Advanced Practice Physiotherapy Progressing Integrated Care of Musculoskeletal Disorders in Ireland: a National Evaluation

Abstract

Introduction: Musculoskeletal (MSK) disorders are a major burden on patients, families and healthcare systems(1). Similar to international initiatives(2, 3), Advanced Practice Physiotherapist (APP) posts (n=22) were introduced to optimize patient flow between primary and acute hospital MSK services at 16 acute hospitals across Ireland in 2012. APP services provide an alternative access route to hospital rheumatology and orthopaedic services (Figure 1) with their scope of practice including traditionally medically-controlled acts: administering injections, ordering investigations, triaging for onward referral to hospital specialities and surgical listing. This study analysed the national MSK data collected by APPs over 2014, using descriptive statistics. The objectives of this study are: to profile the national APP patient caseload, evaluate efficiency and establish clinical outcomes of APP appointments. Results: APPs assessed 13,981 new patients, with 2,596 return patients reviewed. Knee (23%), lower back (22%) and shoulder (15%) disorders were most prevalent. Patients waited a median time of 167 days (IQR 91-316) for their appointment, with favourable reductions noted for patients referred during 2014 (n=6,552) with mean wait times of 107±64 days. For 79% (n=10,036) of new patients, consultant input on patient care management was not required at the APP assessment, thus freeing up consultant time for more urgent cases. The clinical decision made by the APP shows the relatively low proportions of resources required and the demand for conservative management: Primary Care: Physiotherapy: 22% (n=3,568) Secondary Care: Physiotherapy: 19% (n=3,130) MSK injection: 4% (n=685) Clinical Investigations: 29% (=4,833) Clinical Imaging (5-month period): 27% (n=7,010) Orthopaedic/Rheumatology services: 18% (n=2,818) Other Hospital Speciality: 4% (n=563) Surgical Intervention: 2% (n=404) Discussion: The first national evaluation of MSK APP services has demonstrated that as part of an integrated care pathway, APPs can manage a multiplicity of disorders. The addition of APP services enhanced benefits to patients with faster access to specialist MSK care; optimizing flow of patients between primary and secondary care. Screening of referral letters selected appropriate patients for APP assessments with few requiring onward referrals to orthopaedic/rheumatology services. In addition to this, the greater demands for conservative management, high independent APP management and low resource utilisation indicated that APPs may be a more appropriate access route for many MSK patients. Conclusion: The assimilation of APP and consultant MSK services, represents a fast, resource efficient addition to the integrated care pathway for MSK disorders. The continued collection of national service data will enable ongoing service evaluation and development through monitoring key performance indicators. Lessons learned: Collection of national databases enables comprehensive service evaluations. Introduction of APPs reduced waiting times for all patients enabling faster access routes between primary care and specialist MSK care. Given the proportion of patients deemed not to require specialist MSK management, greater resourcing of primary care services could remove necessity for referral to the acute hospital system. Limitations: The current fields in the national database do not track the patient journey throughout the Integrated Care Pathway with data limited to the acute setting only. Future: Future research should gain patients' perspective and evaluate patient-centred outcomes.