Referrals to hospital-based rheumatology and orthopaedic services: seeking direction

C. A. Speed and A. J. Crisp

Rheumatology, Sports and Exercise Medicine, Addenbrooke's Hospital and Department of Medicine, University of Cambridge, Cambridge, UK.

Correspondence to: C. A. Speed, Rheumatology, Sports and Exercise Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Objectives. While both community and hospital-based services strive to cope with the considerable burden posed by musculoskeletal disorders, multidisciplinary-led, integrated approaches are frequently lacking. It has been suggested that referrals to musculoskeletal services are frequently misdirected to an orthopaedic surgeon when non-surgical advice/intervention is warranted, reducing the efficiency of hospital-based services and potentially affecting quality of care. Triage of referrals may help to prevent this, but this system is dependent upon accurate and thorough information being provided in the referral letter. Our aim was to assess the feasibility of triage of musculoskeletal referrals to rheumatology and orthopaedic services at a large teaching hospital.

Methods. One thousand and eighty-seven consecutive referral letters to orthopaedic and rheumatology services were reviewed by a consultant rheumatologist. Letters were assessed for both basic content and the appropriate destination for that referral. In order to evaluate the accuracy of the assessor's prediction of the most appropriate destination of the referrals, the number of patients who were ultimately listed for surgical intervention was calculated in a random sample of orthopaedic referrals, 1 yr after the initial hospital appointment was requested.

Results. Six hundred and eighty-two referrals were to orthopaedics and 393 to rheumatology. Referrals relating to spinal pain were excluded. The content of letters was scant and no diagnosis was volunteered in 63.4% of referrals. Fifty-eight per cent of referrals to orthopaedics were considered appropriate; 27% of referrals to orthopaedics were defined as ‘should definitely see a rheumatologist’ (12%) or ‘should probably see a rheumatologist’ (15%). Fifteen per cent of referrals to orthopaedics were defined as ‘could see either a surgeon or a rheumatologist’. Ninety-four per cent of referrals to rheumatology were defined as appropriate, 2% were not and 4% were defined as ‘could see either a surgeon or a rheumatologist’. One year later, in a random sample of 373 of the orthopaedic referrals, 42.2% of those who were categorized as ‘should see surgeon’ and 9.7% of the ‘should see a physician’ group were listed for surgical intervention.

Conclusions. Many referrals to hospital-based musculoskeletal services are likely to be misdirected. Integrated referral and care pathways are required for efficient and optimal care of patients with musculoskeletal diseases. The development of such pathways will require significant support, education and training for general practitioners.

KEY WORDS: Hospital referral, Rheumatology, Orthopaedics


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Musculoskeletal disorders are the most common causes of severe long-term pain and physical disability, chronic musculoskeletal pain affecting at least a quarter of the adult population [1]. Soft tissue and spinal complaints represent the most common source of pain, the most frequent cause of limitation of activity in the young and middle-aged, and one of the commonest reasons for medical consultation. The incidence of musculoskeletal complaints increases with age; peripheral articular complaints account for half of all chronic conditions in people aged 60 and over and 25% of people over the age of 60 have significant pain and disability from osteoarthritis. The cost to society of illness for musculoskeletal disorders is far higher than that for any other group of complaints, even compared with brain and mental diseases added together [2], and with our ageing society the burden will become greater.

Hence, musculoskeletal disorders pose a considerable burden on both primary and secondary care and account for over a quarter of general practitioner (GP) consultations [3]. While both community and hospital-based services strive to cope with the demand, integrated approaches using a multidisciplinary framework and guidelines for management and referral are frequently lacking. General and primary care physicians frequently express low levels of confidence in their abilities to diagnosis and manage musculoskeletal disorders [4–8] and this may contribute to early referral to hospital-based musculoskeletal services, represented in the most part by orthopaedics and rheumatology. It has been suggested that referrals to musculoskeletal services are frequently misdirected to an orthopaedic surgeon when non-surgical advice/intervention is warranted, reducing the efficiency of hospital-based services and potentially affecting quality of care.

The use of triage systems in order to ensure referrals reach the most appropriate destinations has become a popular concept. Various triage structures exist, perhaps the most simplistic of these consisting of ‘paper triage’, where the referral is directed by a specialist acting as gatekeeper. However, this system is dependent upon accurate and thorough information being provided in the letter of referral.

In order to assess the potential for paper triage of existing referrals to musculoskeletal services in our hospital, an audit study was performed of GP referrals to rheumatology and orthopaedic services in our hospital.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The study was performed in a large teaching hospital with an approximate catchment population of 550 000. In the year in question there were approximately 6000 referrals to trauma, 6200 to orthopaedics and 4100 to rheumatology; referrals have risen significantly by over 20% to rheumatology and by 12% to trauma and orthopaedics since then.

One thousand and eighty-seven consecutive referral letters in 2002 to orthopaedics and rheumatology services at a large teaching hospital were reviewed by a consultant rheumatologist. Letters were assessed for (i) basic content (including patient demographics, details of the complaint, whether a diagnosis was given, investigations performed, treatments to date), and (ii) the appropriate destination for that referral. Criteria for referral to orthopaedics and rheumatology were devised empirically (as there is no such information in the literature) and were deliberately wide (Table 1).


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TABLE 1. Criteria for assessing the appropriateness of the chosen destination for each referral

 

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TABLE 2. Content of GP referral letters to orthopaedic and rheumatology services

 

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TABLE 3. Appropriate destination of referrals

 
The first two categories were each divided into ‘definite’ and ‘probable’ according to the level of confidence (strong or moderate) in the allocated destination. In order to evaluate the accuracy of the assessor's prediction of the most appropriate destination of the referrals, the number of patients who were ultimately listed for surgical intervention was calculated in a random sample of orthopaedic referrals 1 yr after the initial request for an appointment. Reliability of the assessment was assessed using 60 random referrals assessed twice at an interval of a fortnight.

Spinal conditions were excluded from this audit as they are historically not part of the orthopaedic surgical practice in our hospital, being the remit of a combined spinal triage system run by a rheumatology, neurosurgical and physiotherapy team.


    Results
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The assessor's evaluation was found to be reliable (r = 0.978). Of the 1087 referrals (519 males and 568 females), 682 referrals were to orthopaedics and 393 to rheumatology.

Content of referral letters
No details were given of duration of symptoms in 46.2% of referrals, of impact on function in 64.9% of referrals, investigations prior to referral in 57.5% of referrals, of management prior to referral in 41%, or of examination in 68% of referrals.

No diagnosis was volunteered in 63.4% of referrals. GPs appeared to be most confident in making a diagnosis of osteoarthritis, meniscal damage to the knee, recurrent instability of the shoulder or knee and mechanical back pain.

Appropriateness of referral destinations
The appropriate destination for referrals to the services was then evaluated according to the preset criteria.

Fifty-eight per cent of referrals to orthopaedics were defined as ‘should definitely see a surgeon’ (41%) or ‘should probably see a surgeon’ (17%). Twenty-seven per cent of referrals to orthopaedics were defined as ‘should definitely see a rheumatologist’ (12%) or ‘should probably see a rheumatologist’ (15%). Fifteen per cent of referrals to orthopaedics were defined as ‘could see either a surgeon or a rheumatologist’, because (i) investigations were clearly needed prior to decisions on management, or (ii) the letter was unclear, or (iii) surgery may be indicated in the future but medical management was clearly required in the first instance.

Ninety-four per cent of referrals to rheumatology were defined as ‘should definitely see a rheumatologist’ (85%) or ‘should probably see a rheumatologist’ (9%). Two per cent of referrals to rheumatology were defined as ‘should definitely see surgeon’ (1%) or ‘should definitely, probably see surgeon’ (1%). Four per cent of referrals to rheumatology were defined as ‘could see either a surgeon or a rheumatologist’, for the reasons listed earlier in relation to orthopaedic referrals.

One year later, the number of patients ultimately listed for surgical intervention was calculated in a random sample of 373 of the orthopaedic referrals. Of those who were categorized as ‘should see surgeon’ 42.2% (86/204) were listed for an operative intervention. Of those who were categorized as ‘should see a physician’ 9.7% (10/103) were listed for an operative intervention. This represented the two subgroups: 1/41 (2.4%) who ‘should definitely’ and 9/62 (14.5%) of those who ‘should probably’ see a physician’. Of those who were categorized as ‘could see either’, 27.3% (15/55) were listed for an operative intervention.


    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
It is clear from the results of this study that the content of referral letters to musculoskeletal services is highly varied and often there is insufficient information provided to accurately determine the most appropriate destination for that referral. There are many potential reasons for this, including time constraints in preparation of the referral, a lack of guidance from specialists on the information required and limitations in the recognition and understanding of musculoskeletal disorders in primary care.

The orthopaedic surgery conversion rate (the proportion of referred patients who ultimately are listed for surgery) is a simplistic approach to the evaluation of the appropriateness of the destination of referral. Choice of investigations, non-surgical treatments and counselling may all be part of a surgeon's role. Nevertheless, the results of our study indicate that too many referrals into a hospital service are being misdirected. It must be emphasized that, unlike most hospitals, patients with spinal pain are seen not by orthopaedic surgeons but by a multidisciplinary team composed of rheumatologists, neurosurgeons and physiotherapists. If this were not the case, then the percentage of misdirected referrals to orthopaedics is likely to have been much greater.

The purpose of this study was not to evaluate the potential for referrals to allied professions and in particular to physiotherapists, although of course this is an important question. We considered that all referrals were appropriate for secondary care services on the basis that the referring GP felt it necessary to request help with ongoing management. Nevertheless, it is likely that increased support from hospital-based specialists would improve care in the community and have an impact upon referral rates. Such support should consist of education and training in the recognition of basic musculoskeletal conditions in addition to guidelines for both management and referral. Roberts et al. found that GPs in Sheffield and Barnsley reported high levels of confidence in the diagnosis and management of back pain, osteoarthritis, gout and some sporting injuries, provided adequate education and consultant support were available [9]. Crossing specialty boundaries in the provision of this support is essential to ensure integrated approaches to care. Clear guidance on referral pathways from primary to secondary care musculoskeletal services, including the criteria for referral and its appropriate destination, is often absent or non-specific [7, 8], adding to inefficiency of services.

Other forms of triage do exist, including pre-assessment of referrals by a physiotherapist, or by a ‘community rheumatologist’ or a musculoskeletal physician. All models seem to have their limitations and none has been subjected to rigorous scrutiny. Perhaps the development of simple referral proformas, for example for shoulder pain and knee pain, is the simplest and most efficient approach; this also remains to be evaluated. Provision of resources in the development of community and hospital services to cope with the revised demand in certain areas will have to follow in order to ensure the benefit is felt by both the patient and the health service.

Conclusion
Many referrals to hospital based musculoskeletal services are misdirected. Integrated referral and care pathways are required in both primary and secondary care for efficient and optimal care of patients with musculoskeletal diseases. The development of such pathways will require significant support by hospital specialists in the form of education, training and the provision of advice to GPs.

The authors have declared no conflicts of interest.


    References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. The Bone and Joint Decade. http://www.bonejointdecade.org/background/default.html
  2. White KP, Harth M. the occurrence and impact of generalised pain. Baillieres Clin Rheumatol 1999;13:379–89.
  3. McCormack A, Fleming D, Charlton J. Morbidity statistics from general practice. 4th National study 1991–1992. Series MB5 no. 3. London: HMSO, 1995.
  4. Bolumar F, Ruiz MT, Hernandez I, Pascual E. Reliability of the diagnosis of rheumatic conditions at the primary health care level. J Rheumatol 1994;21:2344–8.[ISI][Medline]
  5. Matheny JM, Brinker MR, Elliott MN, Blake R, Rowane MP. Confidence of graduating family practice residents in their management of musculoskeletal conditions. Am J Orthop 2000;29:945–52.
  6. Lillicrap MS, Byrne E, Speed CA. Musculoskeletal assessment of general medical in-patients—joints still crying out for attention. Rheumatology 2003;42:951–4.[Abstract/Free Full Text]
  7. Roland MO, Porter RW, Matthews JG, Redden JF, Simonds GW, Bewley B. Improving care: a study of orthopaedic outpatient referrals. BMJ 1991;302:1124–8.[ISI][Medline]
  8. Gamez-Nava JI, Gonzalez-Lopez L, Davis P, Suarez-Almazor ME. Referral and diagnosis of common rheumatic diseases by primary care physicians. Br J Rheumatol 1998;37:1215–9.[CrossRef][ISI][Medline]
  9. Roberts C, Adebajo AO, Long S. Improving the quality of care of musculoskeletal conditions in primary care. Rheumatology 2002;41:503–8.[Abstract/Free Full Text]
Submitted 30 June 2004; revised version accepted 2 November 2004.