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Roberts JH, Gunn C, Mackinnon JE, Parlee S, Bakowsky V, Taylor T, Barber CEH, Hanly JG. Feasibility of Physiotherapist-Led Rheumatology Triage: A Randomized Study. J Rheumatol 2024; 51:715-720. [PMID: 38621798 DOI: 10.3899/jrheum.2023-1071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE Given global shortages in the rheumatology workforce, the demand for rheumatology assessment often exceeds the capacity to provide timely access to care. Accurate triage of patient referrals is important to ensure appropriate utilization of finite resources. We assessed the feasibility of physiotherapist (PT)-led triage using a standardized protocol in identifying cases of inflammatory arthritis (IA), as compared to usual rheumatologist triage of referrals for joint pain, in a tertiary care rheumatology clinic. METHODS We performed a single-center, prospective, nonblinded, randomized, parallel-group feasibility study with referrals randomized in a 1:1 ratio to either PT-led vs usual rheumatologist triage. Standardized information was collected at referral receipt, triage, and clinic visit. Rheumatologist diagnosis was considered the gold standard for diagnosis of IA. RESULTS One hundred two referrals were randomized to the PT-led triage arm and 101 to the rheumatologist arm. In the PT-led arm, 65% of referrals triaged as urgent were confirmed to have IA vs 60% in the rheumatologist arm (P = 0.57), suggesting similar accuracy in identifying IA. More referrals were declined in the PT-led triage arm (24 vs 8, P = 0.002), resulting in fewer referrals triaged as semiurgent (6 vs 23, P = 0.003). One case of IA (rheumatologist arm) was incorrectly triaged, resulting in significant delay in time to first assessment. CONCLUSION PT-led triage was feasible, appeared as reliable as rheumatologist triage of referrals for joint pain, and led to significantly fewer patients requiring in-clinic visits. This has implications for waitlist management and optimal rheumatology resource utilization.
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Affiliation(s)
- Janet H Roberts
- J.H. Roberts, MD, Division of Rheumatology and Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, and Dalhousie University, Halifax, Nova Scotia, and Arthritis Research Canada, Richmond, British Columbia;
| | - Cheri Gunn
- C. Gunn, BSc, PT, J.E. Mackinnon, BSc, PT, S. Parlee BSc, PT, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia
| | - Jennifer E Mackinnon
- C. Gunn, BSc, PT, J.E. Mackinnon, BSc, PT, S. Parlee BSc, PT, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia
| | - Susan Parlee
- C. Gunn, BSc, PT, J.E. Mackinnon, BSc, PT, S. Parlee BSc, PT, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia
| | - Volodko Bakowsky
- V. Bakowsky MD, T. Taylor, MD, J.G. Hanly, MD, Division of Rheumatology and Department of Medicine, Queen Elizabeth II Health Sciences Centre, and Dalhousie University, Halifax, Nova Scotia
| | - Trudy Taylor
- V. Bakowsky MD, T. Taylor, MD, J.G. Hanly, MD, Division of Rheumatology and Department of Medicine, Queen Elizabeth II Health Sciences Centre, and Dalhousie University, Halifax, Nova Scotia
| | - Claire E H Barber
- C.E.H. Barber, MD, PhD, Department of Medicine and Department of Community Health Services, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John G Hanly
- V. Bakowsky MD, T. Taylor, MD, J.G. Hanly, MD, Division of Rheumatology and Department of Medicine, Queen Elizabeth II Health Sciences Centre, and Dalhousie University, Halifax, Nova Scotia
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Gagnon R, Hébert LJ, Guertin JR, Berthelot S, Desmeules F, Perreault K. Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: Protocol for an economic evaluation. PLoS One 2023; 18:e0277369. [PMID: 37708179 PMCID: PMC10501643 DOI: 10.1371/journal.pone.0277369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 08/08/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES 1) To compare the average cost of an emergency department (ED) visit for various minor musculoskeletal disorders between two models of care (physiotherapist and ED physician or ED physician alone); 2) To evaluate the incremental cost-effectiveness ratio (ICER) of these two models of care over a 3-month period post-initial visit; and 3) To estimate the ICER of three ED models of care (physiotherapist and ED physician, ED physician alone, physiotherapist alone) over a two-year period. METHODS Obj.1: The costs incurred by participants in the two groups during their ED visit will be calculated using the Time-Driven Activity-Based Costing (TDABC) method. These costs will be compared using generalized linear models. Obj. 2: The ICER of the two models will be evaluated over three months via a cost-utility analysis that will combine costs and effectiveness data (quality-adjusted life years) using both Health system and Societal perspectives (patient + health system costs). Obj. 3: The 2-year ICER of the three above-mentioned models will be estimated using a mathematical model including a decision tree (0-3 months post-visit) and a Markov model (3-24 months post-visit), also using both Health system and Societal perspectives. Data to answer the three objectives will come from data collected during a randomized clinical trial (n = 78, CHU de Québec)which will be supplemented with data obtained via some of the CHU de Québec administrative databases (nominative data; SIURGE (ED management software), Cristal-Net (patient electronic record), and the ED's pharmacy transactions directory; administrative data: drug costs repository), the literature, and public cost repositories. CONCLUSION This study will help to determine which model of care is most efficient for the management of individuals who come to the ED with minor musculoskeletal disorders. The increased involvement of various health professionals in the management of patients in the ED paves the way for the development of new avenues of practice and more efficient organization of services.
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Affiliation(s)
- Rose Gagnon
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
| | - Luc J. Hébert
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
| | - Jason R. Guertin
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du Centre Hospitalier Universitaire de Québec, Université Laval, Quebec, Quebec, Canada
| | - Simon Berthelot
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du Centre Hospitalier Universitaire de Québec, Université Laval, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
- Centre Hospitalier Universitaire de Québec, Université Laval, Quebec, Quebec, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Est-de-l’Île-de-Montréal, Montreal, Quebec, Canada
| | - Kadija Perreault
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
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Gallotti M, Campagnola B, Cocchieri A, Mourad F, Heick JD, Maselli F. Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review. J Clin Med 2023; 12:5832. [PMID: 37762773 PMCID: PMC10531538 DOI: 10.3390/jcm12185832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.
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Affiliation(s)
- Marco Gallotti
- Catholic University of the Sacred Heart, Rome Campus, 00168 Rome, Italy
| | - Benedetta Campagnola
- University Hospital Foundation Campus Bio-Medico, Rome University, 00128 Rome, Italy
| | | | - Firas Mourad
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, 4671 Luxembourg, Luxembourg
- Luxembourg Health & Sport Sciences Research Institute A.s.b.l., 50, Avenue du Parc des Sports, 4671 Luxembourg, Luxembourg
| | - John D. Heick
- Department of Physical Therapy, Northern Arizona University, P.O. Box 15105, Flagstaff, AZ 86011, USA
| | - Filippo Maselli
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
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van Delft ETAM, Barreto DL, van der Helm-van Mil AHM, Alves C, Hazes JMW, Kuijper TM, Weel-Koenders AEAM. Diagnostic Performance and Clinical Utility of Referral Rules to Identify Primary Care Patients at Risk of an Inflammatory Rheumatic Disease. Arthritis Care Res (Hoboken) 2022; 74:2100-2107. [PMID: 34553506 DOI: 10.1002/acr.24789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/24/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the diagnostic performance and clinical utility of the Rotterdam Early Arthritis Cohort (REACH) and the Clinical Arthritis Rule (CARE) referral rules in an independent population of unselected patients from primary care. METHODS This study consisted of adults who were suspected of the need for referral to a rheumatologist by their general practitioner. Diagnostic accuracy measures and a net benefit approach were used to compare both rules to usual care for recognizing inflammatory arthritis and inflammatory rheumatic diseases (IRDs). Using the least absolute shrinkage and selection operator method and cross-validation we created an optimal prediction rule for IRD. RESULTS This study consisted of 250 patients, of whom 42 (17%) were diagnosed with inflammatory arthritis and 55 (22%) with an IRD 3 months after referral. Considering inflammatory arthritis, the area under the receiver operating characteristic curve (AUC) was 0.72 (95% confidence interval [95% CI] 0.64-0.80) for REACH and 0.82 (95% CI 0.75-0.88) for CARE. Considering IRD, the AUC was 0.66 (95% CI 0.58-0.74) for REACH and 0.76 (95% CI 0.69-0.83) for CARE. CARE was of highest clinical value when compared to usual care. The composite referral rule for IRD of 10 parameters included sex, age, joint features, acute onset of symptoms, physical limitations, and duration of symptoms (AUC 0.82 [95% CI 0.75-0.88]). CONCLUSION Both validated rules have a net benefit in recognizing inflammatory arthritis as well as IRD compared to usual care, but CARE shows superiority over REACH. Although the composite referral rule indicates a greater diagnostic performance, external validation is needed.
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Thompson J, Gabriel L, Yoward S, Dawson P. The advanced practitioners' perspective. Exploring the decision-making process between musculoskeletal advanced practitioners and their patients: An interpretive phenomenological study. Musculoskeletal Care 2022; 20:128-136. [PMID: 33993603 DOI: 10.1002/msc.1562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Advanced practice roles for allied health professionals continue to expand and provide key services within pathways of care for patients with musculoskeletal conditions. Despite the extensive utilisation of these roles and previously reported high patient satisfaction, little is understood about how these practitioners interact with their patients and the factors that influence decision-making conversations. STUDY A qualitative study utilised Interpretive Phenomenological Analysis (IPA) to explore the decision-making process occurring between Advanced Practitioners (APs) and their patients in a musculoskeletal service. AP data were collected through focus groups and analysed using IPA methodology. CONCLUSIONS Advanced practice decision-making is a complex process and APs exhibit a range of styles, from paternalistic to shared decision-making. APs may have a personal preference, but exhibit the ability to flex between styles in consultations. Multiple themes emerged from the data that influenced the decision-making process, including AP staff understanding the importance of patient expectations and the complex factors that influence patient interactions. It is important that clinicians have an awareness of the multiple factors that contribute to the decision-making process.
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Affiliation(s)
| | | | | | - Pamela Dawson
- Northumbria University, Newcastle upon Tyne, UK
- Plymouth Marjon University, Plymouth, UK
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Sarabia S, Farrer C, Yeung J, Jerome D, Cook RJ, Eder L. Comparative Efficacy of Different Triage Methods for Psoriatic Arthritis - Prospective Study in a Rapid Access Clinic. Arthritis Care Res (Hoboken) 2021; 74:1254-1262. [PMID: 33544974 DOI: 10.1002/acr.24570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/04/2020] [Accepted: 02/02/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The study aimed to identify the optimal combination of triage methods to identify PsA among psoriasis patients with musculoskeletal symptoms in a rapid access clinic and to describe their outcome after 1 year. METHODS Patients with psoriasis and no prior diagnosis of PsA were referred for assessment of their musculoskeletal complaints. Each patient was assessed by the following three triage modalities: 1) assessment by an advanced practice physiotherapist; 2) targeted musculoskeletal ultrasound (MSK-US) and; 3) PsA screening questionnaires. The patients were then evaluated by a rheumatologist who determined their disease status and classified them as: "Not PsA", "Possibly PsA" or "PsA". Patients returned for a one year follow up visit and were re-assessed for change in their disease status. Sensitivity and specificity were calculated for each individual modality as well as for combinations of modalities. RESULTS 203 patients with psoriasis and musculoskeletal symptoms were enrolled. 8.8% were classified as PsA and 23.6% as possibly PsA. There was no significant difference in the individual performance of the modalities. The highest sensitivity was seen with MSK-US (89%) and the highest specificity was found with the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire (79%). The addition of MSK-US data improved the performance of the modalities. A total of 9 patients converted to PsA after 1 year. All patient reported outcome measures have significantly improved at one year (P<0.001). CONCLUSION Combining MSK-US with a screening questionnaire for PsA improved the triage of patients with suspected PsA.
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Affiliation(s)
| | - Chandra Farrer
- Division of Rheumatology, Women's College Hospital and the Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Jensen Yeung
- Division of Dermatology, Women's College Hospital and the Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dana Jerome
- Division of Rheumatology, Women's College Hospital and the Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Lihi Eder
- Division of Rheumatology, Women's College Hospital and the Department of Medicine, University of Toronto, Toronto, ON, Canada
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Lafrance S, Lapalme JG, Méquignon M, Santaguida C, Fernandes J, Desmeules F. Advanced practice physiotherapy for adults with spinal pain: a systematic review with meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:990-1003. [PMID: 33123757 DOI: 10.1007/s00586-020-06648-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/23/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To appraise the available evidence on advanced practice physiotherapy (APP) models of care (MoC) in specialized secondary care such as orthopaedic, rheumatology or neurosurgery outpatients' clinics for adults with spinal pain. METHODS Systematic review with meta-analysis. Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL. Studies on APP MoC in specialized secondary care for adults with spinal pain were included. RESULTS Eighteen studies (n = 9405), including two randomized controlled trials and sixteen observational studies were included. One study was considered at high quality, fourteen studies were considered of moderate quality and three were considered of low quality. Pooled results for change in disability for patients with spinal pain reported no significant difference between APP and usual medical care (UMC). Mean wait time for initial consultation was lower with APP (1-9.4 weeks) than with UMC MoC (23-65 weeks). Following the implementation of APP MoC, wait time for a consultation with a medical specialist was reduced (6-16 weeks). Physiotherapists in APP MoC managed independently 89.2% of the patients referred (n = 8393). Stakeholders and patients reported high satisfaction with APP care. CONCLUSIONS APP MoC and UMC likely result in comparable pain, disability and quality of life improvement for adults with spinal pain. However, APP MoC have the potential to improve health care access by reducing wait time for consultation in specialized care and maintaining a high level of satisfaction among stakeholders and patients.
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Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada. .,Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada.
| | - Jean-Gabriel Lapalme
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - Marianne Méquignon
- Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Faculty of Medecine, McGill University Health Center, Montreal, QC, Canada
| | - Julio Fernandes
- Hôpital du Sacré-Coeur de Montréal Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada.,Department of Surgery, Faculty of Medecine, Université de Montréal, Montreal, QC, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
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