Physiotherapy 101 (2015) 13–24
Systematic review
Intermediate Care pathways for musculoskeletal conditions – Are they working? A systematic review A. Hussenbux a , D. Morrissey a,b,∗ , C. Joseph a , C.M. McClellan c a
Centre for Sports and Exercise Medicine, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London E1 4DG, UK b Physiotherapy Department, Bart’s Health NHS Trust, London, UK c Academic Department of Emergency Care, Adult Emergency Department, Bristol Royal Infirmary, University Hospitals NHS Foundation Trust, Bristol BS28HW, UK
Abstract Background Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services. Objectives This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence. Data sources PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013. Study selection/eligibility criteria Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded. Results Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists’ clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction. Limitations These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services. Funding Part funded by EPSRC and AXA-PPP. Conclusion Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients. © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Musculoskeletal clinical assessment and treatment service; Physiotherapy triage; Appropriate referral; Effectiveness; Waiting times; Patient outcome
Introduction It is estimated that a quarter of the global adult population are affected by chronic musculoskeletal pain, musculoskeletal disorders being the commonest cause of pain and physical disability [1]. Further, there is an increasing ∗
Corresponding author. Tel.: +44 07941710273. E-mail addresses: [email protected], [email protected] (D. Morrissey).
burden on primary and secondary care as musculoskeletal disorders account for over a quarter of all general practitioner (GP) consultations [2]. Primary care physicians have expressed low confidence in their abilities to diagnose and manage musculoskeletal skeletal conditions appropriately [3]. This results in early and misdirected referral to hospital based secondary care, primarily orthopaedics and rheumatology [4]. This ultimately affects the patient’s quality of care and leads to long waiting times within secondary care [5].
http://dx.doi.org/10.1016/j.physio.2014.08.004 0031-9406/© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
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The Musculoskeletal Services Framework [6] and the UK Government White Paper entitled “Our Health, Our Care, Our Say” [7] outlined a change in current management of musculoskeletal conditions in the UK away from secondary care and towards a Musculoskeletal Clinical Assessment Treatment Service (MSK CATS) model, typically situated in Intermediate Care. These services typically aim to provide triage, rapid assessment, facilitate access to treatment, improve efficiency, and reduce inappropriate referrals to secondary musculoskeletal care [8]. Triage is the process of determining the package of care for a patient based on the nature and severity of their condition in order to optimise care and make best use of resources. Increasingly, triage settings are being used to manage patients with musculoskeletal conditions at the interface between primary and secondary care. The effectiveness of such services has been the subject of increasing interest and investigated in terms of service delivery, referral appropriateness and patient satisfaction, but there has been limited synthesis of the available evidence thus limiting generalisation of findings to guide commissioning of innovative services and outcome evaluation. The aim of our work was to provide an evidence summary to guide commissioners, service managers and clinicians by systematically reviewing the evidence pertaining to MSK CATS pathways. We particularly sought to summarise the evidence relating to the effectiveness and referral outcome of MSK CATS, physiotherapy-led triage as well as the effect on waiting times and patient satisfaction.
Methods Inclusion and exclusion criteria for the systematic review This systematic review included studies that were original, scientific journal publications evaluating MSK CATS, or similar services assessing musculoskeletal conditions. Any study that described primary care based triage that was led by: allied health practitioners (such as physiotherapists and occupational therapists), general practitioners with a special interest in MSK medicine, and musculoskeletal physicians were included as were studies evaluating referral pathways in a more general sense. Outcome measures of particular interest were: effectiveness and referral outcome of MSK CATS, physiotherapy-led triage and physiotherapy services, as well as the overall effect on waiting times and patient satisfaction. Studies from all countries were included. Reports needed to have been written in English, while editorials, conference reports, commentaries and abstracts were excluded. Further, studies assessing patients with non-musculoskeletal pathology, referrals to secondary care dealt with by the GP only, paediatric and emergency medicine, self-referral, and studies concerning referral from MSK secondary care were excluded.
Search and evaluation strategy The electronic databases; PubMed, Web of Science, EMBASE, Ovid Medline, PEDro and Google scholar were searched for all articles published from inception to October 2013. The Medical Subject Headings are detailed in Supplementary Table S1. Titles and abstracts were imported into Endnote (Version X6, Thompson Reuters, Philadelphia, PA), and duplicates removed. Study titles and abstracts were reviewed by two authors (AH and DM). If the title was identified as potentially meeting the inclusion criteria, the abstract was read, and if the paper met the inclusion criteria, the full paper was obtained for further analysis. If insufficient information was available from a title or abstract, the full paper was obtained to make a decision on inclusion. Reference lists and citing articles of retained studies were also scrutinised to identify any additional papers. The search yielded a total of 23 articles (Fig. 1). Supplementary Table S1 related to this article can be found, in the online version, at http://dx.doi.org/ 10.1016/j.physio.2014.08.004. Quality assessment The 23 papers were analysed using a modified Downs and Black Checklist [9]. The modified checklist consisted of 15 questions giving a maximum score of 16. A modified checklist was used as questions regarding adverse effects, blinding, compliance, randomisation and power calculations were omitted as they were deemed not relevant to all observational studies in this review. This quality assessment scale is feasible and can be used to assess the methodological quality of randomised controlled trials and non-randomised studies [9]. Review process All studies were independently assessed for quality by two reviewers (AH and CJ). Any differences in quality scores were discussed among the reviewers until a consensus was reached. To determine inter-rater agreement, percentage agreements were calculated for each quality score item. Summary tables were created, detailing study characteristics, participant characteristics, outcome measures, key results, statistics and level of evidence from each study (Tables 1a to 1c). These tables have been grouped into three areas of interest; MSK CATS, physiotherapy led triage and physiotherapy services.
Results A total of 23 articles met the inclusion criteria and were included in this review (Fig. 1).
Table 1a Summary of studies included relating to MSK CATS. Study design
Study size
Intervention compared
Group characteristics
Duration
Outcome measure
Outcome measure result
Statistical analysis
Level of evidence
Salisbury et al. (2013)
RCT
2256
Usual care vs phone
MSK
6 months
PhysioDirect = shorter waiting times (7 days vs 34 days). Health outcome equivalent in both groups. Lower satisfaction compared to control group −3.8%
Multivariate regression
High
Razmjou et al. (2013)
Observational: prospective study
347
Evaluation of PT service
Patients with shoulder complaints referred to speciality shoulder clinic
36 months
SF-36v2 questionnaire, The Measure Yourself Medical Outcomes Profile, EQ-5D, 7-point scale of overall improvement, response to treatment, time lost from work, Patient satisfaction Role of APP with respect to: 1. Agreement with orthopaedic surgeon on diagnosis and management. 2. Waiting times. 3. Patient satisfaction.
Kappa
High
Sephton et al. (2010)
Observational: prospective cohort
217
PT in MCAS triaging MSK patients
MSK
12 months
1. Agreement in major diagnostic categories varied from 0.68 (good) to 0.96 (excellent). Agreement of surgery was κ = 0.75, p < 0.001; 95% CI, 0.62 to 0.88 (good). 2. Average wait time reduced from 198 days in 2008 to 75 days in 2011 p < 0.001. 3. Patient satisfaction significantly better in APP group p = 0.004 Significant improvement in EQ-SD questionnaire (p = 0.035), and pain VAS scale (p = 0.002). No significant differences in SF-36 (P = 0.87) and high levels of patient satisfaction (94% good satisfaction)
t-Test
Medium
Roberts et al. (2003)
Observational: prospective cohort
461
Survey of MSK services
MSK
12 months
71% of organisations had more than one MSK service within the community consisting of PT services and triaging services. Purpose of service described in 83% of services.
N/A
Low
Treatment outcomes for patients triaged by physiotherapists at 3 and 12 months following care (no control group) Pain VAS (/10), EQ-5D and SF-36 questionnaire, perceived improvement PIVAS scale (%), and Deyo and Diehl satisfaction questionnaire (%) Characteristics of community based musculoskeletal services provided by primary care organisations.
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Author
15
16
Table 1a (Continued) Study design
Study size
Intervention compared
Group characteristics
Duration
Outcome measure
Outcome measure result
Statistical analysis
Level of evidence
Roddy et al. (2013)
Observational: retrospective cohort
2166
Outcome of MSK CATS
All patients referred to MSK CATS from Feb 2008 to June 2009
16 months
Describe characteristics, investigations and treatment of adults attending MSK CATS
Chisquared
Medium
Bridgman et al. (2005)
Observational: organisational intervention
10,000
Outcome of slot system
32 months
Rate of new referrals into orthopaedics
N/A
Medium
Hattam et al. (1999)
Observational: retrospective cohort
84
Outcome of orthopaedic screening service
Musculoskeletal patients assessed in 36 practices; 12 intervention, 24 control MSK
12 months
Description and intervention of patients. Waiting times.
N/A
Low
Maddison et al. (2004)
Observational: over time comparisons
N/A (1000+)
Outcome of TEAMS service
MSK
18 months
Assess waiting times into secondary care in relation to number of referrals and number of patients seen.
Characteristic = chronic pain > 1 year (55%). 45% of patients took 6 months of work off due to MSK problems and psychosocial issues. 48% = no investigation: X-ray-23%, MRI = 18% 23% referred to PT 13% required injection. 22% mean referral rate reduction in slot group compared to control group and other practices. Reduction in referral rate increased with time. Description = 60.9% lower limb complaints. Intervention of OSS = 29% advice/exercise. 19% = PT, 14% = referral, 5% = investigation (blood, X-ray). Overall 72.4% of orthopaedic patients dealt with in primary care setting using OSS. Over 18 months, number of referrals doubled (403 to 823). Waiting times reduced. Surgery conversion rates were unchanged.
N/A
Low
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Author
Table 1b Summary of studies included relating to Physiotherapy-led triage. Observational: prospective cohort
198
PT triaging spinal cases
Low back pain patients
8 months
Patient and provider satisfaction
Morris et al. (2011)
Intervention: quasiexperimental
112
PT triaging orthopaedic patients
MSK
3 months
Cost of service, waiting time and percentage of patients using management options. Results compared with 2009 data
Hattam (2004)
Observational
192
ESP triaging orthopaedic patients
MSK
15 months
Specificity and appropriateness of referral to orthopaedic secondary care
Bath et al. (2012)
Observational: retrospective
1096
PT triaging spinal cases
Low back pain patients
36 months
Blackburn et al. (2009)
Observational: retrospective cohort
105
PT triaging MSK patients
MSK
12 months
Describe the characteristics of patients in the triage programme and whether surgery is necessary. Waiting times to first appointment, patient attendance, and surgery conversion rates. Compared with 2002 data
Roger (2008)
Audit
277
MST triaging MSK patients
MSK
9 months
Waiting times, agreement in diagnosis and referral
66% of participants were “very satisfied.” Diverse range of themes coded into positive such as good understanding, communication, management direction and efficiency. Negative feedback was time to follow up and costs. Telephone triage led to 16.4% patients being discharged directly. 25.9% referral to physiotherapy 41.4% referred to MDT for review of condition or referral to surgery. Telephone triage validated surgical referral for 40% of patients 70.6% of subjects referred were considered appropriate. Reasons for referral: Surgery = 55.9%. Further opinion = 27.6%. Investigation (MRI) = 16.5% 746 participants. 92.5% had mechanical spine. 2% had surgical spine. Proportionally more people referred to the surgeon from triage had an outcome of surgery (70%) Waiting time decreased by 11%. 79% patients referred to physiotherapy from PLTC. From there 16% referred to surgery. 87% of GP’s felt PLTC management was appropriate MPTT waiting times significantly longer (140 days compared to 62 days). MPTT: 22% incorrect diagnosis, 33% no diagnosis
PASW, Chi-square or Fischer’s exact, and independent t-test or Mann–Whitney
High
Mann–WhitneyU test
Low
SPSS Chi-squared test
Medium
Shapiro–Wilk test. Fischer’s Exact test. PASW
Medium
N/A
Low
ANOVA
Medium
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Bath and Janzen (2012)
17
18
Table 1c Summary of studies included relating to physiotherapy-led referral. Observational: retrospective cohort
7951
PT referral source
Patients with low back pain
24 months
Clinical characteristics of patients with low back pain who are managed and referred by PTs.
O’Cathain (1995)
Observational: Controlled before and after study
N/A (1000+)
PT referral source and outcome
MSK
24 months
Physiotherapy contact rates. Orthopaedic referral rate. Rheumatology referral rate
Oldmeadow et al. (2007)
Observational: prospective cohort
52
PT referral source and outcome
MSK
6 months
Proportion of MSK patients who could be managed without seeing a surgeon. Level of agreement between physiotherapist and surgeon.
Rabey et al. (2008)
Observational: retrospective cohort/descriptive
3758
PT referral sources
MSK
31 months
Extent and appropriateness of surgical and radiological referral by ESPs in orthopaedic service
Menzies and Young (2010)
Observational: retrospective cohort
4925
Sports Doctor referral source
MSK
12 months
Referral rate from sports medicine to orthopaedic clinic. % of referred patients who were recommended surgery by orthopaedics. Effect on waiting time. Most common conditions and procedures.
PCPs and OCC medicine associated with 1.6(95% CI: 0.7 to 2.6) and 4.8 (95%CI: 2.7, 6.9) in discharge overall health score compared to specialist referral. PCP and OCC medicine associated with 0.44(95%CI: 0.27 to 0.61) and 0.83 (95%CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral. 79.5% increased contact rates with physiotherapy services. 12% reduced orthopaedic referral rate. 44% reduced rheumatology referral rate. 38 of 45 patients seen by PT saw an orthopaedic surgeon. 7 patients agreed for surgery, 3 patients for injection and 4 patients for imaging. PT and surgeon appropriateness was 74%. Patients and Doctors reported high satisfaction. 79% patients managed by ESP solely. 9% referred for surgical opinion. 13% referred for X-Ray 10% referred for MRI Of patients referred for surgical opinion, surgery was appropriate for 89% of patients 2.4% of patients referred from sports medicine to orthopaedics. Of these patients, surgery was offered to 68% of patients. Waiting time for orthopaedic clinic decreased from 97 to 19 days. Most common condition referred was knee (25.3%). Knee injections and epidural steroid injections most common conditions performed.
Independent t-test ANOVA
High
Chi-squared test
Low
Kappa with 95%
Low
N/A
Low
Chi-squared test
Medium
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Brooks et al. (2012)
Table 1c (Continued) Inter-rater agreement
38
PT referral source
MSK
N/A
Pearse et al. (2006)
Audit
150
ESP referral
MSK
6 months
Harrison et al. (2001)
Observational: retrospective audit
130
PT referral source
Patients with shoulder complaints
12 months
Aiken et al. (2009)
Observational: retrospective
147
PT referral outcome
MSK
12 months
Agreement between APP and orthopaedic surgeon 1. Identification of surgical candidates 2. Surgical urgency using WCWL-HKPT tool 3. Treatment recommendations Assessment and management by ESP. Assess whether patients were re-referred to surgery with the same problem. Patient satisfaction. Waiting times for patients managed in the physiotherapy shoulder assessment clinic Role of APP in terms of numbers of patients seen, number of patients who did not see a surgeon and effect on waiting times.
1. Observed agreement 100% 2. Observed agreement 64% Level of agreement κ = 0.68
Kappa
Low
55% of patients managed by ESP alone. Consultant review required for 81% of shoulder and 34% of knee cases. GPs re-referred 3% of patients. 77% patient satisfaction.
N/A
Medium
130 patients were assessed with an average waiting time of 58 days and 50% of patients were treated with physiotherapy alone 147 patients screened by APP. 34% of patients managed by APP alone. From 2007 to 2008 waiting times to orthopaedic surgeons reduced from 140 days to 40 days
N/A
Low
N/A
Low
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Aiken et al. 2008
MSK, musculoskeletal; MSK CATS, musculoskeletal clinical assessment and treatment services; N/A, not applicable; PT, physiotherapist/physical therapist; MPTT, multi-professional triage teams; OSS, orthopaedic screening service; PTLC, physiotherapist led triage clinic; APP, advanced practice physiotherapist; ESP, extended scope physiotherapist; GPwSI, general practitioner with special interest; OCC, occupational medicine; PT, physiotherapist/physical therapist; PCP, primary care physician; WCWL-HKPT, western Canada wait list hip and knee prioritisation tool.
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ISI Web of Science
PUBMED Limited to English language, human studies
Limited to English language, human studies and arcles
Total=7956
Total=9883
PEDro advanced search
EMBASE
OVID Medline
Limited to human studies and journal arcles
Limited to English language, human studies and journal arcles
Physical therap* AND referral*
Total=3374
Total=3313
Total=224
22 Titles
39 Titles
24 Titles
24 Titles
18 Titles
4 abstracts
9 abstracts
5 abstracts
4 Titles
12 Titles
Google Scholar Limited to English language, human studies
Total 7956
1 abstract
35 abstracts
Duplicates manually deleted Total = 22
Search of reference lists: 2 Titles 1 abstract
Records excluded on screening of abstracts ad full text (n=104) Duplicates (n=12) Review (n=6) Too broad/too general/non MSK related (n=24) Protocol study (n=3) No referral/outcome from Intermediate Care to secondary care (n=18) Primary to secondary care only (n=12) Intermediate Care for specific condions (n=29)
Total = 23
Fig. 1. PRISMA flow diagram showing Intermediate Care pathway literature and reasons for excluding certain studies.
Study design The search revealed one pragmatic randomised control trial [17], 14 observational retrospective studies [10,15,16,18,21–26,28–31], five observational prospective studies [13,14,19,20,27], one prospective quasi-experimental study [12], and two audits [11,32]. Two studies used a low sample size (e.g. n = 84, n = 45) [21,27], and four studies were site specific [14,18,28,29]. Studies included assessed Intermediate Care services on average for 1 year [10,23,31]. Some studies were observed for shorter time periods – nine months [11], six months [19,32], and three months [12]. A majority of studies assessed the services during the first year of starting. Quality assessment scores Overall, the studies utilised a wide range of outcome measures but typically resulted in a low level of evidence (Tables 1a to 1c). The modified checklist ranked the observational studies into three sub-levels of evidence; high (score = 13 to 16), medium (score = 9 to 12) and low (score ≤ 8). The modified checklist revealed 11 low [10,12,18,20,21,25–30], eight medium
[11,15,16,19,22,23,31,32], and four high quality studies [13,14,17,24]. The complete Downs and Black check list was used for the randomised controlled trial. The study scored 24 out of 30. The raw agreement between reviewers for the total quality score was 84%. Individual items in the quality checklist demonstrated good inter-rater reliability (Supplementary Table S2). Supplementary Table S2 related to this article can be found, in the online version, at http://dx.doi.org/ 10.1016/j.physio.2014.08.004. Type of studies Overall, 14 studies explored the use of MSK CATS. This included seven studies that assessed triage services in reducing waiting times [10–12], diagnostic agreement [13,14], patient satisfaction [15] and appropriateness of triage referral [16]. The other seven studies evaluated musculoskeletal assessment services in the patient management and referral [17,18] and the overall outcome and characteristics of the services [19–23] – here defined as referral procedures, interventions, investigations, patient satisfaction and reduction in waiting times.
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A total of nine studies evaluated referral pathways within Intermediate Care, including experienced physiotherapist referral, level of agreement between physiotherapist and orthopaedic consultant [24–27], role in reducing waiting times [28–30], referrals from a sports and exercise medicine department [31], and referrals led by an extended scope physiotherapist [32]. Fig. 1 demonstrates an overview of all studies included. Main findings This systematic review reports 72% to 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the most common investigations. Physiotherapists’ clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction.
Discussion We aimed to systematically identify, critique and summarise Intermediate Care pathways in order to guide service design and delivery. Further, we aimed to assess the effectiveness of Intermediate Care when managing musculoskeletal patients, referring patients to secondary care and exploring cost containment, waiting times, patient satisfaction and overall health outcomes. Musculoskeletal clinical assessment and treatment services (MSK CATS) The earliest MSK CATS study assessed the characteristics of community-based musculoskeletal services in the UK [20]. Postal questionnaires were sent to five professional groups within UK primary care, and services reported were physiotherapy rehabilitation services, joint injection services and implementation of integrated care pathways. In 46% of services, patients were assessed and triaged by physiotherapists. The purpose of the service was described in 83% however, only 11% of services had a clear evaluation strategy such as pre- and post-service data for orthopaedic initiative, numbers treated, discharge profiles and scoring systems for physiotherapist triage. Despite high response rate, it is unclear who completed the questionnaires and whether that person is bestqualified to respond. Due to reduced mention of evaluation strategies, it is difficult to critique the quality of the services provided.
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Rate of referral Overall, the introduction of MSK CATS has led to a reduced referral to secondary care. A Targeted Early Access to Musculoskeletal Services (TEAMS) [18] programme led to a 116% increase in total referral to appropriate secondary care. Reported surgery conversion rates remained constant at 37%, and significant reductions in waiting times to orthopaedic services went from 50 weeks to 5 weeks. In contrast, a similar structured “orthopaedic slot system” [22] led to a 22% reduction in referral rate to secondary care when compared to a control group. Both studies used a nonrandomised selection of general practices and did not address the cost implications of these assessment services. The contrast in referral rates may be due to differences in the time period; the TEAMS study was observed for 1 year, whilst the slot system was observed for 3 years. The slot system results were more reliable as they were compared to similar control practices whilst there were no comparisons in the TEAMS study. A similar study reported a 60% reduction in referrals to orthopaedics and 40% reduction in referrals to rheumatology over 12 months [19]. This is most likely due to increased patient discharge, thorough patient education and self-management solutions within the MSK CAT services. Outcome and characteristics of services Overall, investigations and management plans for patients within MSK CATS were deemed appropriate and displayed positive outcomes. MSK CATS identified patients that were in need of referral to secondary care and as a result reduced waiting times and increased patient satisfaction were reported. The earliest evaluation of an orthopaedic screening service (OSS) in primary care [21] reported 72.4% of MSK patients could be managed in primary care using the OSS. Intervention of OSS included advice and exercise (29%), physiotherapy (18%), referral (14%) and investigations such as blood tests and plain films (5%). The most common intervention was steroid injection (5%). Waiting times for patients were reduced by nine months in this 1 year, small sample study (n = 76), necessitating caution in interpretation. Common investigations in MSK CATS reported are Xray (23%), MRI (18%) and blood tests (14%) however, 48% received no investigation [23]. A large proportion of the MSK patients in the study suffered with depression (47%) and anxiety (37%) due to chronic pain, suggesting the necessity of MSK CATS to successfully and appropriately manage their care. In regard to referral pathways, the most common was to physiotherapy (23%), and the most common intervention was steroid injections (13%); showing similarities with previous research [21]. Physiotherapy-led triage Triaging is a process that occurs within MSK CATS; below critically analyses the findings of physiotherapy-led triage
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in terms of appropriate referral, waiting times and patient satisfaction. Appropriate referral The literature suggests physiotherapists with postgraduate training are effective at diagnosing and managing musculoskeletal patients. Further, postgraduate-trained physiotherapists display an ability to appropriately triage patients into orthopaedic care. Extended scope physiotherapists (ESP) may be comparable to medical doctors in appropriate referral and is highlighted from the literature. One study [16] reported 16.5% referrals made by general practice based physiotherapists were for investigations and 55.9% were for surgical procedures. Overall, 70.6% of referrals made by ESPs to consultants were considered appropriate suggesting that ESPs can appropriately refer. However, appropriateness was decided by various members of an orthopaedic team, ranging from senior house officer to consultant and the difference in experience across professions may affect the accuracy of judging appropriateness. In addition, physiotherapists have also been shown to have high levels of agreement with orthopaedic surgeons [27]. Waiting times There is clear evidence that suggests the use of physiotherapy-led triage reduces waiting times for musculoskeletal patients. This reduction in waiting times is mainly due to reductions in inappropriate referrals and increases in the number of patients discharged with a thorough explanation of self-management procedures. One multidisciplinary study report was shown to reduce waiting times for an orthopaedic consultation from 25.1 months to 6.6 months through telephone triage combined with initial management [12]. However, the triage system was only observed for three months. This is supported by previous research reporting a reduction in waiting times from 23 weeks to 9 weeks in a physiotherapy led clinic [10]. Further, the physiotherapy-led initiative appeared to validate the need for prompt referral for surgery and effective management for non-surgical patients. In contrast, an audit suggested waiting times increased for orthopaedic referrals via a multi-professional triage team (MPTT) [11]. The likely cause for this was 22% of cases referred from the MPTT clinic were deemed to have an incorrect diagnosis and 33% with no diagnosis therefore, resulting in unnecessary secondary care referral and increased confusion due to diagnostic indecision. Two Canadian studies suggest the role of advanced practice physiotherapists in decreasing surgical waiting times [28,29]. Although low quality, these reinforce the positive findings made that physiotherapy-led triage significantly reduces waiting times. One randomised controlled trial was included in this review [17]. Telephone assessment service for musculoskeletal patients reduced waiting times compared to usual care (median = 7 days vs 34 days). Over the 6 months this trial was conducted, the telephone triage service reduced waiting
list time, led to less face-to-face appointments and consultations, and those who were triaged via telephone were less likely to not attend appointments than those receiving usual care. Alternately, there was no difference in health outcomes, lost time for work, or patient satisfaction in the ability to access the service. This suggests that the service was successful in providing appropriate assessment and treatment however, made no difference to function, pain, or psychological status of the patient. Of potential interest, those patients who were in the usual care arm (face-to-face consultation) had a higher level of patient satisfaction when compared to the telephone consultation arm. This coincides with the observational studies included in this review which all report high patient satisfaction in face-to-face consultations. Patient satisfaction Studies investigating physiotherapy-led triage report high patient satisfaction. A quantitative analysis of patient satisfaction using a physiotherapy spinal triage assignment service reported 66% of patients were “very satisfied” with the service [14]. A diverse range of themes such as good understanding, communication, management direction and efficiency were identified as being related to the service. Negative feedback was received regarding time to follow up, costs and limited local availability of the service. Other lower quality studies also reported high levels of patient satisfaction within Intermediate Care [18,19,32]. Appropriate referral The number and appropriateness of referrals made by ESPs to orthopaedic surgeons and the description of investigations were investigated further [26]. The study reported 9% of patients seen by the ESP were referred to surgical opinion, suggesting the majority of MSK patients could be managed by an ESP. Of these patients, 43% had knee complaints, which is similar previous research employing ESPs [16]. The study reported 79% of patients had their care completely managed by an ESP. This concurs with many studies reporting ESPs managed 50% to 85% of all cases in an orthopaedic department [16,30,33,34]. In terms of common investigations, ESPs refer 25% of patients for investigations; this included X-ray (13%), MRI (10%) and others investigations including blood tests, bone scans and ultrasound [26]. These investigation findings show similarities with previous research [21,23]. Knee conditions were most commonly referred for further investigations. The study [26] is an observational study with a large sample size (n = 3758) assessing the referrals for 3 years; therefore the conclusions of this study are reliable. Primary care based sports medicine A retrospective study assessed referrals from a primary care based sports medicine department to orthopaedic secondary care in 1 year [31]. The study reported 118 out of 4925 patient encounters (2.4%) resulted in referral to
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secondary care. Of these, 68% were recommended a surgical procedure. Knee arthrocentesis (34.8%), sacroiliac injection (17.3%) and facet injection (16.6%) were the most common interventions. The study suggests most musculoskeletal patients can be managed within Intermediate Care. These findings coincide with similar, earlier studies [35,36]. Limitations This study is not without limitations. A highly inclusive search strategy was reformed for this review however, certain key terms may have been missed from the search strategy due to differences in spelling or different terminology. In considering this, the probability of missing relevant literature was reduced by checking the references of all studies included. The strength of the evidence presented within this paper may be uncertain due to the low quality of the included studies. Furthermore, only one study was a randomised controlled trial, with the majority of studies being cross-sectional or retrospective and making pre-post, or historical comparisons. This highlights the need for more randomised controlled trials to assess the effectiveness of Intermediate Care pathways. Conclusion It is clear from this review that local needs have driven the introduction of intermediate pathways in the UK with audit, service evaluation and research has typically been retrospective. Heterogeneity, lack of embedded evaluation before services are underway and the lack of randomised research has made evaluation of effectiveness difficult. This review has however highlighted components of care and service delivery that demonstrate Intermediate Care is working. MSK CATS and physiotherapy triage appropriately manage and suitably refer patients to Intermediate Care. A reduction in waiting times and high patient satisfaction in face-to-face consultations were consistent findings, as observed in this review. The literature suggests that physiotherapists may be comparable with medical doctors in terms of clinical decision-making and appropriate referral for patients with orthopaedic conditions. Further, there are indications that physiotherapy services may improve the efficiency of secondary care management pathways for orthopaedic patients. Reasons for referral from Intermediate Care to secondary care are surgical procedures, further investigations such as X-ray and MRI, and minor interventions such as steroid injections. However, most musculoskeletal patients can be appropriately managed within Intermediate Care. This review highlights the necessity for further research of a higher methodological quality. A causal relationship between Intermediate Care and patient outcomes can only be established when the information is derived from randomised controlled trials. Large, long-term, prospective, government funded comparative studies are recommended
23
for future research to make more robust conclusions on the effectiveness of Intermediate Care pathways. There are clear gaps in research surrounding patients who do not benefit from Intermediate Care. Furthermore, a better understanding of patient pathways and costs aligned with those who do not optimally benefit from secondary care is required. There is also a paucity of evidence pertaining to the cost implications of Intermediate Care, and whether this system is feasible. Ethical approval: This study was approved by the Queen Mary University of London Ethics of Research Committee. Funding: This project was co-funded by the Engineering and Physical Sciences Research Council (EPSRC) grant EP/H500162/1: Knowledge Transfer Account. Conflict of interest: There were no conflicts of interest in this study.
References [1] Taskforce SIP. Sports injury prevention taskforce final report. Melbourne, Australia; 2013. [2] McCormack A, Fleming D, Charlton J. Morbidity statistics from general practice. In: 4th National study 1991–1992. Series MB5 no. 3. London: HMSO; 1995. [3] Matheny JM, Brinker MR, Elliott MN, Blake R, Rowane MP. Confidence of graduating family practice residents in their management of musculoskeletal conditions. Am J Orthop (Belle Mead NJ) 2000;29(12):945–52. [4] Speed CA, Crisp AJ. Referrals to hospital-based rheumatology and orthopaedic services: seeking direction. Rheumatology 2005;44(4):469–71. [5] Lofvendahl S, Eckerlund I, Hansagi H, Malmqvist B, Resch S, Hanning M. Waiting for orthopaedic surgery: factors associated with waiting times and patients’ opinion. Int J Qual Health Care 2005;17(2):133–40. [6] Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health 1999;89(9):1322–7. [7] FIFA. 11+. F-MARC; 2006. [8] Dixey J, Bamji A. What is a rheumatologist for? Rheumatology (Oxford, England) 2007;46(3):377–8. [9] Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52(6):377–84. [10] Blackburn MS, Cowan SM, Cary B, Nall C. Physiotherapy-led triage clinic for low back pain. Aust Health Rev 2009;33(4): 663–70. [11] Rogers BA, Kabir C, Bradley N. An audit of orthopaedic referrals via multi-professional triage teams. Ann R Coll Surg Engl 2008;90(8):671–4. [12] Morris J, Grimmer-Somers K, Kumar S, Murphy K, Gilmore L, Ashman B, et al. Effectiveness of a physiotherapy-initiated telephone triage of orthopedic waitlist patients. Patient Relat Outcome Meas 2011;2:151–9. [13] Razmjou H, Robarts S, Kennedy D, McKnight C, MacLeod AM, Holtby R. Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times. Physiother Can 2013;65(1):46–55.
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[14] Bath B, Janzen B. Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service. J Multidiscip Healthc 2012;5:1–15. [15] Bath B, Grona SL, Janzen B. A spinal triage programme delivered by physiotherapists in collaboration with orthopaedic surgeons. Physiother Can 2012;64(4):356–66. [16] Hattam P. The effectiveness of orthopaedic triage by extended scope physiotherapists. Clin Gov 2004;9(4):244–52. [17] Salisbury C, Foster NE, Hopper C, Bishop A, Hollinghurst S, Coast J, et al. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of ‘PhysioDirect’ telephone assessment and advice services for physiotherapy. Health Technol Assess 2013;17(2): 1–157. [18] Maddison P, Jones J, Breslin A, Bargon C, Fleur J, Lewis R, et al. Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. Br Med J 2004;329(7478):1325–7. [19] Sephton R, Hough E, Roberts S, Oldham J. Evaluation of a primary care musculoskeletal clinical assessment service: a preliminary study. Physiotherapy (London) 2010;96(4):296–302. [20] Roberts C, Dolman EA, Adebajo AO, Underwood M. A national qualitative survey of community-based musculoskeletal services in the UK. Rheumatology (Oxford, England) 2003;42(9): 1074–8. [21] Hattam P, Smeatham A. Evaluation of an orthopaedic screening service in primary care. Br J Clin Gov 1999;4(2):45–9. Available from: http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/553/CN00463553/frame.html [22] Bridgman S, Li XF, Mackenzie G, Dawes P. Does the North Staffordshire slot system control demand of orthopaedic referrals from primary care? A population-based survey in general practice. Br J Gen Pract 2005;55(518):704–9. [23] Roddy E, Zwierska I, Jordan KP, Dawes P, Hider SL, Packham J, et al. Musculoskeletal clinical assessment and treatment services at the primary–secondary care interface: an observational study. Br J Gen Pract 2013;63(607):e141–8.
[24] Brooks G, Dolphin M, Vanbeveren P, Hart DL. Referral source and outcomes of physical therapy care in patients with low back pain. J Orthop Sports Phys Ther 2012;42(8):705–15. [25] O’Cathain A, Froggett M, Taylor MP. General practice based physiotherapy: its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments. Br J Gen Pract 1995;45(396):352–4. Available from: http://onlinelibrary. wiley.com/o/cochrane/clcentral/articles/954/CN-00270954/frame.html [26] Rabey M, Morgans S, Barrett C. Orthopaedic physiotherapy practitioners: surgical and radiological referral rates. Clin Gov 2009;14(1):15–9. [27] Oldmeadow L, Bedi H, Burch H, Smith J, Leahy E, Goldwasser M. Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Med J Aust 2007;186(12):625–8. [28] Aiken AB, Harrison MM, Hope J. Role of the advanced practice physiotherapist in decreasing surgical wait times. Healthc Q 2009;12(3):80–3. [29] Aiken AB, Harrison MM, Atkinson M, Hope J. Easing the burden for joint replacement wait times: the role of the expanded practice physiotherapist. Healthc Q 2008;11(2):62–6. [30] Harrison J, Rangan A, Shetty A, Robinson C. Reducing waiting times: physiotherapy shoulder assessment clinic. Br J Ther Rehabil 2001;8(2):57–9. [31] Menzies RD, Young RA. Referrals from a primary care-based sports medicine department to an orthopaedic department: a retrospective cohort study. Br J Sports Med 2011;45(13):1064–7. [32] Pearse EO, Maclean A, Ricketts DM. The extended scope physiotherapist in orthopaedic out-patients – an audit. Ann R Coll Surg Engl 2006;88(7):653–5. [33] Hockin J, Bannister G. The extended role of a physiotherapist in an out-patient orthopaedic clinic. Physiotherapy 1994;80(5):281–4. [34] Hourigan PG, Weatherley CR. The physiotherapist as an orthopaedic assistant in a back pain clinic. Physiotherapy 1995;81(9):546–8. [35] Kennedy M, Dunne C, Mulcahy B, Molloy M. The sports’ clinic: a one year review of new referrals. Ir Med J 1993;86(1):29–30. [36] Butcher JD, Zukowski CW, Brannen SJ, Fieseler C, O’Connor FG, Farrish S, et al. Patient profile, referral sources, and consultant utilization in a primary care sports medicine clinic. J Fam Pract 1996;43(6):556–60.
Available online at www.sciencedirect.com
ScienceDirect
Systematic review
Intermediate Care pathways for musculoskeletal conditions – Are they working? A systematic review A. Hussenbux a , D. Morrissey a,b,∗ , C. Joseph a , C.M. McClellan c a
Centre for Sports and Exercise Medicine, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London E1 4DG, UK b Physiotherapy Department, Bart’s Health NHS Trust, London, UK c Academic Department of Emergency Care, Adult Emergency Department, Bristol Royal Infirmary, University Hospitals NHS Foundation Trust, Bristol BS28HW, UK
Abstract Background Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services. Objectives This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence. Data sources PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013. Study selection/eligibility criteria Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded. Results Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists’ clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction. Limitations These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services. Funding Part funded by EPSRC and AXA-PPP. Conclusion Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients. © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Musculoskeletal clinical assessment and treatment service; Physiotherapy triage; Appropriate referral; Effectiveness; Waiting times; Patient outcome
Introduction It is estimated that a quarter of the global adult population are affected by chronic musculoskeletal pain, musculoskeletal disorders being the commonest cause of pain and physical disability [1]. Further, there is an increasing ∗
Corresponding author. Tel.: +44 07941710273. E-mail addresses: [email protected], [email protected] (D. Morrissey).
burden on primary and secondary care as musculoskeletal disorders account for over a quarter of all general practitioner (GP) consultations [2]. Primary care physicians have expressed low confidence in their abilities to diagnose and manage musculoskeletal skeletal conditions appropriately [3]. This results in early and misdirected referral to hospital based secondary care, primarily orthopaedics and rheumatology [4]. This ultimately affects the patient’s quality of care and leads to long waiting times within secondary care [5].
http://dx.doi.org/10.1016/j.physio.2014.08.004 0031-9406/© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
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The Musculoskeletal Services Framework [6] and the UK Government White Paper entitled “Our Health, Our Care, Our Say” [7] outlined a change in current management of musculoskeletal conditions in the UK away from secondary care and towards a Musculoskeletal Clinical Assessment Treatment Service (MSK CATS) model, typically situated in Intermediate Care. These services typically aim to provide triage, rapid assessment, facilitate access to treatment, improve efficiency, and reduce inappropriate referrals to secondary musculoskeletal care [8]. Triage is the process of determining the package of care for a patient based on the nature and severity of their condition in order to optimise care and make best use of resources. Increasingly, triage settings are being used to manage patients with musculoskeletal conditions at the interface between primary and secondary care. The effectiveness of such services has been the subject of increasing interest and investigated in terms of service delivery, referral appropriateness and patient satisfaction, but there has been limited synthesis of the available evidence thus limiting generalisation of findings to guide commissioning of innovative services and outcome evaluation. The aim of our work was to provide an evidence summary to guide commissioners, service managers and clinicians by systematically reviewing the evidence pertaining to MSK CATS pathways. We particularly sought to summarise the evidence relating to the effectiveness and referral outcome of MSK CATS, physiotherapy-led triage as well as the effect on waiting times and patient satisfaction.
Methods Inclusion and exclusion criteria for the systematic review This systematic review included studies that were original, scientific journal publications evaluating MSK CATS, or similar services assessing musculoskeletal conditions. Any study that described primary care based triage that was led by: allied health practitioners (such as physiotherapists and occupational therapists), general practitioners with a special interest in MSK medicine, and musculoskeletal physicians were included as were studies evaluating referral pathways in a more general sense. Outcome measures of particular interest were: effectiveness and referral outcome of MSK CATS, physiotherapy-led triage and physiotherapy services, as well as the overall effect on waiting times and patient satisfaction. Studies from all countries were included. Reports needed to have been written in English, while editorials, conference reports, commentaries and abstracts were excluded. Further, studies assessing patients with non-musculoskeletal pathology, referrals to secondary care dealt with by the GP only, paediatric and emergency medicine, self-referral, and studies concerning referral from MSK secondary care were excluded.
Search and evaluation strategy The electronic databases; PubMed, Web of Science, EMBASE, Ovid Medline, PEDro and Google scholar were searched for all articles published from inception to October 2013. The Medical Subject Headings are detailed in Supplementary Table S1. Titles and abstracts were imported into Endnote (Version X6, Thompson Reuters, Philadelphia, PA), and duplicates removed. Study titles and abstracts were reviewed by two authors (AH and DM). If the title was identified as potentially meeting the inclusion criteria, the abstract was read, and if the paper met the inclusion criteria, the full paper was obtained for further analysis. If insufficient information was available from a title or abstract, the full paper was obtained to make a decision on inclusion. Reference lists and citing articles of retained studies were also scrutinised to identify any additional papers. The search yielded a total of 23 articles (Fig. 1). Supplementary Table S1 related to this article can be found, in the online version, at http://dx.doi.org/ 10.1016/j.physio.2014.08.004. Quality assessment The 23 papers were analysed using a modified Downs and Black Checklist [9]. The modified checklist consisted of 15 questions giving a maximum score of 16. A modified checklist was used as questions regarding adverse effects, blinding, compliance, randomisation and power calculations were omitted as they were deemed not relevant to all observational studies in this review. This quality assessment scale is feasible and can be used to assess the methodological quality of randomised controlled trials and non-randomised studies [9]. Review process All studies were independently assessed for quality by two reviewers (AH and CJ). Any differences in quality scores were discussed among the reviewers until a consensus was reached. To determine inter-rater agreement, percentage agreements were calculated for each quality score item. Summary tables were created, detailing study characteristics, participant characteristics, outcome measures, key results, statistics and level of evidence from each study (Tables 1a to 1c). These tables have been grouped into three areas of interest; MSK CATS, physiotherapy led triage and physiotherapy services.
Results A total of 23 articles met the inclusion criteria and were included in this review (Fig. 1).
Table 1a Summary of studies included relating to MSK CATS. Study design
Study size
Intervention compared
Group characteristics
Duration
Outcome measure
Outcome measure result
Statistical analysis
Level of evidence
Salisbury et al. (2013)
RCT
2256
Usual care vs phone
MSK
6 months
PhysioDirect = shorter waiting times (7 days vs 34 days). Health outcome equivalent in both groups. Lower satisfaction compared to control group −3.8%
Multivariate regression
High
Razmjou et al. (2013)
Observational: prospective study
347
Evaluation of PT service
Patients with shoulder complaints referred to speciality shoulder clinic
36 months
SF-36v2 questionnaire, The Measure Yourself Medical Outcomes Profile, EQ-5D, 7-point scale of overall improvement, response to treatment, time lost from work, Patient satisfaction Role of APP with respect to: 1. Agreement with orthopaedic surgeon on diagnosis and management. 2. Waiting times. 3. Patient satisfaction.
Kappa
High
Sephton et al. (2010)
Observational: prospective cohort
217
PT in MCAS triaging MSK patients
MSK
12 months
1. Agreement in major diagnostic categories varied from 0.68 (good) to 0.96 (excellent). Agreement of surgery was κ = 0.75, p < 0.001; 95% CI, 0.62 to 0.88 (good). 2. Average wait time reduced from 198 days in 2008 to 75 days in 2011 p < 0.001. 3. Patient satisfaction significantly better in APP group p = 0.004 Significant improvement in EQ-SD questionnaire (p = 0.035), and pain VAS scale (p = 0.002). No significant differences in SF-36 (P = 0.87) and high levels of patient satisfaction (94% good satisfaction)
t-Test
Medium
Roberts et al. (2003)
Observational: prospective cohort
461
Survey of MSK services
MSK
12 months
71% of organisations had more than one MSK service within the community consisting of PT services and triaging services. Purpose of service described in 83% of services.
N/A
Low
Treatment outcomes for patients triaged by physiotherapists at 3 and 12 months following care (no control group) Pain VAS (/10), EQ-5D and SF-36 questionnaire, perceived improvement PIVAS scale (%), and Deyo and Diehl satisfaction questionnaire (%) Characteristics of community based musculoskeletal services provided by primary care organisations.
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Author
15
16
Table 1a (Continued) Study design
Study size
Intervention compared
Group characteristics
Duration
Outcome measure
Outcome measure result
Statistical analysis
Level of evidence
Roddy et al. (2013)
Observational: retrospective cohort
2166
Outcome of MSK CATS
All patients referred to MSK CATS from Feb 2008 to June 2009
16 months
Describe characteristics, investigations and treatment of adults attending MSK CATS
Chisquared
Medium
Bridgman et al. (2005)
Observational: organisational intervention
10,000
Outcome of slot system
32 months
Rate of new referrals into orthopaedics
N/A
Medium
Hattam et al. (1999)
Observational: retrospective cohort
84
Outcome of orthopaedic screening service
Musculoskeletal patients assessed in 36 practices; 12 intervention, 24 control MSK
12 months
Description and intervention of patients. Waiting times.
N/A
Low
Maddison et al. (2004)
Observational: over time comparisons
N/A (1000+)
Outcome of TEAMS service
MSK
18 months
Assess waiting times into secondary care in relation to number of referrals and number of patients seen.
Characteristic = chronic pain > 1 year (55%). 45% of patients took 6 months of work off due to MSK problems and psychosocial issues. 48% = no investigation: X-ray-23%, MRI = 18% 23% referred to PT 13% required injection. 22% mean referral rate reduction in slot group compared to control group and other practices. Reduction in referral rate increased with time. Description = 60.9% lower limb complaints. Intervention of OSS = 29% advice/exercise. 19% = PT, 14% = referral, 5% = investigation (blood, X-ray). Overall 72.4% of orthopaedic patients dealt with in primary care setting using OSS. Over 18 months, number of referrals doubled (403 to 823). Waiting times reduced. Surgery conversion rates were unchanged.
N/A
Low
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Author
Table 1b Summary of studies included relating to Physiotherapy-led triage. Observational: prospective cohort
198
PT triaging spinal cases
Low back pain patients
8 months
Patient and provider satisfaction
Morris et al. (2011)
Intervention: quasiexperimental
112
PT triaging orthopaedic patients
MSK
3 months
Cost of service, waiting time and percentage of patients using management options. Results compared with 2009 data
Hattam (2004)
Observational
192
ESP triaging orthopaedic patients
MSK
15 months
Specificity and appropriateness of referral to orthopaedic secondary care
Bath et al. (2012)
Observational: retrospective
1096
PT triaging spinal cases
Low back pain patients
36 months
Blackburn et al. (2009)
Observational: retrospective cohort
105
PT triaging MSK patients
MSK
12 months
Describe the characteristics of patients in the triage programme and whether surgery is necessary. Waiting times to first appointment, patient attendance, and surgery conversion rates. Compared with 2002 data
Roger (2008)
Audit
277
MST triaging MSK patients
MSK
9 months
Waiting times, agreement in diagnosis and referral
66% of participants were “very satisfied.” Diverse range of themes coded into positive such as good understanding, communication, management direction and efficiency. Negative feedback was time to follow up and costs. Telephone triage led to 16.4% patients being discharged directly. 25.9% referral to physiotherapy 41.4% referred to MDT for review of condition or referral to surgery. Telephone triage validated surgical referral for 40% of patients 70.6% of subjects referred were considered appropriate. Reasons for referral: Surgery = 55.9%. Further opinion = 27.6%. Investigation (MRI) = 16.5% 746 participants. 92.5% had mechanical spine. 2% had surgical spine. Proportionally more people referred to the surgeon from triage had an outcome of surgery (70%) Waiting time decreased by 11%. 79% patients referred to physiotherapy from PLTC. From there 16% referred to surgery. 87% of GP’s felt PLTC management was appropriate MPTT waiting times significantly longer (140 days compared to 62 days). MPTT: 22% incorrect diagnosis, 33% no diagnosis
PASW, Chi-square or Fischer’s exact, and independent t-test or Mann–Whitney
High
Mann–WhitneyU test
Low
SPSS Chi-squared test
Medium
Shapiro–Wilk test. Fischer’s Exact test. PASW
Medium
N/A
Low
ANOVA
Medium
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Bath and Janzen (2012)
17
18
Table 1c Summary of studies included relating to physiotherapy-led referral. Observational: retrospective cohort
7951
PT referral source
Patients with low back pain
24 months
Clinical characteristics of patients with low back pain who are managed and referred by PTs.
O’Cathain (1995)
Observational: Controlled before and after study
N/A (1000+)
PT referral source and outcome
MSK
24 months
Physiotherapy contact rates. Orthopaedic referral rate. Rheumatology referral rate
Oldmeadow et al. (2007)
Observational: prospective cohort
52
PT referral source and outcome
MSK
6 months
Proportion of MSK patients who could be managed without seeing a surgeon. Level of agreement between physiotherapist and surgeon.
Rabey et al. (2008)
Observational: retrospective cohort/descriptive
3758
PT referral sources
MSK
31 months
Extent and appropriateness of surgical and radiological referral by ESPs in orthopaedic service
Menzies and Young (2010)
Observational: retrospective cohort
4925
Sports Doctor referral source
MSK
12 months
Referral rate from sports medicine to orthopaedic clinic. % of referred patients who were recommended surgery by orthopaedics. Effect on waiting time. Most common conditions and procedures.
PCPs and OCC medicine associated with 1.6(95% CI: 0.7 to 2.6) and 4.8 (95%CI: 2.7, 6.9) in discharge overall health score compared to specialist referral. PCP and OCC medicine associated with 0.44(95%CI: 0.27 to 0.61) and 0.83 (95%CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral. 79.5% increased contact rates with physiotherapy services. 12% reduced orthopaedic referral rate. 44% reduced rheumatology referral rate. 38 of 45 patients seen by PT saw an orthopaedic surgeon. 7 patients agreed for surgery, 3 patients for injection and 4 patients for imaging. PT and surgeon appropriateness was 74%. Patients and Doctors reported high satisfaction. 79% patients managed by ESP solely. 9% referred for surgical opinion. 13% referred for X-Ray 10% referred for MRI Of patients referred for surgical opinion, surgery was appropriate for 89% of patients 2.4% of patients referred from sports medicine to orthopaedics. Of these patients, surgery was offered to 68% of patients. Waiting time for orthopaedic clinic decreased from 97 to 19 days. Most common condition referred was knee (25.3%). Knee injections and epidural steroid injections most common conditions performed.
Independent t-test ANOVA
High
Chi-squared test
Low
Kappa with 95%
Low
N/A
Low
Chi-squared test
Medium
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Brooks et al. (2012)
Table 1c (Continued) Inter-rater agreement
38
PT referral source
MSK
N/A
Pearse et al. (2006)
Audit
150
ESP referral
MSK
6 months
Harrison et al. (2001)
Observational: retrospective audit
130
PT referral source
Patients with shoulder complaints
12 months
Aiken et al. (2009)
Observational: retrospective
147
PT referral outcome
MSK
12 months
Agreement between APP and orthopaedic surgeon 1. Identification of surgical candidates 2. Surgical urgency using WCWL-HKPT tool 3. Treatment recommendations Assessment and management by ESP. Assess whether patients were re-referred to surgery with the same problem. Patient satisfaction. Waiting times for patients managed in the physiotherapy shoulder assessment clinic Role of APP in terms of numbers of patients seen, number of patients who did not see a surgeon and effect on waiting times.
1. Observed agreement 100% 2. Observed agreement 64% Level of agreement κ = 0.68
Kappa
Low
55% of patients managed by ESP alone. Consultant review required for 81% of shoulder and 34% of knee cases. GPs re-referred 3% of patients. 77% patient satisfaction.
N/A
Medium
130 patients were assessed with an average waiting time of 58 days and 50% of patients were treated with physiotherapy alone 147 patients screened by APP. 34% of patients managed by APP alone. From 2007 to 2008 waiting times to orthopaedic surgeons reduced from 140 days to 40 days
N/A
Low
N/A
Low
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Aiken et al. 2008
MSK, musculoskeletal; MSK CATS, musculoskeletal clinical assessment and treatment services; N/A, not applicable; PT, physiotherapist/physical therapist; MPTT, multi-professional triage teams; OSS, orthopaedic screening service; PTLC, physiotherapist led triage clinic; APP, advanced practice physiotherapist; ESP, extended scope physiotherapist; GPwSI, general practitioner with special interest; OCC, occupational medicine; PT, physiotherapist/physical therapist; PCP, primary care physician; WCWL-HKPT, western Canada wait list hip and knee prioritisation tool.
19
20
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ISI Web of Science
PUBMED Limited to English language, human studies
Limited to English language, human studies and arcles
Total=7956
Total=9883
PEDro advanced search
EMBASE
OVID Medline
Limited to human studies and journal arcles
Limited to English language, human studies and journal arcles
Physical therap* AND referral*
Total=3374
Total=3313
Total=224
22 Titles
39 Titles
24 Titles
24 Titles
18 Titles
4 abstracts
9 abstracts
5 abstracts
4 Titles
12 Titles
Google Scholar Limited to English language, human studies
Total 7956
1 abstract
35 abstracts
Duplicates manually deleted Total = 22
Search of reference lists: 2 Titles 1 abstract
Records excluded on screening of abstracts ad full text (n=104) Duplicates (n=12) Review (n=6) Too broad/too general/non MSK related (n=24) Protocol study (n=3) No referral/outcome from Intermediate Care to secondary care (n=18) Primary to secondary care only (n=12) Intermediate Care for specific condions (n=29)
Total = 23
Fig. 1. PRISMA flow diagram showing Intermediate Care pathway literature and reasons for excluding certain studies.
Study design The search revealed one pragmatic randomised control trial [17], 14 observational retrospective studies [10,15,16,18,21–26,28–31], five observational prospective studies [13,14,19,20,27], one prospective quasi-experimental study [12], and two audits [11,32]. Two studies used a low sample size (e.g. n = 84, n = 45) [21,27], and four studies were site specific [14,18,28,29]. Studies included assessed Intermediate Care services on average for 1 year [10,23,31]. Some studies were observed for shorter time periods – nine months [11], six months [19,32], and three months [12]. A majority of studies assessed the services during the first year of starting. Quality assessment scores Overall, the studies utilised a wide range of outcome measures but typically resulted in a low level of evidence (Tables 1a to 1c). The modified checklist ranked the observational studies into three sub-levels of evidence; high (score = 13 to 16), medium (score = 9 to 12) and low (score ≤ 8). The modified checklist revealed 11 low [10,12,18,20,21,25–30], eight medium
[11,15,16,19,22,23,31,32], and four high quality studies [13,14,17,24]. The complete Downs and Black check list was used for the randomised controlled trial. The study scored 24 out of 30. The raw agreement between reviewers for the total quality score was 84%. Individual items in the quality checklist demonstrated good inter-rater reliability (Supplementary Table S2). Supplementary Table S2 related to this article can be found, in the online version, at http://dx.doi.org/ 10.1016/j.physio.2014.08.004. Type of studies Overall, 14 studies explored the use of MSK CATS. This included seven studies that assessed triage services in reducing waiting times [10–12], diagnostic agreement [13,14], patient satisfaction [15] and appropriateness of triage referral [16]. The other seven studies evaluated musculoskeletal assessment services in the patient management and referral [17,18] and the overall outcome and characteristics of the services [19–23] – here defined as referral procedures, interventions, investigations, patient satisfaction and reduction in waiting times.
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A total of nine studies evaluated referral pathways within Intermediate Care, including experienced physiotherapist referral, level of agreement between physiotherapist and orthopaedic consultant [24–27], role in reducing waiting times [28–30], referrals from a sports and exercise medicine department [31], and referrals led by an extended scope physiotherapist [32]. Fig. 1 demonstrates an overview of all studies included. Main findings This systematic review reports 72% to 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the most common investigations. Physiotherapists’ clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction.
Discussion We aimed to systematically identify, critique and summarise Intermediate Care pathways in order to guide service design and delivery. Further, we aimed to assess the effectiveness of Intermediate Care when managing musculoskeletal patients, referring patients to secondary care and exploring cost containment, waiting times, patient satisfaction and overall health outcomes. Musculoskeletal clinical assessment and treatment services (MSK CATS) The earliest MSK CATS study assessed the characteristics of community-based musculoskeletal services in the UK [20]. Postal questionnaires were sent to five professional groups within UK primary care, and services reported were physiotherapy rehabilitation services, joint injection services and implementation of integrated care pathways. In 46% of services, patients were assessed and triaged by physiotherapists. The purpose of the service was described in 83% however, only 11% of services had a clear evaluation strategy such as pre- and post-service data for orthopaedic initiative, numbers treated, discharge profiles and scoring systems for physiotherapist triage. Despite high response rate, it is unclear who completed the questionnaires and whether that person is bestqualified to respond. Due to reduced mention of evaluation strategies, it is difficult to critique the quality of the services provided.
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Rate of referral Overall, the introduction of MSK CATS has led to a reduced referral to secondary care. A Targeted Early Access to Musculoskeletal Services (TEAMS) [18] programme led to a 116% increase in total referral to appropriate secondary care. Reported surgery conversion rates remained constant at 37%, and significant reductions in waiting times to orthopaedic services went from 50 weeks to 5 weeks. In contrast, a similar structured “orthopaedic slot system” [22] led to a 22% reduction in referral rate to secondary care when compared to a control group. Both studies used a nonrandomised selection of general practices and did not address the cost implications of these assessment services. The contrast in referral rates may be due to differences in the time period; the TEAMS study was observed for 1 year, whilst the slot system was observed for 3 years. The slot system results were more reliable as they were compared to similar control practices whilst there were no comparisons in the TEAMS study. A similar study reported a 60% reduction in referrals to orthopaedics and 40% reduction in referrals to rheumatology over 12 months [19]. This is most likely due to increased patient discharge, thorough patient education and self-management solutions within the MSK CAT services. Outcome and characteristics of services Overall, investigations and management plans for patients within MSK CATS were deemed appropriate and displayed positive outcomes. MSK CATS identified patients that were in need of referral to secondary care and as a result reduced waiting times and increased patient satisfaction were reported. The earliest evaluation of an orthopaedic screening service (OSS) in primary care [21] reported 72.4% of MSK patients could be managed in primary care using the OSS. Intervention of OSS included advice and exercise (29%), physiotherapy (18%), referral (14%) and investigations such as blood tests and plain films (5%). The most common intervention was steroid injection (5%). Waiting times for patients were reduced by nine months in this 1 year, small sample study (n = 76), necessitating caution in interpretation. Common investigations in MSK CATS reported are Xray (23%), MRI (18%) and blood tests (14%) however, 48% received no investigation [23]. A large proportion of the MSK patients in the study suffered with depression (47%) and anxiety (37%) due to chronic pain, suggesting the necessity of MSK CATS to successfully and appropriately manage their care. In regard to referral pathways, the most common was to physiotherapy (23%), and the most common intervention was steroid injections (13%); showing similarities with previous research [21]. Physiotherapy-led triage Triaging is a process that occurs within MSK CATS; below critically analyses the findings of physiotherapy-led triage
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in terms of appropriate referral, waiting times and patient satisfaction. Appropriate referral The literature suggests physiotherapists with postgraduate training are effective at diagnosing and managing musculoskeletal patients. Further, postgraduate-trained physiotherapists display an ability to appropriately triage patients into orthopaedic care. Extended scope physiotherapists (ESP) may be comparable to medical doctors in appropriate referral and is highlighted from the literature. One study [16] reported 16.5% referrals made by general practice based physiotherapists were for investigations and 55.9% were for surgical procedures. Overall, 70.6% of referrals made by ESPs to consultants were considered appropriate suggesting that ESPs can appropriately refer. However, appropriateness was decided by various members of an orthopaedic team, ranging from senior house officer to consultant and the difference in experience across professions may affect the accuracy of judging appropriateness. In addition, physiotherapists have also been shown to have high levels of agreement with orthopaedic surgeons [27]. Waiting times There is clear evidence that suggests the use of physiotherapy-led triage reduces waiting times for musculoskeletal patients. This reduction in waiting times is mainly due to reductions in inappropriate referrals and increases in the number of patients discharged with a thorough explanation of self-management procedures. One multidisciplinary study report was shown to reduce waiting times for an orthopaedic consultation from 25.1 months to 6.6 months through telephone triage combined with initial management [12]. However, the triage system was only observed for three months. This is supported by previous research reporting a reduction in waiting times from 23 weeks to 9 weeks in a physiotherapy led clinic [10]. Further, the physiotherapy-led initiative appeared to validate the need for prompt referral for surgery and effective management for non-surgical patients. In contrast, an audit suggested waiting times increased for orthopaedic referrals via a multi-professional triage team (MPTT) [11]. The likely cause for this was 22% of cases referred from the MPTT clinic were deemed to have an incorrect diagnosis and 33% with no diagnosis therefore, resulting in unnecessary secondary care referral and increased confusion due to diagnostic indecision. Two Canadian studies suggest the role of advanced practice physiotherapists in decreasing surgical waiting times [28,29]. Although low quality, these reinforce the positive findings made that physiotherapy-led triage significantly reduces waiting times. One randomised controlled trial was included in this review [17]. Telephone assessment service for musculoskeletal patients reduced waiting times compared to usual care (median = 7 days vs 34 days). Over the 6 months this trial was conducted, the telephone triage service reduced waiting
list time, led to less face-to-face appointments and consultations, and those who were triaged via telephone were less likely to not attend appointments than those receiving usual care. Alternately, there was no difference in health outcomes, lost time for work, or patient satisfaction in the ability to access the service. This suggests that the service was successful in providing appropriate assessment and treatment however, made no difference to function, pain, or psychological status of the patient. Of potential interest, those patients who were in the usual care arm (face-to-face consultation) had a higher level of patient satisfaction when compared to the telephone consultation arm. This coincides with the observational studies included in this review which all report high patient satisfaction in face-to-face consultations. Patient satisfaction Studies investigating physiotherapy-led triage report high patient satisfaction. A quantitative analysis of patient satisfaction using a physiotherapy spinal triage assignment service reported 66% of patients were “very satisfied” with the service [14]. A diverse range of themes such as good understanding, communication, management direction and efficiency were identified as being related to the service. Negative feedback was received regarding time to follow up, costs and limited local availability of the service. Other lower quality studies also reported high levels of patient satisfaction within Intermediate Care [18,19,32]. Appropriate referral The number and appropriateness of referrals made by ESPs to orthopaedic surgeons and the description of investigations were investigated further [26]. The study reported 9% of patients seen by the ESP were referred to surgical opinion, suggesting the majority of MSK patients could be managed by an ESP. Of these patients, 43% had knee complaints, which is similar previous research employing ESPs [16]. The study reported 79% of patients had their care completely managed by an ESP. This concurs with many studies reporting ESPs managed 50% to 85% of all cases in an orthopaedic department [16,30,33,34]. In terms of common investigations, ESPs refer 25% of patients for investigations; this included X-ray (13%), MRI (10%) and others investigations including blood tests, bone scans and ultrasound [26]. These investigation findings show similarities with previous research [21,23]. Knee conditions were most commonly referred for further investigations. The study [26] is an observational study with a large sample size (n = 3758) assessing the referrals for 3 years; therefore the conclusions of this study are reliable. Primary care based sports medicine A retrospective study assessed referrals from a primary care based sports medicine department to orthopaedic secondary care in 1 year [31]. The study reported 118 out of 4925 patient encounters (2.4%) resulted in referral to
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secondary care. Of these, 68% were recommended a surgical procedure. Knee arthrocentesis (34.8%), sacroiliac injection (17.3%) and facet injection (16.6%) were the most common interventions. The study suggests most musculoskeletal patients can be managed within Intermediate Care. These findings coincide with similar, earlier studies [35,36]. Limitations This study is not without limitations. A highly inclusive search strategy was reformed for this review however, certain key terms may have been missed from the search strategy due to differences in spelling or different terminology. In considering this, the probability of missing relevant literature was reduced by checking the references of all studies included. The strength of the evidence presented within this paper may be uncertain due to the low quality of the included studies. Furthermore, only one study was a randomised controlled trial, with the majority of studies being cross-sectional or retrospective and making pre-post, or historical comparisons. This highlights the need for more randomised controlled trials to assess the effectiveness of Intermediate Care pathways. Conclusion It is clear from this review that local needs have driven the introduction of intermediate pathways in the UK with audit, service evaluation and research has typically been retrospective. Heterogeneity, lack of embedded evaluation before services are underway and the lack of randomised research has made evaluation of effectiveness difficult. This review has however highlighted components of care and service delivery that demonstrate Intermediate Care is working. MSK CATS and physiotherapy triage appropriately manage and suitably refer patients to Intermediate Care. A reduction in waiting times and high patient satisfaction in face-to-face consultations were consistent findings, as observed in this review. The literature suggests that physiotherapists may be comparable with medical doctors in terms of clinical decision-making and appropriate referral for patients with orthopaedic conditions. Further, there are indications that physiotherapy services may improve the efficiency of secondary care management pathways for orthopaedic patients. Reasons for referral from Intermediate Care to secondary care are surgical procedures, further investigations such as X-ray and MRI, and minor interventions such as steroid injections. However, most musculoskeletal patients can be appropriately managed within Intermediate Care. This review highlights the necessity for further research of a higher methodological quality. A causal relationship between Intermediate Care and patient outcomes can only be established when the information is derived from randomised controlled trials. Large, long-term, prospective, government funded comparative studies are recommended
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for future research to make more robust conclusions on the effectiveness of Intermediate Care pathways. There are clear gaps in research surrounding patients who do not benefit from Intermediate Care. Furthermore, a better understanding of patient pathways and costs aligned with those who do not optimally benefit from secondary care is required. There is also a paucity of evidence pertaining to the cost implications of Intermediate Care, and whether this system is feasible. Ethical approval: This study was approved by the Queen Mary University of London Ethics of Research Committee. Funding: This project was co-funded by the Engineering and Physical Sciences Research Council (EPSRC) grant EP/H500162/1: Knowledge Transfer Account. Conflict of interest: There were no conflicts of interest in this study.
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