Objectives
Advanced Practice Physiotherapists (APP) are well established internationally in the triage of patients with musculoskeletal disorders. Systematic reviews of APP practice have reported excellent rates of diagnostic accuracy when compared with the medical profession and gold standard imaging (Desmeules et al, 2012). 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 (O Mir, 2016), however a rigorous evaluation of clinical effectiveness must also address the question of diagnostic accuracy in this sub-speciality.
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.
Method
A retrospective review of all patients referred from APP clinic to Consultants for year 2013 was conducted, 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 categorised firstly according to ICD-10 codes, and then by site of lesion to allow for comparison. Criteria for “Appropriate Referral” were decided in advance. Descriptive statistics using SPSS 20.0 were performed to calculate Surgical Conversion Rate as well as % agreement on “Appropriateness” of referral and “Diagnostic Agreement.”
To maintain methodological rigour, categories were stratified by
ICD-10 codes and site of lesion before calculating a Kappa Co-efficient
Results
The agreement between the diagnosis made by the Physiotherapist and the Orthopaedic consultant was assessed by 3 independent raters with complete consensus between the raters (kappa = 1.0). The level of agreement between the Physiotherapist and Orthopaedic Consultant was 82% . Appropriateness of onward orthopaedic referral was 87% with a Surgical Conversion Rate of 23%. There was good to substantial agreement (kappa > .65) in all diagnostic codes bar one.
Conclusions
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. 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.
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
References
Desmeules, F., Roy, J.S., MacDermid, J.C., Champagne, F., Hinse, O. and Woodhouse, L.J., 2012. Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review. BMC musculoskeletal disorders, 13(1), p.107.
Mir, M.O., Cooney, C., O’Sullivan, C., Blake, C., Kelly, P., Kiely, P., Noel, J. and Moore, D., 2016. The efficacy of an extended scope physiotherapy clinic in paediatric orthopaedics. Journal of children's orthopaedics, 10(2), pp.169-175.
Ethical Approval
Ethical approval for this study has been granted by Our Lady’s Children,s Hospital Ethics (Medical Research) Committee.
Musculoskeletal , Paediatrics , Service Development
