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Abstract
Objective To describe the impact of an expanded primary care-based sports medicine clinic on referrals to an orthopaedics clinic and to describe the patients seen and procedures performed.
Design Retrospective cohort study.
Setting Primary care-based sports medicine clinic and orthopaedics clinic at a tax-supported American safety net healthcare system.
Participants All patients referred to the sports medicine clinic by other primary care physicians over a 1-year time period of July 2006–June 2007.
Main outcome measures The referral rate from sports medicine clinic to orthopaedics clinic, the percentage of referred patients who were recommended surgery by the orthopaedists, the change in average waiting time to be seen in orthopaedics clinic and the most common conditions and procedures.
Results 4925 patients were seen by the sports medicine department; 118 (2.4%) of those patients were referred to the orthopaedic department. Of the referred patients, surgery was offered by orthopaedists to 80 (68%) patients. The average wait for initial consultation by the orthopaedic spine clinic decreased from 199 to 70 days; the wait for general orthopaedic clinic decreased from 97 to 19 days. No single patient complaint or musculoskeletal pathology predominated: knee degenerative joint disease (25.3%), mechanical low back pain (21.6%) and lumbar disc disease (19.9%). Knee injections and epidural steroid injections were the most common procedures performed.
Conclusions Very few patients with musculoskeletal pathology were referred by a primary care-based sports medicine clinic to an orthopaedics clinic. Of the referred patients, sports medicine physicians and orthopaedists frequently agreed on the need for surgery. Expansion of a primary care-based sports medicine service could help relieve overburdened orthopaedics departments of patients with conditions not requiring surgery.
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Background
Healthcare systems around the world continually attempt to determine which patients and conditions are appropriate for primary versus secondary care. Overburdened specialty departments result in long waiting times for patients to see specialist physicians, with further waits for indicated procedures. Long waiting times have been observed for orthopaedic services in several countries.1,–,3
Within primary care, sports medicine has evolved into a focused discipline. Accreditation of the first sports medicine fellowships began in 1996, and there are now more than 60 primary care sports medicine (PCSM) fellowship programmes.4 Currently there are more than 1300 primary care physicians (primary care, internists, paediatricians and emergency physicians) with Certificates of Added Qualification (CAQ) in sports medicine.4 Qualification for a CAQ in sports medicine is offered only to those who have completed a minimum of 1 year in an Accreditation Council for Graduate Medical Education-accredited sports medicine fellowship.
The complementary nature of the PCSM physician and orthopaedic physicians allows for a potential reduction in the demands on an orthopaedist for non-surgical treatment. The purpose of our study was to measure the impact of an expanded primary care-based sports medicine department on processes of care: the referral rate from sports medicine clinic to orthopaedics clinic, the percentage of referred patients who were recommended surgery by the orthopaedists and the change in average waiting time to be seen in orthopaedics clinic. We also describe the patients seen at the sports medicine clinic and report on the most common procedures performed.
Methods
This was a retrospective cohort evaluation of the patients seen at the sports medicine clinic from 1 July 2006 through 30 June 2007. JPS Health Network (JPS) is the tax-supported provider of healthcare services for mostly the low-income residents of Tarrant County, Texas. JPS has a 457-bed main hospital and approximately 45 primary care centres of varying size and personnel.
The JPS family medicine residency programme sports medicine fellowship began in 2003. The sports medicine fellows and faculty cover many high school and university sporting events. However, a significant portion of their patients are not young athletes but are more commonly middle-aged or older patients with acute or chronic musculoskeletal conditions that have previously been treated by a primary care physician.
In the autumn of 2006, the capacity of the sports medicine clinic was expanded when it moved to a larger facility. Simultaneously, processes within JPS were changed so that primary care physicians with patients with musculoskeletal conditions were first evaluated by the sports medicine department instead of a direct referral to orthopaedics. This process change was recommended throughout the JPS system but was not rigidly controlled. Orthopaedic referrals were then made by the sports medicine physicians as they deemed necessary.
A log of all patient visits to the sports medicine clinic was generated using billing data to capture diagnoses and basic demographics. This information included procedures performed at the sports medicine clinic. Additionally, a log of all patients referred to the orthopaedics department was maintained, and the orthopaedic clinic charts were reviewed to determine the final disposition of the patient.
All referrals and appointments within the JPS Health Network were coordinated through a centralised call and referral centre. When a referral was requested by the sports medicine clinic to the orthopaedic clinic, the scheduling system listed the first available appointment date. At the beginning of each month of the study, the time from date of the referral request to the first available appointment at the general orthopaedics and orthopaedic spine clinics was calculated.
Statistical analyses included descriptive statistics. Categorical data were analysed using χ2. Continuous data were analysed using the Student t test or analysis of variance. This research was approved by the JPS Health Network Institutional Review Board.
Results
A total of 4925 patients were seen at the PCSM clinic during the study year; 5197 patients were seen at the general and spine orthopaedic clinics during the same time period;
118 out of the 4925 patient encounters (2.4%) resulted in referrals by the PCSM clinic to the JPS orthopaedics department; and four patients who were counted as referred had requested to see the orthopaedists, though the sports physicians thought the referral was unnecessary. None of these patients were offered surgery by the orthpaedists.
Of those referred, a surgical procedure was recommended by the orthopaedic clinic 68% (80/118) of the time, and the recommendation for the procedure occurred on the first orthopaedic visit 95% (76/80) of the time. In the majority of the other cases, the orthopaedists chose to attempt other non-surgical approaches first.
The average wait for initial consultation by the orthopaedic spine clinic decreased from 199 days just prior to the sports medicine clinic expansion to 70 days. The wait for general orthopaedic clinic decreased from 97 to 19 days at the lowest point. In the last month of the study, the waiting time temporarily increased to 70 days, because of scheduling and staffing changes in the orthopaedics department.
The majority of the PCSM clinic patients were female (72.6%) with an average age of approximately 52 years (table 1). The top three diagnoses were knee degenerative joint disease (25.3%), mechanical low back pain (21.6%) and lumbar disc disease (19.9%).
Characteristics of unique patient visits to the sports medicine department.
Knee arthrocentesis, sacroiliac joint injections, facet joint injections and lumbar epidural injections were the most frequent interventions performed (table 2). A total of 1820 procedures were performed.
Most common procedures performed at the sports medicine centre
Hand/elbow and foot/ankle complaints were most frequently seen in younger patients. Knee complaints were more common in the older people. Back pain was common in all ages (table 3). Lumbar epidural steroid injections were the most common procedures performed in people under 45 years of age. Knee injections became the most frequent procedure performed after 45 years of age. Men with back symptoms were more likely to receive facet injections for back pain (37% vs 28%, p < 0.001); women were more likely to receive sacroiliac injections (35% vs 22%, p < 0.001). There were no differences in treatment by race/ethnicity.
Effect of age on the location of the presenting symptom and the procedure performed
Discussion
This study demonstrated a very low referral rate from a primary care-based sports medicine department to an orthopaedic department. The orthopaedists frequently agreed that surgery was indicated in referred patients. By expanding the capacity of the primary care-based sports medicine department, waiting times to general orthopaedics clinic and orthopaedic spine clinic were significantly reduced.
The referral rate by the JPS PCSM clinic of 2.4% was less than the 8% rate reported by Butcher, Kennedy and Hoffman.5,–,7 Our lower referral rate may be explained in part because fewer acute injuries were seen at the JPS PCSM clinic than the other centres. Kennedy examined acute sports injuries on a primarily young population (mostly 15–29 years).6 Butcher et al evaluated referred military beneficiaries also younger than our population (mean age 34).5 The vast majority of our study population was older (mean age 51.9) and evaluated for chronic musculoskeletal pathology.
Previous studies did not report agreement rates for surgical intervention between the sports medicine and orthopaedic physicians in referred patients.5,–,7 Though the intentions of the referring sports physicians are not explicitly stated, it makes little sense to refer a patient to an orthopaedist if surgery is not very likely. Therefore, a strength of our study is that it adds further information on the orthopaedic decision-making after the initial referral (68% of our referred patients received surgical intervention).
Another possible explanation for the difference in referral rates is that the JPS sports medicine department provides flouroscopically guided procedures, such as epidural injections, and facet and sacroiliac nerve ablations, which were not mentioned in the other papers. The other sports medicine centres did not provide this comprehensive list of services.
Concern has been raised by orthopaedic physicians that a substantial portion of referrals from primary care physicians are inappropriate.8 9 Referrals to an orthopaedic practice can be misdirected, as well as having poor consistency and extreme variability between primary care physicians on what is an appropriate referral.10 11 A large proportion of these referrals may indicate either a lack of basic textbook knowledge or a lack of examination skills by certain primary care providers.8 10 Our high rate of agreement with the orthopaedic physicians on the benefits of surgery suggests that the referrals were very appropriate. The 68% surgical intervention rate also suggests that borderline cases were also referred to orthopaedists. A 100% surgery rate may indicate that appropriate patients are not being referred.
Medical school training in musculoskeletal medicine is frequently seen as inadequate. In one study, 82% of the medical school graduates failed a valid musculoskeletal competency examination.12 Similarly, a majority of primary care providers tested failed to demonstrate adequate musculoskeletal knowledge and confidence, particularly in joint injection techniques.13 14
Therefore, to create a healthcare system that is as efficient as possible to care for patients with musculoskeletal symptoms and diseases, there is evidence that musculoskeletal training should improve in medical schools and residencies. This might decrease the number of referrals from primary care to either sports medicine or orthopaedics.
This study was limited by its retrospective observational design and inability to capture all possible confounding variables, such as other system changes not known to the researchers. Thus, cause–effect relationships could not be proven. It is not known how many patients who were not referred by the sports medicine clinic to the orthopaedics clinic might have benefitted from surgery. However, patients could receive appointments to the orthopaedics clinic by other pathways. From discussions with the orthopaedic physicians and other chart reviews, there were no patients identified who were considered non-surgical by sports medicine but who were then determined to have a surgical condition by orthopaedic physicians, though this result was not explicitly measured. This study was also limited in that no patient or disease-specific outcomes were measured, such as pain scales, functional assessments or measures of patient satisfaction. Finally, we assumed that reducing the patient volume at orthopaedic clinics would result in efficiencies for the greater healthcare system, though financial outcomes were not measured.
What is already known on this topic
▶ Many patients referred to orthopaedics have non-surgical pathology.
▶ Sports medicine physicians reduce referrals from primary care to orthopaedics.
▶ Previous research primarily evaluated acute injuries in young populations.
What this study adds
▶ There is a high rate of agreement between primary care sports medicine physicians and orthopaedics on the need for surgery.
▶ Enhanced sports medicine capacity reduces non-surgical referrals to orthopaedics.
▶ Sports medicine departments that see older patients with more chronic pathology and provide fluoroscopic procedures may have lower referral rates.
Future research should continue to explore the relationships between primary care, primary care-based sports medicine and orthopaedics that will lead to the highest quality and most efficient care of musculoskeletal symptoms and diseases.
References
Footnotes
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Ethics approval Ethics approval was provided by the JPS Health Network IRB.
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Provenance and peer review Not commissioned; externally peer reviewed.