Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department

Patients were recruited from April 2017 to July 2018 from two EDs in Montréal (Canada).

The three physiotherapists participating to this study were already working in both recruitment sites and were already involved in the ED. They had previous experience working in theses EDs as secondary contact providers, with experience ranging from 2 years to 14 years, and had experience for care of patients with MSKD, in both an inpatient and outpatient settings, with experience ranging from 2 to 29 years. Thirty-seven ED physicians participated in the current study. In the province of Québec, APP models of care include direct access to patients in hospital settings. Ability to prescribe x-rays is soon to be allowed under new regulation.

All patients presenting to the ED and that were identified by the triage nurse as having a possible minor MSKD or identified on the ED triage list by a research assistant as having a possible minor MSKD were considered for this study on days that recruitment was taking place. Other inclusion criteria were: 1) 18 years or older; 2) legally able to consent; 3) able to understand/speak French or English; 4) resident of the province of Quebec and beneficiary of the provincial health insurance coverage (RAMQ). Exclusion criteria were patients having: 1) been previously treated by one of the APPs or physicians involved in this study; 2) an injury resulting from significant trauma (such as major motor vehicle accident) or a major musculoskeletal injury, such as open fracture or open wound; 3) obvious red flags, such as progressing neurological deficits or infection related signs or symptoms; 4) diagnosed inflammatory arthritis and 5) other active/unstable non-musculoskeletal conditions, such as pulmonary, cardiac, digestive or psychiatric conditions.

Prior to being seen by the APP or the ED physician, eligible participants completed a structured questionnaire with the research assistant where they provided anthropometric data as well as data on their education, employment, household income, household living status, and information on clinical variables such as the joint affected, the reason for consulting, the history of the lesion, the duration of their symptoms, the use of a walking aid and the presence of any comorbidities. Participants also completed the acute 36-item Short Form Survey Questionnaire (SF-36) to assess their health-related quality of life and, depending on the affected body region, the relevant standardized self-reported disability questionnaires among the Neck Disability Index (NDI), the Oswestry Disability Index (ODI) for spine disorders, the Disability of the Arm, Shoulder and Hand (DASH) questionnaire for upper extremity disorders or the Lower Extremity Functional Scale (LEFS) for lower extremity disorders. The SF-36 has been shown to be valid, reliable and responsive to change with various populations with MSKD [21‐23]. The NDI, ODI, DASH and LEFS are standardized self-reported disability questionnaires that are validated, reliable and responsive to change [24‐30].

The participants were then independently assessed by both providers. The clinical evaluation and specific physical tests used by both providers to complete the evaluation were not standardized, as so they could use any evaluation techniques or physical tests they felt appropriate to reach a diagnosis. After the assessment, the physiotherapist and the ED physician each independently completed a standardized evaluation form where they indicated the primary, and secondary if relevant, diagnoses, their request for additional medical imaging necessary to provide appropriate care or to confirm or exclude a diagnosis, their detailed treatment plan, including conservative treatment options, referral to other providers (such as orthopedics) and medication recommendations, and their discharge plan from the ED (Appendix). Due to feasibility considerations, the physiotherapist always completed the assessment before the ED physician. A research assistant ensured that the physiotherapist and the ED physician were blinded to each other’s diagnosis, treatment plan and discharge plan until both providers had completed the evaluation and had filled out the standardized form. Also, physiotherapists were asked to not initially disclose information on their diagnosis or management plan to the patients to avoid any influence on the ED physician’s diagnosis. Both providers had access to the patient’s medical file, including any previous medical imaging results available. If medical imaging was judged necessary to specify either the diagnosis or treatment plan, providers were asked to specify which type of imaging was needed. Within their treatment plans, providers were also asked to specify the relevant conservative treatment options for the patient from among the following options: 1) advice and education, 2) walking aids/orthosis, 3) home exercises or 4) specify other options. They were also asked to specify if supervised physiotherapy follow-up was relevant and any medication recommendations, either prescription or non-prescription. Regarding the ED discharge plan, providers needed to select between three options: 1) hospitalization, 2) discharge home without medical follow-up or 3) discharge with a medical follow-up (family physician, specialist as an outpatient, other). The time in minutes for each provider to complete the evaluation was recorded. To record any change in the patient’s condition that would modify the ability for the second provider to make a diagnosis, participants were asked to complete a form where they specified if their pain level had changed after the first assessment (1- no change in condition 2- pain is slightly higher; 3- pain is moderately higher; 4- pain is significantly higher). To ensure that patients’ conditions were similar for both evaluations, patients were excluded from the study if pain was recorded as significantly higher after the initial assessment by the physiotherapist.

After assessment by both the physiotherapist and the ED physician, patients completed before discharge a modified version of the 9-item Visit-Specific Satisfaction Questionnaire (VSQ-9) in relation to each provider they had seen [6, 31, 32]. Participants were informed that answers would remain confidential. The questionnaire included 7 questions rated on a 1 to 5 scale (1 = excellent and 5 = poor) and relates to satisfaction with care received, including perceived quality of assessment, personal manner of the provider and quality of advice and information received.

Descriptive statistics were used to describe the patients’ characteristics. Cohen’s kappa (κ) as well as Prevalence and Bias Adjusted Kappas (PABAK) with associated 95% confidence intervals (95% CI) were calculated for diagnosis concordance, medical imaging requests, treatment plan, including recommendation for medication and physiotherapy care, and discharge plans. Interpretation of inter-rater agreement was made according to the following scale in which 0–0.20 is weak, 0.21–0.40 slight agreement, 0.41–0.60 moderate agreement, 0.61–0.80 good agreement, 0.81–0.90 very good agreement and > 0.90 excellent agreement [33, 34]. Due to the multiple possible diagnoses as well as the different nomenclature sometimes used by physicians and physiotherapists, diagnoses were put into diagnostic categories based on the assessment by two independent reviewers to establish if diagnoses were concordant. The main categories were soft tissue disorders, spinal disorders, articular disorders, fracture or luxation and neurological disorders or other disorders. An independent third rater was used if consensus could not be reached. Ultimately the patient was managed according to the physician directives as the study only assessed the potential ability of the physiotherapist to manage autonomously these types of cases. In addition, Chi Square tests were used to compare treatment and discharge plan modalities and student t-tests were used to compare patient satisfaction. Analyses were preformed using SPSS version 25 (SPSS Inc., Chicago) and R version 3.4.3.

We calculated the sample size with an expected kappa inter-rater agreement of at least κ = 0.8, a raw proportion of agreement of 80% and power of 80% [35]. A minimum sample size of 75 participants was required, but to insure representability of the sample and to take into account the multiple MSKD encountered in an ED setting, we aimed to recruit a sample size of at least 100 participants.

All participants signed a consent form prior to entering the study. This study was approved by the Research Ethics Boards of both hospitals.

One hundred and twenty-five potential participants were identified after initial assessment at triage during recruitment periods, 70 in the first site and 55 in the second site. Eight declined participation to this study and the reasons were: fatigue (n = 1), pain was too severe (n = 2), was presenting to the ED to have a joint injection (n = 1), only wanted to see a physician (n = 2) and did not want to grant access to their medical file (n = 2). Four patients were excluded: two patients had obvious red flags (infection for both), one left after being assessed by only one out of two providers and one participant was recruited but afterward none of the providers were available for the assessments. A total of 113 participants were included in the analyses (Fig. 1).

Participants’ characteristics are included in Table 1. Subjects had a mean age of 50.3 years (SD: 17.4) with 49.6% of men and 50.4% of women. With some patients presenting disorders in more then one body region, 29% of patients had an upper limb disorder, 43% a lower limb disorder, 5% a cervical spine disorder, 4% a thoracic disorder and 19% a lumbar disorder. Most patients (51.3%) had an atraumatic disorder. Participants had a mean score of 38.3% (SD ±10.4) on the Physical Component Scale and 44.3% (SD ±13.3) on the Mental Component Scale of the acute version of the SF-36, indicating fairly impaired health-related quality of life. In terms of the various self-reported disability questionnaires based on the affected body regions, the mean scores were: LEFS 23.3 (SD ±17.3), ODI 54.8% (SD ±0.2), quick-DASH 44.2 (SD ±29.3) and NDI 25.7 (SD ±1.5).

Overall, raw agreement regarding diagnosis between ED physicians and APPs was 87%, based on both primary and secondary diagnoses. A secondary diagnosis was present for 54% of patients (61/113). Inter-rater diagnosis agreement was very good (κ = 0.81; 95% CI: 0.72–0.90) (Table 2).

In terms of requests for medical imaging, APPs and ED physicians ordered almost the same amount of imaging tests (respectively for 71% and 70% of participants, p = 0.884). Raw agreement proportion was 80% and inter-rater agreement was moderate (Kappa = 0.51; PABAK = 0.59; 95% CI: 0.42–0.73) (Table 3).

In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (50% compared to 34%, p = 0.018). Raw agreement was 64% and overall there was only slight agreement between providers (Kappa = 0.27; PABAK = 0.27; 95% CI: 0.07–0.45) (Table 3). In terms of medication, non-prescription and prescription drugs were analysed separately. APPs recommended more non-prescription drugs than ED physicians, but there was no significant difference (50% compared to 39%, p = 0.126). Raw agreement proportion was 61% and only slight agreement between providers was observed (Kappa = 0.22; PABAK = 0.22; 95% CI: 0.02–0.41) (Table 3). In terms of prescription drugs, ED physicians recommended them significantly more than APPs (70% compared to 47%, p < 0.001). Raw agreement proportion was 66% and overall only slight agreement was obtained between raters (Kappa = 0.33; PABAK = 0.31; 95% CI: 0.11–0.49) (Table 3).

In terms of discharge plans from the ED, providers were asked to specify if the patient needed any type of medical follow-up upon ED discharge (No follow-up, hospitalisation, referral to a specialist, return to general practitioner or other medical follow-up). Twenty-one percent of patients had no medical follow-up upon ED discharge, 34% were sent back to their family physician, 43% were referred to an outpatient speciality clinic and 2% were hospitalized. There was significant agreement between providers with an 82% raw agreement proportion and a moderate inter-rater agreement (Kappa = 0.46; PABAK = 0.64; 95% CI: 0.46–0.77) (Table 3).

Overall, ED physicians had significantly shorter overall consultation times (mean 5.8 min; SD ± 4.2) than APPs (mean 13.5 min; SD ±8.6) (p < 0.001). There were no significant differences between providers in terms of patients’ satisfaction with received care, with both providers obtaining high satisfaction scores (p = 0.57) (Table 4).