Intermediate care pathways for musculoskeletal conditions--are they working? A systematic review

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain

BACKGROUND

Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings.

PURPOSE

This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy.

METHODS

An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices.

RESULTS

Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices.

CONCLUSION

Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

A scoping review to map evidence regarding key domains and questions in the management of non-traumatic wrist disorders

Introduction

Non-traumatic wrist disorders (NTWD) are commonly encountered yet sparse resources exist to aid management. This study aimed to produce a literature map regarding diagnosis, management, pathways of care and outcome measures for NTWDs in the United Kingdom.

Methods

An interdisciplinary team of clinicians and academic researchers used Joanna Briggs Institute guidelines and the PRISMA ScR checklist in this scoping review. A mixed stakeholder group of patients and healthcare professionals identified 16 questions of importance to which the literature was mapped. An a-priori search strategy of both published and non-published material from five electronic databases and grey literature resources identified records. Two reviewers independently screened records for inclusion using explicit eligibility criteria with oversight from a third. Data extraction through narrative synthesis, charting and summary was performed independently by two reviewers.

Results

Of 185 studies meeting eligibility criteria, diagnoses of wrist pain, De Quervain's syndrome and ulna-sided pain were encountered most frequently, with uncontrolled non-randomised trial or cohort study being the most frequently used methodology. Diagnostic methods used included subjective questioning, self-reported pain, palpation and special tests. Best practice guidelines were found from three sources for two NTWD conditions. Seventeen types of conservative management, and 20 different patient-reported outcome measures were suggested for NTWD.

Conclusion

Substantial gaps in evidence exist in all parts of the patient journey for NTWD when mapped against an analytic framework (AF). Opportunities exist for future rigorous primary studies to address these gaps and the preliminary concerns about the quality of the literature regarding NTWD.

Organisational capabilities, outcomes, and benefits of trigger finger release surgery in primary care: a service evaluation study

BACKGROUND

Trigger finger is a common hand condition in which a finger is unable to fully extend owing to a thickening of the tendon and its sheath, causing the finger to lock in a bent position.

AIM

To assess the viability of carrying out trigger finger surgeries in NHS primary care in terms of clinician and patient acceptance, experience, and outcomes; and operational requirements of this service for wider application.

DESIGN & SETTING

A pilot study for a new service in primary care in Leicestershire, UK.

METHOD

A total of 214 trigger finger release surgery procedures were carried out between 22 August 2019 and 25 October 2022 by a single hand surgeon in a single primary care surgery. Data were analysed using information from SystmOne, which is a patient database linked with the NHS.

RESULTS

Thirty-two cases out of 214 (15.0%) experienced a wait time of <10 days from the GP referral to the first outpatient appointment (OPA). Out of 214 procedures, there were 26 (12.1%) postoperative complications that required follow-up action. Of the total number of cases where postoperative complications were identified, 13 cases required further follow-up action, while the remaining 13 did not have any identifiable further follow-up action and were regarded as closed cases thereafter.

CONCLUSION

Trigger finger release surgery in primary care offers an opportunity to reduce pressures on secondary care orthopaedic referrals, as well as offering patients faster and effective surgical treatment while utilising fewer NHS resources.

The Five-Year Growth of an Orthopedic Urgent Care Center: Identifying Patient and Center Trends

INTRODUCTION

With emergency department utilization rising at a dramatic rate, orthopedic urgent care centers (oUCCs) have become increasingly popular. The financial viability and basic advantages of oUCCs have been described in the literature, but little is known about the characteristics of patients treated and the diagnoses encountered. The purpose of this study is to report and evaluate the patients and diagnoses that are most commonly seen in an oUCC so that future care may be better tailored to the needs of the patients seeking these services.

MATERIALS AND METHODS

All patients seen at a single suburban oUCC in its first and fifth years of operation (2014 and 2019) were identified. The medical records were reviewed to assess patient demographics, diagnoses encountered, and services rendered. The clinical courses of patients treated were also reviewed to identify those who underwent eventual surgery for their presenting complaint.

RESULTS

A total of 24,756 patient visits occurred during the study period, and the number of visits nearly doubled between the first and fifth years (8,301 in 2014 and 16,455 in 2019). The most common diagnoses encountered were lower leg pain, back pain, and foot/ankle pain. Radiographs were obtained in 17,236 visits (70%), most commonly of the knee, elbow, foot, or ankle. A total of 1,334 patients (5.4%) underwent eventual surgery for their presenting complaint - defined as a surgical conversion. Of all the orthopedic subspecialties, sports medicine had the highest rate of surgical conversion (29% of all conversions). The surgical conversion rate increased slightly from year one (4.7%) to year five (5.8%).

CONCLUSIONS

OUCCs are an effective means of expanding access to care for patients and increasing the volume of an orthopedic practice. Continued monitoring of the types of patients seen within oUCCs will further optimize care delivery.

Validation of the international classification of functioning, disability, and health (ICF) core sets for musculoskeletal conditions in a primary health care setting from physiotherapists' perspective using the Delphi method

PURPOSE

To analyze the possibilities of using ICF core sets for musculoskeletal conditions in primary care physiotherapy units of the Health Service of "Castilla y León" (Spain).

METHODS

A three-round Delphi study was conducted by physiotherapists working in a primary care setting. The data obtained were linked to second-level ICF categories and their relevance was assessed by the participants. The most relevant categories were compared with those present in the existing ICF core sets for musculoskeletal conditions.

RESULTS

Eighty-four physiotherapists participated in the survey. The consensus was reached for 45 ICF categories and 5 personal factors after the survey. Thirty-five of these categories were present in the Comprehensive Core Set for post-acute Musculoskeletal Conditions. In addition, 35 categories present in the core set were not considered relevant from the participants' perspective.

CONCLUSIONS

Physiotherapists mainly considered movement-related categories as relevant. The ICF core set for post-acute musculoskeletal conditions comprises many of these categories and can therefore be taken as a basis for the adoption of ICF in the clinical context.

RELEVANCE

Primary care physiotherapists should be aware of the advantages of using ICF in their clinical settings.Implications for RehabilitationThis study shows which body functions and structures, activities and participation, environmental factors, and personal characteristics are relevant from primary care physiotherapists' perspective assessing persons with musculoskeletal conditions.The Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions includes most of the categories identified in this study, but they need to be refined to fully represent the primary care physiotherapists' perspective.The results of this study support the use of the Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions as a basis for operationalizing ICF in this clinical setting.

Acceptability of a task sharing and shifting model between family physicians and physiotherapists in French multidisciplinary primary healthcare centres: a cross-sectional survey

OBJECTIVES

The rising prevalence of musculoskeletal disorders increases pressure on primary care services. In France, patients with musculoskeletal disorders are referred to physiotherapist (PT) by family physician (FP). To improve access to musculoskeletal care, a new model of task sharing and shifting is implemented between FPs and PTs for patients with acute low back pain. This new model enables French PTs to expand their usual scope of practice by receiving patients as first-contact practitioner, diagnosing low back pain, prescribing sick leave and analgesic medication. The aim of this study is to investigate the acceptability of FPs and PTs regarding this new model.

DESIGN

A cross-sectional survey design was used. Acceptability was measured using a questionnaire on the perception of the model and the perception of PTs' skills to manage low back pain. Descriptive analyses were performed to compare results among participants.

SETTING

French FPs and PTs working in multidisciplinary primary healthcare centres were invited to complete an online survey.

PARTICIPANTS

A total of 174 respondents completed the survey (81 FPs and 85 PTs).

RESULTS

A majority of participants had a positive perception of the task sharing and shifting model. A majority of the participants were mostly or totally favourable towards the implementation of the model (FPs: n=46, 82% and PTs: n=40, 82%). The perceived level of competencies of PTs to manage acute low back pain was high. The confidence level of FPs was higher than that of PTs regarding PTs' ability to adequately diagnose low back pain, refer patient to physiotherapy and prescribe sick leave or analgesic medication.

CONCLUSION

Based on this limited sample of participants, there appears to be good acceptability of the task sharing and shifting model for acute low back pain. Additional studies are needed to better determine the factors affecting the acceptability of such a model.

Musculoskeletal Physiotherapy in the Emergency Department – Evaluation of a New Physiotherapy Service in a Swiss University Hospital

Background Many countries report a significant increase in emergency department (ED) visits. Patients with musculoskeletal disorders account for a large proportion of non-urgent cases.

Objective Characterization and evaluation of a new service that provides immediate access to physiotherapy for patients in the ED.

Method To characterize a new service at the Department of Emergency Medicine, Bern University Hospital, and to evaluate first experiences with it, a mixed methods approach was chosen. Data was collected from the electronic patient file and from a logbook kept by the physiotherapists. In addition, guideline-based interviews with involved health care staff were conducted.

Results During the 63 days of the pilot study 79 patients were treated by physiotherapists. The most frequently reported patient complaint was back pain (47 %). Interventions included taking the medical history, performing manual tests and multimodal treatment and developing recommendations for further treatment. In 59 % of patients no medical imaging and in 58 % no additional physiotherapy was prescribed. Patients rated the physiotherapeutic service as very good or excellent (88 %). Physiotherapy was experienced as positive and appreciated by the other professions, and all interviewees emphasized the added value for patients.

Conclusion The pilot study indicates that the physiotherapeutic consultation service has the potential to improve quality of care. The findings of this study are therefore valuable when considering the introduction of such a service in an ED.

Advanced practice physiotherapists are effective in the management of musculoskeletal disorders: a systematic review of systematic reviews

BACKGROUND

There are increasing demands for orthopaedic specialist services due to the increasing burden of musculoskeletal (MSK) disorders. This situation creates a barrier for patients to access appropriate health care. Advanced practitioner physiotherapists (APP) may provide an alternative service for patients with MSK disorders.

OBJECTIVE

To evaluate the evidence on whether APPs are accurate at diagnosis, can triage appropriately and improve patient treatment outcomes and access to care for patients with musculoskeletal disorders.

DATA SOURCES

CINAHL, MEDline, Web of Science, SPORTdiscus, SCOPUS and AMED between January 2000 and March 2020.

STUDY SELECTION

Systematic reviews evaluating the efficacy of APPs, in any healthcare setting, treating patients of any age range with MSK disorders, in comparison to orthopaedic surgeons or doctors.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently extracted and synthesised data according to the inclusion and exclusion criteria. Methodological quality was independently assessed by two reviewers using the AMSTAR tool. A third reviewer resolved discrepancies.

RESULTS

Thirteen systematic reviews met the inclusion criteria. The evidence consistently found APPs are accurate at diagnosis, can triage appropriately, and improve patient treatment outcomes and access to care. There was a lack of high-quality primary studies in the included reviews, however, the highest quality studies had similar findings.

LIMITATIONS

A meta-analysis was not possible due to heterogeneity of outcome measures. There was an overlap of primary studies which may cause bias.

CONCLUSION

The evidence of varying quality consistently shows that APPs can accurately diagnose, appropriately triage and effectively manage patients with musculoskeletal disorders in various clinical settings.

Impacts of a Re-designed Care Path for Back Pain Directing Patients to Physiotherapists: A Pre-Post Intervention Study

OBJECTIVE

To evaluate impact of directing patients with back pain for first visit to a physiotherapist on sick leaves, healthcare utilization, and patient satisfaction.

METHODS

Pre-post intervention study of 70,138 patients treated in Poland for back pain: 27,034 before the care pathway redesign and 43,104 after.

RESULTS

After the redesign, all per-patient measures (mean ± SD) significantly decreased over the 12-month follow-up: sick leaves number from 0.32 ± 0.87 to 0.29 ± 0.86, sick leaves days from 2.78 ± 11.56 to 2.56 ± 11.25, doctors' visits from 2.02 ± 1.70 to 1.51 ± 1.63, diagnostic imaging services from 0.63 ± 0.79 to 0.43 ± 0.71 and rehabilitation services from 7.55 ± 14.90 to 4.70 ± 12.61.The Net Promoter Score was higher for physiotherapist (83), than for orthopedists (59), primary care (74), or neurologists (67).

CONCLUSIONS

Involving physiotherapists early in the back pain care may result in benefits for patients and healthcare organizations.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies

BACKGROUND

Physiotherapist-led (PT-led) orthopaedic triage is an evolving model of care for patients with musculoskeletal disorders. Objectives for this study were to establish the current evidence body on the impact of PT-led orthopaedic triage on health, quality, and service outcomes for patients referred for orthopaedic consultation, compared with standard (orthopaedic surgeon) care.

METHODS

Medline, EMBASE, Scopus and CINAHL were searched from inception until 7 May 2018; search updated 24 April 2020. Search terms (including derivatives) included physiotherapy, advanced/extended scope, musculoskeletal/orthopaedic, triage. The search was framed as Population = patients referred for orthopaedic consultation; Intervention = PT-led orthopaedic triage; Comparison = standard care; Outcomes = health, quality and process outcomes. Only randomised controlled trials (RCTs) and prospective comparative cohort studies were eligible for inclusion. Screening, study selection, data extraction, and assessment of methodological quality were performed independently by reviewer pairs. Quality was scored with the Downs and Black checklist. Certainty of evidence was determined using GRADE. PROSPERO registration number CRD42017070950.

RESULTS

We included two RCTs and eleven cohort studies (n = 1357 participants) of variable methodological quality (range 14-23 of possible 28). Certainty of evidence was low to moderate. There was no difference between PT-led orthopaedic triage and standard care for patient-reported outcomes (two RCTs). Perceived quality of care with PT-led orthopaedic triage was higher (two RCTs, four cohort studies) or equal (one cohort study) compared with standard care. PT-led orthopaedic triage had higher surgery conversion rates (one RCT, three cohort studies) (55-91% vs 22-38%), lower (two RCTs) or equal rate (two cohort studies) of referral for investigations, shorter waiting times (one RCT, one cohort study), and lower costs (one RCT). Furthermore, there was high agreement between physiotherapists' and orthopaedic surgeons' treatment approach (eight cohort studies), referral for investigation (five cohort studies), and diagnosis (nine cohort studies). Study limitations were the low number of RCTs, and variable methodological quality.

CONCLUSIONS

Evidence of low to moderate certainty suggests that PT-led orthopaedic triage leads to similar diagnostic decisions as standard care, has a higher conversion-to-surgery rate, reduces waiting times, is cost effective and valued by patients, and that health outcomes are equivalent.

What do people need?

The key question addressed in this Chapter is "What do people need?", with "people" here meaning those who live with a rheumatic or musculoskeletal disease. The word "patient" is avoided at this point as not all of the problems or solutions identified are medical in nature. Many are personal, societal and/or environmental. The lead authors are all people who not only live with a rheumatic or musculoskeletal disease, but who are experienced "patient representatives". Therefore, their insights here stem from a combination of personal and collective experiences and views. Although from different continents, the authors identify a range of common barriers to social participation and optimum management of these conditions, such as late diagnosis, stigma and access to care. However, several solutions are common across these regions too, such as the need for supported self-management and greater public awareness of the impact of these diseases.

Determining responsiveness and meaningful changes for the Musculoskeletal Health Questionnaire (MSK-HQ) for use across musculoskeletal care pathways

OBJECTIVES

We have previously developed and validated the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ) for use across musculoskeletal care pathways, showing encouraging psychometric test results. The objective of this study was to determine the responsiveness of MSK-HQ following MSK treatments and to determine the minimally important change (MIC).

SETTING

We collected data in four cohorts from community physiotherapy and secondary-care orthopaedic hip, knee and shoulder clinics.

PARTICIPANTS

592 individuals were recruited; 210 patients treated with physiotherapy for a range of MSK conditions in primary care; 150 patients undergoing hip replacement, 150 patients undergoing knee replacement and 82 undergoing shoulder surgery in secondary care.

OUTCOME MEASURES

Preoperative data were collected including the MSK-HQ, European Quality of Life-5D (EQ-5D) and the OHS, OKS or OSS in each joint-specific group. The same scores, together with anchor questions, were collected postintervention at 3 months for the physiotherapy group and 6 months for all others. Following COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines, responsiveness was assessed using correlation between scores and the MIC was calculated for the entire cohort using receiver operating characteristic curve analysis.

RESULTS

The MSK-HQ demonstrated strong correlation (R=0.73) with EQ-5D across the entire cohort and with each of the joint-specific Oxford scores (hip R=0.87, knee R=0.92 and shoulder R=0.77). Moderate correlation was seen between MSK-HQ and EQ-5D across each individual group (R value range 0.60-0.68), apart from the hip group where correlation was strong (R=0.77). The effect size with MSK-HQ was 0.93, in the entire cohort, double that measured with EQ-5D (0.43). In all subgroups, MSK-HQ measured a greater treatment effect compared with EQ-5D. The MIC is 5.5 (95% CI 2.7 to 8.3).

CONCLUSION

Our study demonstrates that the MSK-HQ questionnaire is responsive to change across a range of musculoskeletal conditions, supporting its use as a generic MSK measurement instrument.

Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review

OBJECTIVE

Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion.

DESIGN

Systematic review.

DATA SOURCES

Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature.

ELIGIBILITY CRITERIA

All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively.

RESULTS

The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the 'meso' level of a whole systems approach.

CONCLUSION

It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways.

PROSPERO REGISTRATION NUMBER

CRD42016035510.

Route to diagnosis of degenerative cervical myelopathy in a UK healthcare system: a retrospective cohort study

OBJECTIVES

Degenerative cervical myelopathy (DCM) presents insidiously, making initial diagnosis challenging. Surgery has been shown to prevent further disability but existing spinal cord damage may be permanent. Delays in surgery lead to increased disability and reduced postoperative improvements. Therefore, rapid surgical assessment is key to improving patient outcomes. Unfortunately, diagnosis of DCM in primary care is often delayed. This study aimed to characterise patients with DCM route to diagnosis and surgical assessment as well as to plot disease progression over time.

DESIGN

Retrospective, observational cohort study.

SETTING

Single, tertiary centre using additional clinical records from primary and secondary care centres.

PARTICIPANTS

One year of cervical MRI scans conducted at a tertiary neurosciences centre (n=1123) were screened for cervical cord compression, a corresponding clinical diagnosis of myelopathy and sufficient clinical documentation to plot a route to diagnosis (n=43).

PRIMARY OUTCOME MEASURES

Time to diagnosis from symptom onset, route to diagnosis and disease progression were the primary outcome measures in this study. Disease severity was approximated using a prospectively validated method for inferring modified Japanese Orthopaedic Association (i-mJOA) functional scoring from clinical documentation.

RESULTS

Patients received a referral to secondary care 6.4±7.7 months after symptom onset. Cervical MRI scanning and neurosurgical review occurred 12.5±13.0 and 15.8±13.5 months after symptom onset, respectively. i-mJOA was 16.0±1.7 at primary care assessment and 14.8±2.5 at surgical assessment. 61.0% of patients were offered operations. For those who received surgery, time between onset and surgery was 22.1±13.2 months.

CONCLUSIONS

Route to surgical assessment was heterogeneous and lengthy. Some patients deteriorated during this period. This study highlights the need for a streamlined pathway by which patients with cervical cord compression can receive timely assessment and treatment by a specialist. This would improve outcomes for patients using existing treatments.

Physiotherapist as an alternative to a GP for musculoskeletal conditions: a 2-year service evaluation of UK primary care data

BACKGROUND

Physiotherapists are currently working in primary care as first contact practitioners (FCP), assessing and managing patients with musculoskeletal conditions instead of GPs. There are no published data on these types of services.

AIM

To evaluate a new service presenting the first 2 years of data.

DESIGN AND SETTING

Analysis of 2 years' data of patient outcomes and a patient experience questionnaire from two GP practices in Forth Valley NHS, UK. The service was launched in November 2015 in response to GP shortages.

METHOD

Data were collected from every patient contact in the first 2 years. This included outcomes of appointments, GP support, capacity of the service, referral rates to physiotherapy and orthopaedics, numbers of steroid injections, and outcomes from orthopaedic referrals. A patient experience questionnaire was also conducted.

RESULTS

A total of 8417 patient contacts were made, with the majority managed within primary care (n = 7348; 87.3%) and 60.4% (n = 5083) requiring self-management alone. Referrals to orthopaedics were substantially reduced in both practices. Practice A from 1.1 to 0.7 per 1000 patients; practice B from 2.4 to 0.8 per 1000 patients. Of referrals to orthopaedics, 86% were considered 'appropriate'. Extended scope physiotherapists (ESPs) asked for a GP review in 1% of patients.

CONCLUSION

The results suggest that patients with musculoskeletal conditions may be assessed and managed independently and effectively by physiotherapists instead of GPs. This has the potential to significantly reduce workload for GPs as the service requires minimal GP support. The majority of patients were managed within primary care, with low referral rates and highly appropriate referrals to orthopaedics. Patients reported positive views regarding the service.

Team-based musculoskeletal assessment and healthcare quality indicators: A systematic review

The primary objective of this review was to describe health quality indicator (HQI) outcomes of team-based musculoskeletal (MSK) assessments aimed at directing patient care. Secondary objectives included determining the most commonly assessed HQIs, extent of team collaboration, and the healthcare practitioners that most commonly comprise MSK-assessment teams. This review was registered in the PROSPERO database and conducted according to PRISMA guidelines. Five databases were systematically searched to August 2017. Studies selected met a priori inclusion criteria and investigated an HQI outcome of a primary or intermediate care MSK team-based assessment aimed at directing treatment. Two independent raters assessed study quality [Downs and Black (DB) criteria] and level of evidence (Oxford Centre of Evidence-Based Medicine model). Ten studies were included. The majority were low-quality [median DB score 14/32 (range 6-18)] pre-experimental studies (level 4 evidence). Heterogeneity in methodology and HQIs precluded meta-analyses. Hospital length-of-stay (LOS; 3/10 studies) and pain level (3/10) were the most common HQIs investigated. Teams (9/10) were most commonly comprised of a physiotherapist and another healthcare practitioner. Most teams (8/10) demonstrated low-levels of collaboration. There is limited low-level evidence to suggest that team-based MSK assessments are associated with improved clinical outcomes (i.e., pain, quality-of-life) and shorter LOS.

Early Access to Physical Therapy and Specialty Care Management for American Workers With Musculoskeletal Injuries

OBJECTIVE

The aim of this study was to investigate the effect of very early access to physical therapy and specialty care management in a workers' compensation population.

METHODS

A prospective pilot (n = 75) was conducted from 2012 to 2013 in which injured workers with musculoskeletal complaints received physical therapy and started care management during their initial occupational medicine clinic visit. Two retrospective comparator groups with workers' compensation claims from 2009 and 2012 were included in this study.

RESULTS

When comparing 2009 data with the 2012 to 2013 prospective pilot study, statistically significant differences were noted in favor of the prospective pilot for total costs per claim, cost of indemnity, number of therapy visits, and time to access physical therapy. When compared with the 2012 nonpilot cohort, differences were not statistically significant.

CONCLUSIONS

Expedited access to physical therapy and care management can reduce duration of care, cost of claims, and therapy visits.

Effect of extended scope physiotherapists assessments in orthopaedic diagnostic setting: a systematic review

BACKGROUND

Patients with musculoskeletal diseases can potentially be assessed by an extended scope physiotherapist (ESP) instead of by an orthopaedic surgeon (OS).

OBJECTIVES

To evaluate the effectiveness of the diagnostic musculoskeletal assessment performed by ESP compared to OS.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PEDro and reference lists of included studies and previous reviews were searched in November 2015.

ELIGIBILITY CRITERIA

Studies were included if they evaluated adults with a musculoskeletal disease referred to an outpatient orthopaedic clinic where a diagnostic assessment had been conducted by an ESP.

DATA EXTRACTION

Data were extracted using a customised data extraction sheet. Two reviewers using checklists evaluated methodological independently.

RESULTS

We included one randomised controlled trial and 31 observational studies. Diagnostic agreement between ESPs and OSs was 65 to 100% across studies. Health care cost savings for diagnostic assessments performed by ESPs were 27 to 49% compared to OSs. Overall, 77 to 100% of the patients were satisfied with the ESP assessment. Results were comparable on diagnostic agreement, cost and satisfaction in studies with high, moderate and low risk of bias.

LIMITATIONS

Risk of bias in the included studies.

CONCLUSION AND IMPLICATION OF KEY FINDINGS

Diagnostic assessments performed by ESP may be as beneficial as or even better than assessment performed by OSs in terms diagnostic agreement, costs and satisfaction. However, the methodological quality was generally too low to determine the clear effectiveness of ESP assessment, and more high quality studies are needed. Systematic review registration number: PROSPERO CRD42014014229.

Better arthritis care: What training do community-based health professionals need to improve their care of people with arthritis? A Delphi study

OBJECTIVE

The aim of the present study was to identify the competencies that non-specialist community-based nurses and allied health professionals (AHPs) need to enable them to assess, care for and manage arthritis appropriately.

METHODS

A Delphi survey with an expert panel of 43 rheumatology specialists and expert patients was used to identify the competencies needed by community-based nurses and AHPs to enable them to improve their care of people with arthritis. The process was informed by feedback from focus groups with arthritis patients, community-based nurses and AHPs.

RESULTS

The core competencies in arthritis care needed by non-specialist community-based nurses and AHPs were identified. The key goals identified were to increase the understanding of arthritis and its impact on patients' lives, and to increase the ability to help patients to self-manage their condition and access support. Competencies included an understanding of the pathology underlying inflammatory and non-inflammatory arthritis, the ability to distinguish between the two and the ability to recognize early warning signs, with an emphasis on osteoarthritis (OA), rheumatoid arthritis, gout and septic arthritis. Essential competencies included the ability to engage in shared decision making, goal setting and signposting, to provide patients with education and information and to make appropriate referrals.

CONCLUSIONS

Health professionals working in the community commonly encounter arthritis as a presenting problem or as a co-morbidity. The quality of care provided to people with inflammatory arthritis and OA in the community is currently variable. The present study identified the core competencies that all community-based nurses and AHPs should have in relation to OA and inflammatory arthritis.

Advanced practice physiotherapy in paediatric orthopaedics: innovation and collaboration to improve service delivery

INTRODUCTION

One in eight paediatric primary care presentations is for a musculoskeletal (MSK) disorder. These patients are frequently referred to paediatric orthopaedic surgeons; however, up to 50% of referrals are for normal variants. This results in excessive wait-times and impedes access for urgent surgical cases. Adult MSK medicine has successfully utilised advanced practice physiotherapists (APP) managing non-surgical candidates, with documented benefits both to patients and services. There is a gap in the literature with regard to APP in paediatric orthopaedics.

AIM

In this review, we investigate demands on paediatric orthopaedic services, examine the literature regarding APP in paediatric orthopaedics and explore the value the role has to offer current outpatient services.

RESULTS

Paediatric orthopaedic services are under-resourced with concurrent long wait times. Approximately 50% of referrals are for normal variants, which do not require specialist intervention. Poor musculoskeletal examination skills and low diagnostic confidence amongst primary care physicians have been identified as a cause of inappropriate referrals. APP clinics for normal variants have reported independent management rate and discharge rates of 95% and marked reduction in patient wait times.

CONCLUSION

There is limited evidence to support the APP in paediatric orthopaedics. Further studies are needed investigating diagnostic agreement, patient/stakeholder satisfaction, patient outcomes and economic evaluation. Paediatric orthopaedics is in crisis as to how to effectively manage the overwhelming volume of referrals. Innovative multidisciplinary solutions are required so that the onus is not solely on physicians to provide all services. The APP in paediatric orthopaedics may be part of the solution.

Support and preferences for intermediate health care services for back and neck pain: a survey among members of the Dutch patient association for spinal pain

RATIONALE, AIMS AND OBJECTIVES

Recent health care reforms in the Netherlands have led to the introduction of intermediate health care. Intermediate health care combines features of primary care and secondary (hospital) care. It is characterized by a task shift from hospital care to primary care. The initial experiences of medical specialists and general practitioners with intermediate health care are positive. However, the patients' perspectives regarding this reform are unknown. This study aimed to evaluate the level of support from patients with back and/or neck pain for intermediate health care services and to provide insight into their preferences how this care should be organized.

METHODS

A cross-sectional survey was conducted in which members of the patient association for spinal pain in the Netherlands completed electronic questionnaires to measure the level of support and preferred organization of intermediate health care services.

RESULTS

Questionnaires were returned by 367 patients (response rate: 51%). Respondents supported the concept of intermediate health care (numeric rating scale: 7/10). Aspects considered important for intermediate health care included knowledge and expertise of staff, multidisciplinary cooperation, patient contact time, reimbursement via health insurance, quality control of care, evidence-based treatments and electronic medical records. Although intermediate care is a health care reform, patients continued to think according to traditional primary and secondary care constitutions.

CONCLUSIONS

Patients with neck and/or back pain support the introduction of intermediate health care services and have explicit preferences regarding its organization, but may need to be better informed when intermediate care is introduced.

Perceived quality of physiotherapist-led orthopaedic triage compared with standard practice in primary care: a randomised controlled trial

BACKGROUND

Physiotherapist-led orthopaedic triage, where physiotherapists diagnose and determine management plans, aims to enhance effectiveness and provide the best care. However, scientific evidence for the effectiveness of this model of care remains limited, and there are few studies reporting on patients' perceptions of the care provided. The purpose of this study was to evaluate patients' perceived quality of care in a physiotherapist-led orthopaedic triage in primary care, compared with standard practice.

METHODS

In a randomised controlled trial, patients of working age referred for orthopaedic consultation at a primary healthcare clinic in Sweden received either physiotherapist-led triage (n = 102) or standard practice (orthopaedic surgeon assessment) (n = 101). Neither subjects nor clinicians were blinded. The questionnaire Quality from the Patient's Perspective (QPP) was used to evaluate perceived quality of care focusing on the caregivers' medical-technical competence and identity-orientated approach. Also, to what extent patients' expectations were met, and their intention to follow advice was evaluated.

RESULTS

For this study, 163 patients (80 %) were analysed (physiotherapist-led triage (n = 83), standard practice (n = 80)). Participants perceived significantly higher quality of care with the triage than with the standard practice in regards to receiving best possible examination and treatment (medical-technical competence) (p < 0.001). This was also found in regards to receiving information about examination and treatment (p < 0.001), results (p < 0.001), and self-care (p < 0.001), the caregiver's understanding (p < 0.001), respect (p < 0.001) and commitment (p < 0.001) as well as the opportunity to participate in decision-making (p = 0.01) (identity-orientated approach). Participants in the physiotherapist-led triage group reported to a significantly higher extent that their expectations of the treatment were met (p < 0.001), as well as the intent to follow the advice and instructions received (p = 0.019).

CONCLUSIONS

This paper reports on patients' perceptions of quality of care in a physiotherapist-led orthopaedic triage compared with standard practice. Patients in both groups reported that they perceived good quality of care, with the patients in the physiotherapist-led triage reporting significantly higher perceived quality of care than those in the standard practice group. This model of care seems to meet patients' expectations and result in a greater intention to follow advice and instructions for self-management. Our findings are in line with existing literature that this model of care provides an opportunity to shape patient-centered care that can improve access and offer care on the most appropriate level, with maintained good quality of care.

TRIAL REGISTRATION

Clinical Trials NCT02265172 . Registered 10 June 2014.

The efficacy of an extended scope physiotherapy clinic in paediatric orthopaedics

BACKGROUND

The demand for paediatric orthopaedic care is growing, and providing the service required is an increasingly challenging task. Physiotherapist-led triage clinics are utilised in adult orthopaedics to enable the provision of care to patients who may not require a surgical consult. The Physiotherapy Orthopaedic Triage Clinic (POTC) was established in Our Lady's Children's Hospital Crumlin in response to increasing demands on the paediatric orthopaedic service. The clinic is run by physiotherapists working in an advanced practice role (APP), and is the first paediatric clinic of its type and scale in the Republic of Ireland.

PURPOSE

To evaluate the efficacy of the service over the 3-year period from January 2011 to December 2013.

METHODS

A review of the prospectively gathered database was performed in order to establish the demographic profile of patients, investigate clinic outcomes, and evaluate the reduction in patient waiting times.

RESULTS

2650 patients were managed by the clinic over the 3-year period. A total of 77 % of patients were managed without consultant intervention. Fifty-three percent of patients were diagnosed as having a normal presentation. The mean waiting time reduced from 101.9 weeks pre-2010 to 15.4 weeks in 2013 for those patients managed by the POTC.

CONCLUSION

Since its inception, the clinic has significantly reduced waiting times for routine elective paediatric orthopaedic patients while managing the majority of patients independent of surgical opinion. This study shows that the APP can deliver high-quality care in the paediatric orthopaedic setting, benefitting both patients and service.

An environment for representing and using medical checklists on mobile devices

Checklists have been recently introduced in the medical practice playing the role of summarized guidelines, streamlined for rapid consultations. However, there are still some barriers preventing their widespread diffusion. Those concern the representation, dissemination and update of their underlying knowledge, as well as the means currently adopted for their actual use, that is still mostly paper-based. In this paper we propose a new platform for the implementation and use of checklists. First, an editor supports domain experts in porting the checklist from the traditional paper-based format into an electronic one. Then, an application allows the distribution and usage of checklists on portable devices such as smartphones and tablets, exploiting their additional features in comparison with those made available by Personal Computers. The platform will be illustrated through some examples designed to support volunteers and paramedic staff in dealing with emergency situations.