Task

Background: The World Health Organization defines task shifting as the rational redistribution of tasks among the healthcare workforce teams. The transfer of tasks to physical therapy is well suited for musculoskeletal conditions, either where exercise and physical activity are an important part of the treatment, or to sort the flow of emergency patients. Methods: What are the benefits, limits and implementation challenges associated to the employment of enhanced physical therapy in the redistribution of secondary healthcare workforce? The aim of this narrative review is to collect evidence from the most recent publications, in order to address clinical studies, policy making and further research. Results: A clear correlation between healthcare system and type of service was not found, supporting that task shifting can be employed to meet different needs. In emergency departments, enhanced physical therapists are employed to improve the flow of musculoskeletal patients, reduce waiting time, length of stay and free up professionals in support of more complex conditions. Otherwise, enhanced physical therapists are employed to sort the flow of chronic musculoskeletal patients, triaging to orthopaedic surgery, and performing follow-up. Clinical outcomes were equal or better than those achieved by other professionals. Appropriate diagnoses and referrals were also demonstrated, despite two studies show enhanced physical therapy to be effective but dependent by medical support. Specific training is therefore fundamental. Conclusion: Task shifting is a promising innovation which is worthy introducing in the management of chronic musculoskeletal conditions, when most of the treatments may be repeated under the supervision of medical consultants.


INTRODUCTION
The World Health Organization (WHO) defines task shifting as the rational redistribution of tasks among the healthcare workforce teams [1].Task shifting means that work traditionally performed by one health professional is transferred to another, in order to maximize the benefits produced by the amount and qualification of resources available [2], either humans, or machines [3].For instance, task shifting is frequently used in low-income countries to make up for the shortage of healthcare professionals [4], as well as in high-income countries in support of healthcare quality, waiting times and sustainability [5][6][7].
Task shifting is traditionally practised from medical doctors to nurses [8,9], but physical therapy is gaining momentum [10].The transfer of tasks to physical therapy is well suited for musculoskeletal (MSK) conditions, either where exercise and physical activity are an important part of the treatment, or to sort the flow of emergency patients affected by trauma or soft tissue injury.Physical therapists (PTs) have emerged as key providers in such roles, by supporting or replacing traditional medical skills such as performing triage, communicating a diagnosis, triaging potential surgical candidates, ordering diagnostic imaging or laboratory tests, performing injections and in some countries prescribing medications.
The challenge of enhanced physical therapy is to improve healthcare access, free up medical resources and reduce costs while achieving the same patient satisfaction and quality.This is especially true for those countries in which healthcare resources are shared or distributed under public regulation, which are accountable for the effectiveness and efficiency of their policies [11].In the UK, around 21% of the 18.3 million people who attended Emergency Departments (ED) in a year presented with MSK-related injuries which generated an estimated £ 440 million costs.With the average cost of an ED visit costing the National Health Service (NHS) approximately £ 115, enhanced physical therapy is catching on in order to reduce direct costs with similar clinical outcomes [12,13].
The enormous potential disclosed by a profitable adoption of task shifting has pushed the European Commission to recognize his value [3].However, such a serious consideration from international institutions (together with the high amount of experiences in which enhanced physiotherapy is informally employed worldwide) does not enjoy equal attention in literature.The majority of reports available are indeed descriptive studies which focus on single components of the practice, such as organizational benefits, clinical outcomes, diagnostic accuracy, patient satisfaction, or direct cost savings to the provider.Although each of these focuses are appropriate and necessary, several reviews complain about the lack of an overall sight on the multiple components included in the process [14][15][16][17][18][19].As long as healthcare value is expressed by multiple benefits to multiple stakeholders [20,21], the more dimensions are included in a study, the more complete evaluation of task shifting.
What are the benefits, limits and implementation challenges associated to the employment of enhanced physical therapy in the redistribution of secondary healthcare workforce?The aim of this narrative review is to collect evidence from the most recent publications, in order to address clinical studies, policy making and further research.

METHODS
Items are generated from a review of the literature.Web searches on and PubMed database have been conducted between July and September 2019, by one researcher, and subsequently approved by a supervisor, according to inclusion criteria.Grey literature is employed to address background and support discussion.Scientific papers are entirely screened and summarized in the synthesis.
The search terms used are the following: task shifting, review, physiotherapy, musculoskeletal, orthopaedics, joint replacement, fast-track, diagnostics, community medicine, barriers, human replacement, robotics, wearable.The purpose of the research is described more in detail by the following bullet points, in which inclusion criteria are also made explicit.
• Enhanced physical therapy can be declined in different tasks according to local regulation, provider organization, care-givers qualifications and healthcare systems characteristics.In this manuscript, enhanced physical therapy includes those roles and specific functions typically adopted in the UK (such as Advanced Practitioner, Extended Scope Practitioner, Emergency Physiotherapy Practitioner, Consultant Physiotherapist) [9].Sometimes well distinct, sometimes overlapping [22], these roles and functions are also highly representative of similar employment in other countries [9,11,14,[23][24][25][26]. • The focus is limited to secondary care practice, be it inpatient or outpatient, be emergency or not.
Therefore, studies about enhanced physical therapy in primary care are excluded from the synthesis.• The target of the present research is to evaluate the benefits of enhanced physical therapy as a task shifting modality from other traditional practice (i.e.physical therapy instead of medical); not to evaluate 1. the benefits of physical therapy as an alternative (or an integration) to other treatments; 2. the benefits of task shifting from other professions to physical therapy (i.e.nurses instead or PTs [27] or assistant PTs instead of qualified PTs [28]).Therefore, similar studies were excluded from the synthesis.qualitative research is fundamental to understand the degree of commitment of the workforce involved in task-shifting, be them those who replace functions (in this case, enhanced physical therapists) or those who are replaced (in most of the case medical doctors or surgeons).• Room for improvement: identifying structural limits, implementation challenges, patients worries or care-givers perplexities provides evidence-based information to improve or abandon the implementation of the program, providing in turn fundamental support to effective early technology assessment.Just like rarely a study includes all the information under consideration, rarely a study focuses on a single one.Missing data are represented by empty cells.Rather than a limit of the present study, the authors believe this strategy to address more brightly the evidence to rely on, as well as the challenges to address.

RESULTS
15 studies are included in the synthesis.

DISCUSSION
Task shifting to secondary care enhanced physical therapy is a widespread empirical practice which is attracting increasing interest in literature.Where these shifts have been evaluated, they often, but not always, are associated with outcomes that are as good or even better than with the status quo.However, the results are often context dependent, and it cannot be assumed that what works in one situation will apply equally to another.
In order to provide a clearer discussion of these paper findings, considerations are reported in bullet points.
• Task shifting is employed in 5 different countries (Australia, Ireland, Netherlands, Norway, United States), among which 9 services are employed in ED and 6 are not.A clear correlation between healthcare system and type of service was not found, supporting that task shifting can be employed to meet different needs.• In ED, enhanced PTs are mostly employed to improve the flow of MSK patients, reduce waiting time and length of stay (i.e.guarantee assistance before 4h) and free up other professionals in support of more complex medical conditions.Otherwise, enhanced PTs are employed to sort the flow of chronic MSK patients, triaging to orthopaedic surgery, and performing follow-up visits after discharge.

TABLE 1 (CONTINUED). Results
Task shifting into enhanced physical therapy achieved by other professionals in 3 studies, which in one case were also associated with less imaging prescriptions.Appropriate diagnoses and referrals were also demonstrated.No studies reported worse clinical outcomes, despite medical support was sometimes considered determinant.On this regard, it is fundamental to guarantee medical supervision and full collaboration at least in the early phase of implementation.Task shifting may therefore require more investments in the short term, but guarantee cost-effectiveness in the long-.At this purpose, longitudinal studies and early health technology assessments are highly recommended.
• 2 studies show enhanced physical therapy to be effective but still dependent by medical support, questioning the overall value of its introduction.If reduced waiting times were only due to bypassing an initial doctor's assessment which is only delayed later, the benefits of tash skifting would be only superficial.Task shifting into enhanced physical therapy by patients in comparison to medical doctos or enhanced nurses [47].This finding is challenged in this review.While the case of nurses supports the idea that greater patient satisfaction is associated to better empathy and communicative skills (rather than clinical outcomes in themselves), according to others greater patient satisfaction is simply determined by the reduction in waiting times, regardless to which professional takes charge of the need [23].If so, benefits are a natural consequence of extra staff working, with consequent need of major funding or unpaid work.
• In order to clarify this issue, furthers studies should investigate 1. the correlation between empathy, communication skills and patient satisfaction in ED settings, 2. whether a correlation between these skills and professionals do exist.Moreover, in exceptional settings such as the Netherlands, in which patients are able to self-referral to physical therapy, other bias may play an important role (i.e. a clinician is more motivated in performing his visit when referral is made by another professional).

CONCLUSIONS
The evidence reviewed demonstrated that many tasks traditionally been performed by one type of health worker, can be performed as well as (or even better) by others.However, task shifting cannot be considered a panacea of all the challenges faced by health systems.In this regard, it is worthy distinguishing between the setting in which enhanced physical therapy is employed.
With respect to ED MSK conditions, the authors agree that task shifting may probably be only a quickfix to a problem that requires governmental, educational and societal input to be addressed seriously [16].The increase in patients flow to ED is not only due to the increase in elderly, fragile patients which represent a demographic challenge long from being solved; it is a cultural and organizational challenge which comes as a consequence of poor collaboration between hospital and community, poor communication between primary and secondary care, poor education in support of selfcare and consequently poor prevention from patients themselves.Redistributing skills between professionals can improve efficiency, but major benefits are likely to come from addressing the problem at the source (i.e.secondary fracture service prevention) [48].
Task shifting is instead a promising innovation which is worthy introducing in the management of chronic MSK conditions, when most of the treatments may be repeated under the supervision of medical consultants.Authorizing trained PTs to perform injections and prescribe a range of drugs which is consistent with the disease they are responsible to manage can indeed be a cost-effective solution to the evolution of the healthcare demand: first of all by meeting the needs of the elderly increasingly affected by chronic diseases; and secondly by freeing up medical resources to treat more patients affected by multiple and complex comorbidities.
At this purpose, more studies on task shifting in support of elective treatments and chronic patients management are likely to add significant value to healthcare innovation.
The authors declare there is no conflict of interest regarding the publication of the article.

TABLE 1 (
CONTINUED). Results • At this purpose, specific enhanced training is fundamental.Enhanced physical therapist appreciate to learn from doctors, consultants or specialist, and to support their activity; in turn, the latter appreciate the support of the former, provided compatibility with local regulation and maintenance