O Mir M.1,2, Blake C.2, O' Sullivan C.2
1Our Lady's Children's Hospital, Physiotherapy, Dublin, Ireland, 2University College Dublin, School of Public Health, Physiotherapy and Sports Science, Dublin, Ireland
Background: Extended Scope/ Advanced Practice Physiotherapists (APP) are well established internationally in the triage of patients with musculoskeletal disorders. Several systematic reviews have looked specifically at diagnostic agreement rates and found that “APP role can provide equal or better than usual care in comparison with that of physicians in terms of diagnostic accuracy”. However all studies to date have been conducted on adult populations.
Paediatric orthopaedic APP clinics have shown excellent outcomes in terms of patient management and wait-time reduction, however a rigorous evaluation of clinical effectiveness must also address the question of diagnostic accuracy in this sub- specialty.
Paediatric orthopaedic APP clinics have shown excellent outcomes in terms of patient management and wait-time reduction, however a rigorous evaluation of clinical effectiveness must also address the question of diagnostic accuracy in this sub- specialty.
Purpose: The purpose of this study is to establish diagnostic agreement rates between orthopaedic consultants and APP for paediatric orthopaedic patients examine the appropriateness of referrals by APP to consultant and report on surgical conversion rates (SCR).
Methods: A retrospective review of all patients referred from APP clinic to Consultants was conducted for year 2013, with a two-year longitudinal follow-up to end year 2015. Study participants were two APPs and four Orthopaedic Consultants at a single site. Physiotherapy and Consultant diagnoses for the same patient cohort were garnered from the patients Health Care record. Diagnoses were categorized according to ICD-10 codes to allow for comparison.
Referrals to consultant were deemed appropriate if they resulted in previously agreed upon criteria and proportions for the same were calculated using descriptive statistics, as was the Surgical Conversion Rate.
Results: The agreement between the diagnosis made by the Physiotherapist and the Orthopaedic consultant was assessed by 3 independent raters (n=113 cases). There was complete consensus between the raters (kappa = 1.0). The level of agreement between the Physiotherapist and Orthopaedic Consultant was 81.4% (92/113). Appropriateness of onward orthopaedic referral was 87% with a Surgical Conversion Rate of 23%.
Conclusion(s): The study demonstrated substantial diagnostic agreement between APPs and Orthopaedic Consultant for routine elective paediatric orthopaedic patients and is consistent with agreement levels reported in the adult literature. It should be noted that the APP diagnosis was drawn from the initial consultation, whilst the consultant diagnosis was finalised after investigation/ surgical procedure. While the SCR may seem low, it is in fact high, as other studies have reported 3% to 10% of all pediatric orthopaedic referrals resulted in surgery. This study supports the APP as clinically effective in diagnosis and onward referral of paediatric orthopaedic patients in a triage setting.
Implications: To our knowledge, this is the first study to evaluate diagnostic agreement rates between APP and consultants, appropriateness of referral and SCR for paediatric musculoskeletal patients.
A barrier to adoption of this new service delivery model may be the perception that patients would receive inaccurate or missed diagnoses from an APP. This study supports the conclusion that APPs make similar diagnoses to consultants for the same patient cohort and adds to the growing volume of evidence supporting APP triage in paediatric orthopaedics. Future studies should employ a diagnostic gold standard e.g. MRI and be conducted as prospective studies over more than one site to improve generalisability of results.
Funding acknowledgements: None
Topic: Paediatrics
Ethics approval: Ethical approval for this study was granted by the Research and Ethics Committee of Our Lady´s Children´s Hospital, Crumlin, Dublin
All authors, affiliations and abstracts have been published as submitted.
