Intermediate care pathways for musculoskeletal conditions--are they working? A systematic review.

BACKGROUND: Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services. OBJECTIVES: This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence. DATA SOURCES: PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013. STUDY SELECTION/ELIGIBILITY CRITERIA: Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded. RESULTS: Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists' clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction. LIMITATIONS: These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services. FUNDING: Part funded by EPSRC and AXA-PPP. CONCLUSION: Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients.

Musculoskeletal triage: a mixed methods study, integrating systematic review with expert and patient perspectives.

BACKGROUND: Triage is implemented in healthcare settings to optimise access to appropriate care and manage waiting times. OBJECTIVES: To determine the optimum features of triage systems for patients with musculoskeletal conditions. DATA SOURCES: AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, MEDLINE, Cochrane Library, Web of Science and Google Scholar. STUDY SELECTION OR ELIGIBILITY CRITERIA: Studies that included non-musculoskeletal conditions, concerned patients aged <18 years or were set in emergency departments were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was graded using the Downs and Black quality index. Qualitative methods were used to further inform the findings of the literature review. RESULTS: Thirty-four studies met the inclusion criteria, with study quality ranging from eight to 24 out of a possible 27. Musculoskeletal triage is conducted via face-to-face consultation, paper referral letter or telephone consultation. Triage performed by physiotherapists, general practitioners, multidisciplinary teams, nurses, occupational therapists and speech therapists has been shown to be effective using a range of outcomes. Qualitative data revealed the value of supportive interdisciplinary teams, and suggested that this support is more important than choice of clinician. Patients trusted, and expressed preferences for, experienced clinicians to perform triage. CONCLUSION: Triage can be performed effectively via a number of methods and by a range of clinicians. Satisfaction, cost, diagnostic agreement, appropriateness of referral and waiting list time have been improved though triage. Multidisciplinary support mechanisms are critical elements of successful triage systems. Patients are more concerned with access issues than professional boundaries.