LITERATURE REVIEW

The Clinical Effectiveness of the Extended-Scope Physiotherapist Role in Musculoskeletal Triage: A Systematic Review Caroline Oakley1* & Carol Shacklady2 1

Staffordshire and Stoke on Trent Partnership Trust, Haywood Hospital, Stoke on Trent, UK

2

Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK

ABSTRACT Background: Extended-scope physiotherapists (ESPs) are working in musculoskeletal (MSK) triage clinics to assess, diagnose and refer patients for appropriate management. However, there is inadequate appraisal of their clinical effectiveness. Objectives: The aim of the present systematic review was to appraise the evidence on the diagnostic ability of ESPs in MSK triage, and patient and general practitioner (GP) satisfaction when seen by an ESP in a MSK clinic. Method: CINAHL, AMED, MEDLINE and EMBASE databases were searched from 1989 to February 2014 using the keywords ‘physiotherapy’, ‘extended practitioner’ and ‘musculoskeletal disease’. Data extraction was compiled using the Centre for Reviews and Dissemination (2009) method. Diagnostic accuracy studies were assessed for methodological quality using the Scottish Intercollegiate Guideline Network (SIGN). Patient/GP satisfaction was assessed using a tool adapted by Desmeules et al. (2012). Results: From 146 studies initially identified, 14 were eligible for review. Only one diagnostic study was of high quality, and satisfaction study scores ranged from 40% to 73%. All studies reported favourable outcomes for ESPs in MSK triage clinics, with ESPs demonstrating a good level of diagnostic ability in comparison with a gold standard such as surgery. In addition, patients and GPs were satisfied with the overall performance and service provided by ESPs. Conclusion: The evidence suggests that ESPs are clinically effective. However, there were methodological shortcomings in the reviewed studies, and further research, using larger sample sizes, multiple locations and comparisons of the same patient cohorts, would strengthen the evidence available to influence future commissioning of these services. Copyright © 2015 John Wiley & Sons, Ltd. Keywords Extended scope; triage; musculoskeletal; physiotherapy *Correspondence Caroline Oakley, Staffordshire and Stoke on Trent Partnership Trust, Haywood Hospital, Stoke on Trent, UK. Tel: +44 (0)1782 673560; Fax: +44 (0)1782 673562. Email: [email protected]

Published online 11 March 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1100

Introduction Musculoskeletal (MSK) conditions are a common cause of ill health, disability and pain, comprising up 204

to 30% of primary care consultations in England [Department of Health (DOH), 2006a]. Within the United Kingdom (UK), in line with the government agenda, efforts have been made to modernize the Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

Oakley and Shacklady

National Health Service (NHS) (Department of Health, 2000a, b; 2006a,b,c) by moving healthcare traditionally provided in secondary care into a primary care setting (Department of Health, 2009), using Clinical Assessment Treatment Services (DOH, 2006c) to provide efficient, rapid assessment, diagnosis and treatment of patients with MSK problems (McPherson et al., 2004). Extended-scope physiotherapists (ESPs) are increasingly involved in managing patients with MSK disease in a variety of settings, including accident and emergency (A&E) departments, orthopaedic clinics and MSK triage. With the increased demands on the NHS and implementation of new models of care for managing patients with MSK disease (Sephton et al., 2010), there is a need for research to evaluate the clinical effectiveness of ESP roles in MSK. Patient satisfaction has been shown to be valuable for evaluating quality assurance and accreditation of healthcare clinics (Draper and Hill, 1995). Reservations have been expressed regarding the proficiency of ESPs to accurately diagnose patients to ensure appropriate management (Ashmore et al., 2014). Traditionally, people with MSK conditions such as low back pain (LBP) and knee pain were seen in secondary care by orthopaedic surgeons (Roddy et al., 2010). The development of MSK interface clinics for patients with non-surgical, non-inflammatory MSK problems means that these conditions can be managed in the community, with appropriate cases directed to rheumatology and orthopaedic services (Roddy et al., 2013). Currently, the role of an ESP in MSK clinics involves using clinical reasoning skills to assess patients, request and interpret investigations, and undertake diagnostic procedures as well as considering onward referral to other departments, such as physiotherapy, and direct listing for surgery (Rabey et al., 2009). The main body of evidence regarding ESP roles is within the management of minor injuries in A&E departments (Richardson et al., 2005; Anaf and Sheppard, 2010; McClelland et al., 2006, 2010). McClelland et al. (2010) found that ESPs can provide a high standard of care at an affordable cost, while positively influencing patient satisfaction and providing an alternative to managing staffing shortages in emergency care. A review by Desmeules et al. (2012) included 16 research studies looking specifically at advanced practice physiotherapy (APP) in patients with MSK disorders in a variety of settings, including A&E and a military hospital. The term ‘APP’ is considered synonymous Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

Extended-Scope Physiotherapists in Musculoskeletal Triage

with ‘ESP’ (Cramp, 2011). The findings of the review by Desmeules et al. (2012) suggest that the APP role can provide equal or better than usual care in comparison with that of physicians in terms of diagnostic accuracy, treatment effectiveness, patient satisfaction, use of healthcare resources and economic costs. The review by Stanhope et al. (2012) included 12 studies exploring diagnostic accuracy, reduced cost, waiting times and health outcomes of ESPs in orthopaedic outpatients, which could be considered as MSK. The conclusions from this review were positive in all of the reported outcomes but generally there was a low level of evidence. For diagnostic accuracy, two studies were identified from this review and considered to be of high methodological quality. These studies found that ESPs may be comparable with medical doctors regarding diagnostic accuracy of MSK conditions. The present review builds on the findings of Desmeules et al. (2012) and Stanhope et al. (2012) and looks specifically at the clinical effectiveness of the ESP role within MSK triage by appraising the evidence on: • The diagnostic ability of ESPs in MSK triage and how this compares with that of other assessors; • Patient and general practitioner (GP) satisfaction when the former is seen by an ESP in a MSK clinic.

Methods A systematic review was carried out to assess the effectiveness of the ESP role in MSK clinics using the Participants, Intervention, Comparison and Outcomes (PICO) model to identify appropriate search terms (Centre for Reviews and Dissemination, 2009; Counsell, 1997). Participants and interventions Participants were defined as physiotherapists working in an extended role, designated as ESPs or advanced MSK practitioners within orthopaedic/MSK triage in primary, secondary or interface settings. Only physiotherapists triaging patients independently, without assistance from other health professionals such as orthopaedic surgeons, were included. Physiotherapists working within A&E were excluded from the review. All patients were adults (≥18 years of age) being treated for an MSK condition, including peripheral and spinal, 205

Extended-Scope Physiotherapists in Musculoskeletal Triage

and excluding inflammatory conditions such as ankylosing spondylitis (Roddy et al., 2013). Comparison It was appreciated that in some studies there may be no direct comparison dependent on the study design. The types of practitioners considered for the present study were orthopaedic surgeons, rheumatology consultants and GPs with a special interest in MSK disease. In studies investigating diagnostic accuracy, clinical examination findings should be compared with a gold standard such as an arthroscopy or magnetic resonance imaging (MRI). Outcomes Outcomes included the diagnostic ability of ESPs assessing MSK conditions, and patient and GP satisfaction with, for example, the quality of assessment and waiting times in MSK triage clinics. Studies that only provided information concerning cost-effectiveness, waiting lists, surgical conversion rates and numbers of patients managed independently by ESPs were excluded. Searching the literature MEDLINE, CINAHL, AMED and EMBASE were searched using the keywords ‘physiotherapy’, ‘extended practice’ and ‘musculoskeletal disease’, as used in Desmeules et al. (2012) and the review by Stanhope et al. (2012). The first record of use of specially trained ESPs for orthopaedic patients not requiring surgery was

Oakley and Shacklady

in the UK (Byles and Ling, 1989); therefore, the period from 1989 to the present date was specified. Both the abstract and full article had to be accessible for review. Both published and unpublished studies were eligible for the review. After initial screening of the titles and abstracts, potentially relevant studies were screened for practicality to identify studies that contained information pertinent to the topic area, using a standardized protocol for excluding and including studies (Fink, 1998) (Table 1). Studies meeting the criteria were eligible for the review process and this screening was carried out by two reviewers (CO and GP). To check and maximize reliability in selecting individual study articles, five of the studies that had been selected were re-screened by the same reviewer to identify and improve intra-rater reliability. There was 100% agreement between the two reviewers.

Data extraction Data extraction from selected studies was undertaken (see Table 2) by a single reviewer (CO) and entries were checked and amended by a second reviewer (GP). A data extraction form was constructed using recommendations from the Centre for Reviews and Dissemination (CRD, 2009) and forms used in similar reviews by Desmeules et al. (2012), Laurant et al. (2009) and Stanhope et al. (2012). Diagnostic accuracy was assessed using Scottish Intercollegiate Guideline Network (SIGN) (Harbour, 2008) as this tool has been utilized in a previous systematic review (McClelland et al., 2010) and has been

Table 1. Practicality screen (based on the format by Fink, 1998) Inclusion criteria

Tick if the study meets the inclusion criteria

Tick if the study meets the exclusion criteria

Written in the English language Study involves MSK triage by ESPs Studies the clinical effectiveness of MSK triage (correct diagnosis or patient/GP satisfaction) Patients in the study are adults (≥18 years of age) Patients are assessed in primary or secondary care, or primary– secondary interface setting Patients must have an MSK condition (including peripheral joints and spinal). Exclude A&E and inflammatory It is a primary study (reporting first-hand (i.e. experimental, clinical trials or surveys) (Greenhalgh, 1997) The abstract and full article are accessible at the time of the review ESPs, extended scope physiotherapists; GP, general practitioner; MSK, musculoskeletal.

206

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Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

et al. (2014)

Ashmore

(2008)

Aiken et al.

McColl (2008)

Aiken and

Author

apist and orthopaedic surgeon for appropriateness and priority

- Not clear if more than one

surgeon involved - No randomized order of Ax

training

outcomes of ESP in

Evaluate activity and

imaging

- No details on time of Ax to

- Small sample size, only one ESP knee clinic - Only one clinical location

SIGN diagnostic accuracy: + Limitations

on results

- No statistical tests performed

tool used

- No standardized satisfaction

collection unknown

- Individual responsible for data

- Age of patients unknown

of THR or TKR

ative assessments by physiother-

- No report of ESPs’ experience/

Cross-sectional study

Study design

Prospective audit

Examine correlation of preoper- Cross-sectional study

Satisfaction: 6/15 (40%) Limitations

calculations

- No sensitivity/ specificity

- No patient demographics

surgery unknown

- Time between Ax and imaging/

arthroscopy/imaging

- Different reference standards:

assessment rater agreement) - No details length of time of Ax

and orthopaedic surgeon (inter-

dance between physiotherapist

- Small sample

- Non-random order of

curacy, and treatment concor-

Diagnostic concordance and ac-

Research aims

SIGN diagnostic accuracy: + Limitations

score/study limitations

SIGN score/satisfaction

Table 2. Data extraction form and results of the included studies

Knee All patients assessed by ESP

Ireland

curacy (n = 25)

140 patients, diagnostic acSecondary care

clinic

surgeon

physiotherapist and then

Canada

40 (38 useable data) Hip/knee Patients assessed by

Orthopaedic

Diagnostic accuracy

Outcome measure(s)

ESP - Surgical conversion

- Managed independently by

measures:

Diagnostic accuracy Additional outcome

measures: - Diagnostic concordance - Surgical priority

Patient satisfaction (survey) Additional outcome

- diagnostic concordance

Shoulder/knee Additional outcome One physiotherapist and two measures: orthopaedic surgeons - treatment concordance

25 patients (convenience)

Population

clinic Secondary care

Orthopaedic

Canada

Secondary care

clinic

Orthopaedic

Setting

(Continues)

confidence interval 0.58–1.00)

88% agreement in CDA (95%

seen once arrived at clinic

able rated lower was wait to be

All subjects satisfied, only vari-

knee and shoulder impairments

90% concordance in diagnosis of

methods.

with definitive diagnostic

75% accuracy when compared

Main results

Oakley and Shacklady Extended-Scope Physiotherapists in Musculoskeletal Triage

207

208 Population

et al. (1999)

- Patients not blinded

Satisfaction: 10/15 (66%) Limitations

on results

- No statistical tests performed

tool used

- No standardized satisfaction

partment (two hospitals)

assessment and management of

outpatient de-

Orthopaedic

trained physiotherapists in the

cost-effectiveness of specially

RCT

All MSK areas

481 patients

could be consulted

care

collection unknown

- Individual responsible for data

Evaluate the effectiveness and

- Waiting times

but orthopaedic consultant

Secondary

Daker-White

measures:

All patients assessed by ESP

Australia

GP satisfaction with the PLTC

- Retrospective data

measures

Patient satisfaction No additional outcome

Additional outcome

LBP

led triage clinic

Evaluate a physiotherapy-led tri- Retrospective audit GP satisfaction

Outcome measure(s)

age clinic (PLTC) and investigate

Physiotherapist- 105 patients

Setting

Satisfaction: 8/15 (53%)

Study design

Limitations

Research aims

et al. (2009)

- Kappa given, not CI

arthroscopy

standard: some imaging, some

- Did not all have same reference

score/study limitations

SIGN score/satisfaction

Blackburn

Author

Table 2. (Continued)

(Continues)

ceived treatment quality’ sub-

measures except for the ‘per-

ences in secondary outcome

No statistically significant differ-

patients with LBP

continuation of the PLTC for

94% of GPs would support the

in the PLTC

ceived appropriate management

GPs felt that their patients re-

thopaedic clinic, whereas 87% of

management in the general or-

patients received appropriate

Only 58% of GPs felt that their

precise, and received promptly

physiotherapist was clear and

feedback received from the clinic

agreed or strongly agreed that

In comparison, 62% of the GPs

feedback

with time spent waiting for this

however, only 33% were satisfied

the general orthopaedic clinic;

the quality of the feedback from

42% of GPs were satisfied with

was appropriate

the waiting time for the PLTC

whereas 69% of the GPs felt that

the general orthopaedic clinic,

satisfied with the waiting time for

25% of GPs were satisfied or very

Main results

Extended-Scope Physiotherapists in Musculoskeletal Triage Oakley and Shacklady

Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

throscopic diagnosis of the knee

- One location used

Turner (2002)

Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

Orthopaedic

and NOPs (p < 0.001), and between orthopaedic surgeons and

geons or NOPs

(Analysis on agreement between clinical diagnosis and MRI findings)

allowed for comparison of di-

agnostic accuracy using same

patient group

- Different cohorts

(Continues)

difference in CDA between

NOPs (p < 0.001). There was no

in CDA between physiotherapists

There was a significant difference

(86/243) for NOPs

orthopaedic surgeons and 35.4% therapists, orthopaedic sur-

iotherapists, 80.8% (139/172) for measures

referred for MRI

Patients assessed by physio-

All MSK areas

CDA 74.5% (108/145) for physNo additional outcome

- Prospective study would have

healthcare provider

Primary care USA

period)

and NOPs on patients with MSK injuries

hospital

- Patient groups differed from

sectional study

therapists, orthopaedic surgeons

other, similar studies

were notably higher than in

dards fell below those pre-set but

from doctors. The overall stan-

findings compared with 37%

in agreement with arthroscopic

52% of listings by the ESPs were

medical counterparts

arthroscopic diagnosis than her

between clinical diagnosis and

ESP showed a greater agreement

Compare CDA between physio-

Diagnostic accuracy

- Surgical conversion

- Treatment concordance

measures:

Additional outcome

Diagnostic accuracy

SIGN diagnostic accuracy: +

560 patients (18-month

consultant

Patients assessed by ESP or

23/128) Knee

128 medical notes (ESP saw

racy, sensitivity and specificity

juries with a high rate of accu-

able to diagnose acute knee in-

Limitations

Community

UK

Secondary care

clinics

outpatient

cases Experienced physiotherapists are

by physiotherapist 2 in 80% of

therapist 1 in 84% of cases and

tant in 92% of cases, by physio-

study was made by the consul-

random order - Diagnostic concordance

measures:

Correct initial diagnosis in this

enced physiotherapists in

tant surgeon and two experi-

Patients assessed by consul-

Acute knee clinic Additional outcome

physiotherapist arm

surgeon

Diagnostic accuracy

which slightly favoured the

therapist or sub-consultant

50 patients

scale of patient satisfaction,

Randomized to see physio-

(2005)

Retrospective cross-

Retrospective audit

outpatients

Secondary care UK Orthopaedic

Secondary care UK

Moore et al.

affected arthroscopic diagnosis

different surgeons may have

listed for arthroscopy - Separate cohorts - No details of Ax - No details of ESP experience - No independent auditor - Arthroscopies performed by

- No evaluation of patients not

- Only one ESP, different medics when compared with those of her medical counterparts used

Establish if an ESP was making reasonable clinical decisions

SIGN diagnostic accuracy: +

Limitations

Gardiner and

training, only their experience

- No report of physiotherapists’

pists’ clinical diagnoses and ar-

Limitations

(2003)

sectional study

Agreement between physiothera- Prospective cross-

SIGN diagnostic accuracy: ++

Dickens et al.

- Different cohorts

physiotherapist autonomy

defined referrals to orthopaedic therapists involved - Unknown training and level of departments

- Unknown number of physio-

Oakley and Shacklady Extended-Scope Physiotherapists in Musculoskeletal Triage

209

210

Main results

Prospective

and acceptability of a MSK screening clinic provided by physiotherapists

Limitations

- Only compared diagnosis of

ESP and consultant but no at-

et al. (2007)

45 assessed by physiothera-

management by the ESP of 85% of patients seen by them; (2) No patient to be re-referred to a

experience

- ESP carried out all data

collection

nostic accuracy

- No attempt to determine diag- surgeon with the same problem;

(1) Independent assessment and

- No details of ESP training/

UK

ary care

physiotherapist

primary/second- All patients assessed by

All MSK

Unknown if

data sets:

- Not clear number of ESPs

month period

against three benchmark

Limitations

(2006)

150 patients seen in sixoutpatients

Activity of the ESPs assessed

Satisfaction: 7/15(47%)

Pearse et al.

on results

- No statistical tests performed

satisfaction tool used

Orthopaedic

paedic surgeon

- No standardized

(2) and then by an ortho-

collection unknown

Knee/shoulder/LBP Patients

surgeon

pointment with orthopaedic

pist, 38 attended later ap-

- Individual responsible for data

Australia

Secondary care

department

thopaedic

assessed by a physiotherapist

Audit

study

observational

accuracy

tempt to determine diagnostic

Investigate the impact, quality

Satisfaction: 8/15 (53%)

Patient and GP Satisfaction

dently by ESP

sures:- Managed indepen-

Additional outcome mea-

Patient satisfaction

- Treatment concordance

ESP

measures: - Managed independently by

Additional outcome

tool used

Oldmeadow

Satisfaction in person seen:

- No standardized satisfaction

(Continues)

any stage in their management

76% did not see a consultant at

Of patients who were dissatisfied,

with their management by ESPs.

phone: 97 (77%) were satisfied

Contacted 126 patients by tele-

the physiotherapist-led service

high levels of satisfaction with

Patients and doctors reported

p = 0.26; consultant: p = 0.17

GPwSI: p = 0.5; physiotherapist:

faction (p = 0.2) in those seen by the consultant

collection unknown

Outpatient or-

no significant difference in satis-

GPwSI and physiotherapist, with

physiotherapist

reduced satisfaction (p = 0.17)

ing the clinician anticipated and

No correlation between not see-

15% of patients were seen by

measures

No additional outcome

tant, registrar, GPwSI or

Types of MSK not known Patients assessed by consul-

Patient stisfaction

Outcome measure(s)

- Individual responsible for data

- Different cohorts

Secondary care UK

patient clinics

patient satisfaction

- Types of MSK conditions not

known

thopaedic out-

Two general or- 106 new patients

tient consultation associated with

Satisfaction: 8/15 (53%)

Limitations

(2005)

- No information on Ax time Identify factors regarding outpa- Satisfaction survey

Population

surgeons (p >0.05)

Setting

physiotherapists and orthopaedic

Study design

training/qualifications

Research aims

- Limited information on ESP

score/study limitations

SIGN score/satisfaction

Nielsen et al.

Author

Table 2. (Continued)

Extended-Scope Physiotherapists in Musculoskeletal Triage Oakley and Shacklady

Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

et al. (2010)

Trompeter

(2013)

Razmjou et al.

Orthopaedic

100 patients

measures: - Diagnostic concordance

Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

paedic surgeon

50 patients seen by ortho-

Secondary care

surgeons when seeing elective UK

50 patients seen by ESP and

Knee

department

outpatient

iotherapists and orthopaedic

diagnosis made by trained phys- note analysis (audit)

Compare the accuracy of clinical Retrospective case

- No detail on length of Ax time patients in the outpatient clinic

- Patients not truly randomized - Separate cohorts

SIGN diagnostic accuracy: + Limitations

not stated, possible recall bias

- Timing for data collection was

on results

- No statistical tests performed

data collection unknown

nosis compared with 82% by the

(Continues)

that of physiotherapists, although

by trained surgeons is better than

The accuracy of clinical diagnosis

surgery

have a condition treatable by

by the physiotherapists did not

the doctors and three (6%) seen

(14%) out of 50 patients seen by

the arthroscopic findings. Seven

a clinical diagnosis that matched

seen by the physiotherapists had

doctors and 33 (66%) patients

41 (82%) patients seen by the

for physiotherapists.

be 71.4% for surgeons and 66.6%

whereas specificity was shown to

68.1% for physiotherapists,

was 90.7% for surgeons and

doctors (p = 0.07). Sensitivity

a 66% clinically accurate diagMeasures

Physiotherapist was able to make

from both healthcare providers

all components of care received

High satisfaction was reported in

Diagnostic accuracy No Additional Outcome

- Waiting times

care

tempt to determine diagnostic

then orthopaedic surgeon

Additional outcome

- Treatment concordance

times; and (3) satisfaction with

ESP and consultant, with no at-

Patients seen by APP and

Patient satisfaction

- Individual responsible for

shoulder problems; (2) wait

- Only compared diagnosis of

Holland

Shoulder

100 consecutive patients.

accuracy

management of patients with

Limitations

Tertiary centre

dic surgeon on the diagnosis and

Orthopaedic clinic

Prospective study

(1) agreement with an orthopae-

Role of an APP with respect to

of 89%

stated

Satisfaction: 11/15 (73%)

and (3) Patient satisfaction rate

- Reason for dissatisfaction not

Oakley and Shacklady Extended-Scope Physiotherapists in Musculoskeletal Triage

211

212

Oakley and Shacklady

endorsed by the National Institute for Health and Clinical Excellence (National Institute for Health and Clinical Excellence, 2012). Quality was coded against 13 criteria, against which fulfilment of all or most (++), some (+), or few of or no criteria (-) was noted. Clinical audits were assessed for quality using a checklist adapted from the Centre for Reviews and Dissemination (2005), as used in previous work (Naylor and Guyatt, 1996; Morrell and Harvey, 1999; Millard, 2000; National Institute for Health and Clinical Excellence, 2002). For studies exploring the outcome of patient satisfaction, there was no validated screening tool; therefore, the tool used by Desmeules et al. (2012), which had been adapted from previous work (Carr-Hill, 1992; Sackett et al., 2002 Chow et al., 2009), was used.

Results A total of 146 studies were identified from the search strategy. After initial screening of the titles and abstracts, 106 were excluded and 40 were screened for practicality (Figure 1). Given the number of research studies available, case series and case reports were excluded from the review, owing to the high potential for bias in these study designs (Centre for Reviews and Dissemination, 2009). Fourteen studies were eligible for the final review (Table 2) and 26 were excluded. Seven of the eligible articles had not been appraised in the previous systematic reviews. The methodological quality of six studies for diagnostic accuracy, based on the SIGN criteria (Harbour, 2008), ranged from + to ++, indicating that some of the criteria had been fulfilled. Dickens et al. (2003) was the only cross-sectional study that demonstrated all or most of the SIGN criteria, with ++ ratings for level of evidence (Table 3). Of the eight studies investigating the satisfaction levels of patients and GPs, their methodological quality ranged from 40% to 73%, with five studies having a mean methodological score of over 53% ( Daker-White et al., 1999; Nielsen et al., 2005; Oldmeadow et al., 2007; Blackburn et al., 2009; Razmjou et al., 2013). This demonstrates the moderate methodological quality of the studies regarding satisfaction outcomes (Table 4). Study characteristics replacement

resonance imaging; MSK, musculoskeletal; NOP, non-orthopaedic provider; RCT, randomized controlled trial; SIGN, Scottish Intercollegiate Guideline Network; THR, total hip replacement; TKR, total knee

quire surgery

referral letter as unlikely to re-

APP, advanced-practice physiotherapist; Ax, assessment; CDA, clinical diagnostic accuracy; CI, confidence interval; GP, general practitioner; GPwSI, GP with a special interest; LBP, low back pain; MRI, magnetic

surgeons were satisfied ject/issue orthoses outpatients judged from the GP

physiotherapist

pist and 80% seen by staff-grade Physiotherapists able to inagement of orthopaedic on results

grade surgeons satisfied by

of patients seen by physiotherastaff-grade surgeons (2). thopaedic surgeons in the man- No statistical tests performed

95% of GPs and 92% of staff-

cantly between two groups; 89% therapist (1) and 95 seen by compared with staff-grade ormonths after clinic discharge)

92% by staff-grade surgeons

Outcome did not differ signifimeasures partment UK

221 patients seen by physiothotics and steroid injection was satisfaction assessed (6–12 (1995)

85% response physiotherapist,

All MSK areas thopaedic deLimitations - Long period before with extended training in orBannister

significant

the difference is not statistically

Patient and GP satisfaction No additional outcome 316 patients Outpatient orEffectiveness of a physiotherapist Audit and survey Satisfaction: 6/15 (40%) Weale and

score/study limitations Author

Table 2. (Continued)

SIGN score/satisfaction

Research aims

Study design

Setting

Population

Outcome measure(s)

Main results

Extended-Scope Physiotherapists in Musculoskeletal Triage

Design Overall, one randomized controlled trial (Daker-White et al., 1999), six clinical audits (Weale and Bannister, Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

Oakley and Shacklady

Extended-Scope Physiotherapists in Musculoskeletal Triage

Potentially relevant citations: Abstracts identified and screened for review n = 146 Electronic searches n = 131 Hand-searching of reference lists n = 15 Unpublished studies n = 0

Citations excluded based on abstract and title review n = 106 Reasons for exclusion: Review article: 10 Duplicate: 19 Nurse-led triage: 4 Consultant-led: 1 Did not investigate ESP: 59 Did not investigate clinical effectiveness: 5 A&E triage: 7 Inflammatory pathology: 1

Full text of studies retrieved and screening for practicality n = 40 Reasons for exclusion: Insufficient data (n = 3) ESP not independently working (n = 3) Not ESP triage (n = 5) Health professional data not provided separately (n = 1) Qualitative study (n = 2) Assessment of treatment (n = 2) Did not investigate desired outcomes: (n = 10)

Relevant studies for inclusion in systematic review n = 14 Figure 1. Flowchart of the literature search based on the method of (Moher et al. 2009). A&E, accident and emergency; ESP, extended scope physiotherapist

1995; Gardiner and Turner, 2002; Pearse et al., 2006; Blackburn et al., 2009; Trompeter et al., 2010 Ashmore et al., 2014), six cross-sectional studies (Dickens et al., 2003; Moore et al., 2005; Oldmeadow et al., 2007; Aiken and McColl, 2008; Aiken et al., 2008; Razmjou et al., 2013) and one survey (Nielsen et al., 2005) were identified. Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

Participants Patients evaluated in the studies encompassed a variety of MSK areas, such as the knee, low back and shoulder (Weale and Bannister, 1995; Daker-White et al., 1999; Pearse et al., 2006; Oldmeadow et al., 2007). One study failed to identify the types of area

213

214

SIGN, Scottish Intercollegiate Guideline Network

Not reported +

Adequate

Well covered +

N/A

Not reported

Adequate

Poor

Poor

Well covered

Adequate

Adequate

Adequate

Adequate

Adequate

Adequate

Well covered

Adequate

Poor

Adequate Well covered Well covered Not reported

Ashmore et al. (2014)

Adequate Adequate Well covered Not reported

Aiken and McColl (2008)

1.1 Representative of patients 1.2 Selection criteria 1.3 Correct reference standard 1.4 Period between reference standard and index test 1.5 Verification using reference standard 1.6 Patients received same reference standard regardless of index result 1.7 Reference standard was independent of index test 1.8 Execution of index text sufficiently described 1.9 Execution of reference standard sufficiently described 1.10 Index test results interpreted without knowledge of results of reference standard 1.11 Reference standard results interpreted without knowledge of results of index test 1.12 Uninterpretable or immediate test results are reported 1.13 Explanation for withdrawals Overall quality assessment

Criteria

Well covered ++

Well covered

Not reported

Not reported

Well covered

Well covered

Well covered

Well covered

Well covered

Well covered Well covered Well covered Adequate

Dickens et al. (2003)

N/A +

N/A

Not reported

N/A

Not reported

Adequate

Adequate

N/A

Well covered

Adequate Adequate Adequate Not addressed

Gardiner and Turner (2002)

N/A +

N/A

Not reported

Not reported

Poor

Not addressed

Well covered

Well covered

Well covered

Well covered Well covered Well covered Not reported

Moore et al. (2005)

Well covered +

N/A

Not reported

Not addressed

Well covered

Well covered

Well covered

Well covered

Well covered

Well covered Well covered Not addressed Not reported

Trompeter et al. (2010)

Table 3. Methodological quality of diagnostic accuracy by SIGN criteria (Harbour, 2008). Coding system: (++) All or most of the criteria have been fulfilled; (+) some of the criteria have been fulfilled; (-) few or no criteria fulfilled

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Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

N/A, not applicable.

1. Relevant background cited to establish a foundation for research question 2. Adequate description of the study setting and patients’ characteristics 3. Inception cohort sampled 4. Data collection process administered by independent evaluators 5. Respondents informed that their results are anonymous or not shared with treatment providers 6. Standardized satisfaction tool/measure used with known validity and reliability 7. Timing of data collection sufficiently close to care encounter as to minimize recall bias 8. Accounted for missing data 9. ≥80% of eligible patients sampled 10. Clearly defined measurements of components of satisfaction: Affability/patientcenteredness and interpersonal interactions with providers 11. Satisfaction: Process (accessibility, availability, efficiency of care) 12. Satisfaction: Perceived competency of professionals 13. Satisfaction: With outcomes 14 Appropriate statistical test(s) performed 15. Conclusions and clinical recommendations supported by the study objectives, analysis and results Total Rank

Criteria 1 0 1 0 0 0 1 1 0 N/A 1 1 1 0 1 8/15 (53%) 3

0 1 N/A 1 0 0 0 0 0 1 6/15 (40%) 5

Blackburn et al. (2009)

1 1 1 0 0

Aiken et al. (2008)

10/15 (66%) 2

1 1 0 1 1

0 1 1

0 0

1 1 1 1 0

Daker-White et al. (1999)

8/15 (53%) 3

0 N/A 1 1 1

N/A 1 0

0 1

1 1 1 0 0

Nielsen et al. (2005)

8/15 (53%) 3

0 0 1 0 0

1 1 0

0 1

1 1 1 0 1

Oldmeadow et al., (2007)

7/15(47%) 4

0 0 1 0 1

1 1 0

0 0

1 1 1 0 0

Pearse et al (2006)

11/15 (73%) 1

1 1 1 1 1

1 0 1

1 0

1 1 1 0 0

Razmjou et al. (2013)

6/15 (40%) 5

0 0 0 1 1

N/A 1 0

0 0

1 1 1 0 0

Weale and Bannister (1995)

Table 4. Methodological quality of patient satisfaction (Desmeules et al., 2012). Each criterion satisfied contributes 1 point to the total satisfaction score; 1 indicates that criterion was fulfilled and 0 indicates that criterion was not fulfilled or not reported (range 0–15 points)

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triaged in the study (Nielsen et al., 2005). Two studies encompassed two areas – either shoulder and knee (Aiken and McColl, 2008) or hip and knee (Aiken et al., 2008). Some studies focused on one specific area only: the knee (Gardiner and Turner, 2002; Dickens et al., 2003; Trompeter et al., 2010 Ashmore et al., 2014), low back (Blackburn et al., 2009) or shoulder (Razmjou et al., 2013).

Outcomes Diagnostic accuracy Six studies investigated diagnostic accuracy (Gardiner and Turner, 2002; Dickens et al., 2003; Moore et al., 2005; Aiken and McColl, 2008; Trompeter et al., 2010; Ashmore et al., 2014). Overall, the sample size was small; for example, in two studies only 25 patients were examined (Aiken and McColl, 2008; Ashmore et al., 2014). Moore et al. (2005) used a large total sample size of 560 participants but these were from separate cohorts, dependent upon the practitioner that they saw. Only 145 patients had been examined by an ESP and this did not allow for comparison of diagnostic accuracy between clinicians. Aiken and McColl (2008) found that 75% of patients with shoulder or knee pathologies had been diagnosed accurately by ESPs and orthopaedic surgeons. However, there was no statistical analysis on the data to enable an estimation to be made of the sensitivity and specificity of the clinical examination when compared with diagnostic methods (surgery or further imaging such as MRI). There were also no data to compare the diagnostic accuracy of the ESPs to that of orthopaedic surgeons. Moore et al. (2005) compared the clinical diagnostic accuracy of ESPs not only with that of orthopaedic surgeons compared with MRI, but also with that of other, non-orthopaedic providers such as emergency and paediatric physicians. Although orthopaedic surgeon accuracy was slightly higher [80.8% (139/172)] than that of ESPs [74.5% (108/145)], this was not statistically significant (p > 0.05). There was a statistically significant difference (p < 0.001) in clinical accuracy between ESPs and non-orthopaedic providers [35.4% (86/243)]; however, in comparison to Aiken and McColl (2008), Moore et al. (2005) used different cohorts of subjects in which to make the comparisons. Three audits (Gardiner and Turner 2002; Trompeter et al., 2010; Ashmore et al., 2014) assessed diagnostic 216

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accuracy. However, all failed to document or adequately describe in sufficient detail how the clinical assessment was performed. The study by Trompeter et al. (2010) was considered to be the best-performed audit in comparison with the others and, although the accuracy of clinical diagnosis of knee pathologies by surgeons was better than that of physiotherapists, the difference was not statistically significant. The physiotherapist was able to make a 66% clinically accurate diagnosis compared with 82% by the doctors (p = 0.07). Sensitivity was 92% for surgeons and 68% for physiotherapists, whereas specificity was 71% for surgeons and 67% for physiotherapists. However, patients were not truly randomized, two separate cohorts of patients were used and there was no detail on length of assessment time. The audit by Gardiner and Turner (2002) found that an ESP had greater agreement between clinical diagnosis and arthroscopic diagnosis of knee pathologies than their medical counterparts but this was much lower than in the other clinical audits. While sensitivity and specificity of clinical diagnostic accuracy was not assessed, they were compared with pre-defined standards set by the consultant prior to data collection. The consultant recommended that 80% of clinical diagnoses should agree with arthroscopic findings but there was no evidence to support this standard. Overall, ESPs achieved 52% agreement compared with 40% in the orthopaedic team. The audit by Ashmore et al. (2014) found much higher agreement in diagnostic accuracy than Gardiner and Turner (2002) and Trompeter et al. (2010), with 88% agreement in clinical diagnostic accuracy (95% confidence interval 0.58–1.00). However, there was no comparison with a medical counterpart and they did not always use the same reference standard as some patients were assessed by arthroscopy and some via imaging. Aiken and McColl (2008) also used different reference standards to establish diagnostic accuracy but had 75% diagnostic agreement. Previous studies have found some inconsistencies with MRI and arthroscopy findings for knee pathologies (Ryan et al., 1998; Stanitski, 1998). If all patients had been assessed using the same reference standard, this would have helped to minimize this risk of bias in these two audits.

Patient and GP satisfaction Eight studies investigated satisfaction for the service provided by ESPs, using questionnaires to collect data Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

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regarding variables such as waiting times, their clinical assessment, clinician seen, treatment quality and management of their condition. Seven audits assessed patient satisfaction (Daker-White 1999; et al., Nielsen et al., 2005; Pearse et al., 2006; Oldmeadow et al., 2007; Aiken et al., 2008; Razmjou et al., 2013; Weale and Bannister, 1995). The percentage of overall patient satisfaction ranged from 77% (Pearse et al., 2006) to 89% (Weale and Bannister, 1995). Other studies described patient satisfaction as ‘high’ (Oldmeadow et al., 2007; Razmjou et al., 2013) with ESP-led services. Aiken et al. (2008) found that all patients were satisfied with ESPs but did not provide further information to rate satisfaction levels, other than highlighting that one variable rated a ‘lower’ level of satisfaction (waiting time to be seen following their arrival at clinic). Of the studies that evaluated GP satisfaction with ESPs working in MSK triage, Blackburn et al. (2009) found that 94% of GPs were satisfied overall with the service delivered by ESPs. Oldmeadow et al. (2007) found that all 22 GPs in their audit were ‘satisfied’ or ‘very satisfied’ with the ESPs’ patient management. Only Blackburn et al. (2009) provided data regarding specific aspects of GP satisfaction, including waiting times, quality and information of feedback by ESPs, and appropriate management. Weale and Bannister (1995) assessed both overall patient and GP satisfaction with the service but these data were obtained via questionnaires or telephone between 6 and 12 months following discharge from clinic, which would have introduced recall bias. While there was no statistically significant difference in patient satisfaction between seeing an ESP or a staff-grade surgeon, it is difficult to compare as they assessed different patient cohorts. In comparison, the satisfaction survey by Nielsen et al. (2005) did assess patient satisfaction of the health professional seen immediately after the consultation. Although satisfaction was generally high, only descriptive statistics were available and no further information was provided concerning the types of patient satisfaction evaluated or if some areas of satisfaction were higher rated than others. Only one study (Razmjou et al., 2013) utilized a standardized satisfaction measure of known validity and reliability; this was a modified version of the nine-item visit-specific satisfaction instrument (Rubin et al., 1993; Campos et al., 2002). The study found that high satisfaction was reported in all components of care: responding to patient queries, advice and information Musculoskelet. Care 13 (2015) 204–221 © 2015 John Wiley & Sons, Ltd.

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about exercise and returning to activities, time spent with the ESP, and technical skills and personal manner of the ESP. In the eight studies discussed above, the majority of patients were satisfied with aspects of their attendance at the triage clinic but insufficient data were provided concerning the specific areas of patient satisfaction. Daker-White et al. (1999) investigated patient satisfaction with their treatment quality and Nielsen et al. (2005) evaluated patient satisfaction with the clinician that they saw but neither study showed any statistically significant differences between different elements of patient satisfaction.

Discussion The present systematic review highlighted that research evidence is supportive of the clinical effectiveness of ESPs working specifically within MSK triage, in terms of the diagnostic accuracy of ESPs and of patient and GP satisfaction with the service provided; however, the evidence lacks robustness. Some studies failed to provide the number of ESPs involved or used only one or two ESPs, and some were undertaken in one clinical location. These issues make it difficult to generalize findings to all ESPs in MSK triage, agreeing with the previous findings of Cramp (2011). The National Health and Medical Research Council (2000) stated that the ideal design for studies of diagnostic test performance is a cross-sectional study in which the results of tests on consecutively attending patients are cross-classified against disease status determined by a reference (gold) standard. Three studies (Dickens et al., 2003; Moore et al., 2005; Aiken et al., 2008) correctly utilized this study design but only Dickens et al. (2003) demonstrated all or most of the SIGN criteria (Harbour, 2008) to identify a good strength of evidence to support the diagnostic ability of ESPs in triage. In agreement with Aiken and McColl (2008), ideally, to compare diagnostic accuracy it would be necessary to use the same cohort of patients to determine if they would receive similar diagnoses from an ESP compared with an orthopaedic surgeon. Clinical audits have been published frequently to investigate the diagnostic accuracy of ESPs but only one used predefined criteria (Gardiner and Turner, 2002), which are suggested by National Institute for Health and Clinical Excellence (2002) as a definition of an audit. In general, the majority of audits included in the present 217

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review were poorly reported. Often, there was no detail of the length of time or procedure for assessment (Gardiner and Turner, 2002; Ashmore et al., 2014; Moore et al., 2005; Aiken and McColl, 2008), which could have influenced both diagnostic accuracy and perceived satisfaction with the clinical assessment. While all of the studies provided information regarding their ESPs’ levels of experience, some studies did not provide sufficient evidence concerning their training (Daker-White et al., 1999; Gardiner and Turner, 2002; Moore et al., 2005; Pearse et al., 2006; Aiken et al., 2008). This may have influenced their diagnostic accuracy and might explain the variation in diagnostic accuracy scores achieved. Often an ESP in MSK triage will manage a patient’s complete episode of care (Rabey et al., 2009). This may reduce the workload placed upon orthopaedic consultants and allow them to be deployed more efficiently; however, this is dependent upon the accurate diagnosis by ESPs, and their subsequent appropriate referral of the patient to the correct discipline, such as physiotherapy and surgery (Cramp, 2011). The present systematic review has identified that patients and GPs are generally satisfied with the ESP role in MSK triage, similar conclusions to those drawn by McClelland et al. (2010), who investigated ESPs working within an emergency department and found that their role positively influenced patient satisfaction. However, the different aspects of satisfaction cannot be evaluated as sufficient data were often not provided; in the majority of studies, patient satisfaction was not the only outcome measured (others included treatment concordance and patients managed independently by ESPs) and this may explain why details were not presented regarding satisfaction domains. There was a large variation in the methodological quality satisfaction scores (40–73%) of the studies identified in the current review as the data collection was often not administered by independent evaluators, satisfaction tools lacked detail, and papers did not clearly define the types of patient satisfaction investigated or how it was measured. This missing information makes it difficult to infer their findings to the larger population and implicate or address areas of dissatisfaction. Pearse et al. (2006) found that 77% of patients were satisfied with their management by ESPs but the reasons for dissatisfaction were not stated. This may have been due to a variety of factors, such as the perceived treatment 218

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quality of the ESP or more general issues such as waiting times. Nielsen et al. (2005) suggested that addressing patients’ expectations as a routine part of the consultation could help to improve satisfaction levels. As healthcare provision is becoming more patientcentred, patient satisfaction has emerged as a critical outcome of care (Hush et al., 2012), so satisfaction levels should be investigated. In the included studies, ESPs had a variety of clinical roles in MSK triage. While some ESPs were able to offer joint injections (Weale and Bannister, 1995) and/or diagnostic imaging (Aiken and McColl, 2008; Trompeter et al., 2010), others were restricted to a standard clinical examination (Aiken et al., 2008; Ashmore et al., 2014), which is also likely to directly affect patient satisfaction levels. These differences in ESP roles are likely to coincide with the developments in ESP practice and service developments as it is now common for ESPs working in MSK triage to offer joint injections and request further investigations as part of their clinical role, without the direct supervision of a medical colleague (Roddy et al., 2010). For further evaluation, the ESP role needs to be clearly described and up to date with current ESP clinical practice/competencies (Chartered Society of Physiotherapy, 2002) to allow any findings to be of relevant clinical value. The main limitation to the present systematic review is the potential for publication bias, and contacting experts in this field may have helped to guide unpublished studies and identify any works in progress. In agreement with previous systematic reviews (McPherson et al., 2006; Desmeules et al., 2012; Stanhope et al., 2012), further research is still required, using larger sample sizes, in different clinical locations, to generalize findings to the larger population. For studies investigating patient satisfaction, the specific elements of satisfaction should be explicitly stated to provide meaningful data, using a valid and reliable satisfaction tool. To compare diagnostic accuracy between health professionals it is recommended that the same cohort of patients is used and that clinical assessment is compared to a gold standard.

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The Clinical Effectiveness of the Extended-Scope Physiotherapist Role in Musculoskeletal Triage: A Systematic Review.

Extended-scope physiotherapists (ESPs) are working in musculoskeletal (MSK) triage clinics to assess, diagnose and refer patients for appropriate mana...
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