms and signs of the symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified chapter although conditions referring to developmental disorders of scholastic skills are classified in the mental/behavioural disorders chapter. Pre-/post-natal rehabilitation and impaired mobility were respectively classified as supervision of normal pregnancy and reduced mobility in the factors influencing health status and contact with health services chapter. On the contrary, by using the ICPC-2, delayed milestone was classified as child behaviour symptom/complaint in the psychological chapter; pre-/post-natal rehabilitation as pregnancy in the pregnancy/childbearing/family planning chapter; and impaired mobility as limited function/disability NOS in the general and unspecified chapter. For all of these reasons, the ICPC-2 classification that has been specifically developed for community care seems to be easier and more adequate within the framework of ambulatory physiotherapy. The validity of the data relative to the physiotherapeutic sessions has been investigated by comparing the Belgian physiotherapeutic nomenclature codes recorded in the survey with the benefits payments recorded by the INAMI/RIZIV during the year 2005. Significant differences were found for all variables of the Belgian nomenclature code. A slightly higher proportion of 30-minutes sessions (costing 18 ) performed in the physiotherapists office to treat acute and chronic conditions of FA/FB lists was observed in the survey as compared with the INAMI/RIZIV data. The significant differences cannot be explained by a nonrepresentativeness of the demographic characteristics of the respondents with regard to the sampling frame. Nevertheless, the sampling frame of the survey was exclusively constituted by physiotherapists performing at least 1000 benefit payments of types Ia and/or II and/or VI per year while the data of the INAMI/RIZIV included all benefit payments of types Ia and/or II and/or VI recorded during the year 2004. Despite the significant differences found between survey and INAMI/RIZIV data, the differences of proportions observed between them were, on the whole, small (average proportion difference: 2.25 ± 3.06%). Why small proportion differences are detected as significant could be explained by the very high number of sessions recorded by the INAMI/RIZIV (n = 29,198,425). Indeed, high data size may increase type 1 errors resulting in the finding of a significant difference when in fact there is not. Moreover, the same general trend is observed for all variables of the Belgian nomenclature code both in survey and in INAMI/RIZIV data: 30-minutes sessions performed to treat common pathologies in the physiotherapists office and costing 18 represent the most usual situation observed in Belgian ambulatory physiotherapy. However, survey data understimate the number of heavy pathologies treated in Belgian ambulatory physiotherapy. 1.3.2. Treatment modalities applied in Belgian ambulatory physiotherapy The treatment modalities applied in Belgian ambulatory physiotherapy would be now discussed for each of the five selected conditions in the light of the literature review on evidence-based physiotherapeutic modalities.
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