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J Epidemiol Community Health. 1999 Oct; 53(10): 643–650.
PMCID: PMC1756791

A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments


OBJECTIVE: To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments. DESIGN: Randomised controlled trial. SETTING: Orthopaedic outpatient departments in two hospitals. SUBJECTS: 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion. INTERVENTIONS: Initial assessment and management undertaken by post- Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists). MAIN OUTCOME MEASURES: Patient centred measures of pain, functional disability and perceived handicap. RESULTS: A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238). CONCLUSIONS: On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.


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Selected References

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  • Hopkins A, Solomon J, Abelson J. Shifting boundaries in professional care. J R Soc Med. 1996 Jul;89(7):364–371. [PMC free article] [PubMed]
  • English T. Personal paper: medicine in the 1990s needs a team approach. BMJ. 1997 Mar 1;314(7081):661–663. [PMC free article] [PubMed]
  • Heath I. Skill mix in primary care. BMJ. 1994 Apr 16;308(6935):993–994. [PMC free article] [PubMed]
  • Salvage J. What's happening to nursing? BMJ. 1995 Jul 29;311(7000):274–275. [PMC free article] [PubMed]
  • Dowling S, Barrett S, West R. With nurse practitioners, who needs house officers? BMJ. 1995 Jul 29;311(7000):309–313. [PMC free article] [PubMed]
  • Dowling S, Martin R, Skidmore P, Doyal L, Cameron A, Lloyd S. Nurses taking on junior doctors' work: a confusion of accountability. BMJ. 1996 May 11;312(7040):1211–1214. [PMC free article] [PubMed]
  • Rashid A, Watts A, Lenehan C, Haslam D. Skill-mix in primary care: sharing clinical workload and understanding professional roles. Br J Gen Pract. 1996 Nov;46(412):639–640. [PMC free article] [PubMed]
  • Casey N, Smith R. Bringing nurses and doctors closer together. BMJ. 1997 Mar 1;314(7081):617–618. [PMC free article] [PubMed]
  • Hourigan PG, Weatherley CR. Initial assessment and follow-up by a physiotherapist of patients with back pain referred to a spinal clinic. J R Soc Med. 1994 Apr;87(4):213–214. [PMC free article] [PubMed]
  • Weale AE, Bannister GC. Who should see orthopaedic outpatients--physiotherapists or surgeons? Ann R Coll Surg Engl. 1995 Mar;77(2 Suppl):71–73. [PubMed]
  • Durrell S. Expanding the scope of physiotherapy: clinical physiotherapy specialists in consultants' clinics. Man Ther. 1996 Sep;1(4):210–213. [PubMed]
  • Roland M, Torgerson DJ. What are pragmatic trials? BMJ. 1998 Jan 24;316(7127):285–285. [PMC free article] [PubMed]
  • Carr AJ. Margaret Holroyd Prize Essay. A patient-centred approach to evaluation and treatment in rheumatoid arthritis: the development of a clinical tool to measure patient-perceived handicap. Br J Rheumatol. 1996 Oct;35(10):921–932. [PubMed]
  • Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980 Aug;66(8):271–273. [PubMed]
  • Beaton DE, Richards RR. Measuring function of the shoulder. A cross-sectional comparison of five questionnaires. J Bone Joint Surg Am. 1996 Jun;78(6):882–890. [PubMed]
  • Karlson EW, Daltroy LH, Liang MH, Eaton HE, Katz JN. Gender differences in patient preferences may underlie differential utilization of elective surgery. Am J Med. 1997 Jun;102(6):524–530. [PubMed]
  • Hill J, Bird HA, Hopkins R, Lawton C, Wright V. Survey of satisfaction with care in a rheumatology outpatient clinic. Ann Rheum Dis. 1992 Feb;51(2):195–197. [PMC free article] [PubMed]

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