Surveys of GPs, staff, and patients
Pre-implementation surveys were sent to 111 GPs. Eighty-one respondents completed the survey, for a 73% response rate. The survey found that approximately 90% of GPs were ‘unsatisfied’ or ‘very unsatisfied’ with the access to FSA for their patients with advanced hip or knee OA. Once referred patients were seen, however, approximately 65% of GPs were ‘satisfied’ or ‘very satisfied’ with overall patient management provided, although approximately 30–35% expressed dissatisfaction with the overall management of their patients. Specific comments indicated that GPs thought
“getting patients into the system is difficult” and
“too many referrals are returned unseen”, and that
“Re-referral wastes time (GP and Specialist)” [see the appendices in Additional file
3].
Post-implementation surveys were sent to 111 GPs. Fifty-eight surveys were completed, for a response rate of 52%. Most GP respondents (78%) had patients seen at the Joint Clinic. The majority of GPs (91%) remained ‘very unsatisfied’ or ‘unsatisfied’ with patient access to a FSA. Sixty percent of GPs reported being ‘satisfied’ or ‘very satisfied’ with overall patient access to the Joint Clinic; however, 40% reported being ‘unsatisfied’. Most GPs (91%) were ‘satisfied’ or ‘very satisfied’ with the quality and timeliness of feedback from the Joint Clinic appointment, and 76% were ‘satisfied’ or ‘very satisfied’ with the overall patient management regarding the Joint Clinic [see the appendices in Additional file
3 for figures and additional data].
Specific comments about the Joint Clinic indicated that GPs were “… very pleased to have the Joint Clinic in the current environment where specialist appointments are so difficult to get” and “I think the joint clinic overall does a good job. I think patients also appreciate this service”. However, some thought the Clinic added to the waiting problem, saying “In my experience the Joint Clinic whilst no doubt well-intentioned functions as a further delay for patients whose need for joint replacement is already pressing by the time I have made a referral to orthopaedics”, and suggested that “…The joint clinic would be good for those at an earlier stage of the disease process - not those really for an operation but declined because of insufficient funding”.
The patient survey indicated the majority of patients were ‘satisfied’ or ‘very satisfied’ with the knowledge and expertise of Joint Clinic staff (98%), the treatment plan given by Joint Clinic staff (89%), their treatment at Physiotherapy Outpatients (92%) and other treatments provided (82%). Most patients were ‘satisfied’ or ‘very satisfied’ to be seen by Joint Clinic staff rather than an Orthopaedic Surgeon (70%). The majority of patients (86%) were ‘satisfied’ or ‘very satisfied’ with the time they waited to be seen at the Clinic.
Interim interviews of GPs and staff
Interim evaluation interviews were conducted among staff and GPs. After three phases of the chain sampling process, there were a total of 21 potential respondents, of which 16 were interviewed. These comprised six Orthopaedic Department or Joint Clinic clinicians, one allied health clinician, seven hospital administrative or managerial staff, one SDHB Māori (New Zealand’s indigenous peoples) liaison, and one GP. Overall, data from the interim implementation evaluation indicated that the Joint Clinic had been implemented in close concordance with the proposed model and was well accepted by the key stakeholders, staff, and patients. Six major themes resulted: staffing, appropriate care provision, care coordination, promotion of the service, the Joint Clinic model and Hauora Māori (health and wellbeing of Māori).
Recurrent themes relating to staffing included high levels of confidence in the competence of personnel, and concerns regarding adequacy of allocated administrative staff time in light of heavier than expected additional workload. One aspect of the proposed model that was not implemented was the employment of “advanced physiotherapy practitioners”. Instead, due to loss of the initial lead physiotherapist the Joint Clinic role was filled by an experienced physiotherapist without advanced practice experience or specific OA expertise. However a training programme had been provided. Staff surveys found that adequate leave cover for both the physiotherapist and the nurse were lacking. A physiotherapist was allocated and trained for ‘back-up’ cover, but became unavailable.
Some planned aspects were not concordant. It was found that some GPs wrote referrals of patients directly to the Joint Clinic, instead of following the existing protocol that referrals should be triaged by the orthopaedic surgeons, as any other referral would be. Also, clinic staff reported occasional difficulty in accessing orthopaedic surgeons for discussion regarding complex patients, leading to gaps in communication. The lead orthopaedic surgeon’s time spent discussing cases with Joint Clinic staff had not been budgeted a priori.
Final implementation interviews
In the final implementation evaluation, six SDHB staff and seven GPs were invited to take part in one-on-one in-depth post-implementation interviews; all but one GP accepted and were interviewed. Six themes resulted from the data: clinic impacts, clinic value, access, knowledge and understanding of the clinic, communication, and the future of the clinic.
The main impacts of the Joint Clinic were generally seen as positive, as patients who previously would have been returned to their GPs were being seen at a secondary level. Providers commented that “...it’s absolutely plugged a huge gap...” (SDHB staff), “…instead of the referrals being triaged and sent back to the GP, not being seen at all... they’re now being seen” (SDHB staff) “…more quickly, more efficiently, and more to the point...and help GP[s] to, to manage a long term problem” (GP).
Interviewees had the impression that patients valued the service as well, and had benefited, at least psychologically, commenting that “...patients do have the perception that they, that something’s happening” (GP), and “All of them [patients] have had an improvement in their function. That doesn’t translate into leading, needing less pain relief. It doesn’t translate into not needing joint replacement. It does translate into believing that they haven’t been abandoned by the system, into realising that they will recover from what is major surgery and holds considerable fear for most people still” (GP).
The perception was raised that some may patients express initial disappointment because they didn’t get to see an orthopaedic surgeon: “...patients might feel fobbed off if the purpose of the Joint Clinic has not been explained to them” (GP); “There are some patients that are initially quite upset or potentially frustrated with actually the fact that they’re not seeing an orthopaedic doctor. However, I think with just a little bit of explanation of what that clinic actually involves, I think they realise that what the clinic has to offer is really, is really quite beneficial for them” (SDHB).
The Joint Clinic was valued by the GPs interviewed, but the idea was raised that not all patients would gain substantial value from the clinic. While typical GP comments conveyed that they “…think it’s enormously valuable” (GP), and “Most of my patients would be enormously grateful for the care they receive. All of them have had an improvement in function” (GP), some also commented that “They like meeting the people, but it hasn’t helped their hip” (GP).
The SDHB staff interviewed generally agreed the programme was helping to meet unmet need, and there was good acceptance of the programme among the interdisciplinary team. “It’s helping the demand for FSA which it was, is also in excess of what we could supply” (SDHB staff) and “...the GPs are definitely coming on board too. Because, I mean on their referrals they’re actually, quite a few of them are very proactive in writing that they think their patient would be suitable for the Joint Clinic” (SDHB). The consensus was unequivocal that “the allied health team do a really great job with it” (Participant 2, SDHB) and“There’s a lot of trust and respect there within that relationship [between staff members]” (SDHB).
Lack of clarity and understanding about the Joint Clinic was a noted weakness:
“I think the perceptions of what the Joint Clinic’s trying to achieve or is actually doing differ across the primary care, secondary care sort of interface. So I’m not sure it’s, people are totally clear about what’s happening” (SDHB). During interviews it was suggested that, to be successful in the future, the Joint Clinic needed to increase its visibility, communicate its mission clearly to stakeholders, maintain its funding, and decrease attrition among physiotherapists and staff. Further details of the themes, subthemes, and additional data are available in the online-only supplemental material [see the appendices in Additional file
3].
Service level outcomes
Over 2 years, 358 new patients and 279 follow-ups were seen at the Joint Clinic, for a total of 637 patient visits during 2 years of operation (Table
1). Un-notified ‘did not attends’ (DNAs) were low with only 11 DNAs overall (3.8%) in the first year, and 16 DNAs (4.3%) in the second year.
Table 1
Description of the patients and patient pathways of the first 2 years of Joint Clinic operation
Patients referred to Joint clinic | 376 | |
Declined | 9 | 2.4% |
Did not attend | 9 | 2.4% |
Patients attending Joint Clinic | 358 | |
Patient characteristics | | (of 358) |
Age (SD) | 76 | 9.8 |
Female | 200 | 55.9% |
Hip OAa | 155 | 43.3% |
Knee OAa | 199 | 55.6% |
Not OAa | 19 | 5.3% |
Met inclusion criteriab | 339 | 94.7% |
Joint Clinic management |
Initial consultation | 358 | 95.2% (of 376) |
1 follow-up | 252 | 74.3% (of 339) |
2 follow-ups | 114 | 36.6% (of 339) |
3 follow-ups | 28 | 8.3% (of 339) |
mean (SD) visits | 2.1 | 0.91 |
Referred for FSA: |
Initial visit | 59 | 16.5% (of 358) |
Subsequent visit | 74 | |
By another service | 15 | |
Total | 148 | 41.3% |
The primary outcome of reducing unmet need for secondary care consultations and management in patients with hip or knee OA was achieved, with the proportion of GP referrals for hip or knee OA returned without offer of consultation reduced by 90%. Increased efficiency in its secondary care setting was demonstrated by reductions in overall (all-cause) referrals returned to GPs without consultation, despite an overall decrease in FSAs provided by the Department. The Joint Clinic resulted in an overall 5.7% increased capacity of the Orthopaedic Outpatient service to provide initial consultations compared with the year prior to implementation of the Joint Clinic. These changes were observed on a background of a decreased volume of referrals received overall (Table
2).
Table 2
Reductions in the number of patient referrals received by Orthopaedic Outpatients, number of First Specialist Assessments (FSAs) delivered, and number of referrals sent back to the GP without consultation: baseline and first 2 years of Joint Clinic operation
Referrals | 2,078 | 1,584 | −24% | 1539 (3123) | −25% |
FSAs | 1,305 | 1,134 | −13% | 1267 (2401) | −8% |
Referrals returned to GP | 557 | 390 | −30% | 462 (852) | −24% |
Referrals returned to GP [hip, knee OA only] | 74 | 5 | −93% | 10 (15) | −90% |
Patient level outcomes have been reported elsewhere [
30,
31]. In summary, approximately 60% of patients were managed non-operatively by the Joint Clinic, with a significant improvement (18% improvement on baseline Oxford score,
p = .0013 for change by paired, 2-tailed t-test) noted in that group; the remaining 143/358 (40%) were referred for FSA, with 115 (80%) received or were listed for surgery [
31]. At referral to Joint Clinic, no differences in age, sex, or patient-reported outcome measures were evident between those with hip versus knee OA, however mean BMI was higher in the knee OA group. Patients with knee OA improved significantly, on average, while patients with hip OA were more likely to deteriorate significantly and require surgery [
30].