Physiotherapy-led care in paediatric orthopaedics

Aim

To evaluate an advanced practice physiotherapy-led outpatient model of care for children with orthopaedic variants.

Outcomes

An advanced practice physiotherapy-led model of care for children with orthopaedic variants  demonstrated

• strong clinical concordance
• a higher surgical conversation rate compared to community-based referrals
• excellent caregiver satisfaction, and
• cost-effectiveness comparable to other models of care.

Background

Childhood orthopaedic variants, including genu valgum, genu varum, in-toeing, out-toeing and foot postures can account for up to 50% of referrals to paediatric orthopaedic surgeons (O’Mir and O’Sullivan, 2018). The majority of these presentations self-resolve (Bourgleh et al., 2019), with a low surgical conversion rate of 3-10% from community referrers (Bourgleh et al., 2019; McCarthy et al., 2011). Increased pressure on healthcare systems has compelled services to explore novel models of care to manage waiting lists and enable patients to be seen within specific time-based targets.

The high referral rates and low surgical management rate of orthopaedic variants is ideal for an advanced practice (AP) physiotherapy-led model of care (MoC). Advanced practice physiotherapy-led MoCs have gathered in popularity (Fennelly et al., 2018) including within paediatric orthopaedics. An AP physiotherapy-led MoC enables physiotherapists with advanced clinical skills to manage patients autonomously or in collaboration with the medical team (Australian Physiotherapy Association, 2024). An advanced practice (AP) physiotherapy-led model of care (MoC) facilitates timely access to assessment, reduces parental anxiety (McCarthy et al., 2011), reduces orthopaedic wait lists and expedites access to orthopaedic care for those children who require orthopaedic input (Fennelly et al., 2018;  O’Mir & O’Sullivan, 2018). Studies from UK and Ireland have demonstrated very high agreement between the AP physiotherapist and orthopedic consultants (Miller et al., 2016; O’Mir et al., 2018) and excellent satisfaction among caregivers (Miller et al., 2016; O’Mir et al, 2019). Physiotherapy-led MoCs have been evaluated for cost efficiency. Lafrance et al. (2021) undertook a meta-analysis of the cost effectiveness of AP physiotherapy-led MoCs.

They found low level evidence for lower health care costs and higher  patient costs through a meta-analysis of 12 studies. However, the meta-analysis was adult-centric and only two of these studies included paediatric participants, O Mir et al (2019) and Belthur et al., (2003). O Mir (2019) compared the cost of an AP physiotherapy-led  MoC with an Orthopaedic Consultant Elective Clinic for paediatric musculoskeletal presentations in Ireland. The study found incremental savings in the AP physiotherapy MoC but only gathered information for a 12-month period rather than evaluating the cost  of each patient’s journey. Belthur et al., (2003) compared the cost of a physiotherapy-led MoC versus the orthopaedic consultant for children with musculoskeletal considered unlikely to require surgery, in Wales. Belthur et al., evaluated the labour costs  based on the number of appointments the clinicians would manage each clinic but didn’t consider frequency of patient appointments in the staff costs, imaging expenses or patient expenses. There is an ongoing gap in the literature for the cost consequence of  an AP physiotherapy-led MoC within paediatric orthopaedics, that assesses both healthcare and patient costs across the patient journey and is outside the United Kingdom.

Discussion

Of 737 children in the retrospective study, 81.3% presented with nil findings or received  physiological diagnoses which typically self-resolve over time. Among children presenting with orthopaedic alignment conditions such as in-toeing, out-toeing, flat feet or foot postures, 79.6% were managed by physiotherapy alone. The surgical conversation  rate of referrals from the AP physiotherapist to the orthopaedic surgeon was 19.5% compared to 3.5% for community referrals. Physiotherapy-led management pathways were appropriate for 98.6% of children. Prospective clinical concordance between the AP physiotherapist  and orthopaedic surgeon was high for diagnosis (83%), management decisions (83%) and follow-up recommendations (100%). Caregiver satisfaction with the AP physiotherapy-led MoC was excellent (median=100, IQR=3).

The thematic analysis identified five themes:
Four reflected positive feedback on clinician rapport, clinician skills, reassurance and summation, and service operation and efficiency.

The fifth theme - service access – highlighted opportunities for improvement, such as car parking costs. The cost consequence
results showed comparable costs for the three different models of care. The paediatrician-led model was more costly than the physiotherapist-led model of care after accounting for the patient case-mix. The different models of care were not strong predictors
of the overall cost of care. Most cost variation was driven by patient condition. The most desirable model of care is better determined by considering the clinical outcomes, patient satisfaction and the availability of different workforces to meet demand for  care.

The value of a physiotherapy-led model enables limited orthopaedic surgeon resources to be directed to manage patients requiring their specialist care including surgical intervention. Advanced practice physiotherapy-led models of care for paediatric  orthopaedic conditions are accepted and valued by clinicians and caregivers and offer safe and effective alternatives to medically-led models.

References

Belthur MV, Clegg J, Strange A. A physiotherapy specialist clinic in paediatric orthopaedics:  is it effective? Postgrad Med J. 79(938):699-702. PMCID: PMC1742895

Bourgleh, S. M., R Nemeş, Hetaimish, B. M., & L Chiuţu. (2019). Prevalence of musculoskeletal normal variations of the lower limbs in pediatric orthopedic clinic.  Saudi Medical Journal,  40(9),  930–935. https://doi.org/10.15537/smj.2019.9.24478

Bourgleh, K., Zaidman, C., De Gaudemar, I., & Glard, Y. (2019). Referral patterns and characteristics of children with common orthopaedic variants. Orthopaedics & Traumatology: Surgery & Research, 105(3),
529 533. https://doi.org/10.1016/j.otsr.2018.12.003

Fennelly, O., Blake, C., FitzGerald, O., Breen, R., Ashton, J., Brennan, A., Caffrey, A., Desmeules, F., & Cunningham, C. (2018). Advanced practice physiotherapy-led triage in Irish orthopedic and rheumatology services: national data audit.  BMC Musculoskeletal Disorders,  19(1). https://doi.org/10.1186/s12891-018-2106-7

Lafrance, S., Demont, A., Thavorn, K., Fernandes, J., Santaguida, C., & Desmeules, F. (2021). Economic evaluation of advanced practice physiotherapy  models of care: a systematic review with meta-analyses. BMC Health Serv Res, 21(1):1214. https://doi/org/10.1186/s12913-021-07221-6

McCarthy, J. J., Armstrong, D. G., Davey, J. P., Epps, H. R., Gerardi, J. A., Kanel, J. S., Mehlman, C. T., Roach, J. W., Schwend,
R. M., Smith, B. G., & Ward, W. T. (2011). The Current Medical Practice of the Pediatric Orthopedic Surgeon in North America.  Journal of Pediatric Orthopedics,  31(3), 223–226. https://doi.org/10.1097/bpo.0b013e31820fc8b7

Miller, S., Harris, S. R., & Mulpuri,  K. (2016). Agreement Between a Physical Therapist and an Orthopedic Surgeon in Children Referred for Gait Abnormalities. Pediatric Physical Therapy, 28(1), 85–92. https://doi.org/10.1097/pep.0000000000000207 Ó Mír, M., McCarthy, C., & Condon, F. (2019). Caregiver satisfaction with physiotherapy-led paediatric orthopaedic clinics. Physiotherapy, 105(2), 226 232. https://doi.org/10.1016/j.physio.2018.07.006

Ó Mír, M., & O’Sullivan, C. (2018). Advanced practice physiotherapy in paediatric orthopaedics: innovation and  collaboration to improve service delivery.  Irish Journal of Medical Science,  187(1), 131–140. https://doi.org/10.1007/s11845-017-1611-2 O’Mír, M., O’Sullivan, C., Lennon, O., & Blake, C. (2018). An evaluation of diagnostic agreement rates between advanced  practice physiotherapists and pediatric orthopedic consultants for children with musculoskeletal complaints.  Musculoskeletal Care,  16(4), 433–439. https://doi.org/10.1002/msc.1357