Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care

General practitioners who need specialist opinion on the diagnosis and management of patients with musculoskeletal conditions usually refer them to public hospital orthopaedic outpatient clinics.1 In recent years, this referral has been associated with long waiting periods for a first appointment.2

One successful strategy for reducing the backlog of patients, developed in the United Kingdom, is for physiotherapists to screen patients referred by GPs before a first consultation with an orthopaedic surgeon.3,4 The scope of physiotherapists’ practice includes ensuring that relevant tests are completed and alternative treatment options are explored before the patients see orthopaedic surgeons. This gatekeeper role for physiotherapists is supported by the growing body of evidence that it is effective,5,6 and that physiotherapy is an appropriate treatment for many musculoskeletal conditions.7-9 In the UK, the initiative has resulted in reduced and more appropriate referral to orthopaedic surgeons,10 more timely interventions for those unlikely to benefit from surgery, and a shorter waiting time for appropriate care for all patients.11

In 2005, the Victorian Department of Human Services, through the “Better Skills, Best Care” (BSBC) initiative, provided funding for physiotherapists in several hospitals to trial similar “amended” roles.12 One project was undertaken at the Northern Hospital, a tertiary teaching hospital in outer Melbourne. This hospital serves a population of 730 000 and receives an average of 150 new referrals each month to the orthopaedic outpatient department. Three orthopaedic surgeons and a registrar are available to screen 10 new and 18 review patients each week in one 3-hour clinic session. A designated monthly clinic sees an additional 20 new referrals. By 1 October 2005, the waiting list for non-urgent care (patients in categories 3 [government guidelines recommend first outpatient appointment within 90 days] and 4 [within 365 days]) had 1500 patients with an average waiting time of 164 weeks (over 3 years) until their first appointment.

Here, we report the findings of the BSBC initiative at the Northern Hospital. Its primary objectives were to investigate the impact of a physiotherapist-led screening clinic on waiting lists for first appointment, and the acceptability of this initiative to patients, GPs and an orthopaedic surgeon. A secondary objective was to investigate the quality of the service by comparing the levels of agreement between the diagnostic and management decisions of an orthopaedic surgeon and those of the physiotherapists.

The prospective observational design, methods, sample size and timing were determined by the Department of Human Services. Ethical approval was provided by the Department of Human Services and the Northern Hospital, and informed consent was obtained from the patients. The physiotherapist-led screening trial commenced on 29 November 2005 and the last patient in the trial was assessed by the surgeon on 6 June 2006.

Two physiotherapists were employed in the new screening role. Each had postgraduate qualifications in musculoskeletal physiotherapy (Doctor of Physiotherapy, Masters of Manipulative Physiotherapy) and more than 10 years’ experience. One orthopaedic surgeon (Fellow of the Royal Australasian College of Surgeons for 3 years) assessed the same patients at a subsequent session (median, 7 [range, 4–12] weeks later).

Referring letters from GPs (average 40 per week) were triaged by the orthopaedic surgeon and one of the physiotherapists, and eight of each 40 referrals meeting the inclusion criteria were selected. Conditions considered for inclusion were musculoskeletal-related knee, shoulder or back pain (with or without leg pain). Patients were excluded if their subjective history suggested any sinister disorder requiring urgent medical attention, or if they had psychosocial issues that contribute to symptom chronicity (such as depression, low self-efficacy or compensation issues). Also excluded were patients with neck pain, those aged less than 18 years, those with complex diagnostic or pain problems, and those referred by other consultants or the emergency department.

Patients who met the inclusion criteria were invited by letter to attend the physiotherapy screening appointment and informed of their right to wait to see an orthopaedic surgeon. A similar letter was sent to each patient’s GP. The clinic was located in the ambulatory care outpatient department at the Northern Hospital, where the physiotherapists worked independently. Patients who attended for physiotherapy screening were scheduled for a later appointment with an orthopaedic surgeon.

The physiotherapy screening appointment involved a comprehensive assessment, a provisional diagnosis and the development of a management plan in consultation with the patient. These decisions were reported to the patient’s GP by letter in the same week, and a copy of the letter was filed in the patient’s medical record. If appropriate, physiotherapy care was provided at the Northern Hospital or in the community, at the patient’s convenience.

The physiotherapists and the orthopaedic surgeon established clinical guidelines and pathways for each condition. An on-duty orthopaedic registrar was available by phone, if needed.

The physiotherapists developed and completed a standardised data collection form. The orthopaedic surgeon used the same form after his review and the form was kept in each patient’s medical record and retrieved on completion of the trial. Progress notes were completed according to normal procedure at the Northern Hospital.

Data collected included demographic details (age, sex, site of pain, referrer), and clinical information (results of investigations, provisional diagnoses and management decisions). Management decisions were categorised into non-surgical (physiotherapy, weight management, hydrotherapy, self-exercise) or surgical (further investigation/opinion required, or need for surgery). Data on patients’ level of satisfaction with care were obtained from patients by anonymous questionnaire after their physiotherapy consultation, from the orthopaedic surgeon after his consultation, and from the referring GP by telephone interview. Each was asked to rate their level of satisfaction with aspects of the physiotherapist-led initiative on a scale of one (“very satisfied”) to five (“very unsatisfied”).

Principal outcome measures for the preliminary study were:

• proportion of new referrals not needing to see a surgeon;

• the level of agreement between the physiotherapists and the orthopaedic surgeon on diagnoses and management decisions; and

• the patients’, GPs’ and surgeon’s levels of satisfaction with the physiotherapist-led screening initiative.

Fifty-two patients (mean age, 53.3 years) met the inclusion criteria; their demographic and clinical features are shown in Box 1. Between 29 November 2005 and 28 February 2006, the physiotherapists screened 45 of the 52 selected patients (Box 2); these were referred by 44 local GPs. Seven patients did not attend, of whom four reported that they “forgot”, one had no pain (but wanted to stay on the waiting list), and one was unavailable; one appointment was a scheduling error.

Between 7 March 2006 and 6 June 2006, 38 of the 45 patients also attended their consultation with the orthopaedic surgeon (Box 2). For the seven who did not attend, follow-up phone calls found two had moved out of the area, two had no symptoms, two cited domestic reasons, and one had subsequently had a fracture in a fall.

Our small preliminary study found that experienced, well qualified physiotherapists can competently and safely undertake screening of patients referred to public hospital orthopaedic outpatient clinics with non-urgent musculoskeletal pain.

The physiotherapists in the BSBC trial, while working within their legislated scope of practice, achieved a 74% level of agreement with an orthopaedic surgeon, and would have been able to manage 58% of the referrals on their own. To our knowledge, this is the first Australian study to investigate the decision-making competence of experienced, qualified physiotherapists by comparing their decisions with those of a surgeon. Research from the UK has compared the assessment skills of physiotherapists with surgeons-in-training and found they were equally effective.13 However, UK physiotherapists work within an “extended scope of practice”, which includes ordering and interpreting radiological and blood tests, giving injections and listing patients for surgery. In our trial, these tasks, and the responsibility for discharging the patient, remained with the surgeon. Whether extending the scope of practice for physiotherapists in Australia could further decrease the demand for orthopaedic surgical outpatient care — and benefit patients — deserves further investigation.

In the current climate of health care workforce shortages, there is a growing interest in allied health professionals undertaking additional tasks in extended roles.14,15 Two-thirds of the patients screened in this trial did not need to see a surgeon at the time of referral, but required non-surgical care, predominantly physiotherapy and exercise. This finding is similar to research from the UK, where rates of inappropriate referral to specialist orthopaedic outpatient clinics have been reported at over 70%.10,11 Possible reasons for this may include a perception by GPs that early referral is necessary (because of long waiting lists for surgery), and the limited availability of non-surgical care (including physiotherapy) in the community.

We are currently considering redesigning our referral process to allow GPs to refer directly to the physiotherapist-led screening clinic. However, if redirecting these referrals results in similar waiting lists for physiotherapy, the effect will be counterproductive. Further studies are needed to investigate the uptake and cost of alternative management methods, and the outcomes achieved both in the short term and long term.

The physiotherapist-led screening service was well accepted by patients and doctors. We had expected that some patients would refuse to see a physiotherapist, preferring a doctor, but fail-to-attend rates were slightly lower for the physiotherapist-led clinic than the surgeon.

A weakness of our study was the small sample size. Only a sixth of the total number of patients referred to the Northern Hospital during the study period were able to be screened. However, over half of our sample could potentially have been managed by the physiotherapists alone. The future may lie in introducing and evaluating such a clinic on a much larger scale and over a longer period to determine the true impact of screening by physiotherapists on orthopaedic waiting lists.

The results of the BSBC trial suggest that preliminary screening by experienced physiotherapists of patients with non-urgent musculoskeletal conditions can contribute to priority-based waiting list management, while also delivering early alternative care when surgery is not indicated.

2 Patient recruitment and outcomes of the physiotherapist-led screening and orthopaedic surgeon’s assessment