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

Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services:... Background: Many 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. Method: Throughout 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. Results: In 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. Conclusion: This 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. Keywords: Physiotherapy, Advanced practice, Triage, Rheumatology, Orthopaedics, Healthcare service research Background Physiotherapists (APPs), previously known as Extended A rising prevalence of musculoskeletal (MSK) disorders Scope Practitioners (ESPs) [4], work in enhanced roles [1] has impacted on healthcare expenditure and led to [5, 6] and triage the care of patients waiting for Consult- increased wait times for orthopaedic and rheumatology ant Doctor appointments, who have usually been deemed services [2, 3]. However, many of these patients with MSK non-urgent based on referral information [7]. APPs have disorders who wait several months or years to see a been shown to independently manage 55–92% of this Consultant Doctor (i.e., Specialist Physician), may not re- selected caseload from orthopaedic waiting lists [8, 9], quire surgical or medical management. Advanced Practice however, this research has largely been conducted at single sites with a small number of APPs [10]. As APP roles vary between settings, even within the same country [11, 12], * Correspondence: orna.fennelly@ucdconnect.ie multi-site research within each local healthcare context is School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland warranted to ensure these variances are captured [10]. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 2 of 8 When physiotherapist triage roles were first intro- This study performed the first evaluation of the MSK duced in the Republic of Ireland, Clinical Specialist APP services utilising the national database. The objec- Physiotherapists worked only in low back pain clinics tives were to: (i) assess patient wait times from receipt of [13, 14]. Since 2011, a joint initiative of the National Clin- referral at the hospital to APP appointment; (ii) identify ical Programmes for Orthopaedics and for Rheumatology autonomous APP clinical decision-making; (iii) establish [15] established 24 APP posts in Ireland. The purpose of clinical outcomes of APP appointments; (iv) and identify this new service was to triage the care of a broader MSK re-referral rates of APP service-users at one hospital site. population, in 16 of the 33 public adult hospitals with an orthopaedic and/or rheumatology service [16]. The Con- Methods sultant Doctor or APP screen General Practitioner (GP) Ethics referral letters to orthopaedic and rheumatology ser- Full ethical approval was received from University vices, and patients deemed not to require urgent access College Dublin’s Human Research Ethics Committee to Consultant Doctors for surgical or medical interven- (ref. LS-16-04-Fennelly-C), with permission from the tions, are offered an APP appointment. APPs’ roles National Clinical Programmes and the Ethics and include assessment with view to diagnosing, educating, Medical Research Committee at St. Vincent’sUniversity providing advice, and where required, referring on- Hospital (SVUH), Dublin. wards to other hospital specialities. Some APPs are also trained in injection therapy but tasks of ordering Clinical audit clinical imaging and listing for surgery are not part of National MSK APP database physiotherapy scope of practice in Ireland. However, At the time of establishing the APP service, a National some hospitals have operating procedures in place to MSK APP Database was devised in collaboration with allow APPs arrange imaging and surgery through get- the APPs, Consultant Doctors, Physiotherapy Managers ting approval and sign-off from a doctor [12]. and the Head of the National Outpatient Department At the time of APP service introduction in Ireland, in Programme. A 6-month trial of data entry and subse- addition to having more than five years of MSK clinical quent reviews by the Data Manager, resulted in minor experience and the majority holding postgraduate MSc/ amendments. Data quality assurance mechanisms in- PhD degrees, APPs received role-specific training by way cluded a database training workshop for APPs, monthly of medical team shadowing and mentoring. The APPs review by Physiotherapy Managers at each site, data were usually co-located with the Consultant Doctors’ reports sent to sites for validation by APPs, and data re- outpatient clinics, allowing for medical involvement view at quarterly meetings of the national governance where required for clinical decisions and administration team for the MSK initiative. Each APP entered daily data of injections or surgical listing. If a patient’s condition on a local database for all new and follow-up patients at- deteriorated within one year of their initial APP appoint- tending the orthopaedic and rheumatology APP services. ment, some hospital sites permitted patients to self-refer These data were subsequently anonymised and submitted (i.e., without an additional GP referral) for an appoint- on a monthly basis, in line with data protection policy, to ment with the APP or Consultant Doctor. the National Clinical Programmes administration office, The APP service aims to reduce patient wait times and collation by the Data Manager occurred. for orthopaedic and rheumatology appointments in a In 2014, 22 APPs entered data from 16 hospital sites. At cost-effective manner. However, requirement of onward that time, database fields related to clinic (orthopaedic or referrals to Consultants after the APP assessment, or rheumatology), appointment type (new or return), body re-referral of patients to orthopaedic/rheumatology ser- region affected by MSK disorder, dates of receipt of GP re- vices following APP management, could represent add- ferral at the hospital and of APP appointment, Consultant itional appointments and thus, costs [17]. Increased Doctor involvement at the APP appointment (via discus- throughput of patients due to increased access, may sion or seeing the patient), clinical investigations ordered, also have knock-on implications for other hospital ser- injection administered, surgical listing (surgery or guided vices such as physiotherapy [18], and monitoring on- injection), physiotherapy referral (Hospital, Community, ward referral pathways of patients is therefore critical Private), and other hospital specialty (Orthopaedic Con- to facilitate adequate resourcing of services. While a sultant service, Rheumatology Consultant service, Pain National MSK APP Database captured patient clinical clinic, Occupational therapy, Neurosurgery, Neurology, outcomes at the time of new and return/follow-up APP Emergency Department, Geriatrics) referral. If more than appointments, an additional single-site study was re- one other hospital speciality referral was required, priority quired which specifically identified any patients man- was given to recording a Consultant Doctor referral, as aged by the APP that later required a re-referral for the this was the focus of the evaluation. A data field for clin- same MSK disorder. ical imaging was added to the database in August 2014. Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 3 of 8 Patient re-referral rates focused on ‘patients referred in 2014’ and evaluated One hospital site [SVUH] was selected for a re-referral their wait times to reflect current wait times. Patient clin- rate audit, with a view to potentially extending this ical outcomes were reported across: (1) clinic attended across hospital sites, subject to feasibility. At this study (i.e., orthopaedic or rheumatology); (2) new and follow-up site, two APPs worked with six Orthopaedic Consul- appointments; and (3) body regions of presenting MSK tants and four Consultant Rheumatologists, who screened disorder; utilising the cross-tabulation function with all GP referral letters. These APPs arranged clinical im- categorical variables of clinic, appointment type, and body aging and surgery via discussion with the Doctor, and one region. Chi Square [Χ ] test for independence was used to APP was trained in injection therapy. Consecutive patients compare patient clinical outcomes in orthopaedic versus (n = 254) assessed by the APP service during March and rheumatology services. April 2014 were identified on the local MSK APP data- base. An external researcher [OF] extracted the hospital Results medical numbers of patients managed by the APPs with- National MSK APP database out an onward referral for a Consultant appointment; Within one year, APPs assessed 13,981 new patients across including those cases where Consultant opinion was ob- orthopaedic (84%) and rheumatology (16%) services. In- tained at the initial APP appointment. Follow-up of those cluding return (follow-up) patient appointments (n = 2596), patient hospital medical numbers on the patient adminis- there were 16,577 patient consultations, with a higher pro- tration system (PAS) identified any further patient con- portion of patients returning for rheumatology as com- tacts with the orthopaedic or rheumatology services (APP pared to orthopaedics (Table 1). New patients presented or Doctor appointment) within the following two years. most commonly with disorders of the knee, followed by the Review of patients’ GP discharge letters and/or medical lumbar-spine, and shoulder (Fig. 1). charts determined whether the additional appointment was for the same MSK disorder and body region. As this Wait time hospital site permitted patients previously seen by the New patients (n = 13,456) waited a median time of APP to self-refer for an additional appointment, sources 167 days (Interquartile Range [IQR] 91–316) for an APP of re-referrals were identified. Consistency in the clinical appointment. Median wait time for APP rheumatology management decision made at both the ‘re-referral’ and services (110 days, IQR 65–217) was less than for APP first appointment, were thought to be indicative of appro- orthopaedic appointments (177 days, IQR 96–330). APP priate initial management by the APP. appointment wait times for patients referred in 2014 (n = 6549) was 95 days (IQR 59–139). Data analyses All data were cleaned, coded and entered into the Stat- Independent APP assessment istical Package for the Social Sciences (SPSS), version The APPs made clinical decisions regarding patient 20.0. Valid data for new and return patients were ana- management independently at 77.2% (95% CI 76.5–77.9) lysed utilising descriptive statistics. A subgroup analysis of all appointments (n = 15,189). APPs discussed 16.8% Table 1 Comparison of clinical outcomes of patients attending advanced practice physiotherapy orthopaedic and rheumatology services Clinical outcomes Orthopaedics (n = 13,565) Rheumatology (n = 2754) Chi-Square p-value n (%) n (%) Χ Return appointments 2064 (15.2) 532 (19.3) 28.8 < 0.001 Consultant-supported decisions 2719 (21.7) 739 (28.4) 55.2 < 0.001 Clinical investigations 4023 (29.7) 827 (30.0) 0.2 0.7 Injection administered 506 (3.7) 179 (6.5) 43.7 < 0.001 Surgical listing 361 (2.7) 43 (1.6) 11.5 < 0.001 Orthopaedic/Rheumatology Consultant referral 2437 (19.0) 343 (12.9) 55.6 < 0.001 Physiotherapy referral 5492 (41.5) 1022 (38.0) 11.4 < 0.001 (n = 5798) (n = 1211) Clinical imaging 1634 (28.2) 231 (19.1) 42.5 < 0.001 ѱ ф Ω Unknown clinic (n = 258); p < 0.05 considered significant; Consultant-supported decisions valid data for: orthopaedics = 12,541; rheumatology = 2602; Χ ^ Investigations include imaging; Surgical listing includes guided injections (valid data for orthopaedics =13,564); Clinical imaging data recorded for latter b a 5 months; Consultant referral valid data for: orthopaedics = 12,843, rheumatology =2662; Physiotherapy includes hospital, primary care, and private services (valid data for: orthopaedics = 13,244, rheumatology = 2692) Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 4 of 8 Fig. 1 Body regions of the MSK disorders of new patients presenting to the orthopaedic and rheumatology APP services (n = 13,367) of patient cases with the Consultant, and the Consultant (Table 2). A greater proportion of patients with multiple also reviewed a further 6% of patients at the APP joint disorders required clinical investigations, while appointment. A greater percentage of rheumatology clinical imaging was ordered most commonly for knee patients required Consultant-supported decisions com- disorders (Table 3). There was no difference in the propor- pared to orthopaedic patients (Table 1). Where Consult- tion of patients requiring investigations in orthopaedic ant Doctor opinion was obtained at the time of the APP versus rheumatology services, but there was for clinical assessment (22.8%; n = 3461), 38.9% (n = 1346) of those imaging (Table 1). patients were then requested to attend a Consultant appointment. Intra-articular injections Only 4.1% of patients received an injection at their APP appointment from either the Patient clinical outcomes APP or Doctor (Table 2), and more than half of these were for shoulder disorders (Table 3). Injections were adminis- Clinical investigations APPs arranged clinical investiga- tered to a greater proportion of rheumatology than ortho- tions (i.e., imaging, blood tests, neurophysiological tests) paedic patients (Table 1). for 29.3% of patients. Over the documented five-month period during which imaging had been introduced, Surgical intervention At the APP appointment, 2.4% of image referral occurred for 26.6% of patient cases patients were listed for surgery (including guided injections Table 2 Patient clinical outcomes following new and return advanced practice physiotherapy appointments Patient appointment type Total Clinical Outcome New Return 95% Confidence Interval (n = 13,981) (n = 2596) (n = 16,577) n (%) n (%) n (%) Clinical Investigations 4256 (30.4) 604 (23.3) 4860 (29.3) 28.6–30.0 Injections 499 ( 3.6) 186 (7.2) 685 (4.1) 3.8–4.4 Surgical listing 263 ( 1.9) 141 (5.4) 404 (2.4) 2.2–2.6 Consultant services 2205 (17.0) 619 (23.9) 2824 (18.2) 17.6–18.8 Physiotherapy 6220 (45.5) 495 (19.7) 6715 (41.5) 40.7–42.3 (n = 5976) (n = 1033) (n = 7009) Clinical Imaging 1663 (27.8) 202 (19.6) 1865 (26.6) 25.6–27.6 a b c Investigations include imaging; Surgical listing includes guided injections (valid data for: new = 13,980; total = 15,656); Consultant services include both orthopaedic and rheumatology Consultants (valid data for new = 12,970; return = 2587; total = 15,557); Physiotherapy includes hospital, primary care, and private services (valid data for: new = 13,681; return = 2513; total = 16,194); Imaging data recorded for latter five months in 2014 Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 5 of 8 Table 3 Patient clinical outcomes following advanced practice physiotherapy assessments by body region of presenting musculoskeletal disorder Clinical Outcome Body Regions of presenting musculoskeletal disorder Knee Lumbar-spine Shoulder Multiple Joint Foot/ ankle Hip Hand/ wrist Cervical-spine Elbow Thoracic-spine (n = 3569) (n = 3502) (n = 2429) (n = 1525) (n = 1367) (n = 1139) (n = 1011) (n = 716) (n = 222) (n = 177) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Clinical Investigations 1153 (32.3) 961 (27.4) 578 (23.8) 642 (42.1) 332 (24.3) 418 (36.7) 336 (33.2) 182 (25.4) 60 (27.0) 62 (35.0) Injections 129 (3.6) 35 (1.0) 389 (16.0) 21 (1.4) 9 (0.7) 30 (2.6) 44 (4.4) 3 (0.4) 15 (6.8) 1 (0.6) Surgical listing 114 (3.2) 18 (0.5) 98 (4.0) 15 (1.0) 19 (1.4) 58 (5.1) 55 (5.4) 2 (0.3) 7 (3.2) 0 (0) Consultant services 730 (21.6) 418 (12.6) 364 (15.6) 238 (15.6) 204 (15.4) 345 (32.9) 257 (25.9) 71 (10.2) 42 (19.3) 17 (10.6) Physiotherapy 1565 (44.7) 1393 (40.9) 988 (41.8) 646 (42.5) 630 (46.9) 393 (36.7) 165 (16.8) 369 (52.9) 88 (40.9) 86 (50.0) (n = 1573) (n = 1461) (n = 1021) (n = 749) (n = 586) (n = 565) (n = 392) (n = 296) (n = 77) (n = 81) Clinical Imaging 491 (31.2) 387 (26.5) 221 (21.6) 247 (33.0) 139 (23.7) 191 (33.8) 59 (15.1) 75 (25.3) 16 (20.8) 21 (25.9) a b c Investigations include imaging; Surgical listing includes guided injections (valid data for: knee = 3568); Consultant services include both orthopaedic and rheumatology (valid data for knee = 3379; lumbar spine = 3313; shoulder = 2334; multiple joint = 1522; foot/ankle = 1326; hip = 1050; hand/wrist = 992; cervical-spine = 698; elbow = 218; thoracic-spine = 160); Physiotherapy includes hospital, primary care, and private services (valid data for: knee = 3500; lumbar spine =3407; shoulder = 2361; multiple joint = 1520; foot/ankle = 1342; hip = 1070; hand/wrist = 981; cervical-spine = 698; elbow = 215; thoracic-spine = 172); Imaging data recorded for latter five months in 2014 Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 6 of 8 [0.3%])byeitherthe APPorConsultantDoctor orthopaedic or rheumatology services for the same MSK (Table 2), most commonly patients with hand/wrist disorder, within two years of their initial appointment, disorders (Table 3). A larger proportion of surgical and 12 (6.5%; 95% CI 2.9–10) within one year. Three of listing occurred in orthopaedics than rheumatology those patients (15%) had had Consultant involvement (Table 1). at the time of their initial appointment and half of those re-referrals were for knee disorders (n =10). Seven patients self-referred for the additional appoint- Onward referrals While previously Doctors assessed all ment as opposed to a doctor referral (n = 10); with the patients, now only 18.1% of patients required an onward re-referral pathway of three patients unclear. Seventy referral to Orthopaedic or Rheumatology Consultant percent (n = 14) of re-referred patients had no change services (Table 2), most commonly patients with hip dis- made to their clinical care pathway, including four pa- orders (Table 3). A significantly smaller proportion of tients seen by a Consultant Doctor at their return ap- rheumatology patients required a Consultant referral, pointment. Changes to clinical management included compared to orthopaedic patients (Table 1). surgical listing, following a Consultant review (n =2), In addition to onward Consultant referrals, a further and APPs arranged MRIs for two patients, an injection 3.6% of patients (Table 2) received an onward referral to for one patient and a neurological referral for another other hospital specialities (Table 4). Physiotherapy, the patient. most common onward referral (41.5%), included referral to hospital, community, and private physiotherapy (Table 4). A significantly greater proportion of orthopaedic than Discussion rheumatology patients were referred to physiotherapy This is the first national evaluation of MSK APP services (Table 1). Of note, APP referral of patients with hand/ and it demonstrated that this new model of service wrist disorders for physiotherapy was low compared to delivery facilitated APP independent assessment and other body regions (Table 3). clinical decision making regarding the care of patients from Consultant Doctor orthopaedic and rheumatology Re-referral rate audit waiting lists. Nearly 14,000 patients accessed specialist Over two months at a single hospital site (SVUH), APPs orthopaedic and rheumatology reviews via the APP ser- assessed and managed the care of 184 patients without vice within one year. Therefore, these patients gained onward referral to Consultant Doctors. Twenty (10.9%; more timely access to orthopaedic and rheumatology 95% CI 6.4–15.4) of those patients were re-referred to services, compared to national wait time figures of over 12 months for some Consultant services [16]. While APP services have existed for longer in orthopaedic and spinal triage clinics [8, 9, 11, 13], this multi-site study Table 4 Onward referral destinations of patients following demonstrated that APPs managed over 80% of patients advanced practice physiotherapy assessments with a variety of MSK disorders across the two special- Referral destination Patients ities of orthopaedics and rheumatology, without onward n (%) referral to a Consultant. This allowed Consultant Doc- Primary care physiotherapy 3568 (22.0) tors to prioritise their time for more complex or surgical patients [9]. Hospital physiotherapy 3130 (19.3) b Referral for physiotherapy treatment was the most Orthopaedic Consultant services 2453 (15.8) common clinical outcome from the triage process, a Rheumatology Consultant services 365 (2.3) similar finding of previous research in orthopaedic Pain clinic 140 (0.9) settings [8, 19]. Despite this, Blackburn et al. [20]noted Occupational therapy 97 (0.6) that the majority of patients attending their APP ortho- Neurosurgery 23 (0.1) paedic service, had not had prior physiotherapy treat- ment, which potentially could have precluded some Private physiotherapy 17 (0.1) b patients being placed on secondary care waiting lists. Neurology 8 (< 0.1) However, further resourcing of physiotherapy would be Emergency department 3 (< 0.1) required to support larger throughput of patients in Geriatrics 1 (< 0.1) primary care. Other 291 (1.9) Increased autonomy of APPs to order diagnostic im- Database permitted recording of physiotherapy in one column and all other aging and administer injections may potentially reduce hospital specialities in another. Priority was given to recording of a Consultant a b burden on Consultant Doctors’ time. Changes to legis- Doctor referral. Physiotherapy valid data = 16,194; Other Hospital Specialty valid data = 15,557 lation in Ireland to permit physiotherapists to order Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 7 of 8 imaging, as well as further provision of training on im- validity of diagnosis, or subsequent surgical conversion aging interpretation and injection administration, would rates. allow APPs to work more autonomously [12]. Concerns that placing APPs in such roles might drive higher usage Conclusion of diagnostic imaging appeared unfounded, with APPs The APP service allowed 13,981 new patients to access recommending imaging for less than 30% of patients in orthopaedic and rheumatology consultations within the current study, and previous research in orthopaedic one year, and the majority of patients were independently settings demonstrating that APPs arranged similar propor- assessed by the APPs. This first national evaluation of pa- tions of imaging as doctors [21, 22]. tient clinical care pathways from APP services identified While the Irish Health Service Executive (HSE) aims to that less than 20% of patients required a Consultant manage non-surgical patients in the primary care setting, Doctor referral following an APP assessment. This im- many of these patients still receive secondary care special- proved patient access to orthopaedic and rheumatology ist referrals [23]. The results of this study may support the services and thus, clinical management options. Overall, relocation of APP services to primary care, as in the UK these findings support the APP model of care for patients and Sweden [24, 25]. However, close proximity of the in orthopaedic and rheumatology settings. Consultant and clinical investigations in hospitals may alleviate any potential barriers to Consultant referrals [26], Abbreviations 95% CI: 95% Confidence Interval; APP: Advanced Practice Physiotherapist; and concerns of delayed patient management [27]. IQR: Interquartile range; MSK: Musculoskeletal; Χ : Chi-square test Co-location of APP and Consultant clinics may also re- duce referrals to Consultant services, as discussion on Acknowledgements clinical management can occur on the day of the appoint- The National Clinical Programmes for Orthopaedics and for Rheumatology. ment. For example, rheumatology patient management re- Funding quired more Consultant-supported decisions, but these The PhD fees of OFe were partly funded by contributions of the National data showed empirically that only a small proportion were Clinical Programmes for Orthopaedics and for Rheumatology, and the then referred to Consultant services. Health Service Executive (HSE). While well documented in orthopaedics settings [7], Availability of data and materials encouragingly review of the re-referral rate in the APP The datasets analysed during the current study are available from the rheumatology service at one site, did not identify any authors upon reasonable request and with permission from the National medically-urgent re-referrals. Additionally, allowing pa- Clinical Programmes for Orthopaedics and for Rheumatology. tients to self-refer for another MSK appointment Authors’ contributions ensures rapid review if required, while increasing pa- OFe collected the data for the re-referral audit, analysed and interpreted all data, tient satisfaction [28], and this did not over-burden the and drafted the manuscript. CB assisted with data analysis, interpretation and service as few patients utilised this access route. drafting the manuscript. OFi and RB developed the National Database and helped draft the manuscript. AB and JA collated the national data and assisted Australian and UK studies noted similar re-referral in interpretation and drafting the manuscript. AC contributed to data rates [8, 17], which could be attributed to deterioration collection of the re-referral audit and drafting this section of the manuscript. in conditions. Re-referral evaluations should now be FD contributed to data interpretation and critically revised the manuscript as an international expert. CC contributed to data analysis, interpretation and drafting extended to include other sites to capture geographic the manuscript. All authors read and approved the final manuscript. or case-mix discrepancies, and perhaps also identify any re-referrals to other hospitals and changes in the Authors’ information patients’ condition. OFe is a PhD researcher and physiotherapist who has not worked in the advanced practice physiotherapist role. JA, AB and AC work in the advanced Limitations are known to exist with such large ad- practice physiotherapist roles. OFi is a Consultant Rheumatologist who works ministrative databases including missing or invalid data alongside advanced practice physiotherapists and formerly Clinical Lead of fields [29], and for this study, complete data for each the National Clinical Programme for Rheumatology. RB was a physiotherapy manager and formerly the Programme Manager for the National Clinical field were available for 85% of patient cases. Ongoing Programme for Rheumatology. CC and CB are physiotherapists and lecturers monitoring of the National MSK Database is recom- at UCD. FD is a physiotherapist and lecturer at the University of Montreal. mended as the APP service becomes more embedded in the Irish orthopaedic and rheumatology services, and Ethics approval and consent to participate Full ethical approval was received from University College Dublin’sHuman future data collection should include information on Research Ethics Committee (ref. LS-16-04-Fennelly-C), with permission from the prior MSK service interactions, linking of individual pa- National Clinical Programmes, and the Ethics and Medical Research Committee tients’ new and return appointments, and allow selection at St. Vincent’s University Hospital (SVUH), Dublin. Participant consent was not necessary as this study involved the use of an anonymised database which is of multiple onward specialty referrals. Additionally, a not considered ‘personal data’ according to the Data Protection Act 1988. longitudinal follow-up of the patient outcomes is rec- ommended to determine the appropriateness of APP Competing interests management through capturing treatment effectiveness, The authors declare that they have no competing interests. Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 8 of 8 Publisher’sNote 18. Hattam P. The effectiveness of orthopaedic triage by extended scope Springer Nature remains neutral with regard to jurisdictional claims in physiotherapists. Clinical Governance: An Int J. 2004;9(4):244–52. https://doi. published maps and institutional affiliations. org/10.1108/14777270410566661. 19. Daker-White G, Carr AJ, Harvey I, et al. A randomised controlled trial. Author details Shifting boundaries of doctors and physiotherapists in orthopaedic School of Public Health, Physiotherapy and Sports Science, University outpatient departments. J Epidemiol Community Health. 1999;53(10): College Dublin, Dublin, Ireland. Department of Rheumatology, St. Vincent’s 643–50. University Hospital, Dublin, Ireland. Health Service Executive, Dublin, Ireland. 20. Blackburn MS, Cowan SM, Cary B, N C. Physiotherapy-led triage clinic for Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland. low back pain. Aust Health Rev. 2009;33(4) https://doi.org/10.1071/ Department of Physiotherapy, Adelaide and Meath Hospital, Tallaght, AH090663. Dublin, Ireland. School of Rehabilitation, Faculty of Medicine, University of 21. Desmeules F, Toliopoulos P, Roy J, et al. Validation of an advanced practice Montreal, Montreal, Canada. Bone and Joint Clinic, St. Vincent’s University physiotherapy model of care in an orthopaedic outpatient clinic. 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Clincial Strategy and Programmes Division. 2013. Available at: https://www.hse.ie/eng/about/who/cspd/ncps/. 16. (NTPF) National Treatment Purchase Fund. The National Treatment Purchase Fund: Outpatient/Waiting list 2016 [9th June 2016]. Available from: http:// www.ntpf.ie/home/outpatient.htm. 17. Chang AT, Gavaghan B, O'Leary S, McBride LJ, Raymer M. Do patients discharged from advanced practice physiotherapy-led clinics re-present to specialist medical services? Aust Health Rev. 2017; https://doi.org/10.1071/ AH16222. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Musculoskeletal Disorders Springer Journals

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

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Medicine & Public Health; Orthopedics; Rehabilitation; Rheumatology; Sports Medicine; Internal Medicine; Epidemiology
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Abstract

Background: Many 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. Method: Throughout 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. Results: In 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. Conclusion: This 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. Keywords: Physiotherapy, Advanced practice, Triage, Rheumatology, Orthopaedics, Healthcare service research Background Physiotherapists (APPs), previously known as Extended A rising prevalence of musculoskeletal (MSK) disorders Scope Practitioners (ESPs) [4], work in enhanced roles [1] has impacted on healthcare expenditure and led to [5, 6] and triage the care of patients waiting for Consult- increased wait times for orthopaedic and rheumatology ant Doctor appointments, who have usually been deemed services [2, 3]. However, many of these patients with MSK non-urgent based on referral information [7]. APPs have disorders who wait several months or years to see a been shown to independently manage 55–92% of this Consultant Doctor (i.e., Specialist Physician), may not re- selected caseload from orthopaedic waiting lists [8, 9], quire surgical or medical management. Advanced Practice however, this research has largely been conducted at single sites with a small number of APPs [10]. As APP roles vary between settings, even within the same country [11, 12], * Correspondence: orna.fennelly@ucdconnect.ie multi-site research within each local healthcare context is School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland warranted to ensure these variances are captured [10]. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 2 of 8 When physiotherapist triage roles were first intro- This study performed the first evaluation of the MSK duced in the Republic of Ireland, Clinical Specialist APP services utilising the national database. The objec- Physiotherapists worked only in low back pain clinics tives were to: (i) assess patient wait times from receipt of [13, 14]. Since 2011, a joint initiative of the National Clin- referral at the hospital to APP appointment; (ii) identify ical Programmes for Orthopaedics and for Rheumatology autonomous APP clinical decision-making; (iii) establish [15] established 24 APP posts in Ireland. The purpose of clinical outcomes of APP appointments; (iv) and identify this new service was to triage the care of a broader MSK re-referral rates of APP service-users at one hospital site. population, in 16 of the 33 public adult hospitals with an orthopaedic and/or rheumatology service [16]. The Con- Methods sultant Doctor or APP screen General Practitioner (GP) Ethics referral letters to orthopaedic and rheumatology ser- Full ethical approval was received from University vices, and patients deemed not to require urgent access College Dublin’s Human Research Ethics Committee to Consultant Doctors for surgical or medical interven- (ref. LS-16-04-Fennelly-C), with permission from the tions, are offered an APP appointment. APPs’ roles National Clinical Programmes and the Ethics and include assessment with view to diagnosing, educating, Medical Research Committee at St. Vincent’sUniversity providing advice, and where required, referring on- Hospital (SVUH), Dublin. wards to other hospital specialities. Some APPs are also trained in injection therapy but tasks of ordering Clinical audit clinical imaging and listing for surgery are not part of National MSK APP database physiotherapy scope of practice in Ireland. However, At the time of establishing the APP service, a National some hospitals have operating procedures in place to MSK APP Database was devised in collaboration with allow APPs arrange imaging and surgery through get- the APPs, Consultant Doctors, Physiotherapy Managers ting approval and sign-off from a doctor [12]. and the Head of the National Outpatient Department At the time of APP service introduction in Ireland, in Programme. A 6-month trial of data entry and subse- addition to having more than five years of MSK clinical quent reviews by the Data Manager, resulted in minor experience and the majority holding postgraduate MSc/ amendments. Data quality assurance mechanisms in- PhD degrees, APPs received role-specific training by way cluded a database training workshop for APPs, monthly of medical team shadowing and mentoring. The APPs review by Physiotherapy Managers at each site, data were usually co-located with the Consultant Doctors’ reports sent to sites for validation by APPs, and data re- outpatient clinics, allowing for medical involvement view at quarterly meetings of the national governance where required for clinical decisions and administration team for the MSK initiative. Each APP entered daily data of injections or surgical listing. If a patient’s condition on a local database for all new and follow-up patients at- deteriorated within one year of their initial APP appoint- tending the orthopaedic and rheumatology APP services. ment, some hospital sites permitted patients to self-refer These data were subsequently anonymised and submitted (i.e., without an additional GP referral) for an appoint- on a monthly basis, in line with data protection policy, to ment with the APP or Consultant Doctor. the National Clinical Programmes administration office, The APP service aims to reduce patient wait times and collation by the Data Manager occurred. for orthopaedic and rheumatology appointments in a In 2014, 22 APPs entered data from 16 hospital sites. At cost-effective manner. However, requirement of onward that time, database fields related to clinic (orthopaedic or referrals to Consultants after the APP assessment, or rheumatology), appointment type (new or return), body re-referral of patients to orthopaedic/rheumatology ser- region affected by MSK disorder, dates of receipt of GP re- vices following APP management, could represent add- ferral at the hospital and of APP appointment, Consultant itional appointments and thus, costs [17]. Increased Doctor involvement at the APP appointment (via discus- throughput of patients due to increased access, may sion or seeing the patient), clinical investigations ordered, also have knock-on implications for other hospital ser- injection administered, surgical listing (surgery or guided vices such as physiotherapy [18], and monitoring on- injection), physiotherapy referral (Hospital, Community, ward referral pathways of patients is therefore critical Private), and other hospital specialty (Orthopaedic Con- to facilitate adequate resourcing of services. While a sultant service, Rheumatology Consultant service, Pain National MSK APP Database captured patient clinical clinic, Occupational therapy, Neurosurgery, Neurology, outcomes at the time of new and return/follow-up APP Emergency Department, Geriatrics) referral. If more than appointments, an additional single-site study was re- one other hospital speciality referral was required, priority quired which specifically identified any patients man- was given to recording a Consultant Doctor referral, as aged by the APP that later required a re-referral for the this was the focus of the evaluation. A data field for clin- same MSK disorder. ical imaging was added to the database in August 2014. Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 3 of 8 Patient re-referral rates focused on ‘patients referred in 2014’ and evaluated One hospital site [SVUH] was selected for a re-referral their wait times to reflect current wait times. Patient clin- rate audit, with a view to potentially extending this ical outcomes were reported across: (1) clinic attended across hospital sites, subject to feasibility. At this study (i.e., orthopaedic or rheumatology); (2) new and follow-up site, two APPs worked with six Orthopaedic Consul- appointments; and (3) body regions of presenting MSK tants and four Consultant Rheumatologists, who screened disorder; utilising the cross-tabulation function with all GP referral letters. These APPs arranged clinical im- categorical variables of clinic, appointment type, and body aging and surgery via discussion with the Doctor, and one region. Chi Square [Χ ] test for independence was used to APP was trained in injection therapy. Consecutive patients compare patient clinical outcomes in orthopaedic versus (n = 254) assessed by the APP service during March and rheumatology services. April 2014 were identified on the local MSK APP data- base. An external researcher [OF] extracted the hospital Results medical numbers of patients managed by the APPs with- National MSK APP database out an onward referral for a Consultant appointment; Within one year, APPs assessed 13,981 new patients across including those cases where Consultant opinion was ob- orthopaedic (84%) and rheumatology (16%) services. In- tained at the initial APP appointment. Follow-up of those cluding return (follow-up) patient appointments (n = 2596), patient hospital medical numbers on the patient adminis- there were 16,577 patient consultations, with a higher pro- tration system (PAS) identified any further patient con- portion of patients returning for rheumatology as com- tacts with the orthopaedic or rheumatology services (APP pared to orthopaedics (Table 1). New patients presented or Doctor appointment) within the following two years. most commonly with disorders of the knee, followed by the Review of patients’ GP discharge letters and/or medical lumbar-spine, and shoulder (Fig. 1). charts determined whether the additional appointment was for the same MSK disorder and body region. As this Wait time hospital site permitted patients previously seen by the New patients (n = 13,456) waited a median time of APP to self-refer for an additional appointment, sources 167 days (Interquartile Range [IQR] 91–316) for an APP of re-referrals were identified. Consistency in the clinical appointment. Median wait time for APP rheumatology management decision made at both the ‘re-referral’ and services (110 days, IQR 65–217) was less than for APP first appointment, were thought to be indicative of appro- orthopaedic appointments (177 days, IQR 96–330). APP priate initial management by the APP. appointment wait times for patients referred in 2014 (n = 6549) was 95 days (IQR 59–139). Data analyses All data were cleaned, coded and entered into the Stat- Independent APP assessment istical Package for the Social Sciences (SPSS), version The APPs made clinical decisions regarding patient 20.0. Valid data for new and return patients were ana- management independently at 77.2% (95% CI 76.5–77.9) lysed utilising descriptive statistics. A subgroup analysis of all appointments (n = 15,189). APPs discussed 16.8% Table 1 Comparison of clinical outcomes of patients attending advanced practice physiotherapy orthopaedic and rheumatology services Clinical outcomes Orthopaedics (n = 13,565) Rheumatology (n = 2754) Chi-Square p-value n (%) n (%) Χ Return appointments 2064 (15.2) 532 (19.3) 28.8 < 0.001 Consultant-supported decisions 2719 (21.7) 739 (28.4) 55.2 < 0.001 Clinical investigations 4023 (29.7) 827 (30.0) 0.2 0.7 Injection administered 506 (3.7) 179 (6.5) 43.7 < 0.001 Surgical listing 361 (2.7) 43 (1.6) 11.5 < 0.001 Orthopaedic/Rheumatology Consultant referral 2437 (19.0) 343 (12.9) 55.6 < 0.001 Physiotherapy referral 5492 (41.5) 1022 (38.0) 11.4 < 0.001 (n = 5798) (n = 1211) Clinical imaging 1634 (28.2) 231 (19.1) 42.5 < 0.001 ѱ ф Ω Unknown clinic (n = 258); p < 0.05 considered significant; Consultant-supported decisions valid data for: orthopaedics = 12,541; rheumatology = 2602; Χ ^ Investigations include imaging; Surgical listing includes guided injections (valid data for orthopaedics =13,564); Clinical imaging data recorded for latter b a 5 months; Consultant referral valid data for: orthopaedics = 12,843, rheumatology =2662; Physiotherapy includes hospital, primary care, and private services (valid data for: orthopaedics = 13,244, rheumatology = 2692) Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 4 of 8 Fig. 1 Body regions of the MSK disorders of new patients presenting to the orthopaedic and rheumatology APP services (n = 13,367) of patient cases with the Consultant, and the Consultant (Table 2). A greater proportion of patients with multiple also reviewed a further 6% of patients at the APP joint disorders required clinical investigations, while appointment. A greater percentage of rheumatology clinical imaging was ordered most commonly for knee patients required Consultant-supported decisions com- disorders (Table 3). There was no difference in the propor- pared to orthopaedic patients (Table 1). Where Consult- tion of patients requiring investigations in orthopaedic ant Doctor opinion was obtained at the time of the APP versus rheumatology services, but there was for clinical assessment (22.8%; n = 3461), 38.9% (n = 1346) of those imaging (Table 1). patients were then requested to attend a Consultant appointment. Intra-articular injections Only 4.1% of patients received an injection at their APP appointment from either the Patient clinical outcomes APP or Doctor (Table 2), and more than half of these were for shoulder disorders (Table 3). Injections were adminis- Clinical investigations APPs arranged clinical investiga- tered to a greater proportion of rheumatology than ortho- tions (i.e., imaging, blood tests, neurophysiological tests) paedic patients (Table 1). for 29.3% of patients. Over the documented five-month period during which imaging had been introduced, Surgical intervention At the APP appointment, 2.4% of image referral occurred for 26.6% of patient cases patients were listed for surgery (including guided injections Table 2 Patient clinical outcomes following new and return advanced practice physiotherapy appointments Patient appointment type Total Clinical Outcome New Return 95% Confidence Interval (n = 13,981) (n = 2596) (n = 16,577) n (%) n (%) n (%) Clinical Investigations 4256 (30.4) 604 (23.3) 4860 (29.3) 28.6–30.0 Injections 499 ( 3.6) 186 (7.2) 685 (4.1) 3.8–4.4 Surgical listing 263 ( 1.9) 141 (5.4) 404 (2.4) 2.2–2.6 Consultant services 2205 (17.0) 619 (23.9) 2824 (18.2) 17.6–18.8 Physiotherapy 6220 (45.5) 495 (19.7) 6715 (41.5) 40.7–42.3 (n = 5976) (n = 1033) (n = 7009) Clinical Imaging 1663 (27.8) 202 (19.6) 1865 (26.6) 25.6–27.6 a b c Investigations include imaging; Surgical listing includes guided injections (valid data for: new = 13,980; total = 15,656); Consultant services include both orthopaedic and rheumatology Consultants (valid data for new = 12,970; return = 2587; total = 15,557); Physiotherapy includes hospital, primary care, and private services (valid data for: new = 13,681; return = 2513; total = 16,194); Imaging data recorded for latter five months in 2014 Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 5 of 8 Table 3 Patient clinical outcomes following advanced practice physiotherapy assessments by body region of presenting musculoskeletal disorder Clinical Outcome Body Regions of presenting musculoskeletal disorder Knee Lumbar-spine Shoulder Multiple Joint Foot/ ankle Hip Hand/ wrist Cervical-spine Elbow Thoracic-spine (n = 3569) (n = 3502) (n = 2429) (n = 1525) (n = 1367) (n = 1139) (n = 1011) (n = 716) (n = 222) (n = 177) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Clinical Investigations 1153 (32.3) 961 (27.4) 578 (23.8) 642 (42.1) 332 (24.3) 418 (36.7) 336 (33.2) 182 (25.4) 60 (27.0) 62 (35.0) Injections 129 (3.6) 35 (1.0) 389 (16.0) 21 (1.4) 9 (0.7) 30 (2.6) 44 (4.4) 3 (0.4) 15 (6.8) 1 (0.6) Surgical listing 114 (3.2) 18 (0.5) 98 (4.0) 15 (1.0) 19 (1.4) 58 (5.1) 55 (5.4) 2 (0.3) 7 (3.2) 0 (0) Consultant services 730 (21.6) 418 (12.6) 364 (15.6) 238 (15.6) 204 (15.4) 345 (32.9) 257 (25.9) 71 (10.2) 42 (19.3) 17 (10.6) Physiotherapy 1565 (44.7) 1393 (40.9) 988 (41.8) 646 (42.5) 630 (46.9) 393 (36.7) 165 (16.8) 369 (52.9) 88 (40.9) 86 (50.0) (n = 1573) (n = 1461) (n = 1021) (n = 749) (n = 586) (n = 565) (n = 392) (n = 296) (n = 77) (n = 81) Clinical Imaging 491 (31.2) 387 (26.5) 221 (21.6) 247 (33.0) 139 (23.7) 191 (33.8) 59 (15.1) 75 (25.3) 16 (20.8) 21 (25.9) a b c Investigations include imaging; Surgical listing includes guided injections (valid data for: knee = 3568); Consultant services include both orthopaedic and rheumatology (valid data for knee = 3379; lumbar spine = 3313; shoulder = 2334; multiple joint = 1522; foot/ankle = 1326; hip = 1050; hand/wrist = 992; cervical-spine = 698; elbow = 218; thoracic-spine = 160); Physiotherapy includes hospital, primary care, and private services (valid data for: knee = 3500; lumbar spine =3407; shoulder = 2361; multiple joint = 1520; foot/ankle = 1342; hip = 1070; hand/wrist = 981; cervical-spine = 698; elbow = 215; thoracic-spine = 172); Imaging data recorded for latter five months in 2014 Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 6 of 8 [0.3%])byeitherthe APPorConsultantDoctor orthopaedic or rheumatology services for the same MSK (Table 2), most commonly patients with hand/wrist disorder, within two years of their initial appointment, disorders (Table 3). A larger proportion of surgical and 12 (6.5%; 95% CI 2.9–10) within one year. Three of listing occurred in orthopaedics than rheumatology those patients (15%) had had Consultant involvement (Table 1). at the time of their initial appointment and half of those re-referrals were for knee disorders (n =10). Seven patients self-referred for the additional appoint- Onward referrals While previously Doctors assessed all ment as opposed to a doctor referral (n = 10); with the patients, now only 18.1% of patients required an onward re-referral pathway of three patients unclear. Seventy referral to Orthopaedic or Rheumatology Consultant percent (n = 14) of re-referred patients had no change services (Table 2), most commonly patients with hip dis- made to their clinical care pathway, including four pa- orders (Table 3). A significantly smaller proportion of tients seen by a Consultant Doctor at their return ap- rheumatology patients required a Consultant referral, pointment. Changes to clinical management included compared to orthopaedic patients (Table 1). surgical listing, following a Consultant review (n =2), In addition to onward Consultant referrals, a further and APPs arranged MRIs for two patients, an injection 3.6% of patients (Table 2) received an onward referral to for one patient and a neurological referral for another other hospital specialities (Table 4). Physiotherapy, the patient. most common onward referral (41.5%), included referral to hospital, community, and private physiotherapy (Table 4). A significantly greater proportion of orthopaedic than Discussion rheumatology patients were referred to physiotherapy This is the first national evaluation of MSK APP services (Table 1). Of note, APP referral of patients with hand/ and it demonstrated that this new model of service wrist disorders for physiotherapy was low compared to delivery facilitated APP independent assessment and other body regions (Table 3). clinical decision making regarding the care of patients from Consultant Doctor orthopaedic and rheumatology Re-referral rate audit waiting lists. Nearly 14,000 patients accessed specialist Over two months at a single hospital site (SVUH), APPs orthopaedic and rheumatology reviews via the APP ser- assessed and managed the care of 184 patients without vice within one year. Therefore, these patients gained onward referral to Consultant Doctors. Twenty (10.9%; more timely access to orthopaedic and rheumatology 95% CI 6.4–15.4) of those patients were re-referred to services, compared to national wait time figures of over 12 months for some Consultant services [16]. While APP services have existed for longer in orthopaedic and spinal triage clinics [8, 9, 11, 13], this multi-site study Table 4 Onward referral destinations of patients following demonstrated that APPs managed over 80% of patients advanced practice physiotherapy assessments with a variety of MSK disorders across the two special- Referral destination Patients ities of orthopaedics and rheumatology, without onward n (%) referral to a Consultant. This allowed Consultant Doc- Primary care physiotherapy 3568 (22.0) tors to prioritise their time for more complex or surgical patients [9]. Hospital physiotherapy 3130 (19.3) b Referral for physiotherapy treatment was the most Orthopaedic Consultant services 2453 (15.8) common clinical outcome from the triage process, a Rheumatology Consultant services 365 (2.3) similar finding of previous research in orthopaedic Pain clinic 140 (0.9) settings [8, 19]. Despite this, Blackburn et al. [20]noted Occupational therapy 97 (0.6) that the majority of patients attending their APP ortho- Neurosurgery 23 (0.1) paedic service, had not had prior physiotherapy treat- ment, which potentially could have precluded some Private physiotherapy 17 (0.1) b patients being placed on secondary care waiting lists. Neurology 8 (< 0.1) However, further resourcing of physiotherapy would be Emergency department 3 (< 0.1) required to support larger throughput of patients in Geriatrics 1 (< 0.1) primary care. Other 291 (1.9) Increased autonomy of APPs to order diagnostic im- Database permitted recording of physiotherapy in one column and all other aging and administer injections may potentially reduce hospital specialities in another. Priority was given to recording of a Consultant a b burden on Consultant Doctors’ time. Changes to legis- Doctor referral. Physiotherapy valid data = 16,194; Other Hospital Specialty valid data = 15,557 lation in Ireland to permit physiotherapists to order Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 7 of 8 imaging, as well as further provision of training on im- validity of diagnosis, or subsequent surgical conversion aging interpretation and injection administration, would rates. allow APPs to work more autonomously [12]. Concerns that placing APPs in such roles might drive higher usage Conclusion of diagnostic imaging appeared unfounded, with APPs The APP service allowed 13,981 new patients to access recommending imaging for less than 30% of patients in orthopaedic and rheumatology consultations within the current study, and previous research in orthopaedic one year, and the majority of patients were independently settings demonstrating that APPs arranged similar propor- assessed by the APPs. This first national evaluation of pa- tions of imaging as doctors [21, 22]. tient clinical care pathways from APP services identified While the Irish Health Service Executive (HSE) aims to that less than 20% of patients required a Consultant manage non-surgical patients in the primary care setting, Doctor referral following an APP assessment. This im- many of these patients still receive secondary care special- proved patient access to orthopaedic and rheumatology ist referrals [23]. The results of this study may support the services and thus, clinical management options. Overall, relocation of APP services to primary care, as in the UK these findings support the APP model of care for patients and Sweden [24, 25]. However, close proximity of the in orthopaedic and rheumatology settings. Consultant and clinical investigations in hospitals may alleviate any potential barriers to Consultant referrals [26], Abbreviations 95% CI: 95% Confidence Interval; APP: Advanced Practice Physiotherapist; and concerns of delayed patient management [27]. IQR: Interquartile range; MSK: Musculoskeletal; Χ : Chi-square test Co-location of APP and Consultant clinics may also re- duce referrals to Consultant services, as discussion on Acknowledgements clinical management can occur on the day of the appoint- The National Clinical Programmes for Orthopaedics and for Rheumatology. ment. For example, rheumatology patient management re- Funding quired more Consultant-supported decisions, but these The PhD fees of OFe were partly funded by contributions of the National data showed empirically that only a small proportion were Clinical Programmes for Orthopaedics and for Rheumatology, and the then referred to Consultant services. Health Service Executive (HSE). While well documented in orthopaedics settings [7], Availability of data and materials encouragingly review of the re-referral rate in the APP The datasets analysed during the current study are available from the rheumatology service at one site, did not identify any authors upon reasonable request and with permission from the National medically-urgent re-referrals. Additionally, allowing pa- Clinical Programmes for Orthopaedics and for Rheumatology. tients to self-refer for another MSK appointment Authors’ contributions ensures rapid review if required, while increasing pa- OFe collected the data for the re-referral audit, analysed and interpreted all data, tient satisfaction [28], and this did not over-burden the and drafted the manuscript. CB assisted with data analysis, interpretation and service as few patients utilised this access route. drafting the manuscript. OFi and RB developed the National Database and helped draft the manuscript. AB and JA collated the national data and assisted Australian and UK studies noted similar re-referral in interpretation and drafting the manuscript. AC contributed to data rates [8, 17], which could be attributed to deterioration collection of the re-referral audit and drafting this section of the manuscript. in conditions. Re-referral evaluations should now be FD contributed to data interpretation and critically revised the manuscript as an international expert. CC contributed to data analysis, interpretation and drafting extended to include other sites to capture geographic the manuscript. All authors read and approved the final manuscript. or case-mix discrepancies, and perhaps also identify any re-referrals to other hospitals and changes in the Authors’ information patients’ condition. OFe is a PhD researcher and physiotherapist who has not worked in the advanced practice physiotherapist role. JA, AB and AC work in the advanced Limitations are known to exist with such large ad- practice physiotherapist roles. OFi is a Consultant Rheumatologist who works ministrative databases including missing or invalid data alongside advanced practice physiotherapists and formerly Clinical Lead of fields [29], and for this study, complete data for each the National Clinical Programme for Rheumatology. RB was a physiotherapy manager and formerly the Programme Manager for the National Clinical field were available for 85% of patient cases. Ongoing Programme for Rheumatology. CC and CB are physiotherapists and lecturers monitoring of the National MSK Database is recom- at UCD. FD is a physiotherapist and lecturer at the University of Montreal. mended as the APP service becomes more embedded in the Irish orthopaedic and rheumatology services, and Ethics approval and consent to participate Full ethical approval was received from University College Dublin’sHuman future data collection should include information on Research Ethics Committee (ref. LS-16-04-Fennelly-C), with permission from the prior MSK service interactions, linking of individual pa- National Clinical Programmes, and the Ethics and Medical Research Committee tients’ new and return appointments, and allow selection at St. Vincent’s University Hospital (SVUH), Dublin. Participant consent was not necessary as this study involved the use of an anonymised database which is of multiple onward specialty referrals. Additionally, a not considered ‘personal data’ according to the Data Protection Act 1988. longitudinal follow-up of the patient outcomes is rec- ommended to determine the appropriateness of APP Competing interests management through capturing treatment effectiveness, The authors declare that they have no competing interests. Fennelly et al. BMC Musculoskeletal Disorders (2018) 19:181 Page 8 of 8 Publisher’sNote 18. Hattam P. The effectiveness of orthopaedic triage by extended scope Springer Nature remains neutral with regard to jurisdictional claims in physiotherapists. Clinical Governance: An Int J. 2004;9(4):244–52. https://doi. published maps and institutional affiliations. org/10.1108/14777270410566661. 19. Daker-White G, Carr AJ, Harvey I, et al. A randomised controlled trial. Author details Shifting boundaries of doctors and physiotherapists in orthopaedic School of Public Health, Physiotherapy and Sports Science, University outpatient departments. J Epidemiol Community Health. 1999;53(10): College Dublin, Dublin, Ireland. Department of Rheumatology, St. Vincent’s 643–50. University Hospital, Dublin, Ireland. Health Service Executive, Dublin, Ireland. 20. Blackburn MS, Cowan SM, Cary B, N C. Physiotherapy-led triage clinic for Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland. low back pain. Aust Health Rev. 2009;33(4) https://doi.org/10.1071/ Department of Physiotherapy, Adelaide and Meath Hospital, Tallaght, AH090663. Dublin, Ireland. School of Rehabilitation, Faculty of Medicine, University of 21. Desmeules F, Toliopoulos P, Roy J, et al. Validation of an advanced practice Montreal, Montreal, Canada. Bone and Joint Clinic, St. Vincent’s University physiotherapy model of care in an orthopaedic outpatient clinic. BMC Hospital, Dublin, Ireland. Musculoskelet Disorders. 2013;14:162. 22. Razmjou H, Robarts S, Kennedy D, et al. Evaluation of an advanced-practice Received: 12 December 2017 Accepted: 21 May 2018 physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times. Physiother Can. 2013;65(1):46–55. https://doi.org/10. 3138/ptc.2011-56. 23. O Mir M, Cooney C, O Sullivan C, et al. The efficacy of an extended scope References physiotherapy clinic in paediatric orthopaedics. J Child Orthop. 2016;10:169– 1. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World 75. https://doi.org/10.1007/s11832-016-0725-9. Health Organ. 2003;81(9):646–56. 24. Goodwin R, Hendrick P. Physiotherapy as a first point of contact in general 2. Gross J. Projection of Australian healthcare expenditure by disease, 2003 to practice: a solution to a growing problem? Primary Health Care Research 2033. Canberra: AIHW; 2008. and Development. 2016;17(3):289–502. https://doi.org/10.1017/ 3. Morris J, Twizeyemariya A, Grimmer K. What is the current evidence of the S1463423616000189. impact on quality of life whilst waiting for management/treatment of 25. Samsson K, Larsson M. Physiotherapy triage assessment of patients referred orthopaedic/musculoskeletal complaints? A systematic scoping review. Qual for orthopaedic consultation - long-term follow-up of health-related quality Life Res. 2018; https://doi.org/10.1007/s11136-018-1846-z. of life, pain-related disability and sick leave. Man Ther. 2015;20(1):38–45. 4. (CSP) Chartered Society of Physiotherapists. Advanced practice in https://doi.org/10.1016/j.math.2014.06.009. physiotherapy: understanding the contribution of advanced practice in 26. Griffiths S, Taylor C, Yohannes AM. Conversion rates and perceived barriers physiotehrapy to transforming lives. 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BMC Musculoskeletal DisordersSpringer Journals

Published: Jun 1, 2018

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