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.

Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department.

OBJECTIVES: To evaluate the effect of introducing an extended scope physiotherapy (ESP) service on patient satisfaction, and to measure the functional outcome of patients with soft tissue injuries attending an adult emergency department (ED), comparing management by ESPs, emergency nurse practitioners (ENPs), and all grades of ED doctor. METHODS: The ESP service operated on four days out of every seven in a week in an urban adult ED. A satisfaction questionnaire was sent to all patients with a peripheral soft tissue injury and fractures (not related to the ankle) within one week of attending the ED. Patients with a unilateral soft tissue ankle injury were sent the acute Short Form 36 (SF-36) functional outcome questionnaire, with additional visual analogue scales for pain, at 4 and 16 weeks after their ED attendance. Waiting times and time spent with individual practitioners was also measured. RESULTS: The ESP service achieved patient satisfaction that was superior to either ENPs or doctors. Overall 55% of patients seen by the ESP service strongly agreed that they were satisfied with the treatment they received, compared with 39% for ENPs and 36% for doctors (p = 0.048). Assessment of long-term outcome from ankle injury was undermined by poor questionnaire return rates. There was a trend towards improved outcomes at four weeks in those patients treated by an ESP, but this did not achieve statistical significance. CONCLUSION: Adding an ESP service to the interdisciplinary team achieves higher levels of patient satisfaction than for either doctors or ENPs. Further outcomes research, conducted in a wider range of emergency departments and integrated with an economic analysis, is recommended.