To the Editor: We read with interest the recent article by Oldmeadow and colleagues.1 Patients on waiting lists have long waits and poor quality of life,2 and we are currently piloting a similar model for assessment of patients referred for orthopaedic opinion for hip and knee arthroplasty.3

In keeping with other authors, the article by Oldmeadow and colleagues provides encouraging data to support role substitution. However, we suggest that important issues need to be addressed before wide-scale adoption and expansion of the model.

More information is needed about the proportion of all referred patients eligible for the physiotherapist assessment, and the cost–benefit figures for “avoided” orthopaedic consultations. It is quite difficult to evaluate the outcomes given the exclusion criteria, which are common comorbidities in these settings. While the κ statistic implies concordance between two physiotherapists and one surgeon, the disagreement was still about one patient in four. Of course, this level of disagreement may also be found between surgeons. However, for a new health intervention, such discordance needs to be understood within an appropriate evaluation framework.

What level of diagnostic error are consumers prepared to accept from any health care provider? The article reports five episodes of disagreement between the physiotherapists and the surgeon, where the need for surgery, medical treatment or further imaging was missed; this represents 13.2% of patient assessments (were there multiple missed opinions in individual cases?). The fact that a patient refused surgery is irrelevant if that decision was not identified a priori before surgical referral. Every consumer has the right to accept or reject recommendations about care based on the best available information about potential benefits and harms. An important role of specialist medical providers is that of diagnostician, particularly when there are multiple or complex conditions. Changes to the management of common musculoskeletal conditions should not reduce opportunities for expert input when required.

Waiting times for many patients are clinically and ethically unacceptable and we agree new service delivery models are necessary. We suggest that:

• professional groups work together to develop agreed evidence-based protocols for triage, assessment, investigation and management of common musculoskeletal conditions;

• funding providers and health care organisations develop and evaluate new models of care, including their cost-effectiveness, and provide appropriate training and monitoring to ensure role redefinition is associated with maintenance of equal or better quality and safety of care; and

• a musculoskeletal clinical network be developed to support these objectives.

In reply: The proportion of patients who, after being referred to specialist orthopaedic surgeons by general practitioners, are then listed for surgery, is around 20%–30%.1-3 In our trial, the diagnostic and management concordance between the physiotherapists and surgeon for this group was very high. It was also high for the 63% for whom evidence-based physiotherapy was appropriate. Management discordance occurred when surgical treatments that are controversial, and variously used by surgeons (as noted by Brand and colleagues), were recommended. It is important to note that the 74% agreement between the surgeon and physiotherapists in our trial was achieved under research conditions, with the physiotherapists screening independently. We suggest that the physiotherapist clinic be co-located with that of the surgeons, to facilitate further investigations, enhance the pathway to surgery and manage safety concerns.

The advantages of a physiotherapist screening clinic are in (i) triaging out from waiting to see a surgeon, patients predicted to benefit from non-surgical interventions (including those not willing to consider surgery at the time) and (ii) triaging patients in to the appropriate non-surgical care. We agree that patients with degenerative, osteoarthritic conditions, for whom joint replacement surgery may be the eventual treatment, will be best managed through multidisciplinary care.