Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services: national data audit

Abstract

BackgroundMany people with musculoskeletal (MSK) disorders wait several months or years for Consultant Doctor appointments, despite often not requiring medical or surgical interventions. To allow earlier patient access to orthopaedic and rheumatology services in Ireland, Advanced Practice Physiotherapists (APPs) were introduced at 16 major acute hospitals. This study performed the first national evaluation of APP triage services.MethodThroughout 2014, APPs (n = 22) entered clinical data on a national database. Analysis of these data using descriptive statistics determined patient wait times, Consultant Doctor involvement in clinical decisions, and patient clinical outcomes. Chi square tests were used to compare patient clinical outcomes across orthopaedic and rheumatology clinics. A pilot study at one site identified re-referral rates to orthopaedic/rheumatology services of patients managed by the APPs.ResultsIn one year, 13,981 new patients accessed specialist orthopaedic and rheumatology consultations via the APP. Median wait time for an appointment was 5.6 months. Patients most commonly presented with knee (23%), lower back (22%) and shoulder (15%) disorders. APPs made autonomous clinical decisions regarding patient management at 77% of appointments, and managed patient care pathways without onward referral to Consultant Doctors in more than 80% of cases. Other onward clinical pathways recommended by APPs were: physiotherapy referrals (42%); clinical investigations (29%); injections administered (4%); and surgical listing (2%). Of those managed by the APP, the pilot study identified that only 6.5% of patients were re-referred within one year.ConclusionThis national evaluation of APP services demonstrated that the majority of patients assessed by an APP did not require onward referral for a Consultant Doctor appointment. Therefore, patients gained earlier access to orthopaedic and rheumatology consultations in secondary care, with most patients conservatively managed.

Physiotherapist‐Led Triage at a Rheumatology‐Based Musculoskeletal Assessment Clinic: an 18‐Month Service Evaluation of Activity and Outcomes

“…In an audit of Irish national data on the management of patients at physiotherapist‐led musculoskeletal triage clinics in 2014 , there was consultant involvement in the clinical decisions of 28.4% of rheumatology patients, and the remaining 71.6% of patients were independently managed by the advanced practice physiotherapist, which is similar to the proportion independently managed by the CSP in this service evaluation. The high proportion of patients independently managed by the CSP and subsequently discharged back to their GP (74%, n = 375) highlights the appropriateness of the referrals directed to this service.…”

“…In this service evaluation, 17% (n = 87) of patients were referred on to the rheumatology team. In an audit of Irish national data of musculoskeletal triage services , only 12.9% of rheumatology patients were referred on to consultant services. The higher proportion directed to a rheumatology team in this service evaluation is likely explained by our service's access to a specialist rheumatic and musculoskeletal disease unit for multidisciplinary assessment and rehabilitation, which accounted for 47% (n = 37) of referrals to the rheumatology team.…”

“…A substantial number of trials, observational studies, and service evaluations of physiotherapist‐led musculoskeletal triage services in primary and secondary care settings have found that suitably trained CSPs can independently and appropriately manage a significant proportion (50%‐92%) of patients within physiotherapist‐led musculoskeletal triage clinics . A systematic review of extended‐scope physiotherapy practice in patients with musculoskeletal disorders suggests that the quality of care is at least equivalent to that of physician‐led care with respect to diagnostic accuracy, clinical effectiveness, use of health care resources, and patient satisfaction .…”

“…A retrospective review of 462 patients with nonurgent musculoskeletal presentations who were discharged from a musculoskeletal triage service reported that less than 5% of patients re‐presented to the service within 12 months . Similarly, in a service evaluation of 184 patients discharged over a 2‐month period from physiotherapist‐led musculoskeletal triage clinics, only 6.5% of patients (n = 12) were re‐referred to the service within 12 months .…”

Advanced musculoskeletal physiotherapy practice in Ireland: A National Survey

“…Although a National APP Database existed in Ireland to monitor wait time reductions and increased patient throughput (Fennelly, Blake, FitzGerald, et al, ), the lack of standardization of APP services across hospital sites and the absence of a registry or defined APP credentials, rendered it difficult to fully interpret and act on findings on a national basis. Profiling of the services and clinicians in Ireland requires the gathering of broader data from the APPs themselves across the hospitals sites, with a view to informing ongoing development and provision of training, and enabling further interpretation of the process data.…”