title: Substitution of an orthopaedic surgeon with a physiotherapist in the management of shoulder pain
Creators: name: Marks, Darryn M.
Publisher: name: Griffith University
Year: 2019
Subjects: subject: Shoulder pain
subject: Orthopaedic surgeons
subject: Physiotherapists
subject: Pain management

description: Background: Shoulder pain is a common problem and a challenge for public healthcare service providers. Those suffering from it are often referred to an orthopaedic specialist in pursuit of a surgical solution, only to be confronted with long waiting lists and in many instances, the news that surgery is not recommended. As the population ages and demand for health services increases, the need for more efficient service provision will intensify. To address this challenge, traditional orthopaedic pathways are evolving. Today many orthopaedic patients are seen by physiotherapists instead of doctors. This form of professional substitution aims to reduce waiting periods and improve access to the most appropriate care. Yet the health economic impact of expanding physiotherapist duties is not well understood as research in this field has lacked scope and rigour, particularly in relation to prescribing and injecting. Consequently, the optimal contribution of physiotherapists to the delivery of efficient shoulder care is unclear. Shoulder pain provides a clinical platform to explore the efficacy and efficiency of expanding the role of physiotherapists in orthopaedic services. Orthopaedic shoulder care involves assessment, diagnosis and management; selection of individuals for and provision of corticosteroid injection, referral for physiotherapy, identification of individuals requiring surgery and surgical care. Evaluation of the impact of professional substitution with a physiotherapist should consider the safety, efficacy, efficiency and patient-acceptability of a physiotherapist compared with an orthopaedic doctor. Objective: To investigate the health economic impact of substituting an orthopaedic surgeon with a physiotherapist in the management of shoulder pain and determine the optimal role of physiotherapists in the efficient care of patients referred to orthopaedics for shoulder pain. Methods: A number of studies were undertaken to meet the objective: A systematic review was undertaken to clarify the safety, efficacy, cost effectiveness and patient-acceptability of physiotherapists acting as a professional substitute for doctors, in the management of musculoskeletal disorders. Unlike previous reviews (which predominantly comprised of single-group observational case series), the only studies included were those that directly compared management by a physiotherapist with management by a doctor. To address methodological deficiencies identified in the systematic review and related evidence gaps, a series of studies (linked to an overarching randomised controlled trial protocol) were designed. New and unfiltered general practitioner-referred adults with shoulder pain from the orthopaedic waiting list were recruited to attend orthopaedic outpatients at a large public hospital in Australia. Baseline data were collected from 277 participants, of which 274 were assessed by both a physiotherapist and an orthopaedic surgeon and 64 entered an RCT before receiving pragmatic usual care. This permitted three separate investigations: • The economic burden of shoulder pain was estimated with a two-part cost-of-illness analysis. Retrospective cost and impact data, together with work absenteeism and presenteeism information provided by the 277 participants was used to estimate the economic burden of patients on the orthopaedic waiting list. In addition, the cost of hospital care provided to those 277 participants was calculated over a two-year period. • The efficacy and efficiency of physiotherapist decision making was investigated with an agreement study which compared a physiotherapist and orthopaedic surgeon’s care decisions in 274 participants who were independently assessed by the physiotherapist and the orthopaedic surgeon. Shoulder pain diagnosis and management, including decisions regarding investigations and selection for subacromial corticosteroid injection, were compared using inter-rater reliability statistics. • A double blinded non-inferiority randomised controlled trial investigated the efficacy and efficiency of the physiotherapist delivering subacromial corticosteroid and local anaesthetic injection compared with the surgeon. Participants deemed appropriate for injection in their assessment with both the physiotherapist and the orthopaedic surgeon (N=64), were randomized to receive the injection from either one of these professionals. All subjects received routine post-injection physiotherapy (not delivered by the injecting physiotherapist). The primary outcome was the shoulder pain and disability index (SPADI) administered at baseline, six and 12-weeks. The EuroQoL (EQ-5D-5L) supported a within trial cost utility analysis undertaken from the perspective of the health funder. Results: Fourteen studies of moderate to low quality met the inclusion criteria for the systematic review. While substitution of the doctor with a physiotherapist in the management of musculoskeletal disorders did not change health outcomes and produced inconsistent variation in resource use, there were major methodological shortcomings: in all but two studies, selective inclusion criteria removed more complex cases rendering the study cohort different to usual orthopaedic populations, there was insufficient health economic data to judge efficiency and there was no information about prescribing or injecting by physiotherapists in comparison to doctors. Consequently, the efficacy and efficiency of physiotherapist roles in shoulder care was unclear. The cost-of-illness study revealed that public orthopaedic waiting lists create a large cost burden for society. The mean societal cost of healthcare and domestic support was AU$20.72 per day (AU$7563 annually) per patient on the orthopaedic waiting list. When absenteeism and presenteeism are included, the cost per patient who was employed was AU$61.31 per day (AU$22,378 annually) calculated with the Work Productivity and Activity Impairment Questionnaire (WPAI). The mean per patient cost to government of public hospital care was AU$2622 in year one and AU$3836 (SD 4961) over two years. Care delivery lacks efficiency with a surgical conversion rate of only 22% and with 51% of hospital care cost attributable to outpatient services. The agreement study revealed that the physiotherapist made safe and very similar shoulder management decisions to the orthopaedic surgeon, with no apparent impact upon the utilization of healthcare resources. There was near perfect agreement between the physiotherapist and consultant orthopaedic surgeon regarding diagnosis, investigation, surgical versus non-surgical care, referral for physiotherapy treatment and judgement of the safety of subacromial injection of corticosteroid and local anaesthetic. The physiotherapist was moderately less inclined to use subacromial injection as an immediate treatment. The non-inferiority RCT and health economic analysis supported the hypothesis that a physiotherapist can prescribe and deliver subacromial corticosteroid and local anaesthetic injection at least as effectively and at less expense than a consultant orthopaedic surgeon. Conclusion: A physiotherapist trained in prescribing and injection of corticosteroids and local anaesthetic, can safely, efficaciously, less expensively and with high patient satisfaction, be a professional substitute for the orthopaedic surgeon with respect to the non-surgical components of shoulder care including patient assessment, management, and delivery of subacromial injection.