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

Samsson, Karin; Grimmer, Karen; Larsson, Maria; Morris, Joanne; Bernhardsson, Susanne

doi:10.1186/s12891-020-03673-9

Cited by 26 publications

(17 citation statements)

References 69 publications

(240 reference statements)

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“…Historically, less than 7% of non‐urgent patients reviewed in clinic required surgery. Similar low surgical conversion rates have been reported in other orthopaedic clinics, 5 and highlight inefficiencies within clinical pathways.…”

Section: Introductionsupporting

confidence: 76%

“…Within physiotherapy‐led models, advanced or extended scope physiotherapists triage, assess and/or treat patients referred to orthopaedic clinics. Studies have shown that these models can reduce orthopaedic clinic waitlists, 5 increase conversion to surgery rates (thus improving efficiency) 5,6 and are cost‐effective 6,7 . Additionally, clinical outcomes are comparable to traditional models of care, 5,8 re‐referral rates are low, 9 and patients report high levels of satisfaction 5,8 .…”

Section: Introductionmentioning

confidence: 99%

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A Shoulder/Elbow Triage and Assessment model of care reduced a public orthopaedic shoulder/elbow clinic waitlist with high patient satisfaction

Avdalis

Taylor

Cass

et al. 2023

ANZ Journal of Surgery

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Background Patients referred to public orthopaedic clinics can experience long waiting times before assessment. This study aims to evaluate the effectiveness of a collaborative Shoulder/Elbow Triage and Assessment (SHELTA) model of care involving orthopaedic surgeons and physiotherapists to reduce the waitlist and improve service and clinical outcomes for patients on an orthopaedic shoulder/elbow clinic waitlist. Methods Patients on the waitlist were triaged by surgeons and physiotherapists and invited to an assessment by experienced physiotherapists. Patients were treated nonoperatively or transferred to orthopaedic management based on clinical discussion. The primary outcome was the number of patients on the waitlist. Secondary outcomes included adverse events, patient satisfaction, re‐referral and conversion to surgery rates. Pain, function and patient global impression of change were recorded for participants managed nonoperatively. Results From July 2019 to December 2019, the waitlist reduced from 451 to 298 patients with no adverse events. Seventy‐nine patients could not be contacted and 25 no longer required assessment, and were removed from the waitlist. Nonoperatively managed participants reported satisfaction with the service, a median score of 6 on a 7‐point Patient Global Impression of Change scale, change in pain of −2.5/10 (95% CI −3.3, −1.7; P < 0.001) on a numerical pain rating scale, and change in function of −17.4/100 (95% CI: −24.1, −10.8; P < 0.001) on the QuickDASH, indicating improvement. Conclusions The SHELTA model of care effectively reduced the number of patients on an orthopaedic shoulder/elbow clinic waitlist with good service and clinical outcomes.

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Section: Introductionsupporting

confidence: 76%

Section: Introductionmentioning

confidence: 99%

A Shoulder/Elbow Triage and Assessment model of care reduced a public orthopaedic shoulder/elbow clinic waitlist with high patient satisfaction

Avdalis

Taylor

Cass

et al. 2023

ANZ Journal of Surgery

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“…Unfortunately, to our knowledge no current literature on this topic exists. Furthermore, recent systematic reviews have shown that musculoskeletal triage by professionals, such as extended scope physiotherapists, can possibly reduce healthcare utilization and help manage GP workload (19)(20)(21).…”

Section: Discussionmentioning

confidence: 99%

Differences in diagnosis in patients with atraumatic knee complaints between general practitioners and orthopedic surgeons: a retrospective cohort study

Evers

Schers

Ende³

et al. 2022

Preprint

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Background knee complaints are one of the most common reasons to consult the general practitioners in the Netherlands and contribute to the increasing burden on general practitioners. A proportion of patients that are referred to orthopedic outpatient clinics are potentially referred unnecessarily. We believe osteoarthritis is not always considered by general practitioners as the cause of atraumatic knee complaints. This may impede early recognition and timely care of osteoarthritis complaints and lead to unnecessary referrals. Methods the aim of this study was to compare the frequency of (differential) diagnosis of osteoarthritis mentioned in referral letters of general practitioners with the frequency of osteoarthritis mentioned as orthopedic diagnosis at the outpatient clinic. Therefore we conducted a retrospective cohort study based on data collected from referral letters and the corresponding outpatient clinic reports of patients with atraumatic knee complaints of 45 years or older referred to a regional hospital in Nijmegen, The Netherlands in the period from 1-6-2019 until 1-01-2020. Results a total of 292 referral letters were included. In the younger aged patients (45–54 years) osteoarthritis was mentioned less frequent and meniscal lesions were mentioned more frequent in referral letters when compared to diagnoses made at the outpatient clinic. Matching diagnoses were present in 58.2% when all referral letters were analyzed and 75.2% when only referrals containing a (differential) diagnosis were analyzed (n = 226). Matching diagnoses were present in 21.4% in the younger age categories (45–54 years). Conclusions Osteoarthritis was less frequently mentioned in general practitioner referral letters among the differential diagnosis then it was diagnosed at the outpatient clinic, especially in younger patients (45–54 years). Also matching diagnoses in younger patients were evidently lower than in older patients, possibly explained by underdiagnosing of osteoarthritis in younger patients in this cohort. Better recognition of osteoarthritis in younger patients and changing the diagnostic approach of general practitioners might improve efficacy in knee care. Future research should focus on the effectiveness of musculoskeletal triage, the need for multidisciplinary educational programs for patients and promotion of conservative treatment modalities among general practitioners.

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“…Physiotherapists and orthopaedic surgeons have similar high diagnostic accuracy compared to magnetic resonance imaging of musculoskeletal disorders (75% respectively 81%), and significantly higher accuracy than family practice and internal medicine physicians who have an accuracy of 35% [ 25 ]. Moreover, Samsson et al [ 26 ] concluded that physiotherapists and orthopaedic surgeons determined similar diagnoses, and recommended similar management for patients with musculoskeletal disorders.…”

Section: Introductionmentioning

confidence: 99%

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care – a cost-effectiveness analysis of a pragmatic trial

Ho-Henriksson

Svensson

Thorstensson

et al. 2022

BMC Musculoskelet Disord

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Background Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial. Methods Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve. Results 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72–80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care. Conclusion These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients’ perception of this model of care are needed. Clinical trial registration The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

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

Cited by 26 publications

References 69 publications

A Shoulder/Elbow Triage and Assessment model of care reduced a public orthopaedic shoulder/elbow clinic waitlist with high patient satisfaction

A Shoulder/Elbow Triage and Assessment model of care reduced a public orthopaedic shoulder/elbow clinic waitlist with high patient satisfaction

Differences in diagnosis in patients with atraumatic knee complaints between general practitioners and orthopedic surgeons: a retrospective cohort study

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care – a cost-effectiveness analysis of a pragmatic trial

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