Developing direct access skills in authentic primary care placements

ABSTRACT INTRODUCTIONMagnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury. AIMTo evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries. METHODSThis is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression. RESULTSIn total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen’s weighted kappa statistic was 0.38 (95% CI: 0.28–0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio=2.64, 95% CI 1.51–4.62; reviewer 2: odds ratio=4.44, 95% CI 2.47–7.99), compared to scan requests graded not consistent. DISCUSSIONStudy findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.

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The impact of direct access physiotherapy compared to primary care physician led usual care for patients with musculoskeletal disorders: a systematic review of the literature

Disability and Rehabilitation ◽

10.1080/09638288.2019.1674388 ◽

2019 ◽

pp. 1-12 ◽

Cited By ~ 3

Author(s):

Anthony Demont ◽

Aurélie Bourmaud ◽

Amélie Kechichian ◽

François Desmeules

Keyword(s):

Systematic Review ◽

Primary Care ◽

Usual Care ◽

Musculoskeletal Disorders ◽

Primary Care Physician ◽

Care Physician ◽

Direct Access ◽

Review Of The Literature ◽

The Impact

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G312 Improving appropriate and safe management of children in primary care through direct access to specialist paediatric expertise

Archives of Disease in Childhood ◽

10.1136/archdischild-2016-310863.303 ◽

2016 ◽

Vol 101 (Suppl 1) ◽

pp. A179-A181

Author(s):

R Cheung ◽

C Lemer

Keyword(s):

Primary Care ◽

Direct Access ◽

Safe Management

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Primary care direct access cerebral imaging in Lothian, Scotland: a 5-year retrospective analysis of referrals, assessment of utility of referral guidelines, and determination of incidence of abnormalities

British Journal of General Practice ◽

10.3399/bjgp18x697481 ◽

2018 ◽

Vol 68 (suppl 1) ◽

pp. bjgp18X697481

Author(s):

Karolis Zienius ◽

Chak Ip ◽

Mio Ozawa ◽

Robin Grant ◽

Yoav Ben-Shlomo ◽

...

Keyword(s):

Primary Care ◽

Brain Tumour ◽

Diagnostic Value ◽

Direct Access ◽

Intracranial Tumour ◽

Cerebral Imaging ◽

Yellow Flag ◽

Increased Risk ◽

Red Flag

BackgroundDirect Access Cerebral Imaging (DACI) from Primary Care has been recommended by NICE for patients with symptoms suspicious of cancer.AimWe analysed the predictive value of the NICE (2005) and Kernick referral guidance for suspicion of brain tumour in a real-world settingMethodDACI referrals from Lothian-based GPs (31/3/2010 to 1/4/2015) were categorised according to the symptom classifications of NICE 2005 and Kernick referral guidelines. Radiological findings were grouped into 1) normal/non-significant-incidental, 2) abnormal-significant, 3) intracranial tumour.ResultsIn total, 3257 head scans were performed, and after exclusions, 2938 records were analysed. Mean age was 55.6 (SD 18.56), 1748 (60%) females. Forty-two scans (1.43%) revealed significant intracranial tumours, including 17 (40%) metastases, 10 primary intracerebral tumours (24%), 8 pituitary (19%), 7 meningioma (17%). Non-significant incidental findings were observed on 571 (19%) scans, of which 175 (6%) correlated with symptoms. Based on NICE (2005) guidelines, 39% referrals were for ‘symptoms related to the CNS’, 16% for ‘Headache of raised ICP’, 18% for ‘Sub-acute deficits’ and 27% for ‘Unexplained headache’. Kernick guidelines classified 39% referrals red-flag, 25% orange-flag, and 36% yellow-flag symptoms. NICE ‘Symptoms related to CNS’ (OR 5.21, 95% CI = 1.81 to 14.9; PPV 2.9, 95% CI 2.0 to 4.0) and Kernick’s red-flag symptoms (OR 5.73, 95% CI =2.21 to 14.84; PPV 2.8, 95% CI = 1.9 to 3.9) were the only features to have significantly increased risk of brain tumour.ConclusionReferral guidelines confirm the urgency for rapid access head imaging for symptoms ‘highly suspicious’ of brain tumour. We are now assessing diagnostic value of different symptom complexes for intracranial tumour including headache-plus.

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Patient direct access to musculoskeletal physiotherapy in primary care: perceptions of patients, general practitioners, physiotherapists and clinical commissioners in England

Physiotherapy ◽

10.1016/j.physio.2018.11.275 ◽

2019 ◽

Vol 105 ◽

pp. e31 ◽

Cited By ~ 1

Author(s):

C.N. Igwesi-Chidobe ◽

B. Bartlam ◽

K. Humphreys ◽

E. Hughes ◽

J. Protheroe ◽

...

Keyword(s):

Primary Care ◽

General Practitioners ◽

Direct Access

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Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain

Physical Therapy ◽

10.1093/ptj/pzz152 ◽

2019 ◽

Author(s):

Brigid Garrity ◽

Christine McDonough ◽

Omid Ameli ◽

James Rothendler ◽

Kathleen Carey ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Health Care Utilization ◽

Physical Therapist ◽

Care Physician ◽

Direct Access ◽

Care Utilization ◽

Low Back ◽

Unrestricted Access ◽

New Onset

Abstract Background Low back pain (LBP) is one of the most prevalent conditions for which patients seek physical therapy in the United States. The American Physical Therapy Association categorizes direct access to physical therapist services into 3 levels: limited, provisional, and unrestricted. Objective The objective of this study was to evaluate the association of level of access to physical therapist services with LBP-related health care utilization and costs. Design This was a retrospective cohort study of patients with new-onset LBP between 2008 and 2013; data were from OptumLabs Data Warehouse. Methods We identified 59,670 individuals who were 18 years old or older, who had new-onset LBP, and who had commercial or Medicare Advantage insurance through a private health plan. We examined 2 samples. The first was health care utilization among individuals who saw a physical therapist first in states with either unrestricted access or provisional access. The second was LBP-related costs among individuals who saw either a physical therapist or a primary care physician first. Results Individuals who saw a physical therapist first in states with provisional access had significantly higher measures of health care utilization within 30 days, including plain imaging and frequency of physician visits, than individuals who saw a physical therapist first in states with unrestricted access. Compared with individuals who saw a primary care physician first, pooled across provisional-access and unrestricted-access states, those who saw a physical therapist first in provisional-access states had 25% higher relative costs at 30 days and 32% higher relative costs at 90 days, whereas those who saw a physical therapist first in unrestricted-access states had 13% lower costs at 30 days and 32% lower costs at 90 days. Limitations This was a claims-based study with limited information on patient characteristics, including severity and duration of pain. Conclusions Short-term LBP-related health care utilization and costs were lower for individuals in unrestricted-access states than in provisional-access states.

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