PRIMARY CARE ORTHOPAEDIC TRIAGE SERVICE

Abstract

In Britain 8 million people consult their general practitioner annually with musculoskeletal conditions leading to referral of 1.5 million patients to Orthopaedics/ Rheumatology. Northern Ireland has the highest waiting lists for outpatients in Britain. The demand on orthopaedics continues to rise despite past attempts to reduce waiting lists. Trauma and orthopaedics accounted for 14% of the excess waiters for outpatients at June 2002. (DHSSPS Sept 2002) Roland et al 1991, etc. demonstrated that 43% of all orthopaedic referrals were inappropriate. In Belfast, G.P.s and Physiotherapists in partnership with the Regional Orthopaedic Service decided to pilot a Primary Care Orthopaedic Triage Service. The vast majority of orthopaedic referrals relate to three main body parts: lumbar spine 28%, knees 34% and hips 25% and these were chosen to be triaged for the pilot. Approval was sought and granted from Queen’s University Belfast Ethics Committee.

Phase 1 involved the training of 2 GPs and 2 physiotherapists at the Musgrave Park and Royal Victoria Hospital with the full cooperation of the orthopaedic surgeons.

Phase 2 tested independently the diagnostic capability of the trained professionals and assessed the appropriateness and management of orthopaedic referrals against the consultants decision as ‘gold standard’.

95 patients participated in the study.

55.8% of referrals were deemed appropriate by the consultants, compared to 44.6% by the GP/physio team. The Kappa statistical score was 0.79 reflecting a good level of agreement and is comparable to other clinical specialties (Sackett 1991). The sensitivity of the trained professionals on orthopaedic referrals was 83% and the specificity was 97%. Kappa value for management of inappropriate referrals was 0.83.

Orthopaedic referral can be acceptably triaged by primary care professionals reducing the number of onward referrals to outpatients by 40% and increasing the appropriate referrals from 56% to 97%.