The last two decades has seen the emergence of clinical specialisation with Allied Health Professionals (AHPs) working in new roles using skills previously out with their scope of practice to provide a more efficient Health Service utilising the talents of all staff.
One innovation has been the development of the Musculoskeletal Clinical Assessment Treatment Service (MSK CATS) model. These services interface between primary (G.P.) and secondary (hospital) care to manage the growing demand of musculoskeletal (MSK) patients on orthopaedic services. The aim of this paper was to provide an evidence summary of the effectiveness of MSK CATS.
Here’s what they did
The authors searched PubMed, Web of Science, EMBASE, Ovid MEDLINE, PEDro and Google Scholar for studies evaluating MSK CATS or similar services assessing musculoskeletal (MSK) conditions. They included any studies describing primary care based triage led by AHPs, G.P.s and musculoskeletal physicians, or those evaluating referral pathways. Outcomes of interest were: effect on waiting times, patient satisfaction, and effectiveness and referral outcomes of these services.
Here’s what they found
Twenty three studies were identified and after quality assessment using a modified Downs and Black Checklist all were included in the review. These included one randomised controlled trial, 19 observational studies (14 retrospective, 5 prospective), one prospective quasi-experimental study and two audits.
The majority of studies assessed the service during its first year of implementation over varying timescales. Quality assessment of studies varied with 11 studies deemed low, 8 medium and 4 high quality. Main findings reported were:
- 72%-97% of patients could be managed entirely within Intermediate Care resulting in a 20%- 60% reduction in orthopaedic referral rate.
- Knee conditions were most commonly referred onto secondary care (35%-56%) with plain film X-ray (5%-23%) and MRI (10%-18%) the most common investigations requested
- Physiotherapists’ clinical decision making and referral accuracy were comparable to medical doctors in 68% – 96% of cases
- Patient Reported Outcomes Measures typically showed significant symptom improvements
In 46% of services patients were assessed and triaged by physiotherapists. However, only 11% of the services had a clear evaluation strategy such as pre and post implementation data, numbers treated, discharge profiles and scoring systems for triage, making critique of the services difficult. A large proportion of patients suffered with depression (47%) and anxiety (37%) due to chronic pain. The most common referral pathway was to physiotherapy (23%), the most common intervention was steroid injections (13%). Interestingly one audit showed that a referrals via a multi-professional triage team increased waiting times with 22% of those referred onto secondary care deemed to have an incorrect diagnosis and 33% no diagnosis.
The authors concluded
MSK CATS and physiotherapy triage appropriately manage and suitably refer patients to Intermediate Care.
The Musculoskeletal Elf’s view
Pressures on Health Services and the growing problem of an aging population has led to development of new roles and ways of working to cope with the demand for MSK assessment and management. To ease the burden on overstretched primary care services in Wales, several pilot sites are using Physiotherapists rather than G.P.s to provide consultations for people presenting with MSK conditions. The findings of this review suggest that suitably qualified and experienced Physiotherapists can appropriately manage MSK conditions independently, but highlights an urgent need for robust data collection and high quality studies to evaluate effectiveness and impact on other services, including Physiotherapy itself. Other questions such as: whether the shift of experienced staff into MSK CATS services adversely affects skill mix within Physiotherapy departments, and, what skills, training and governance is required to support such posts remain unanswered.
What do you think?
- What has been your experience of MSK CATs or similar services?
- Where do you think research into this area should be focussed?
Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community. Post your comment below, or get in touch via social media (Facebook, Twitter, LinkedIn, Google+).
Hussenbux, A., Morrissey, D., Joseph, C. & McClellan, C.M. 2015, “Intermediate care pathways for musculoskeletal conditions–are they working? A systematic review”, Physiotherapy, Vol. 101, no.1, pp.13-24 [Abstract]
I think this is a great development for quick diagnosis and treatment. GP s are not specialists on everything and referral times can be months to see a physio and all the time you are getting worse. In my own case of a herniated disc I could have had much less pain, etc with earlier physio intervention and guidance. On my evaluation form given at the end of treatment I suggested to Fife Health Board your scheme not knowing it already existed. Professionals need to respond to changes in social and health circumstances and not be bound to conventions. E. Brown
Remove 16.5% of inappropriate referrals…
Thanks for this review. I would bring up another point….
I noticed on reading the original paper that in the section ‘Appropriate referral’
“One study reported 16.5% referrals made by general practice based physiotherapists were for investigations and 55.9% were for surgical procedures”.
I have experience working in an extended scope podiatry position within an orthopaedic foot and ankle clinic. I also observed a proportion of referrals from community based AHPs primarily podiatry and physiotherapy which were for investigation rather than surgical opinion. The referrals were always appropriate and beg the question why not simply provide direct access to diagnostic investigations to front line AHPs.
– This would make the journey easier on the patients
– Reduce unnecessary bureaucracy for staff
– Should not create new work for diagnostic services assuming the referrals are appropriate in the first place.
do Intermediate Care pathways for #musculoskeletal conditions work? http://t.co/r9QmPhZcWC @ScotGovHealth @PO_Scotland
do Intermediate Care pathways for #musculoskeletal conditions work? http://t.co/r9QmPhZcWC @ArthritisCareSC @Arthritis_care @NRASociety
Intermediate Care pathways for musculoskeletal conditions – are they working? http://t.co/W23DmdXGQG via @sharethis
Intermediate Care pathways #musculoskeletal conditions – are they working? http://t.co/r9QmPhZcWC @CochraneMSK @CochraneBack
RT @Salaso_: Importance of robust data collection by physiotherapists highlighted in this post: http://t.co/WJIPCTGCYn by @lesleydmsk @MSK_…
How effective are Intermediate Care pathways #musculoskeletal conditions http://t.co/r9QmPhZcWC @HSJnews @PatientsAssoc
Intermediate Care pathways for musculoskeletal conditions – are they working? http://t.co/giBq3ppAKE
When new systems like this work, then everyone, clinicians and patients alike, will use them. However this point is well made in our experience: ‘Interestingly one audit showed that a referrals via a multi-professional triage team increased waiting times with 22% of those referred onto secondary care deemed to have an incorrect diagnosis and 33% no diagnosis.’
My son had been under a local physiotherapist for foot pain, having been referred by his paediatrician when he received his diagnoses of Ehlers Danlos Hypermobility type. After treatment made no difference the suggestion was made to go back to the GP and ask for a referral to podiatry services. The referral was passed though to MSK CATS.
They made great of the fact that they were there to make sure that people were seen as close to home as possible and made various appointments for hospitals 25 to 50 miles away, when there were three community hospitals within six to 12 miles away. All appointments were for triage with a physio, despite telling them that we were being referred by a physio.
In the end we were rescued from the system by the GP and a recommendation from a podiatric surgeon.
For those self referring or presenting with symptoms that a GP is unsure of, then this system may work well, but when it is applied in a one size fits all fashion to people already in the system with chronic conditions, it ends up being a waste of time and money. These people will already know where their next referral should be, because they are already in the system.
The referral was passed through to
In the current NHS Climate, its high time to introduce- Vertical Integrated- MSK Pathway( same as we have in Cambridgeshire Community services NHS trust), so that main stream MSK Physios can communicate and refer patients directly to Clinicians(ESP’s) in the secondary care.
Unfortunately the communicative link between core physios and secondary care is very patchy – which then leads to failed physiotherapy treatments for patients and delay in addressing clinical dilemmas( refer for imaging, surgical review etc). I feel MSK Physios are better equipped in gatekeeping to secondary care, if provided with good infrastructure( electronic records and clinical pathways) and training.