Patient gender does not influence referral to an orthopaedic surgeon by advanced practice orthopaedic providers: a prospective observational study in Canada.

BACKGROUND: The role of an advanced practice physiotherapist has been introduced in many countries to improve access to care for patients with hip and knee arthritis. Traditional models of care have shown a gender bias, with women less often referred and recommended for surgery than men. This study sought to understand if patient gender affects access to care in the clinical encounter with the advanced practice provider. Our objectives were: (1) To determine if a gender difference exists in the clinical decision to offer a consultation with a surgeon; (2) To determine if a gender difference exists in patients' decisions to accept a consultation with a surgeon among those patients to whom it is offered; and, (3) To describe patients' reasons for not accepting a consultation with a surgeon. METHODS: This was a prospective study of 815 patients presenting to a tertiary care centre for assessment of hip and knee arthritis, with referral onward to an orthopaedic surgeon when indicated. We performed a multiple logistic regression analysis adjusting for severity to address the first objective and a simple logistic regression analysis to answer the second objective. Reasons for not accepting a surgical consultation were obtained by questionnaire. RESULTS: Eight hundred and fifteen patients (511 women, 304 men) fulfilled study eligibility criteria. There was no difference in the probability of being referred to a surgeon for men and women (difference adjusted for severity = - 0.02, 95% CI: - 0.07, 0.02). Neither was there a difference in the acceptance of a referral for men and women (difference = - 0.05, 95% CI: - 0.09, 0.00). Of the 14 reasons for declining a surgical consultation, 5 showed a difference with more women than men indicating a preference for non-surgical treatment along with fears/concerns about surgery. CONCLUSIONS: There is no strong evidence to suggest there is a difference in proportion of males and females proceeding to surgical consultation in the model of care that utilizes advanced practice orthopaedic providers in triage. This study adds to the evidence that supports the use of suitably trained alternate providers in roles that reduce wait times to care and add value in contexts where health human resources are limited. The care model is a viable strategy to assist in managing the growing backlog in orthopaedic care, recently exacerbated by the COVID-19 pandemic.

Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology.

Purpose: The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) is a screening tool that incorporates many important psychosocial domains into one questionnaire to reduce the burden of completing multiple questionnaires. The objectives of this study were to examine the reliability and validity of the 10-item version of the OSPRO-YF with patients with shoulder conditions. Method: The study group consisted of injured workers with an active compensation claim for a shoulder injury. The control group consisted of patients with a complaint of shoulder pain but without a work-related shoulder injury. We examined reliability (internal consistency, test-retest) and validity (factorial, convergent, known groups). The Hospital Anxiety and Depression Scale; the Quick Disabilities of Arm, Shoulder and Hand; and the short Örebro Musculoskeletal Pain Screening Questionnaire were used for comparison. Results: Eighty patients had an active compensation claim, and 160 were in the control group. The intra-class correlation coefficient values for two observations of the domain scores varied from 0.91 to 0.94. The test-retest reliability of the dichotomous constructs was moderate to perfect for 8 of 11 constructs. The 10-item OSPRO-YF questionnaire had three distinct domains, as conceptualized by the developers: mood, fear avoidance, and positive affect-coping. The Cronbach's a coefficients for these domains were 0.88, 0.94, and 0.94, respectively. The associations between the psychological constructs and domains and the similar theoretically derived scales were moderate to high and in the expected direction. Of the 11 constructs of the OSPRO-YF, 10 differentiated between patients with and without a work-related injury (p-values ranging from 0.028 to < 0.001). Conclusions: The 10-item OSPRO-YF reduces the burden of using multiple questionnaires and has acceptable test-retest and internal consistency reliability and factorial, convergent, and known-groups validity.

Objectif : l'Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO­YF) est un outil de dépistage qui regroupe plusieurs volets psychosociaux importants dans un seul questionnaire pour réduire le désagrément de remplir de multiples questionnaires. La présente étude visait à examiner la fiabilité et la validité de la version en dix questions de l'OSPRO­YF chez les patients ayant des problèmes d'épaule. Méthodologie : le groupe d'étude se composait de travailleurs ayant une réclamation d'indemnisation active à cause d'une blessure à l'épaule. Le groupe témoin incluait des patients qui se plaignaient de douleur à l'épaule, mais d'origine non professionnelle. Les chercheurs ont examiné la fiabilité (cohérence interne, test­retest) et la validité (factorielle, convergente et groupes connus) de l'outil. L'échelle d'anxiété et de dépression à l'hôpital, le questionnaire rapide des incapacités du bras, de l'épaule et de la main et le questionnaire court de dépistage de la douleur musculosquelettique Örebro ont été utilisés à des fins comparatives. Résultats : au total, 80 patients avaient une réclamation d'indemnisation active et 160 faisaient partie du groupe témoin. Les valeurs du coefficient de corrélation intraclasse de deux observations se situaient entre 0,91 et 0,94. La fiabilité test­retest des construits dichotomiques était de modérée à parfaite pour huit des 11 construits. Le questionnaire OSPRO­YF en dix questions se divisait en trois volets distincts conceptualisés par les développeurs : humeur, évitement de la peur et affect positif ou adaptation. Les coefficients alpha de Cronbach de ces volets s'établissaient à 0,88, 0,94 et 0,94, respectivement. Les associations entre les construits psychologiques, les volets et les échelles semblables dérivées théoriquement étaient modérées à élevées et se situaient dans l'orientation prévue. Dix des 11 construits du questionnaire OSPRO­YF pouvaient distinguer les patients ayant ou non une blessure professionnelle (valeurs p entre 0,028 et < 0,001). Conclusions : l'OSPRO­YF en dix questions réduit le désagrément lié à l'utilisation de multiples questionnaires et présente une fiabilité test­retest et une cohérence interne acceptables, de même qu'une fiabilité factorielle, convergente et de groupe connu.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists.

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.

Objectif : la présente étude avait comme objectif primaire d'examiner la fiabilité interévaluateur et la validité critérielle d'un intervalle acromio-huméral réduit (IAH < 6 mm) observé à la radiographie simple pour déceler une pathologie de la coiffe des rotateurs (CR). Son objectif secondaire consistait à examiner la relation entre cette caractéristique radiographique, la démographie des patients et l'examen clinique. Méthodologie : étude diagnostique de patients vus dans un centre de soins tertiaires. Deux physiothérapeutes en pratique avancée ont mesuré l'IAH sur deux vues radiographiques. L'imagerie par résonance magnétique servait de norme de référence. Résultats : au total, 150 patients consécutifs (âge moyen de 59 ans [ÉT 11], 57 femmes, 93 hommes) ont été inclus dans l'étude. Dans les deux vues radiographiques, l'IAH inférieur à 6 mm était hautement spécifique de la présence d'une déchirure (99 %), de la dimension de la déchirure (96 % à 98 %) et d'une infiltration graisseuse dans les muscles supra-épineux et infra-épineux (93 % à 96 %). L'absence d'IAH inférieur à 6 mm s'associait à l'absence d'infiltration graisseuse avancée dans les muscles supra-épineux et infra-épineux (92 % à 100 %). Les valeurs de sensibilité étaient faibles pour ce qui est de la présence et de la dimension d'une déchirure de la CR (21 % à 55 %). On constatait une association statistiquement significative entre les catégories d'IAH et une observation clinique d'amyotrophie et de faiblesse musculaire de la CR (p < 0,05). Conclusion : l'IAH inférieur à 6 mm était mesuré en toute fiabilité sur des radiographies simples et s'associait fortement à des caractéristiques de pathologie avancée de la CR, tant sur le plan de la clinique que de l'imagerie. Ces constatations pourraient contribuer aux prises de décision en favorisant l'utilisation judicieuse d'explorations plus coûteuses et de l'orientation en chirurgie.

Reduced acromiohumeral distance and increased critical shoulder angle: implications for primary care clinicians.

Objectives: The literature indicates that reduced acromiohumeral distance (AHD) and increased critical shoulder angle (CSA) are associated with large and massive rotator cuff (RC) tears which may not be amenable to a successful repair. The purpose of this study was to examine the overall accuracy of these two radiographic features in diagnosing significant RC pathology. Methods: This was a diagnostic study of patients with shoulder pain. To examine the overall accuracy of the measurements, the area under the Receiver Operating Characteristic curves (AUC) were calculated. The validity indices (sensitivity, specificity and likelihood ratios) examined the predictive value of specific cutoff categories of AHD<6 mm and the CSA >35°. Results: Data of 200 consecutive patients; mean age: 59(11), 117 males were used for analysis. There was a weak inverse correlation (r = 0.46) between the AHD and CSA. The AUCs for presence and size of RC tear and different stages of fatty infiltration of supraspinatus and infraspinatus muscles varied from fair to excellent for AHD and poor to good for CSA. Specificity was high for the cutoff categories of both AHD and CSA (>90%). The positive LRs were large for AHD and small to moderate for CSA. Conclusion: The AHD and CSA were reliably measured in the true AP radiographic view. Both radiographic features (AHD<6mm and CSA>35°) were able to confirm the presence of a major RC pathology. However, the AHD<6 mm, an acquired radiologic abnormality secondary to failure of the RC muscles/tendons had better measurement properties. This information is of value to primary care physicians, sports medicine specialists and advanced practice physiotherapists in their clinical decision making.