Taylor KGM1, Baxter GD1, Hansen P2, Sullivan TS3, Tumilty S1
1University of Otago, School of Physiotherapy, Dunedin, New Zealand, 2Univeristy of Otago, Department of Economics, Dunedin, New Zealand, 3University of Otago, Department of Preventive and Social Medicine, Dunedin, New Zealand
Background: In New Zealand musculoskeletal disorders are a leading cause of disability in the working age population, imposing a large burden on individuals, employers and the health system. Physiotherapists are a key primary care provider and shoulders are the third most injured body site. Physiotherapists have a major influence on decision-making with respect to possible treatment pathways for shoulder injuries, including whether imaging and / or surgical options are recommended, or alternatively whether conservative treatment is more appropriate. Further imaging and surgery is common place, over utilised, and a concern for funding bodies. Decision-making in this area is neglected in the literature, with no clear guidelines available. The key clinical factors influencing physiotherapists' decision-making with respect to shoulder injury pathways are currently undocumented in the literature.
Purpose: To investigate the extent to which physiotherapists agree and disagree respectively in their decision-making, when recommending patients with shoulder injuries have imaging and / or surgery, and to identify the key clinical factors influencing their decisions.
Methods: A ranking survey was developed and administered, using online software 1000minds (www.1000minds.com).Two groups of physiotherapists were individually asked to rank nine shoulder cases according to the appropriateness of them being referred for imaging and / or surgery. The case scenarios were created by the first author and peer-reviewed by colleagues, the nine shoulder cases covered the spectrum of shoulder injuries seen in primary care. After the survey, each group discussed the reasons for their decisions.
Results: For the two ranking groups (n=12, n=11), there was some agreement with respect to the ranking of the first and last cases, whereas, there was little agreement for the other cases. For group one, the Kendall´s coefficient of concordance is 0.472 and for group two, 0.602.
When the two groups (n=12, n=9) discussed their rankings, they had difficulty prioritising relevant factors. From the focus groups, the common factors agreed on to be more influential, in no particular order are; pain, function, response to treatment, recovery time, comorbidities and previous injuries. However, they agreed to disagree on how much influence each factor had.
Conclusion(s):
For physiotherapists, the decision-making process is idiosyncratic, based on clinical intuition together with clinical experience. This leads to variation and inconsistency. Clinicians found the ranking problematic with respect to the majority of the case scenarios.
Implications: Decision-making with respect to possible treatment pathways for shoulder injuries is challenging for physiotherapists in primary care. Prioritising patients for further imaging and surgery without clear guidelines leads to inconsistent decision-making, and potentially for the patient, misperception. For physiotherapists, identifying key factors that contribute to decision-making contributes to strengthening the decision-making process. This research is a first step towards identifying the key clinical factors and quantifying their relative importance. The next step is to determine the weighting of the identified key factors, representing their relative importance to decision-makers. The resulting 'points system' (i.e. criteria and weights) has the potential to enable physiotherapists to make more valid and reliable decisions, leading to improved patient care and, potentially, less unnecessary further imaging and surgery.
Keywords: Shoulder injury, Decision-making, Primary care
Funding acknowledgements: No funding acknowledgment required
Purpose: To investigate the extent to which physiotherapists agree and disagree respectively in their decision-making, when recommending patients with shoulder injuries have imaging and / or surgery, and to identify the key clinical factors influencing their decisions.
Methods: A ranking survey was developed and administered, using online software 1000minds (www.1000minds.com).Two groups of physiotherapists were individually asked to rank nine shoulder cases according to the appropriateness of them being referred for imaging and / or surgery. The case scenarios were created by the first author and peer-reviewed by colleagues, the nine shoulder cases covered the spectrum of shoulder injuries seen in primary care. After the survey, each group discussed the reasons for their decisions.
Results: For the two ranking groups (n=12, n=11), there was some agreement with respect to the ranking of the first and last cases, whereas, there was little agreement for the other cases. For group one, the Kendall´s coefficient of concordance is 0.472 and for group two, 0.602.
When the two groups (n=12, n=9) discussed their rankings, they had difficulty prioritising relevant factors. From the focus groups, the common factors agreed on to be more influential, in no particular order are; pain, function, response to treatment, recovery time, comorbidities and previous injuries. However, they agreed to disagree on how much influence each factor had.
Conclusion(s):
For physiotherapists, the decision-making process is idiosyncratic, based on clinical intuition together with clinical experience. This leads to variation and inconsistency. Clinicians found the ranking problematic with respect to the majority of the case scenarios.
Implications: Decision-making with respect to possible treatment pathways for shoulder injuries is challenging for physiotherapists in primary care. Prioritising patients for further imaging and surgery without clear guidelines leads to inconsistent decision-making, and potentially for the patient, misperception. For physiotherapists, identifying key factors that contribute to decision-making contributes to strengthening the decision-making process. This research is a first step towards identifying the key clinical factors and quantifying their relative importance. The next step is to determine the weighting of the identified key factors, representing their relative importance to decision-makers. The resulting 'points system' (i.e. criteria and weights) has the potential to enable physiotherapists to make more valid and reliable decisions, leading to improved patient care and, potentially, less unnecessary further imaging and surgery.
Keywords: Shoulder injury, Decision-making, Primary care
Funding acknowledgements: No funding acknowledgment required
Topic: Musculoskeletal: upper limb; Primary health care; Professional practice: other
Ethics approval required: Yes
Institution: University of Otago, New Zealand
Ethics committee: Human Ethics (Health) Committee
Ethics number: REF#: D16/140
All authors, affiliations and abstracts have been published as submitted.
