Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic

Abstract

BackgroundIn Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model.Methods120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen’s kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care.ResultsThe majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05).ConclusionThe diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

A review of the surgical conversion rate and independent management of spinal extended scope practitioners in a secondary care setting

“…9 ESPs have been shown anecdotally to be in diagnostic agreement with surgeons and have traditionally provided a more holistic approach of management for patients, irrespective of whether they are surgical candidates. 6,14 This results in the perception that ESPs are better placed to manage the vast majority of non-surgical cases in a spinal unit. 5,9 Our study demonstrates a high surgical yield of patients discussed with surgeons for surgical consideration; 81% of patients referred for surgical consideration were confirmed to be suitable for surgery.…”

“…4,5,[17][18][19] The NUH ESP service was Did not attend consultationrelatively well established when this service evaluation was performed, which may mean that the ESPs had a greater understanding of the surgical reasoning process and were able to identify suitable surgical candidates more accurately because of increased training and experience. 14 Only 8% of all patients seen in the ESP service required input from a consultant. Coupled with the high surgical conversion rate, this suggests that this service enables a more efficient use of surgeons' time.…”

“…22 However, to date, most studies have reported high satisfaction rates with ESP services as ESPs are more likely to spend more time with the patients, allowing them to feel listened to, and more likely to suggest more than one intervention, allowing a biopsychosocial approach to treatment. 6,14,21 Further evaluation of patient and provider satisfaction of the NUH ESP service will be invaluable in facilitating further growth and service improvements since providers are presently unable to select the ESP service.…”

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon–physiotherapist level of agreement and patient satisfaction

“…13,14 In several countries, physiotherapists trained by orthopedic surgeons have shown high clinical diagnostic accuracy, making similar triage recommendations to those of surgeon colleagues. [15][16][17][18] In the United Kingdom, care teams using physiotherapists with an extended scope of practice have reduced wait times, lowered direct hospital costs owing to a reduction in diagnostic tests, provided more advice and reassurance than physician counterparts, and had high levels of patient satisfaction. 19,20 At our centre, we have employed advanced-practice physiotherapists (APPs) in the arthroplasty program for 10 years and in the shoulder clinic for 5 years, with reliable triage and high levels of patient satisfaction.…”

Patient‐reported outcome measures in advanced musculoskeletal physiotherapy practice: a systematic review

“…Valid and reliable (Binkley, Stratford, Lott, & Riddle, 1999) (Ashmore et al, 2014;Desmeules et al, 2013;McClellan et al, 2012) Oswestry disability index (ODI) 10 items with overall score range 0-50 (best to worst)…”