The Locomotor service is a community based musculoskeletal interface service. Its team of Extended Scope Physiotherapists’ manage complex conditions referred from primary care. To improve the patients’ journey and avoid delay in secondary care diagnostics ESP’s have have trained to become musculoskeletal sonographers to provide diagnostic ultrasound as well as ultrasound guided injections for the MSK conditions they encounter in their clinics in a primary care setting. This was a clinician led initiative influenced by patient feedback, and has led to a reduction in MRI imaging requests, improved patient satisfaction, improved orthopedic conversion rates, reduced the number of follow ups required and has ultimately been a cost effective change.
Challenges
- The NHS funding gap of £30 billion has put pressure on frontline staff to identify cost effective measures without compromising patient satisfaction, quality and safety.
- Magnetic Resonance Images (MRI’s) are common diagnostic tools in complex MSK cases; they have been considered the gold standard but are costly at £185 each and are increasingly shown to poorly correlate with clinical presentations due to a risk of false positives.
- They lead to a delay in diagnosis due to the nature of waiting lists after referring to secondary care.
- Patient feedback data reports they prefer to be seen in a one stop shop of care setting, We wanted to provide this service in the community without need for unnecessary referral to secondary care.
- Musculoskeletal Ultrasound Sonography (MUS) is gaining momentum as a more cost effective alternative producing comparable results to MRI’s; costing approx… £47 a session which includes a full biopsychosocial assessment. In addition to lower costs, this service also provides speedier diagnosis – the ultrasound is interpreted in real time by the ultrasonographer clinician, which in turn frees up radiology reporting resources (HSJ2016_Improving_the_value_of_diagnostic_services_Sheehan_et_al_2016)
Actions
- We ensured that the qualified clinicians have MSc level external training, supplemented by in-house ESP mentorship and we also built links with Radiology to ensure ongoing clinical competence. Currently 2 band 7 physio’s are undertaking a shadow ESP role with in house mentorship and MSc module support. Roadshows and phone support was offered to GP’s to help them refer appropriate patients.
- Data collection and analysis from patient pathway, secondary care referrals (orthopedic and MRI), satisfaction scores, conversion rates, number of follow ups were used to monitor progress.
- Making the case for funding of ultrasound machines; provided via business case submissions to Homerton Hospital.
- Integration with physiotherapy team as they triage the majority of patients; this helped ensure timely and appropriate referrals to ESP. This allows the ESP’s to focus their time on more complex cases and has reduced inappropriate referrals. - Integrated pathways have been developed in partnership with the CCG, GP’s, orthopedics and rheumatology.
Results
- The Locomotor ESP Service carried out an audit of 1000 shoulder patients seen in 2015/16. The service employs 5 WTE ESPs who sent 19 MRIs in total in 2016 amounting to 7 % of all MRI referrals (n=256) (HJS2016_Improving_the_value_of_diagnostic_services_MRI_AUDIT).
- Despite patient referrals to the Locomotor Service increasing by 10% annually over the last 5 years, the number of MRI requests has not increased.
- All patients received an US scan prior to requesting the MRI, a retrospective review has shown the US scan was 90 % accurate using MRI as a comparator. This recent initiative has led to a reduction in MRI requests for shoulders.
- Patient satisfaction scores have been exclusively positive; patients can view their scan in real time allowing the ESP to explain the findings within the context of the patient’s pain and clinical presentation, reducing the negative impacts of false positives. It also allows patients to become actively involved in their assessment and treatment selection, by providing them with the opportunity to get involved with what treatment option to explore.
- Of the 19 MRI referrals for shoulder complaints that were referred, only 9 of those patients were referred to orthopaedics. the combination of clinical and imaging skills has enabled ESP’s to achieve a high conversion rate to surgery (88% or 8/9). 10 were managed within the ESP department and were able to achieve their goals whilst avoiding more invasive interventions.
Value
- The Locomotor service manages 96 % of musculoskeletal patients in the community, referring only 4 % of patients to secondary care.
- The ESP service sees approx. 1000 referrals for shoulder complaints annually; these are complex cases requiring specialist input.
- The Locomotor service requests approx. 255 MRI’s annually (255 * 185= £47175).
- Musculoskeletal Ultrasound Sonography (MUS) is gaining momentum as a more cost effective producing comparable results to MRI scanning.
- MUS’s are approx. £47 per session on an Allied Health Professions Tariff. - 90% of all patients with shoulder complaints receive an ultrasound scan as part their assessment.
- Only 19 of the 1000 shoulder patients (1.9%) were sent for an MRI.
- Total savings at the end of the year included £38,000 from reducing referrals to Trauma & Orthopedics, £16,000 reduction in referrals to secondary care pain service from GPs, a 90% increase in patient contacts and 51% rise in multidisciplinary pain packages of care provided.
- Patient satisfaction in the has been exclusively positive toward the use of MUS
- 95 % of patients were offered an appointment within 5 weeks of referral
In detail
The NHS funding gap is expected to rise to £30 billion by 2020, this is leading to increased pressure on frontline staff to identify cost effective savings that do not compromise patient satisfaction, quality and safety. The Locomotor department sees a large volume of patients with complicated biopsychosocial issues in one of the most deprived local authorities in England. The ESP department is integrated with a physiotherapy department and a community pain service which employs a large and varied multidisciplinary team.
By providing a full biopsychosocial assessment which includes imaging and an expert diagnostic opinion within the same session, the Locomotor department has seen a reduction in referrals to secondary care. This has had direct effect on saving costs and reducing unnecessary treatments/referrals by early provision of appropriate treatment, which has led to improvements in patient safety and experience. The Locomotor Service as a whole managed 16 000 musculoskeletal patients per year referred from GP’s within City and Hackney. In the face of rising demand, the budget for physiotherapy and ESP patients has remained static.
In summary; Locomotor staff have identified areas to improve quality, safety and patient experience while reducing overall costs to the local health economy. One key factor is that patients are able to view their scans in real time, allowing the ESP to explain the findings within the context of the patients pain and clinical presentation. This has assisted in explaining false positives and reducing the incidence of the ever growing phenomena ‘Victim of Modern Imaging Technology’ – a situation where patient’s pain presentation worsens after they are provided with their scans results with non-correlated findings on them. This has allowed patients to become actively involved in their assessment and treatment selection by explaining findings in context to the normal scan changes, and provides the patient the opportunity to explore treatment options such as orthopaedics, injections, referrals to groups and classes in the hospital and in the community.
Ultrasound is a resource to the whole Physiotherapy team who have daily access to ESP’s for clinical queries and are able to refer patients not responding to rehabilitation or with clinical concerns for an ESP opinion supported by ultrasound, as such the use of clinic based ultrasound supports the clinical reasoning development of the whole team. Homerton University Hospital has linked in with the University of East London which provides post graduate training in the use of MUS. Nationally there are currently no national standards or averages for training as a sonographer.
The Homerton has taken the view that all practitioners using US as part of their practice have achieved certified sonographer status via appropriate post graduate training providers. The success of the initiative has also been influenced by the use of social media. One of the ESP’s have set up their own website that allows professionals using MUS in their practice to share skills and experiences (https://theultrasoundsite.co.uk), as well as having had a story in the Chartered Society of Physiotherapy Monthly publication ‘Frontline’. These initiatives are having an impact on the use of this modality on a national level. An underlying value for this initiative was to not emphasize the importance of using ultrasound to improve patient outcomes, but rather to demonstrate what role ultrasound can play in the holistic management of complex musculoskeletal conditions.
Of the 19 patients out of 1000 (1.9%) that required an MRI scan, 53 % (10) of them were managed within the physiotherapy, ESP and pain service. The remaining 47 % (9) were referred to orthopaedics and had a successful conversion rate of 88 %. The specialist practitioners currently employed in the ESP service are afforded a significant degree of autonomy and have used this assessment technique as an opportunity to improve cost effectiveness and reduce unnecessary referrals without compromising patient safety or satisfaction; in fact our data so far suggests patients are more satisfied with the new pathway and it is for that reason we believe they have approved the value of our diagnostic service and we are applying for this award
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