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Process Matters: The Effects of Process Variables on Patient Outcomes in Musculoskeletal Care Pathways

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Thesis(1.68 MB)

Date

2026

Authors

Harvey, Daniel

Supervisor

White, Steve
Reid, Duncan
Cook, Chad

Item type

Thesis

Degree name

Doctor of Philosophy

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Volume Title

Publisher

Auckland University of Technology

Abstract

In New Zealand and globally, the burden of pain, disability, and related healthcare costs due to musculoskeletal conditions is increasing. Researchers and clinicians have endeavoured to tackle this growing issue through various diagnostic and treatment-focused management strategies. Given the limited success of existing assessment and treatment methods, there has been a recent shift among clinicians, researchers and funders towards promoting value-based care for musculoskeletal conditions. This approach enhances efficiency and incentivises better patient outcomes by emphasising the importance of care processes. Consequently, value-based care presents an opportunity to investigate how individual processes experienced by patients during their rehabilitation, known as process variables, impact outcomes for musculoskeletal patients within New Zealand's care pathways. However, there appears to be limited evidence and understanding in the existing literature regarding the role of process variables and their impact on patient outcomes. To address this gap, this thesis primarily aims to investigate how process variables affect patient outcomes in musculoskeletal care pathways. A series of three studies was developed and are presented in this thesis. In the first study, to better understand what a process variable is within a musculoskeletal care pathway, a nominal group technique (a consensus-based approach) was employed among New Zealand experts in the management of care pathways. The operational definition clarified that a process variable is a modifiable factor, within a pathway, that can be measured and when changing it may lead to different operational or patient outcomes. In the second study, a focus group approach was used to explore patient perspectives on process variables in musculoskeletal care pathways, aiming to identify what patients consider important during their rehabilitation journey. Several process variables were identified, including the timeliness of treatment, the order of care, the coordination of care delivery, quantifying progress, equity of access, and patient navigation. Four themes emerged from the reflexive thematic analysis: 1) process matters, 2) how quantifying progress facilitates patient engagement, 3) the benefits of equitable access of care, and 4) recovery is made easier with navigation. In the third study, an observational cohort study retrospectively examined a database of patients with musculoskeletal injuries receiving care within musculoskeletal rehabilitation care pathways. Quantile linear regressions were utilised to analyse the associations between process variables and the outcome measures reported by patients at discharge. Significant associations with varying degrees of effect were found between process variables and patient outcomes in some surgical and non-surgical musculoskeletal care pathways. Collectively, the findings demonstrate that process variables can significantly influence patient outcomes in musculoskeletal care pathways, both positively and negatively. Therefore, this thesis urges clinicians, funders, health system planners, researchers and educators to prioritise the identification, measurement, and utilisation of process variables within musculoskeletal care pathways to enhance patient outcomes.

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http://hdl.handle.net/10292/21016

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Doctoral Theses