Patients' priorities regarding outpatient physiotherapy care: A qualitative and quantitative study

Manual Therapy 18 (2013) 155e164

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Manual Therapy journal homepage: www.elsevier.com/math

Original article

Patients’ priorities regarding outpatient physiotherapy care: A qualitative and quantitative study Wim Peersman a, b, *, Toni Rooms b, Nathalie Bracke b, Hilde Van Waelvelde b, Jan De Maeseneer a, Dirk Cambier b a b

Department of General Practice and Primary Health Care, Ghent University, Campus Heymans e 6K3, De Pintelaan 185, 9000 Gent, Belgium Department of Rehabilitation Sciences and Physiotherapy Ghent, Artevelde University College e Ghent University, Campus Heymans e 2B3, De Pintelaan 185, 9000 Gent, Belgium

a r t i c l e i n f o

a b s t r a c t

Article history: Received 6 May 2012 Received in revised form 18 September 2012 Accepted 21 September 2012

Background: Little knowledge is available on the attributes pertaining to physiotherapy care that patients consider most important. Objectives: To establish patients’ priorities with regard to outpatient physiotherapy care and to determine the association between gender, age, level of education, perceived health, frequency of visiting a physiotherapist (PT), and patients’ priorities. Design, participants and methods: 8 Focus group discussions that were conducted with 53 patients were used to generate aspects of care that were considered important for patients. Subsequently, a selfadministered questionnaire, consisting of the aspects of care that were revealed in the focus group discussions, was handed out to 20 consecutively visiting patients by 22 PTs who were working in an outpatient private practice. The patients were asked to rate the importance of each aspect. Results: The focus group discussions generated 48 aspects of care that were included in the questionnaire; 358 (81%) patients returned the questionnaire. All the proposed aspects were perceived as being important. The most important aspect was that “the PT is expert in his professional field.” Patients who were older, received a lower level of education, were less healthy, and attended more frequently, indicated more aspects as important; however, the different subgroups ranked the priorities, to a large extent, in the same manner. Discussion and conclusion: The findings of the survey can be used to make PTs more responsive to the expectations of patients, to educate patients about the role of physiotherapy care, and to develop instruments for measuring patients’ experience and satisfaction with physiotherapy care. Ó 2012 Elsevier Ltd. All rights reserved.

Keywords: Patient preference Physiotherapy Questionnaires Focus groups

1. Introduction Making health care more responsive to patients’ needs is an important challenge for professionals, providers, and authorities (Tritter, 2009). Therefore, it is crucial to know the aspects of care that are of utmost importance for patients, their so-called priorities. Priorities can be defined as statements that indicate the importance of specific aspects of clinical behavior of care professionals or the organization of care (Uhlmann et al., 1984). Although patient expectations, preferences and priorities are closely related terms, subtle but important differences are apparent

* Corresponding author. Department of General Practice and Primary Health Care, Ghent University, Campus Heymans e 6K3, De Pintelaan 185, B-9000 Gent, Belgium. Tel.: þ32 9 332 5073; fax: þ32 9 332 4962. E-mail address: [email protected] (W. Peersman). 1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2012.09.007

(Uhlmann et al., 1984). Patient expectations are anticipations that given events are likely to occur either during or as a result of medical care, irrespective of whether they are wanted (Uhlmann et al., 1984). Patient preferences or priorities, on the other hand, reflect appraisals. They estimate ideas about what should or what needs to occur in health care systems. The term preferences is most often used to refer to individual patients’ views, and the term priorities is more often used to describe preferences in a population of patients and citizens (Wensing and Elwyn, 2002). Patients’ priorities may differ from the aspects of care that are established and offered by health care professionals, providers, or authorities (Smith and Armstrong, 1989; Jung et al., 1997; Fischer et al., 2002). It is, therefore, essential to understand that patients’ views cannot be inferred from those of managers’ or health professionals and should be assessed both separately and independently. This construct implies the necessity of a valid assessment of patients’ priorities.

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Patients’ priorities may vary according to socio-demographic and other characteristics; so, what is most desired by one type of patient might be considered less important by another (Jung et al., 2003). For instance, older patients may have very different priorities compared with younger patients. The awareness of such differences in the given subgroups, in practice, is quite crucial for health care providers to meet or fulfill patients’ expectations and intrinsic needs. They should, therefore, always be considered qualitative prerequisites for the accomplishment of an effective and efficient treatment content. The importance of acquiring the views of patients is confirmed for different kinds of health care services and professions and the priorities of patients should be established for the given health care services and workers. Several authors have already addressed the concept of patients’ satisfaction with physiotherapy care or developed an instrument that measures patient satisfaction (Roush and Sonstroem, 1999; Goldstein et al., 2000; Oermann et al., 2000; Beattie et al., 2002; Monnin and Perneger, 2002; Beattie et al., 2005; Siebes et al., 2007; Hills and Kitchen, 2007b; Scascighini et al., 2008; Strutt et al., 2008), but none of them focused on patients’ priorities. However, an insight into patients’ priorities is important, as these priorities probably influence their evaluation and satisfaction with regard to health care services (Wensing et al., 1998). At the moment, only little attention is paid to the determination of the attributes that patients consider most important with regard to physiotherapy care (Potter et al., 2003). Only a few studies have attempted to examine which aspects of physiotherapy care patients find important (May, 2001; Potter et al., 2003; Reeve & May, 2009). May (2001) interviewed 34 patients with back pain who had received outpatient physiotherapy to identify the areas of care that patients considered to be important in terms of their satisfaction with the received physiotherapy. Key dimensions were related to the personal and professional manner of therapists, their role in providing information on different matters, making the treatment a consultative process, various aspects of the structure of provision, and the outcomes that ensue. It was concluded that patient care should be personally tailored to meet specific patients’ needs, and that effective treatment outcomes require not only competence in certain techniques, but also that PTs have a range of interpersonal skills that assist in patient management. Potter and colleagues used the nominal group technique and revealed that communication ability, professional behavior and organizational ability, diagnostic and treatment expertise, the environment, and convenience and accessibility were the main qualities of a good PT (Potter et al., 2003). In a semi-structured interview with patients referred to an Extended Scope Practitioner (ESP) physiotherapy screening service, Reeve and May (2009) reported five key themes that were important to the participants for the quality of the service: provision of information, professional skills, interpersonal skills, outcomes, and patient care pathway. Strutt et al. (2008) conducted an inquiry with an open text questionnaire into patients’ perceptions and satisfaction with treatment in a UK osteopathic training clinic. They concluded that the most frequent responses with regard to the question of satisfaction with treatment was competence (effective, thorough, knowledgeable, and dedicated), followed by empathy (caring, reassuring, listening, and continuity), atmosphere (friendly, relaxed, and courteous), information-giving (explanation, advice), students as therapists (confidence of students, quality of supervision), time (not rushed, short waits), and manner of treatment (gentle, holistic, and treating the root cause). An important limitation of these studies is that they used a qualitative method that does not address issues of frequency, distribution, or any other quantitative characteristic. An insight into

patients’ views on what constitutes “good” physiotherapy care is, thus, very limited. The primary aim of this study was to determine the priorities of patients with regard to outpatient physiotherapy care and to establish the relative importance of the different priorities. Second, the associations between specific characteristics of patients (gender, age, level of education, perceived health and frequency of visiting a physiotherapist) and their priorities were investigated to gain an insight into the manner in which different patient subgroups appear to have different priorities with regard to specific aspects of physiotherapy care. 2. Methods 2.1. Part 1: a qualitative descriptive study with focus group discussions A qualitative descriptive approach with focus group discussions was used to generate relevant aspects of care that are important for patients (Fig. 1). A qualitative descriptive study is the method of choice when straight descriptions of phenomena are desired (Sandelowski, 2000) and is especially relevant in questionnaire development (Neergaard et al., 2009). Focus group discussions are useful to gain a range of views and opinions about a particular issue (Petty et al., 2012). The interaction and discussion between the individual participants enhance the breadth and depth of data produced (Kitzinger, 1995). Participants were selected by purposive maximum variation sampling to obtain information-rich cases. This sampling method involves selecting patients who differ to a great extent with regard to theoretical important characteristics. Participants were recruited from 10 different physiotherapy practices by the attending therapist. The participating physiotherapists (PTs) diverged by gender, age, experience, and type of practice (single or group). The patients represented different gender and age groups (from 21 to 84 years old), varied according to educational background (from no educational degree to having a PhD), had a great variety of disorders, complaints, and reasons to visit the practice, and differed in terms of their earlier experience with physiotherapy care. Inclusion criteria for patients were that they should be aged 18 years or older; that they should understand the Dutch language; and that they should be cognitively able to participate in a group discussion. Focus group discussions were organized until new focus group sessions revealed no new priorities. In total, 8 focus group discussions with a total of 53 patients were organized. There was one group with nine patients, one with seven patients, one with three patients, two groups with eight patients and three groups with six patients. Each focus group discussion lasted about 1 h and a half, was semi-structured, and included the following four stages: introduction of the study and explanation of the procedure; silent generation of priorities; sharing and group discussion of the generated priorities; and, finally a discussion of good and bad experiences with physiotherapy care. All discussions were moderated by the same member of the research team (TR). A second member of the research team (NB) was present and assisted the moderator, observed, and took field notes. Participants provided written informed consent at the start of the discussion. There was no previous relationship between researchers and participants. All focus groups were recorded and verbatim transcribed. Transcripts were analyzed with NVivo using thematic analysis (Boyatzis, 1998). Three researchers (one senior researcher with a sociological background (WP) and two PTs (NB and TR)) first coded and classified all transcripts individually using an open coding process. At several consensus discussions, results were compared, common themes were identified, and a list of items or

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Fig. 1. Flow chart of the data collection.

aspects of care were distinguished, covering all priorities that were revealed in the focus groups. 2.2. Part 2: a quantitative study with a self-administered questionnaire 2.2.1. Participants Patients who visited a sample of outpatient private physiotherapy practices in Flanders, the northern part of Belgium, were approached by the attending PT for participation. The practices were selected by a purposive maximum variation sample. A total of 20 questionnaires were handed out by each participating PT (n ¼ 22) to consecutively visiting patients. Inclusion criteria for the patients were that they should be aged 18 years or older; that they should understand the Dutch language; and that they should be cognitively able to answer a questionnaire. 2.2.2. Questionnaire The questionnaire consisted of the items identified in the focus group discussion. The order of the items was determined at

random. Four versions of the questionnaire, with a different item order, were used. The patients were asked to rate the importance of each aspect on a five-point scale ranging from “not important at all” (1) to “most important” (5) or to choose the option “not applicable”. At the end of the list, the patients were asked to mention aspects that were not included in the list but which they considered important. The questionnaire also contained general questions related to the respondent, such as gender, age, level of education, perceived health (five-point rating scale from very good to very bad), reason for consultation, and number of visits to a PT in the last five years. Before starting the data collection, a pilot study with cognitive interviewing about the items (Collins, 2003) and comprising 9 respondents was conducted in order to identify unclear, ambiguous, or misleading statements. 2.2.3. Procedure Patients could complete the questionnaires at home and drop them anonymously at their next visit in a sealed box in the waiting room of the PT.

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2.2.4. Analysis The aspects of care were ranked according to the number of times they were assessed as being “very” or “most important”. Subgroups were created by dividing the participants according to age (“less than 40 years old”, “between 40 and 60 years old” and “more than 60 years old”), education (whether the participant had a degree of higher education or not), health status (“very good” and “good” versus “fair”, “poor” and “very poor”) and the number of visits to a PT in the last five years (“less than 20 visits”, “between 20 and 50 visits” and “more than 50 visits”). The rank order of the aspects between different subgroups was compared using Spearman rank-order correlations (rs). Differences between subgroups in mean rating of the importance of the items were tested with multifactor analysis of variance. The independent variables included in this analysis were sex, age, education, health status, and contact with PT. Bonferroni adjustment was applied for the variables with more than two categories (age and contact with PT). Data were analyzed using SPSS 15. 2.3. Ethical approval The project was approved by the ethics committee of the Ghent University Hospital (ref: 2007/004). 3. Results 3.1. Sample characteristics Of the 440 patients who received the questionnaire, 358 (81%) returned it. Table 1 depicts the patients’ characteristics. Most patients (77%) visited the PT for musculoskeletal-related disorders and complaints. 3.2. Priorities The focus group discussions generated 48 aspects of care or priorities that were included in the questionnaire (Table 2). Table 1 Characteristics of respondents. %

(n)

Sex Male Female

36 64

128 228

Age (years) <40 40e59 60þ

33 39 29

115 137 101

Education 0e18 Years þ18 Years

49 51

174 178

Health status Very good Good Fair Poor Very poor

15 51 28 5 1

54 180 101 18 2

Times seen by PT previous 5 years < 11 11e20 21e50 51e100 þ 100

20 16 23 14 28

68 55 79 47 98

In the quantitative study, almost all 48 aspects were perceived as important at a certain level (Table 2), and no other aspects of care were mentioned on the invitation to mention any other (forgotten) issue of importance. The most important aspect for patients was that “the PT is expert in his professional field.” In addition, the items “your PT refers you on if he/she can’t help you,” “the treatment works,” “your PT advises you how to prevent problems,” “your PT adjusts the treatment if the results are lacking,” and “your PT is enthusiastic in his work” were rated by more than 85% of the patients as very or most important. A relatively low ranking was given to aspects such as “your PT is available at times that suit you,” “your PT is interested in your social situation,” and “you have a good rapport with the other patients during group therapy”; but still one third of the patients rated those items as very or most important. A comparison of the rank order of the priorities according to sex, age, education, health status and contact with PT can be found in Appendix 1. 3.2.1. Gender differences There were only some significant differences in priorities between male and female patients (Table 2). Female patients placed more emphasis on privacy, safety, and freedom of choice as being important. They also preferred more to be treated by the same PT and for the treatment to be given by the PT and not by an intern. The rank order of the items was very similar in both groups (rs ¼ 0.92). 3.2.2. Age differences Significant differences between age groups were found for 20 items. For all these items, the oldest age group judged the items as being more important than the youngest age group. Most differences were, however, observed in the lower-ranked priorities. Nevertheless, in all age groups, the ranking of the items was to a large extent the same: rs between the youngest age group and the middle and oldest age group was 0.89 and 0.70, respectively and rs between the middle and oldest age group was 0.84. The oldest age group ranked the items “your PT adjusts the treatment if the results are lacking” and “your PT explains the treatment” as less important than the other age groups (Appendix 1). The items “you are on good terms with your PT,” “your PT has sufficient time during the treatment to involve himself with you personally,” “your PT is able to relieve your complaints quickly,” “your PT is someone with lots of experience,” “you are always treated by the same PT,” and “your PT always carries out exactly what the doctor has prescribed” were more emphasized by the oldest age group compared with both the other age groups. The item “your PT is discreet” was ranked in both the middle and the oldest age group as one of the 10 most important items. In the youngest age group, on the other hand, this item was ranked in the second half of the list. The youngest age group appreciated the items “your PT can communicate clearly,” “you can make an appointment with your PT at short notice,” and “your PT examines you before starting the treatment,” comparatively speaking, at a higher level of importance than did the oldest age group. 3.2.3. Educational differences In almost half of the items (n ¼ 21), statistically significant differences were found between the participants who did and those who did not receive higher education. Again, most differences were observed in the lower-ranked priorities. Every time, the group who received no higher education found the item more important than the group with a degree of higher education. The differences were most distinctive for the items “your PT is helpful,” “you can have a chat with your PT,” and “the practice is easy to get to.” The items were ranked in a similar manner in both the subgroups (rs ¼ 0.91). The biggest differences in ranking were

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Table 2 Ranking of patients’ priorities by percentage “very/most important”, and subgroups that differed statistical significantly (p < 0.05)a on mean rating of importance of the items. Rank

Item

%

n

1 2 3 4 5 6 7 8

94.9 90.6 89.8 89.5 88.4 85.6 84.4 84.4

356 352 354 354 352 353 353 308

9 10

Your PT is expert in his professional field. Your PT refers you on if he/she can’t help you. The treatment works. Your PT advises you how to prevent problems. Your PT adjusts the treatment if the results are lacking. Your PT is enthusiastic in his work. Your PT takes you seriously. The interns working with your PT are being given sufficient guidance. Your PT pays sufficient attention to hygiene. Your PT guarantees his patients’ privacy.

83.9 82.6

354 356

11 12

Your PT motivates you to keep on with the treatment. Your PT is discreet.

80.8 80.3

354 356

13

Your PT gives you sufficient assistance in doing your exercises. Your PT can communicate clearly. Your PT is friendly. There is sufficient attention to safety when working with equipment. You are on good terms with your PT.

80.3

350

79.3 79.2 77.9

357 356 340

77.9

357

77.5 77.2 75.6 75.6

355 351 352 356

73.9 73.1 73.0

348 353 352

25

Your PT explains the treatment. Your PT discusses things with the doctor if necessary. The treatment is carried out under comfortable conditions. Your PT has sufficient time during the treatment to involve himself with you personally. The treatment room is clean and tidy. Your PT is able to relieve your complaints quickly. You can make an appointment with your PT at short notice. You can confide in your PT.

72.3

357

26 27 28

Your PT’s treatment is affordable. Your PT is helpful. Your PT is aware of your medical history.

70.7 70.3 69.9

348 353 356

29

There are occasions for laughter during the treatment.

69.2

354

30 31

Your PT tells you everything about your ailment. You are free to choose which PT treats you.

68.7 66.9

351 347

32

Your PT regularly goes on courses for further training.

66.9

350

33 34

66.9 64.5

350 344

35 36

You are involved in decisions about your treatment. Your PT gives you exercises you can do by yourself at home. Your PT examines you before starting the treatment. Your PT is someone with lots of experience.

63.0 62.1

351 356

37

You are always treated by the same PT.

59.1

347

38 39

Your PT takes your wishes and desires into account. You can have a chat with your PT.

58.1 55.1

351 356

40

Your PT always carries out exactly what the doctor has prescribed.

54.1

355

41 42 43

The practice is easy to get to. Your treatment starts at the agreed time. The treatment is not tedious.

53.5 52.4 48.4

346 355 349

14 15 16 17 18 19 20 21 22 23 24

Subgroups that differed in mean rating of importanceb

Contact with PT: ‘<20’ > ‘þ50’ (p ¼ 0.003)

Age: ‘<40’ < ‘60þ’ (p ¼ 0.009) Education ‘0e18’ > ‘þ18’ (p ¼ 0.037)

Sex: ‘male’ < ‘female’ (p ¼ 0.021) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.008) Sex: ‘male’ < ‘female’ (p ¼ 0.024) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.001) Health status: ‘good’ < ‘fair/poor’ (p ¼ 0.042)

Sex: ‘male’ < ‘female’ (p ¼ 0.014) Age: ‘<40’ < ‘60þ’ (p ¼ 0.01) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘þ60’ (p ¼ 0.01) Contact with PT: ‘20e50’ < ‘þ50’ (p ¼ 0.025) Age: ‘<40’ < ‘60þ’ (p ¼ 0.005) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.036) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.046) Contact with PT: ‘<20’ < ‘þ50’ (p ¼ 0.017) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.005)

Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.011) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.024) Contact with PT: ‘<20’ < ‘þ50’ & ‘20e50’ < ‘þ50’ (p ¼ 0.012) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.006) Education: ‘0e18’ > ‘18þ’ (p < 0.001) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.027) Contact with PT: ‘<20’ < ‘þ50’ & ‘20e50’ < ‘þ50’ (p ¼ 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.006) Contact with PT: ‘20e50’ < ‘þ50’ (p ¼ 0.025) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.002) Sex: ‘male’ < ‘female’ (p ¼ 0.012) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.004) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.015)

Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p < 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.002) Sex: ‘male’ < ‘female’ (p ¼ 0.012) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p < 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.015) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.034) Age: ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p ¼ 0.004) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.001) Contact with PT: ‘<20’ < ‘þ50’ & ‘20e50’ < ‘þ50’ (p ¼ 0.033) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p < 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.005) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.001) Age: ‘<40’ < ‘60þ’ (p ¼ 0.022) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ (p ¼ 0.003) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.006) (continued on next page)

160

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Table 2 (continued ) Rank

Item

%

n

Subgroups that differed in mean rating of importanceb

44

Your PT also supports you psychologically.

46.0

352

45

The treatment is given by the PT and not by an intern.

44.3

327

Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p < 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.006) Sex: ‘male’ < ‘female’ (p ¼ 0.004) Age: ‘<40’ < ‘40e59’ & ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p < 0.001) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.03)

46 47

Your PT is available at times that suit you. Your PT is interested in your social situation.

37.6 33.4

351 347

48

You have a good rapport with the other patients during group therapy.

32.4

225

Sex: ‘male’ < ‘female’ (p ¼ 0.045) Age: ‘<40’ < ‘60þ’ & ‘40e59’ < ‘60þ’ (p ¼ 0.046) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.004) Contact with PT: ‘<20’ < ‘þ50’ & ‘20e50’ < ‘þ50’ (p ¼ 0.002) Education: ‘0e18’ > ‘18þ’ (p ¼ 0.003)

a Tested with multifactor analysis of variance. Variables (subgroups) used in the model: sex (male, female); age (‘<40’, ‘40e49’, ‘60þ’); education (‘0e18 years’, ‘þ18 years’); health status (‘(very)good’, ‘fair/(very)poor’); contact with PT (‘<20’, ‘20e50’, ‘þ50’). b ‘A’ < ‘B’ ¼ subgroup ‘A’ find it less important than subgroup ‘B’; ‘A’ > ‘B’ ¼ subgroup ‘A’ find it more important than subgroup ‘B’.

found for the item “your PT explains the treatment,” which was more important in the group with a degree in higher education. 3.2.4. Health differences After taking age, education, and contact with PT into account, statistically significant differences were established for only one item at the level of perceived health: “your PT gives you sufficient assistance in doing your exercises.” This was scored as being more important for the group with the poorest health status. There was a strong correlation between the rank order of the items in both subgroups (rs ¼ 0.92). Only the item “your PT discusses things with the doctor if necessary” was ranked differently in both subgroups: 12th in the group with a (very) good health status and 28th in the group with a fair or (very) poor health status. 3.2.5. Differences by number of visits to a PT The difference between the subgroups in the mean rating of importance was statistically significant for eight items. The item “the treatment works” was more important in the group who attended the PT the least. The other seven items were more important in the group who consulted the PT the most. The correlation coefficients between the group with less than 20 visits to the PT and the group with 20e50 contacts and þ50 contacts were respectively, 0.96 and 0.88, and rs was 0.82 between the group with 20e50 visits and the þ50 contact group. The items “there is sufficient attention to safety when working with equipment,” “you are on good terms with your PT,” “you can confide in your PT,” and “your PT is aware of your medical history” had a higher ranking in the group with the most contacts with a PT. 4. Discussion PTs are expected to be responsive to patients’ expectations and needs. However, information about patients’ priorities at the level of expectations and needs related to physiotherapy care is very scarce. Only a few studies have attempted to determine which attributes regarding physiotherapy care patients consider important, and all those studies used a qualitative method. Therefore, the aim of this study was to fill in the substantial and pertinent gap in knowledge and insights by identifying the priorities of patients with regard to outpatient physiotherapy care using a combination of a qualitative and a quantitative method. In a survey conducted among 358 patients, all the 48 proposed aspects of physiotherapy care were perceived as being important at a certain level. This was to be expected, as all aspects were selected

based on their relevance to physiotherapy care depending on the results of focus groups discussions with patients, and this served as a preparatory phase in the development of an adequate assessment tool. No other aspects of care were mentioned by the respondents on the invitation to mention any other (forgotten) issue of importance. This indicates that the generation of aspects of priority in the focus group discussions covered the entire field of eventually perceived priorities. Considerable differences were found with regard to the importance of the different aspects. Patients perceived as the absolute requirement of a good physiotherapy practice that the PT is an expert, that the given treatment is effective, and that the PT refers on or adjusts the treatment if the results are lacking. Patients also expect advice to prevent further health problems, they want to be taken seriously, and they demand attention for hygiene and privacy during the treatment as well as within the practice itself. All these aspects or statements underpin changes in attitude toward health care, such as evidence-based practice, competence-driven care, responsibility, and so on. The results of the qualitative part of this study were in line with those of May (2001), Potter et al. (2003), Strutt et al. (2008) and Reeve and May (2009). In addition, the quantitative results of this survey made it possible to establish the relative importance of the different aspects. The approach of this priority theme by a combined qualitative and a quantitative method is undoubtedly an important strength of this study. Many of the priorities that were revealed in this study are, to a large extent, comparable with those found in studies of priorities or satisfaction of patients with other health professions and in other cultures (Wensing et al., 1998; Grol et al., 1999), although the importance that patients in this study attach to hygiene is less frequently observed in other studies. The study also allowed pinpointing different priorities between some subgroups of patients. In general, patients who are older, received a lower level of education, were less healthy, and attended a PT more frequently indicated more aspects as very important or most important. In particular, the differences between the subgroups were more pronounced for the lowest ranked items. However, the results also showed that notwithstanding the fact that there are differences in the ranking of the items between the different subpopulations, the priorities were ranked to a large extent in the same way. In general, the different subgroups are highlighting similar issues. There are limitations of the research that should be acknowledged. The results of this study are specific to the population and setting. The findings represent the priorities of patients visiting

W. Peersman et al. / Manual Therapy 18 (2013) 155e164

outpatient private practices in Flanders, the Dutch-speaking northern part of Belgium. Patients do not have direct access to physiotherapy in Belgium, as a referral of a medical doctor is needed. This prescription should contain the medical diagnosis and the amount of physiotherapy sessions. The physiotherapist is autonomous and responsible for the content of the treatment and the frequency of sessions, unless the physician has stipulated both on the referral. The total amount of physiotherapy sessions is per se not restricted, although depending on the pathology, the number of sessions is fixed with regard to the highest reimbursement. Once this number of sessions is surpassed, the personal non-reimbursed part for the patient becomes greater. This specific context could influence some of the aspects generated as well as the relative importance. The generalizability to other populations and settings needs to be tested. Another important limitation regarding the sample is the restriction to patients who understand the Dutch language, which reduces the ethnic diversity. In addition, since sample in the questionnaire study was drawn from consecutive visiting patients, a bias could probably be introduced, as high attendees in the population are statistically more likely to be represented. In our study, it is shown that this group had a slightly different opinion than people who rarely visited a PT. The views of non-attenders are not included at all. Although the participants had for every item the possibility to choose the option “not applicable”, the item response rate for most items was 0.97 or more, and only a few items had a lower response rate. This could introduce bias, but there were no indications that this had happened. The focus group discussions were moderated by a PT of the research team, which could have affected the discussion. Also, the presence of others could have influenced what was said by the participants. However, every focus group started with a silent generation of priorities (each participant had to individually write down three most important priorities), and the moderator took care to address at least the written priorities from all the participants. The written notes were collected afterward. The analysis of the qualitative description study stayed close to the data and the patients’ points of views. This resulted in a questionnaire in a language that was similar to the patients’ own language, but it made the analytical process somewhat subjective (Neergaard et al., 2009). To reduce the subjective element, three researchers who independently coded the data and had several consensus discussions were involved in the analysis. 5. Conclusion By ignoring the patients’ views on preferred care, aspects of care provision that are important from the perspective of the consumers of health care may be neglected. It is, therefore, now widely recognized that the views of patients are essential. This study determined

Item

. your PT is expert in his professional field. . your PT refers you on if he/she can’t help you. . the treatment works.

All cases

94.9 (338/356) 1 90.6 (319/352) 2 89.8 (318/354) 3

Sex

161

patients’ priorities with regard to outpatient physiotherapy care. The results of the qualitative and quantitative method supplement each other. The qualitative descriptive study guarantees that the perspectives of patients regarding physiotherapy care are adequately reflected in the questionnaire. The quantitative results made it possible to establish the relative importance of the different priorities. Population surveys conducted on patients’ priorities can help health care professionals and providers set priorities in their efforts to make health care more responsive to patients’ wishes and needs and can, as such, contribute to policy decision making (Valentine et al., 2008). The findings of a study such as this can be used for different purposes. First, this study has identified aspects that patients think to be important for outpatient physiotherapy care, and these should be considered by the private physiotherapy practitioner in the management approach of his or her practice. Policy makers, professional organizations, and educational institutes should stimulate and facilitate the development of qualities to make PTs more responsive to the priorities of patients (Wensing et al., 1998; Wensing and Elwyn, 2002; Jung et al., 2003). The aspects of care that proved to be important for patients can also be used by individual PTs for the formulation of priorities for their education and quality assurance initiatives (Wensing et al., 1998). Second, the results from this study can be used to educate patients about the role of physiotherapy care, in order to make the expectations of patients more realistic (Jung et al., 1997). Finally, the results can be used to develop instruments for measuring patients’ experience and satisfaction with physiotherapy care (van Campen et al., 1998; Wensing et al., 1998; Reeve & May, 2009). Such an instrument can be used to provide PTs and practices with feedback from the patients about their experience with their services. Until now, PTs rely on anecdotal evidence with regard to the quality performance of the delivered physiotherapy care in relation to the views of their patients. At the moment, only a few instruments are available that measure patient satisfaction with outpatient physiotherapy care (Roush and Sonstroem, 1999; Goldstein et al., 2000; Beattie et al., 2002; Monnin and Perneger, 2002; Sadeq and Adib, 2002; Beattie et al., 2005; Hills and Kitchen, 2007a), and the priorities of the patients regarding physiotherapy care are not included in a systematic manner in the process of generating aspects to be evaluated. By ignoring the patients’ view on what they find important, aspects of care provision that are important from the perspective of the consumers of health care may be neglected (Wensing et al., 1994). It is also clear that giving priority to certain services compared with others will not necessarily satisfy all patients. The PTs should actively identify individual patients’ expectations (May, 2001).

Appendix. 1. Description of patients’ priorities: percentages ‘very/most important’ and rank numbers by sex, age, education, health status and contact with PT

Age

Education

Health status

Contact with PT

Male

Female

<40

40e59

60þ

0e18 Years þ18 Years Good

Fair/poor <20

20e50 þ50

92.2 (118/128) 1 89.7 (113/126) 3 88.8 (111/125) 5

96.5 (218/226) 1 91.5 (205/224) 2 90.7 (206/227) 3

95.7 (110/115) 1 92.9 (105/113) 3 88.4 (99/112) 5

94.2 (129/137) 1 90.4 (123/136) 3 91.2 (125/137) 2

94.9 (94/99) 1 87.8 (86/98) 6 90.0 (90/100) 2

93.1 (162/174) 1 89.5 (153/171) 4 89.6 (155/173) 3

91.7 (110/120) 1 89.8 (106/118) 5 90.1 (109/121) 4

97.5 (77/79) 1 93.6 (73/78) 3 94.9 (74/78) 2

97.2 (171/176) 1 92.0 (161/175) 2 90.3 (158/175) 3

96.6 (225/233) 1 91.3 (211/231) 2 89.6 (206/230) 3

94.3 (115/122) 1 90.2 (111/123) 3 92.6 (113/122) 2

94.5 (137/145) 1 89.4 (126/141) 3 84.6 (121/143) 9

(continued on next page)

162

W. Peersman et al. / Manual Therapy 18 (2013) 155e164

(continued ) Item

All cases

Sex

Age

Education

Health status

Contact with PT

Male

Female

<40

40e59

60þ

0e18 Years þ18 Years Good

Fair/poor <20

20e50 þ50

89.5 (317/354) 4 88.4 (311/352) 5 85.6 (302/353) 6 84.4 (298/353) 7 84.4 (260/308) 8

89.8 (115/128) 2 89.0 (113/127) 4 84.9 (107/126) 6 81.0 (102/126) 9 80.0 (88/110) 10

89.3 (200/224) 4 87.9 (196/223) 5 85.8 (193/225) 9 86.7 (195/225) 8 87.2 (171/196) 6

93.9 (108/115) 2 92.0 (104/113) 4 84.8 (95/112) 6 78.9 (90/114) 10 81.8 (81/99) 8

88.3 (121/137) 7 89.8 (123/137) 4 84.7 (116/137) 10 89.8 (123/137) 5 88.5 (108/122) 6

86.6 (84/97) 8 82.5 (80/97) 18 88.9 (88/99) 3 85.6 (83/97) 10 82.9 (68/82) 15

91.3 (157/172) 2 88.8 (151/170) 5 88.3 (151/171) 6 88.2 (150/170) 7 85.4 (129/151) 13

87.5 (154/176) 5 88.1 (155/176) 4 83.0 (146/176) 7 81.4 (144/177) 9 83.6 (127/152) 6

88.4 (205/232) 5 89.6 (206/230) 4 85.7 (198/231) 6 81.5 (189/232) 10 84.5 (174/206) 7

91.6 (109/119) 2 85.7 (102/119) 7 85.0 (102/120) 9 90.7 (107/118) 3 84.0 (84/100) 13

85.4 (105/123) 7 86.1 (105/122) 5 85.4 (105/123) 8 82.8 (101/122) 10 85.8 (91/106) 6

92.3 (72/78) 5 92.3 (72/78) 4 83.1 (64/77) 7 84.4 (65/77) 6 83.1 (59/71) 8

90.9 (130/143) 2 88.7 (126/142) 4 87.4 (125/143) 5 86.1 (124/144) 7 83.5 (101/121) 12

83.9 (297/354) 9 82.6 (294/356) 10 80.8 (286/354) 11 80.3 (286/356) 12 80.3 (281/350) 13 79.3 (283/357) 14 79.2 (282/356) 15 77.9 (265/340) 16

84.3 (107/127) 7 75.0 (96/128) 18 83.6 (107/128) 8 75.8 (97/128) 17 78.4 (98/125) 13 76.6 (98/128) 16 75.0 (96/128) 19 70.2 (87/124) 26

84.1 (190/226) 10 87.2 (197/226) 7 79.5 (178/224) 16 82.7 (187/226) 11 82.1 (183/223) 13 81.1 (184/227) 15 81.4 (184/226) 14 82.7 (177/214) 12

84.3 (97/115) 7 73.9 (85/115) 16 78.9 (90/114) 11 66.1 (76/115) 27 75.2 (85/113) 14 79.1 (91/115) 9 78.3 (90/115) 12 70.6 (77/109) 19

83.1 (113/136) 12 87.6 (120/137) 8 80.9 (110/136) 13 87.6 (120/137) 9 83.9 (115/137) 11 79.6 (109/137) 16 77.4 (106/137) 20 80.5 (107/133) 14

84.8 (84/99) 12 84.8 (84/99) 11 82.8 (82/99) 16 86.9 (86/99) 7 83.2 (79/95) 14 79.0 (79/100) 24 82.8 (82/99) 17 83.9 (78/93) 13

86.1 (149/173) 10 86.2 (150/174) 9 87.4 (152/174) 8 86.1 (149/173) 11 82.8 (140/169) 15 78.2 (136/174) 22 85.5 (148/173) 12 81.7 (134/164) 17

81.8 (144/176) 8 79.0 (139/176) 11 74.7 (130/174) 16 75.1 (133/177) 15 78.3 (137/175) 13 80.2 (142/177) 10 72.9 (129/177) 20 74.1 (126/170) 18

83.7 (195/233) 8 82.0 (191/233) 9 78.8 (182/231) 11 77.6 (180/232) 14 76.3 (174/228) 17 78.2 (183/234) 13 77.3 (180/233) 15 76.8 (172/224) 16

84.0 (100/119) 12 84.2 (101/120) 10 84.2 (101/120) 11 85.1 (103/121) 8 88.2 (105/119) 6 80.8 (97/120) 19 82.5 (99/120) 15 80.7 (92/114) 21

86.2 (106/123) 4 85.2 (104/122) 9 81.0 (98/121) 12 78.7 (96/122) 14 79.2 (95/120) 13 77.2 (95/123) 15 82.0 (100/122) 11 76.9 (90/117) 17

81.8 (63/77) 9 77.2 (61/79) 12 81.0 (64/79) 10 79.7 (63/79) 11 76.9 (60/78) 13 74.7 (59/79) 17 75.6 (59/78) 16 65.4 (51/78) 32

83.3 (120/144) 14 82.8 (120/145) 16 80.6 (116/144) 20 81.4 (118/145) 18 83.8 (119/142) 11 84.1 (122/145) 10 79.3 (115/145) 21 85.2 (115/135) 8

77.9 (278/357) 17 . your PT explains the 77.5 treatment. (275/355) 18 . your PT discusses 77.2 things with the (271/351) doctor if necessary. 19 . the treatment is carried 75.6 out under comfortable (266/352) conditions. 20 . your PT has sufficient 75.6 time during the (269/356) treatment to involve 21 himself with you personally. . the treatment room 73.9 is clean and tidy. (257/348) 22 . your PT is able to 73.1 relieve your (258/353) complaints quickly. 23 . you can make an 73.0 appointment (257/352) with your PT at 24 short notice. . you can confide 72.3 in your PT. (258/357) 25 . your PT’s treatment 70.7 is affordable. (246/348) 26

78.1 (100/128) 14 79.4 (100/126) 12 79.5 (101/127) 11 73.0 (92/126) 21 77.3 (99/128) 15

77.5 (176/227) 17 76.2 (173/227) 20 75.7 (168/222) 22 77.2 (173/224) 18 74.8 (169/226) 23

67.8 (78/115) 24 75.4 (86/114) 13 70.5 (79/112) 20 74.6 (85/114) 15 69.3 (79/114) 22

79.6 (109/137) 18 80.3 (110/137) 15 79.6 (109/137) 17 74.5 (102/137) 22 73.0 (100/137) 26

88.0 (88/100) 4 76.8 (76/99) 28 81.4 (79/97) 21 80.2 (77/96) 23 88.0 (88/100) 5

82.1 (142/173) 16 76.3 (132/173) 27 77.6 (132/170) 24 78.8 (134/170) 19 83.3 (145/174) 14

74.2 (132/178) 17 78.4 (138/176) 12 76.6 (134/175) 14 72.2 (127/176) 21 67.6 (119/176) 24

74.8 (175/234) 19 76.3 (177/232) 18 78.3 (180/230) 12 71.7 (165/230) 21 72.5 (169/233) 20

83.3 (100/120) 14 79.2 (95/120) 24 75.4 (89/118) 28 82.4 (98/119) 17 80.8 (97/120) 20

74.0 (91/123) 21 77.0 (94/122) 16 72.1 (88/122) 23 75.4 (89/118) 18 73.2 (90/123) 22

67.9 (53/78) 28 74.7 (59/79) 18 74.4 (58/78) 19 75.9 (60/79) 15 66.7 (52/78) 29

86.2 (125/145) 6 79.2 (114/144) 22 83.0 (117/141) 15 75.7 (109/144) 24 81.4 (118/145) 19

70.6 (89/126) 25 73.8 (93/126) 20 66.9 (85/127) 28

75.9 (167/220) 21 72.9 (164/225) 27 76.7 (171/223) 19

66.7 (76/114) 26 61.1 (69/113) 33 71.1 (81/114) 18

79.3 (107/135) 19 74.5 (102/137) 24 73.7 (101/137) 25

75.5 (71/94) 30 85.9 (85/99) 9 74.2 (72/97) 32

80.8 (135/167) 18 78.2 (136/174) 21 72.5 (124/171) 30

66.9 (117/175) 25 67.6 (117/173) 23 73.1 (128/175) 19

70.1 (162/231) 23 69.4 (161/232) 24 70.3 (163/232) 22

80.9 (93/115) 18 79.7 (94/118) 23 77.8 (91/117) 26

71.9 (87/121) 24 74.0 (91/123) 20 74.6 (91/122) 19

73.4 (58/79) 20 69.2 (54/78) 25 76.9 (60/78) 14

75.4 (104/138) 25 74.6 (106/142) 26 70.4 (100/142) 29

68.8 (88/128) 27 64.8 (79/122) 30

74.0 (168/227) 25 74.2 (167/225) 24

63.5 (73/115) 29 62.8 (71/113) 30

74.5 (102/137) 23 76.9 (103/134) 21

81.0 (81/100) 22 71.1 (69/97) 37

78.7 (137/174) 20 77.1 (131/170) 25

65.5 (116/177) 26 64.7 (112/173) 27

66.7 (156/234) 29 67.1 (153/228) 27

82.5 (99/120) 16 78.0 (92/118) 25

63.4 (78/123) 31 69.7 (85/122) 26

65.8 (52/79) 30 71.1 (54/76) 22

82.8 (120/145) 17 72.9 (102/140) 27

. your PT advises you how to prevent problems. . your PT adjusts the treatment if the results are lacking. . your PT is enthusiastic in his work. . your PT takes you seriously. . the interns working with your PT are being given sufficient guidance. . your PT pays sufficient attention to hygiene. . your PT guarantees his patients’ privacy. . your PT motivates you to keep on with the treatment. . your PT is discreet.

. your PT gives you sufficient assistance in doing your exercises. . your PT can communicate clearly. . your PT is friendly.

. there is sufficient attention to safety when working with equipment. . you are on good terms with your PT.

W. Peersman et al. / Manual Therapy 18 (2013) 155e164

163

(continued ) Item

All cases

. your PT is helpful.

70.3 (248/353) 27 . your PT is aware of 69.9 your medical history. (249/356) 28 . there are occasions 69.2 for laughter during (245/354) the treatment. 29 . your PT tells you 68.7 everything about (241/351) your ailment. 30 . you are free to choose 66.9 which PT (232/347) treats you. 31 . your PT regularly 66.9 goes on courses for (234/350) further training. 32 . you are involved in 66.9 decisions about (234/350) your treatment. 33 . your PT gives you 64.5 exercises you can do (222/344) by yourself at home. 34 . your PT examines 63.0 you before starting (221/351) the treatment. 35 . your PT is someone 62.1 with lots of experience. (221/356) 36 . you are always treated 59.1 by the same PT. (205/347) 37 . your PT takes your 58.1 wishes and desires (204/351) into account. 38 . you can have a chat 55.1 with your PT. (196/356) 39 . your PT always carries 54.1 out exactly what the (192/355) doctor has prescribed. 40 . the practice is easy 53.5 to get to. (185/346) 41 52.4 . your treatment starts at the agreed time. (186/355) 42 . the treatment is not 48.4 tedious. (169/349) 43 . your PT also supports 46.0 you psychologically. (162/352) 44 . the treatment is given 44.3 by the PT and not by (145/327) an intern. 45 . your PT is available 37.6 at times that suit you. (132/351) 46 . your PT is interested 33.4 in your social situation. (116/347) 47 . you have a good rapport 32.4 with the other patients (73/225) during group therapy. 48

Sex

Age

Education

Health status

Contact with PT

Male

Female

<40

40e59

60þ

0e18 Years þ18 Years Good

Fair/poor <20

20e50 þ50

71.7 (91/127) 23 64.1 (82/128) 32 70.9 (90/127) 24 71.9 (92/128) 22 58.1 (72/124) 35 61.4 (78/127) 34 62.4 (78/125) 33 65.3 (81/124) 29 64.6 (82/127) 31 56.3 (72/128) 36 52.4 (66/126) 39 55.9 (71/127) 37 51.6 (66/128) 40 55.1 (70/127) 38 48.0 (60/125) 42 50.8 (65/128) 41 44.4 (55/124) 44 44.5 (57/128) 43 32.8 (39/119) 47 37.3 (47/126) 45 29.1 (37/127) 48 34.1 (28/82) 46

69.2 (155/224) 31 73.0 (165/226) 26 68.4 (154/225) 32 67.0 (148/221) 33 71.5 (158/221) 28 69.7 (154/221) 29 69.5 (155/223) 30 64.2 (140/218) 35 62.2 (138/222) 37 65.0 (147/226) 34 62.6 (137/219) 36 59.5 (132/222) 38 56.6 (128/226) 39 53.1 (120/226) 42 56.6 (124/219) 40 53.3 (120/225) 41 50.2 (112/223) 44 46.4 (103/222) 45 51.0 (105/206) 43 38.1 (85/223) 46 35.3 (77/218) 47 31.2 (44/141) 48

69.3 (79/114) 23 62.6 (72/115) 31 67.5 (77/114) 25 70.4 (81/115) 21 52.7 (58/110) 36 55.0 (61/111) 34 61.4 (70/114) 32 65.8 (75/114) 28 71.7 (81/113) 17 47.4 (54/114) 39 43.0 (49/114) 41 53.1 (60/113) 35 51.3 (59/115) 37 32.1 (36/112) 44 48.2 (55/114) 38 46.1 (53/115) 40 36.3 (41/113) 42 25.7 (29/113) 46 28.6 (30/105) 45 32.5 (37/114) 43 20.4 (23/113) 48 23.0 (17/74) 47

69.3 (95/137) 29 68.6 (94/137) 30 67.6 (92/136) 31 63.2 (86/136) 34 71.3 (97/136) 27 70.1 (96/137) 28 66.9 (91/136) 32 60.7 (82/135) 36 61.8 (84/136) 35 63.5 (87/137) 33 60.2 (80/133) 37 54.8 (74/135) 38 46.7 (64/137) 43 51.8 (71/137) 39 49.3 (66/134) 42 50.4 (69/137) 41 50.4 (68/135) 40 45.2 (61/135) 44 40.2 (51/127) 45 34.8 (47/135) 46 32.3 (43/133) 48 33.3 (28/84) 47

72.2 (70/97) 34 81.8 (81/99) 20 71.7 (71/99) 35 74.7 (71/95) 31 76.0 (73/96) 29 77.3 (75/97) 26 73.7 (70/95) 33 67.0 (61/91) 41 55.7 (54/97) 45 79.0 (79/100) 25 76.8 (73/95) 27 69.4 (68/98) 39 71.7 (71/99) 36 82.2 (83/101) 19 66.0 (62/94) 42 62.6 (62/99) 43 60.4 (58/96) 44 69.7 (69/99) 38 69.2 (63/91) 40 49.5 (48/97) 47 51.0 (49/96) 46 42.9 (27/63) 48

77.9 (134/172) 23 71.3 (124/174) 33 74.6 (129/173) 28 76.3 (129/169) 26 69.0 (118/171) 34 72.5 (124/171) 29 71.8 (122/170) 32 63.6 (105/165) 38 62.9 (107/170) 40 71.8 (125/174) 31 66.3 (112/169) 35 62.6 (107/171) 41 63.2 (110/174) 39 65.3 (113/173) 36 64.5 (107/166) 37 58.4 (101/173) 43 55.0 (93/169) 45 59.3 (102/172) 42 55.3 (89/161) 44 39.1 (66/169) 48 40.8 (69/169) 47 41.2 (49/119) 46

71.4 (85/119) 30 80.0 (96/120) 22 70.0 (84/120) 32 76.7 (89/116) 27 70.1 (82/117) 31 66.7 (78/117) 36 74.4 (87/117) 29 66.7 (78/117) 37 58.5 (69/118) 42 70.0 (84/120) 33 68.1 (79/116) 34 66.9 (79/118) 35 62.0 (75/121) 39 64.2 (77/120) 38 61.4 (70/114) 40 52.1 (62/119) 45 55.9 (66/118) 43 61.3 (73/119) 41 55.1 (59/107) 44 41.0 (48/117) 47 46.5 (53/114) 46 36.5 (27/74) 48

73.1 (57/78) 21 59.5 (47/79) 35 60.8 (48/79) 34 61.5 (48/78) 33 71.1 (54/76) 23 69.6 (55/79) 24 69.2 (54/78) 26 68.4 (54/79) 27 65.8 (52/79) 31 58.2 (46/79) 36 53.2 (41/77) 38 57.0 (45/79) 37 39.7 (31/78) 44 42.9 (33/77) 43 46.8 (37/79) 41 49.4 (39/79) 39 47.4 (37/78) 40 39.7 (31/78) 45 44.0 (33/75) 42 32.9 (26/79) 46 21.8 (17/78) 48 23.2 (13/56) 47

62.3 (109/175) 32 68.2 (120/176) 22 63.4 (111/175) 30 61.4 (108/176) 33 64.7 (110/170) 29 60.7 (105/173) 35 61.1 (107/175) 34 64.7 (112/173) 28 63.4 (111/175) 31 52.3 (92/176) 37 51.7 (89/172) 38 52.9 (92/174) 36 46.0 (81/176) 39 42.0 (74/176) 41 42.0 (73/174) 42 45.5 (80/176) 40 40.8 (71/174) 43 32.2 (56/174) 46 32.3 (52/161) 45 35.8 (63/176) 44 25.0 (43/172) 47 22.5 (23/102) 48

69.3 (160/231) 25 64.8 (151/233) 30 68.4 (158/231) 26 64.4 (150/233) 33 64.8 (147/227) 32 67.0 (154/230) 28 62.6 (144/230) 35 62.9 (141/224) 34 64.8 (149/230) 31 57.5 (134/233) 36 53.9 (123/228) 37 53.0 (122/230) 38 50.9 (118/232) 40 48.3 (112/232) 42 49.1 (113/230) 41 52.4 (122/233) 39 44.1 (101/229) 43 37.8 (87/230) 45 38.2 (83/217) 44 35.5 (82/231) 46 26.5 (61/230) 48 30.7 (46/150) 47

65.6 (80/122) 28 59.8 (73/122) 36 62.8 (76/121) 33 71.1 (86/121) 25 64.4 (76/118) 30 64.5 (78/121) 29 61.7 (74/120) 34 67.8 (80/118) 27 63.3 (76/120) 32 54.9 (67/122) 37 60.7 (71/117) 35 53.8 (64/119) 38 50.8 (62/122) 41 50.4 (62/123) 42 52.5 (64/122) 39 52.0 (64/123) 40 42.1 (51/121) 44 37.2 (45/121) 45 42.3 (47/111) 43 35.5 (43/121) 46 30.3 (36/119) 48 31.6 (24/76) 47

72.7 (104/143) 28 83.4 (121/145) 13 78.5 (113/144) 23 70.4 (100/142) 30 65.7 (94/143) 34 67.1 (94/140) 33 68.5 (98/143) 32 59.9 (82/137) 40 60.3 (85/141) 39 69.7 (101/145) 31 61.5 (88/143) 36 61.3 (87/142) 37 65.5 (95/145) 35 60.4 (87/144) 38 57.0 (77/135) 41 53.8 (77/143) 43 52.1 (73/140) 44 54.9 (79/144) 42 46.6 (61/131) 45 41.8 (59/141) 46 40.4 (57/141) 47 37.6 (32/85) 48

The rank numbers are in italics.

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