Evaluation of Extended Scope Physiotherapists in an Orthopaedic Outpatient Shoulder Clinic

Clinical Examination by Extended Scope Physiotherapists and Orthopaedic Surgeons in an Outpatient Shoulder Clinic: Agreement on Diagnosis and Treatment Plan and Evaluation of Costs and Organisation

This study investigates the agreement between extended scope physiotherapists (ESP) and orthopaedic surgeons (OS) on diagnosis and treatment plan in an orthopaedic outpatient shoulder clinic. Furthermore a cost analysis and an evaluation of the interdisciplinary collaboration at the orthopaedic outpatient shoulder clinic (termed shoulder clinic in the following) will be performed.

Study Overview

• Status: Completed
• Conditions: Musculoskeletal Pain; Shoulder Pain; Shoulder Injuries and Disorders
• Intervention / Treatment: Other: Examination

Detailed Description

According to current practice, patients referred from a general practitioner (GP) to the Orthopaedic Outpatient Shoulder Clinic, Silkeborg Regional Hospital (SRH), Denmark, will be examined by either an orthopaedic surgeon (OS) or an extended scope physiotherapist (ESP), as these two groups of health professionals share this assignment. The decision on, which health professional is considered most appropriate to examine the patient, is done by a senior orthopaedic surgeon based on the available information in the referral letter from the GP. Three categories of appropriateness are used: most appropriate to be examined by an OS, most appropriate to be examined by an ESP and equally appropriate to be examined by an ESP or an OS.

The overall purpose of this study is to evaluate the quality of the shared assignment investigated through both professional and organisational outcomes. The following three subsidiary objectives are used:

1. To estimate the agreement between ESP's and OS's on diagnosis and treatment plan (primary subsidiary objective)
2. To estimate direct hospital costs of an examination performed by an ESP and an OS, respectively, and to estimate the difference in costs.
3. To describe the interdisciplinary collaborative practice including evaluation of the extent of relational coordination.

Methods are described underneath related to each subsidiary objective.

1. The study is conducted at the shoulder clinic, SRH. Eligibility criteria, intervention and outcomes are described elsewhere.

   Primary analysis:

   Agreement between ESP and OS in choice of treatment plan (three categories: 1) referral to physiotherapy, 2) need of further diagnostic examination, steroid injection or surgery and 3) no intervention) will be evaluated by estimating the proportion of agreement between

   • The individual registrations of the ESP and OS
   • The individual registration of the ESP and the common decision
   • The individual registration of the OS and the common decision Furthermore, McNemar's test will be used to compare the individual registrations of the ESP and OS, respectively, against the common decision

   Secondary analyses:

   Agreement between ESP and OS in choice of treatment plan (five categories: as described in the outcome section) will be evaluated the same way as described above.

   Agreement between ESP and OS in diagnosis of the patient will be evaluated by estimating both the proportion of total agreement and partial agreement between the two health professionals. Total agreement is defined as ESP and OS having registered the same primary diagnosis. Partial agreement is defined as ESP and OS having registered the same diagnosis but one of them considers it the primary diagnosis while the other considers it a secondary diagnosis.

2. Mean hospital costs of an examination of a shoulder patient will be estimated based on the cohort used to evaluate agreement on diagnosis and treatment plan. Mean hospital costs per patient in the cohort will be estimated separately for ESP's and OS's based on salaries for the health professionals and amount of ordered supplemental diagnostic examinations (X-ray, MR imaging, MR arthrography, CT imaging, ENG, EMG) in each group. Difference in costs will be estimated.
3. Relational coordination in interdisciplinary collaborative practice will be described through separate semi-structured group interviews with ESP's and OS's, respectively.

The Association of Danish Physiotherapists is partly funding the salary for the principal investigator.

• Study Type: Observational
• Enrollment (Actual): 69

Contacts and Locations

Study Locations

• Denmark
  • Silkeborg, Denmark, 8600
    • Silkeborg Regional Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

Patients with shoulder problems referred to the shoulder clinic at Silkeborg Regional Hospital.

Description

Inclusion Criteria:

• Above the age of 18 years
• Referred to The Shoulder Clinic at Silkeborg Regional Hospital
• Considered equally appropriate to be examined by an ESP or an OS
• Ability to read and understand Danish

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Cross-Sectional

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

Shoulder patients; Shoulder patients referred to examination at the shoulder clinic, Silkeborg Regional Hospital.

Other: Examination; Patients will be examined twice the same day by an extended scope physiotherapist (ESP) and an orthopaedic surgeon (OS) in random order. They will independently and blinded to each other's opinion register; diagnosis and treatment plan (including need for further diagnostic examinations - i.e. imaging); if the patient needs a new appointment at the shoulder clinic; if they under usual conditions would discuss their results with the opposite health professional before deciding diagnosis and treatment plan. After the individual examinations the ESP and OS discuss their results and come to an agreement (common decision) regarding the patient's diagnosis, treatment plan and need of a new appointment. Patients will be informed only of the common decision of the ESP and OS.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Treatment plan - orthopaedic surgeon	Treatment plan suggested by the OS will be registered in a chart developed for the occasion. The chart has 5 pre-defined categories: 1) referral to physiotherapy, 2) referral to diagnostic examination, 3) steroid injection, 4) surgery and 5) no intervention (categorical)	Baseline
Treatment plan - physiotherapist	Treatment plan suggested by the ESP will be registered in a chart developed for the occasion. The chart has the same 5 pre-defined categories as for the OS: 1) referral to physiotherapy, 2) referral to diagnostic examination, 3) steroid injection, 4) surgery and 5) no intervention (categorical)	Baseline
Treatment plan - common decision	The OS and ESP will discuss their results until they agree which treatment plan to offer the patient. Their decision will be registered in a chart developed for the occasion. The chart has the same 5 pre-defined categories as for the individual examinations: 1) referral to physiotherapy, 2) referral to diagnostic examination, 3) steroid injection, 4) surgery and 5) no intervention (categorical)	Baseline

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Diagnosis - orthopaedic surgeon	One primary diagnosis (and if relevant secondary diagnoses) suggested by the OS will be registered in a chart developed for the occasion. The chart has 9 pre-defined categories of diagnoses: 1) impingement, 2) rotator cuff injury, 3) glenohumeral instability, 4) glenohumeral osteoarthritis, 5) periarthritis humeroscapularis, 6) scapular instability, 7) fracture sequelae, 8) acromioclavicular joint disorder, 9) non-related shoulder diagnoses (categorical).	Baseline
Diagnosis - physiotherapist	One primary diagnosis (and if relevant secondary diagnoses) suggested by the ESP will be registered in a chart developed for the occasion. The chart has the same 9 pre-defined categories of diagnoses as for the OS (categorical).	Baseline
Diagnosis - common decision	The OS and ESP will discuss their results until they agree on patient diagnosis. Their decision will be registered in a chart developed for the occasion. The chart has the same 9 pre-defined categories of diagnoses as for the individual examinations (categorical).	Baseline
New appointment - orthopaedic surgeon	The OS registers whether he considers, that the patient should be offered a new appointment at the shoulder clinic (categorical, yes/no)	Baseline
New appointment - physiotherapist	The ESP registers whether he/she considers, that the patient should be offered a new appointment at the shoulder clinic (categorical, yes/no)	Baseline
New appointment - common decision	The OS and ESP will discuss their results until they agree, whether the patient should have a new appointment at the shoulder clinic or not. Their decision will be registered (categorical, yes/no)	Baseline
Discussion needed - orthopaedic surgeon	The OS registers whether he under usual conditions would discuss his results with an ESP before making a decision on diagnosis or treatment plan (categorical, yes/no).	Baseline
Discussion needed - physiotherapist	The ESP registers whether he/she under usual conditions would discuss his/her results with an OS before making a decision on diagnosis or treatment plan (categorical, yes/no).	Baseline

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Salary - orthopaedic surgeon, first clinical examination	Mean expenditure on salary for an OS performing a clinical examination of a shoulder patient at the first visit. The estimate will be calculated based on time spent on the examination and mean salary for an OS (information on mean salary will be obtained from statistics at the finance department at the hospital)	Baseline
Salary - orthopaedic surgeon, planned new appointment	Mean expenditure on salary for an OS performing a follow up appointment with a shoulder patient. The estimate will be calculated based on time spent on the appointment and mean salary for an OS (information on mean salary will be obtained from statistics at the finance department at the hospital)	Baseline
Salary - extended scope physiotherapist, first clinical examination	Mean expenditure on salary for an ESP performing a clinical examination of a shoulder patient at the first visit. The estimate will be calculated based on time spent on the examination and mean salary for an ESP (information on mean salary will be obtained from statistics at the finance department at the hospital)	Baseline
Salary - extended scope physiotherapist, planned new appointment	Mean expenditure on salary for an ESP performing a follow up appointment with a shoulder patient. The estimate will be calculated based on time spent on the appointment and mean salary for an ESP (information on mean salary will be obtained from statistics at the finance department at the hospital)	Baseline
Costs - computed tomography (CT) imaging	Expenditure on CT imaging. Estimate obtained from the finance department at the hospital.	Baseline
Costs - magnetic resonance (MR) imaging	Expenditure on MR imaging. Estimate obtained from the finance department at the hospital.	Baseline
Costs - MR arthrography	Expenditure on MR arthrography. Estimate obtained from the finance department at the hospital.	Baseline
Costs - electroneurography (ENG)	Expenditure on ENG. Estimate obtained from the finance department at the hospital.	Baseline
Costs - electromyography (EMG)	Expenditure on EMG. Estimate obtained from the finance department at the hospital.	Baseline
Costs - X-ray	Expenditure on X-ray. Estimate obtained from the finance department at the hospital.	Baseline

Collaborators and Investigators

• Sponsor: Central Jutland Regional Hospital
• Investigators: Principal Investigator: Merete N Madsen, MSc, Silkeborg Regional Hospital

Publications and helpful links

General Publications

• Madsen MN, Kirkegaard ML, Klebe TM, Linnebjerg CL, Villumsen SMR, Due SJ, Trostrup J, Rossen CB, Birk HO, Elmengaard B, Mikkelsen LR. Inter-professional agreement and collaboration between extended scope physiotherapists and orthopaedic surgeons in an orthopaedic outpatient shoulder clinic - a mixed methods study. BMC Musculoskelet Disord. 2021 Jan 4;22(1):4. doi: 10.1186/s12891-020-03831-z.

Study record dates

Study Major Dates

• Study Start (Actual): November 17, 2017
• Primary Completion (Actual): April 13, 2018
• Study Completion (Actual): June 19, 2018

Study Registration Dates

• First Submitted: November 10, 2017
• First Submitted That Met QC Criteria: November 10, 2017
• First Posted (Actual): November 17, 2017

Study Record Updates

• Last Update Posted (Actual): August 15, 2018
• Last Update Submitted That Met QC Criteria: August 14, 2018
• Last Verified: February 1, 2018

More Information

Terms related to this study

• Keywords: Diagnosis; Cost Analysis; Physical Therapists; Clinical Competence; Interprofessional Relations
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Wounds and Injuries; Joint Diseases; Musculoskeletal Diseases; Muscular Diseases; Arthralgia; Shoulder Pain; Musculoskeletal Pain; Shoulder Injuries
• Other Study ID Numbers: 654821

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No