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Table 3 Characteristics of included studies

From: Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies

Authors, year

Country

Study design

Clinical setting

Aim/objective

Follow-up

Population, n

Intervention

Comparison

Outcomes

Ashmore et al., 2014

Ireland

Prospective audit

Knee screening clinic

To examine the proportion of patients managed independently by the ESP; analyse the accuracy of an ESP’s clinical diagnosis; calculate conversion rate to surgery of patients referred for orthopaedic consultation.

 

Patients with knee problems referred from GP or ED, n = 140 (subgroup analysis of IRR n = 57). 46% women, mean age 46.2 (SD 15.9, range 15–85) years.

PT triage (clinical assessment, diagnosis, appropriate management)

Medical imaging and/or surgery

Proportion of patients independently managed by the ESP; clinical diagnostic accuracy; surgical conversion rate

Daker-White et al., 1999 [23]

United Kingdom

RCT

Orthopaedic outpatient departments at two hospitals

To evaluate the effectiveness and cost effectiveness of specially trained PTs in assessment and management of defined referrals to hospital orthopaedic departments.

Mean (range) 5.5 (3–11) months

Patients with musculoskeletal problems referred from GP for orthopaedic consultation,

n = 481 (complete data 191 + 192). 48% women in the PT group, 56% women in the OS group. Mean age (range) PT vs OS group 48.4 (17–87) years vs 48.6 (19–89) years.

Initial assessment + management by PT in extended role

Initial assessment + management by post-fellowship junior OS

Primary: Patient-centered measures of pain, functional disability, perceived handicap, self-efficacy, general health status, psychological status, health-related quality of life

Secondary: Patient and GP satisfaction

Desmeules et al., 2013 [20]

Canada

Prospective inter-rater agreement study

Orthopaedic outpatient hospital clinic

To assess the diagnostic agreement of an APP compared to OS as well as to assess treatment concordance, healthcare resource use and patient satisfaction with this model.

 

Patients with hip and knee complaints referred from GP for initial consultation

n = 120. 54% women, mean age 54.1 years.

PT assessment, diagnosis, triage recommendations (conservative or surgical management)

OS assessment, diagnosis, triage recommendations (conservative or surgical management)

Primary: inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered.

Secondary: Patient satisfaction

Dickens et al., 2003 [70]

United Kingdom

Prospective inter-rater agreement study

Outpatient knee clinic

To examine the ability of experienced PTs to make a correct diagnosis of patients presenting with acute knee injuries and to manage the diagnosis safely and effectively.

 

Patients with acute knee injuries, n = 50. 28% women, age 16–34 years.

PT assessment, diagnosis and management decisions (conservative/ surgical)

OS assessment, diagnosis and management decisions (conservative/ surgical)

Primary: Level of agreement between PT and OS. Secondary: Sensitivity, specificity and accuracy of clinicians’ diagnosis and management.

Jovic et al., 2019 [68]

Australia

Prospective inter-rater agreement study

Orthopaedic department, Hospital

To correlate the clinical skills of an ASP with the clinical standard of an OS across several domains, including diagnostic accuracy and treatment plan concordance.

 

Patients referred for hip or knee pain, n = 87. 51% women, mean age 67 (range 50–84).

ASP clinical examination including history and clinical assessment, diagnosis and treatment decision (surgical/ conservative/ further review needed).

OS assessment, diagnosis and treatment decision (surgical/conservative or further review needed).

Primary: diagnostic and treatment ability of the ASP

Secondary: benefits on clinic efficiency and patient satisfaction

Lowry et al.,

2020 [69]

Canada

Prospective

cross-sectional concordance study

Orthopaedic outpatient clinic

To evaluate the diagnostic, surgical triage, and medical imaging agreement between APPs and OSs for the management of patients with shoulder pain; to compare patient satisfaction toward services provided by APPs and OSs.

 

Patients referred for shoulder pain, n = 50. 40% women, mean age 51.2 (yr +/−15.3).

APP clinical evaluation, diagnosis, further tests, treatment approach (conservative/ surgical/ referral to another medical specialist)

OS clinical evaluation, diagnosis, further tests, treatment approach (conservative/ surgical/ referral to another medical specialist)

Primary: diagnostic and treatment approach agreement.

Secondary: imaging request agreement, patient satisfaction

MacKay et al., 2009 [71]

Canada

Prospective inter-rater agreement study

Hospital

To compare the clinical recommendations of specially trained PTs with those of an OS on appropriateness to be seen by an OS; and candidacy and willingness to undergo TJR; to examine their recommendations for non-surgical management and agreement on clinical diagnosis.

 

Patients referred for hip and knee problems with a diagnosis of arthritis,

n = 62. 59% women, mean age 59.7, (range 33–85) years.

PT clinical assessment, diagnostics, treatment recommendations.

OS clinical assessment, diagnostics, treatment recommendations.

Primary: recommendations for OS consultation, recommendations for undergoing TJR.

Secondary: recommendations for non-surgical management and agreement on clinical diagnosis

Marks et al., 2016 [67]

Australia

Blinded inter-rater agreement study

Orthopaedic outpatient setting

To establish the level of agreement between a PT and an OS regarding diagnosis, management and corticosteroid injection, in a representative sample of orthopaedic shoulder referrals

 

Patients with shoulder problems referred from GP to orthopaedic hospital, n = 274. 49% were women, mean age 57.9 (SD 13.0) years.

Clinical assessment by the PT, diagnosis, management plan

Clinical assessment by the OS, diagnosis, management plan

Primary: management and subacromial corticosteroid injection decisions.

Secondary: level of diagnostic and investigation agreement.

Napier et al., 2013 [66]

Canada

Prospective observational trial

Orthopaedic clinic

To investigate the effectiveness of a PT triage service for orthopaedic surgery referrals from primary care physicians.

 

Patients with shoulder or knee problems referred from GP or ED with shoulder or knee (n = 45). 58% women, median age 47 (range 21–75) years.

PT assessment and categorisation as surgical or non-surgical (could be managed conservatively), needing further investigation or tests.

OS assessment and categorisation as surgical, non-surgical (could be managed conservatively), needing further investigation or tests.

Level of agreement, surgical conversion rate (SCR). Patient satisfaction

Oldmeadow et al., 2007 [19]

Australia

Prospective observational trial

Orthopaedic outpatient hospital department

To investigate the impact, quality and acceptability of a MSK screening clinic, provided by PT for patients referred to the outpatient orthopaedic department at a major metropolitan hospital

 

Patients with MSK related knee, shoulder or back pain (with or without leg-pain) referred from GPs, n = 45 (subgroup analysis n = 38). 60% women, mean age 58.6 (range 29–83) years.

PT screenings; comprehensive assessment, provisional diagnosis, management plan.

OS consultation; diagnoses and management decision

Level of agreement between the PT and OS on diagnoses and management decision. Levels of satisfaction (pt, GP, OS)

Razmjou, 2013 [72]

Canada

Prospective observational trial

Tertiary care centre

To examine the role of an APP with respect to agreement with OS on diagnosis and management of patients with shoulder problems; wait times; and satisfaction with care

 

Patients with shoulder complaints referred to a shoulder specialist, n = 100. 37% women, mean age 57 (SD 14; range 19–92) years. For satisfaction with care, n = 247 (similar age distribution).

PT patient history, assessment, diagnosis, management plan

OS patient history from PT, assessment, diagnosis, management plan

Agreement on clinical diagnosis, management (investigations, indications for surgery). Wait time

Satisfaction.

Samsson et al., 2014, 2015, 2016 [24, 58, 57]

Sweden

RCT

Primary care

To evaluate PT-led orthopaedic triage of patients referred for orthopaedic consultation compared with standard practice in primary care; to report a long-term evaluation of patient-reported health-related quality of life, pain-related disability, and sick leave; to evaluate patients’ perceived quality of care.

3,6,12 months

Patients referred from GP with subacute or persistent MSK pain, n = 203. PT vs standard practice group 56% women, mean age 51 (range 18–67) years vs 55% women, mean age 53 (range 21–57) years.

PT-led orthopaedic triage; assessment, diagnosis, management pathway. Brief treatment.

OS assessment diagnosis, management pathway. Advice, prescriptions or injections, when appropriate.

Selection accuracy for orthopaedic intervention (i.e. surgical conversion rate) and other referrals, waiting time. PROMS; Self-reported health state (EuroQol VAS), health related quality of life (EQ-5D-3L) pain related disability (Pain Disability Index), sick leave. PREMS; perceived quality of care focusing on the caregivers’ medical-technical competence and identity-oriented approach; the extent to which patients’ expectations were met, patients’ intention to follow advice

  1. OS orthopedic surgeon; PT physiotherapist; APP advanced practice physiotherapist; CSP clinical specialist physiotherapist; ESP extended scope physiotherapist; pt. patient; GP general practitioner; IRR interrater reliability; MSK musculoskeletal; RCT randomised controlled trial; ED emergency department; QoL quality of life; TJR Total joint replacement; PROM Patient reported outcome measure; PREM Patient reported experience measure; SD standard deviation; SCR surgical conversion rate