Referral decisions and its predictors related to orthopaedic care. A retrospective study in a novel primary care setting

Esther H A Van Den Bogaart,Dirk Ruwaard,Tim A E J Boymans,Ndubuisi Onyemaechi,Mark W Van Den Boogaart,Marieke D Spreeuwenberg,Mariëlle E A L Kroese

doi:10.1371/journal.pone.0227863

Esther H A Van Den Bogaart, Dirk Ruwaard + Show 5 more

Open Access

https://doi.org/10.1371/journal.pone.0227863

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Abstract

Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81–0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient’s diagnosis and the period (p ≤ 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.

Highlights

Problems related to the musculoskeletal system are the second most common causes of disability and affect more than 1.7 billion people worldwide [1]
In the Netherlands, musculoskeletal problems are a significant factor in high healthcare costs [10], with 1.1 billion euros spent on osteoarthritis in 2011, corresponding to 1.2% of total healthcare costs [11]
The referral decision following PC+ for 96 patients was unknown, so these patients were excluded from the analysis

Summary

Introduction

Problems related to the musculoskeletal system are the second most common causes of disability and affect more than 1.7 billion people worldwide [1]. Due to the ageing population in developed countries, the prevalence of musculoskeletal disorders will rise [7]. Due to rapid developments in diagnostics and treatment, it is unrealistic for GPs to be constantly informed about all possibilities [18]. These knowledge gaps that arise in primary care may lead to referrals to outpatient hospital care for diagnosis and/or treatment that GPs could provide if they had the right resources, training, and support [19]

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