Clinical trial NCT03343951: Evaluation of Extended Scope Physiotherapists in an Orthopaedic Outpatient Shoulder Clinic
Official title: 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
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Shoulder Injuries and Disorders
Shoulder Pain
Musculoskeletal Pain
Keywords: Physical Therapists
Diagnosis
Clinical Competence
Interprofessional Relations
Cost Analysis
Lead sponsor: Central Jutland Regional Hospital
Sponsor class: OTHER
First posted: 2017-11-17
Enrollment: 69
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: CROSS_SECTIONAL
Sampling method: PROBABILITY_SAMPLE
Study population: Patients with shoulder problems referred to the shoulder clinic at Silkeborg Regional Hospital.

Brief summary: 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.

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.

Eligibility criteria: 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

Primary outcomes:
measure: Treatment plan - orthopaedic surgeon
timeFrame: Baseline
measure: Treatment plan - physiotherapist
timeFrame: Baseline
measure: Treatment plan - common decision
timeFrame: Baseline
Secondary outcomes:
measure: Diagnosis - orthopaedic surgeon
timeFrame: Baseline
measure: Diagnosis - physiotherapist
timeFrame: Baseline
measure: Diagnosis - common decision
timeFrame: Baseline
measure: New appointment - orthopaedic surgeon
timeFrame: Baseline
measure: New appointment - physiotherapist
timeFrame: Baseline
measure: New appointment - common decision
timeFrame: Baseline
measure: Discussion needed - orthopaedic surgeon
timeFrame: Baseline
measure: Discussion needed - physiotherapist
timeFrame: Baseline
Other outcomes:
measure: Salary - orthopaedic surgeon, first clinical examination
timeFrame: Baseline
measure: Salary - orthopaedic surgeon, planned new appointment
timeFrame: Baseline
measure: Salary - extended scope physiotherapist, first clinical examination
timeFrame: Baseline
measure: Salary - extended scope physiotherapist, planned new appointment
timeFrame: Baseline
measure: Costs - computed tomography (CT) imaging
timeFrame: Baseline
measure: Costs - magnetic resonance (MR) imaging
timeFrame: Baseline
measure: Costs - MR arthrography
timeFrame: Baseline
measure: Costs - electroneurography (ENG)
timeFrame: Baseline
measure: Costs - electromyography (EMG)
timeFrame: Baseline
measure: Costs - X-ray
timeFrame: Baseline
Locations:
city: Silkeborg
country: Denmark
facility: Silkeborg Regional Hospital
Study officials:
affiliation: Silkeborg Regional Hospital
name: Merete N Madsen, MSc
role: PRINCIPAL_INVESTIGATOR
References:
citation: 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.