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Abstract
The Sengkang General Hospital Orthopaedic Spine Outpatient Service is facing a growing challenge of increasing number of referrals and waiting times, placing a significant burden on the system. Primary care referrals have an average wait time of 61.1 days, with 34.5%f patients waiting longer than 60 days from referral to appointment, to see a spine physician.
Back pain is a very common presentation, with the vast majority resolving after conservative management which commonly includes analgesia, physiotherapy and reassurance. Unfortunately, many referrals from primary care involve patients who have yet to explore the avenues of conservative management with 90% of our referrals being managed without surgery. Globally, triage services in Western countries conducted by allied health professionals have shown to be an effective method at addressing the escalating wait times with high satisfaction rates. We have endeavoured to emulate this within our department through the implementation of the Spine Triage and Rehabilitation (STAR) Clinic. The STAR clinic aims to empower physiotherapists with the ability to triage patients into surgical and non-surgical categories with their primary physiotherapy expertise to reduce waiting times and increase outpatient capacity.
More than 300 patients were recruited, and their progress was tracked over 13 months under the four Ss of: waiting timeS, cost Savings, Safety and patient Satisfaction. This pilot study has been overwhelmingly positive, with significantly reduced waiting times and high cost savings, without any compromise on patient safety and satisfaction.
- Back Pain
- Quality improvement
- Quality improvement methodologies
- Teams
- Outpatients
Data availability statement
Data sharing is not applicable as no data sets were generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Back pain is a prevalent global health issue, commonly addressed through conservative management, with surgical intervention required for only a fraction of patients.
The strain on healthcare systems worldwide has led to innovative approaches, such as triage services by allied health professionals, aiming to alleviate wait times.
WHAT THIS STUDY ADDS
The Spine Triage and Rehabilitation Clinic aims to empower physiotherapists with the ability to triage patients into surgical and non-surgical categories alongside their primary physiotherapy expertise, aiming to reduce waiting times and increase outpatient capacity.
This study marks the first comprehensive documentation of the implementation steps, ongoing troubleshooting and problem-solving processes, while demonstrating the results of extended scope physiotherapists in managing lower back pain.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
With promising outcomes, our intention is to expand our service and share our first-hand experiences with other institutions considering a similar strategy for improved efficiency.
Problem
Our institute is the Sengkang General Hospital Orthopaedic Spine Department located in Singapore which caters for a predominantly Asian population. We are facing a growing challenge due to the increasing number of referrals and prolonged waiting times, which are placing a significant burden on the system. Referrals from primary care have a median wait time of 61.1 days, with 34.5% of patients waiting longer than 60 days from referral to an appointment to see an Orthopaedic Spine Physician. Long waiting times have been associated with higher cancellation rates, resulting in wasted clinic slots and delaying the flow of care.
The following Quality Improvement Project has been designed and carried out in accordance with the Standards for Quality Improvement Reporting Excellence Framework.1
Background
Lower back and neck pain are common issues managed in both primary and tertiary care centres, with most of these conditions being conservatively managed, while severe or refractory cases are offered interventional management.2–4 However, despite a low proportion of patients requiring surgery or interventions, referrals to spine specialists are still numerous, which may negatively affect waiting times, patient satisfaction, costs and healthcare system efficiencies.5 6 Patients' overall experience and timely medical attention are crucial factors affecting good accessibility to healthcare, and long waiting times have been cited as an important barrier to receiving care.7 With an increasing load on the healthcare system worldwide due to an ageing population worldwide, patients may have to wait longer periods for their referral appointments, which could negatively impact their quality of life and psychological well-being.8 Long waiting times could also lead to higher defaulting rates, resulting in wasted clinic slots and delaying the flow of care. Moreover, delays in diagnosing patients with 'red flag' presentations who require urgent care increase the likelihood of unfavourable recovery prognosis.9
Allied health-run triage services or extended scope physiotherapist clinics have become a popular model of care to address the issue of rising wait times and increased patient load on the healthcare system, particularly in the context of degenerative spine conditions.10 Studies have cited satisfactory outcomes with little safety concerns when such patients are managed independently by specialised physiotherapists or nurses rather than in a more costly orthopaedic spine consult.11 Various studies also report benefits to costs, waiting times and improved accuracy of triaging patients for subsequent interventions.12–14 Given these positive outcomes seen worldwide, we endeavoured to replicate these successes within our institution Sengkang General Hospital, Singapore.
Measurement
Primary outcome
For the primary outcome of wait times two measurements were selected which were the median monthly wait time in days and the percentage of patients waiting longer than 60 days each month for all patients designated to see a conventional spine physician. Baseline measurements prior to the initiation of the project were collected 10 months prior to the initiation of the project.
Secondary outcome
Cost analysis
Cost analysis was performed by comparing the average costs per patient for outpatient consultation services between 350 Spine Triage and Rehabilitation (STAR) Clinic patients against a cohort of 350 non-surgical patients attending a conventional spine consultant clinic for lower back pain or neck pain.
Safety
Safety of our STAR Clinic service was assessed by having every case discussed with a consultant spine surgeon to determine the concordance rate of physiotherapist-physician diagnosis and management.
Patient satisfaction
Patient satisfaction was assessed by giving patients a voluntary questionnaire to complete following the completion of the first STAR clinic visit (figure 1).
Patient satisfaction survey. STAR, Spine Triage and Rehabilitation.
Design
The STAR Clinic team comprised three Orthopaedic Spine Consultants, one Orthopaedic Senior House Officer and four Physiotherapists who collaborated to develop a comprehensive framework for the clinic. Initially, our project aimed to reduce the outpatient load on Spine Physicians by increasing the availability of clinic slots. However, during the planning phase, it became evident that this initiative could also lead to cost savings for patients by minimising unnecessary appointments where non-surgical patients were shuttled between physicians and physiotherapists. Additionally, we recognised the importance of ensuring patient satisfaction and safety as integral components of this project’s success. Therefore, we collected data on patient satisfaction and safety. For a visual representation of the methodology and workflow, please refer to figure 2.
Workflow Illustration.
One of the challenges we foresaw was low recruitment due to patients' lack of enthusiasm for the programme, especially if they had already seen and failed conservative management at a primary care level. We hoped to use data from this pilot study to encourage and accelerate the growth of such a programme, both at the patient level and in terms of recruiting new physiotherapists as an effort to maintain sustainability and growth for the programme.
Prior to the commencement of the STAR Clinic, four selected physiotherapists underwent an accreditation course run by an Orthopaedic Spine Surgeon who is the senior author of this paper. This course ran over a period of 3 months and included, shadowing clinic sessions, two MRI Interpretation Workshops, three case Discussion Workshops, a log-book consisting of various common and red-flag spine conditions and lastly a case concordance log where physiotherapists needed to log a minimum of 10 cases where Physiotherapist and Spine Consultant had the same diagnosis and management plan.
Patients were voluntarily recruited into the STAR Clinic by primary care physicians for clinically diagnosed lumbar degenerative conditions. To ensure the safety and appropriateness of referrals, all referral letters from primary care physicians underwent a rigorous virtual screening process conducted by the physiotherapist in charge. This process aimed to identify red flags such as inflammatory, malignancy and infective causes of back pain, as well as significant neurological deficits discovered during clinical examination. Please consult figure 2 for a detailed overview of our exclusion criteria.
The clinic session consisted of a 15 min history and examination followed by a 15 min physiotherapy session totalling 30 min. This initial assessment followed a premeditated workflow for history and physical examination with careful attention to review red-flag features (figure 3) based on the Keele STaRT Back Model and American Spinal Injury Association Scoring.15 16
STAR Clinical Documentation Template.
Clinical plans were determined by the physiotherapist in charge and patients were either open-dated, given further physiotherapy sessions or offered a physician consult. Medications in the form of oral paracetamol, oral non-steroidal anti-inflammatories (NSAIDs) with gastric protection, topical NSAIDs, oral gabapentin, oral pregabalin and oral vitamin B complex could be prescribed in STAR. Radiographs and MRI scans could also be ordered where indicated. All cases required a discussion between physiotherapist and a consultant to determine concordance rate. Patients were subsequently given a qualitative survey to determine patient satisfaction (figure 1).
Strategy
Our SMART aim was to reduce the percentage of patients with a waiting time to an appointment of more than 60 days from 34.5% to less than 10% over an 8-month period. We conducted three Plan-Do-Study-Act (PDSA) test cycles.
PDSA 1
Initially, we launched the STAR Clinic for a trial period of 1 month. It operated as a single bi-weekly clinic led by our head physiotherapist. The goal was to determine the demand, identify workflow inefficiencies, and address any safety or patient satisfaction concerns. At the outset, we tested a 60 min clinic, with 30 min allocated to history taking and 30 min for physiotherapy sessions. However, it became apparent that this session was too long, often leading to early endings and inefficiencies. Consequently, we adjusted it to a 30 min session, dividing it into 15 min for history taking and 15 min for physiotherapy, a configuration we have retained. As the STAR Clinic’s popularity grew, we gradually introduced more physiotherapists, along with the shorter 30 min clinic, which increased our outpatient service’s capacity.
PDSA 2
In the initial months after introducing more physiotherapists, patients were not consistently scheduled to see the same physiotherapist for follow-up appointments. However, to ensure continuity of care, we made an effort to match patients with the same physiotherapist for subsequent visits. This change elicited positive feedback from patients, who appreciated the consistency, and from physiotherapists, who felt a greater sense of ownership and responsibility for each patient. We have maintained this practice since then.
PDSA 3
For our final test cycle, we sought to further promote the STAR Clinic at the primary care level as we noticed an underutilisation of our services. We engaged with the heads of relevant primary care departments and presented our preliminary results, highlighting shorter wait times, high patient satisfaction rates, reduced costs and a very high standard of safety. Through these efforts, we increased STAR Clinic attendance by nearly 60%. However, as junior primary care physicians rotated through their postings, the increase in patient recruitment was not sustained without continuous reminders.
Results
Over a period of 13 months, more than 350 patients were recruited to the STAR Clinic Programme, and their progress was tracked across the four domains, or the four Ss: waiting times, cost savings, safety and patient satisfaction.
Primary outcome: waiting time
The waiting time to see a spine specialist following a referral from primary care or the emergency department was assessed in terms of the percentage of patients waiting longer than 60 days and the median monthly wait time (figure 4).
Wait times before and after Spine Triage and Rehabilitation (STAR) Clinic implementation.
Starting in February 2022, the department initiated a major effort to reduce existing wait times by allocating additional clinics and human healthcare resources. This resulted in a period of improved wait times before the STAR programme was implemented. These resources were subsequently removed postimplementation. Following the full implementation of the STAR Clinic with the four physiotherapists, the percentage of patients waiting longer than 60 days reduced from 34.5% to 0%–1.3%, while the median wait time reduced from 61 days to 36–44 days (figure 4).
Secondary outcome
Cost savings
Costs were calculated based on the outpatient consultation fees charged to patients, prior to government subsidies. Following a diagnosis-matched comparison between 350 patients from a conventional spine physician clinic and another 350 from the STAR Clinic, the average cost savings per patient in the STAR Clinic was SGD415 (SGD602 to >SGD187), representing a 69% decrease compared with a conventional physician clinic. We found that these cost savings primarily resulted from two factors. First, physiotherapy appointments cost less compared with those with a spine physician. Additionally, patients no longer had to shuttle between these two clinics, reducing inefficiencies. However, we do acknowledge that the running of additional clinics to operate the STAR Clinic does come with its own set of costs to the hospital as well as human healthcare resources which may counterbalance the cost savings seen.
Safety
The STAR Clinic achieved a concordance rate of over 99.5% agreement between physiotherapists and spine consultants. Only one case of non-concordance was logged: Mrs Z, a 60-year-old woman referred for a 1-week history of lower back pain after carrying heavy furniture. During the review, she complained of ongoing left calf pain that developed approximately at the same time. The physiotherapists at the STAR Clinic initially suspected lower back and left calf strain and planned for further physiotherapy. However, after discussions with the spine consultant in charge, both agreed that although left calf strain was more likely, the spine consultant found it difficult to assess for neurological power deficits due to pain and believed that an MRI was indicated. Fortunately, after the MRI, no nerve compression was found, and the patient improved with simple analgesia. She was given open-ended appointments for two more physiotherapy sessions.
Patient satisfaction
Out of the first 200 patients in STAR, 87 filled out the patient satisfaction survey. There was a 100% satisfaction rate, with no recorded cases of patients being neutral or dissatisfied with the STAR clinic in any of the survey elements. Moreover, 92%–99% of reviews in all survey elements were scored as very positive. The details are as follows:
‘The manners of the clinician(s) who saw you for your appointment’—94% very satisfied, 6% satisfied.
‘The clarity of the instructions provided to you, verbal and written, about your condition and the follow up care.’—98% very satisfied, 2% satisfied.
‘The professionalism and helpfulness of your clinician when handling your condition.’ 97% very satisfied, 3% satisfied.
‘Your wait time before the clinic appointment.’—92% very satisfied, 8% satisfied.
‘The competence and capability of the clinician who saw you for the clinical consult.’—98% very satisfied, 2% satisfied.
‘The extent to which staff respected your privacy.’—94% very satisfied, 6% satisfied.
‘The time that was given to me in the STAR clinic for consult was adequate.’—98% strongly agree, 2% somewhat agree.
‘I would return to see this clinician for further care.’—98% strongly agree, 2% somewhat agree.
‘I would recommend this clinic to family and friends.’—99% strongly agree, 1% somewhat agree.
Lessons and limitations
In this section, we will discuss the lessons learnt from the project, its limitations, strengths, challenges faced and potential improvement. We will also address the project’s continuous improvement and measurement approach.
Lessons
The primary objective of this project was to enhance waiting times for patients attending spine clinics. Throughout the project’s implementation, we continuously worked on optimising our processes. As previously mentioned, key adjustments included shifting from 60 min appointments to 30 min appointments and assigning the same physiotherapist for follow-up cases to ensure consistency and a sense of ownership for patients.
Due to hospital and national guidelines and policies, physiotherapists were unable to prescribe medications. Any cases requiring prescriptions necessitated either a doctor’s physical review during the clinic visit or a repeat primary care consultation. We are actively working to improve this aspect by involving pharmacists in the prescription process.
Effective multidisciplinary communication played a crucial role. We found that verbal and written feedback from physiotherapists, physicians, clinic assistants, administrative staff and patients was essential for continuous improvement. During the project’s initiation, we held numerous multidisciplinary meetings, where feedback guided our workflow, clinic safety measures and efforts to meet patient expectations while improving wait times.
This past year served as a pilot study, and we aim to build on it. Our primary goal is to promote the clinic and leverage these data to attract more patients interested in such a clinic, as recruitment is currently voluntary. However, we encountered under-recruitment issues, even with continuous reminders to primary care. We hope to use this study as a means to promote awareness to the public.
Limitations
While our study offers valuable insights, it has its limitations. First, our spine department is relatively small, comprising three consultants. Factors like consultants going on leave or temporarily closing their clinics significantly impact our waiting time data, making them less generalisable. Second, just before the project’s initiation, the spine department received additional clinic resources in the form of extra Senior House Officers to manage outpatient clinic loads. This influx of resources made it challenging to establish accurate pre-STAR and post-STAR Clinic implementation data. Another limitation is the relatively low survey response rate, with fewer than half of the patients participating, potentially introducing bias.
Conclusion
In our pilot study of the implementation of a physiotherapy-led triage clinic, we observed significant improvements in waiting times and cost savings for patients. There was a very low rate of discordance between physiotherapist and physician management, and patient satisfaction rates remained high. Furthermore, our system has proven to be sustainable, operating for over a year with an increasing number of patients. We strongly recommend that other institutions consider implementing an allied health-led spinal triage clinic, given the growing burden on healthcare systems worldwide. However, we also stress the importance of paying careful attention to the training and safety aspects of such a system to ensure that healthcare efficiency does not come at the expense of patient safety and satisfaction.
Data availability statement
Data sharing is not applicable as no data sets were generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
In accordance with policy guidelines in Sengkang General Hospital, the study presented is intended to improve the care of patients and expedite recovery. Patients were informed and agreeable to attend the STAR Clinic prior to their recruitment with every case thoroughly vetted by at least one spine consultant. The processes of this study were also scrutinised by the Medical Board of Sengkang General Hospital to ensure safety to patients during the study and subsequently in its subsequent implementation.
Acknowledgments
We would like the thank the following essential and integral members of the STAR Clinic Team: Chen Haobin, Neo Ghimhoe, Phoebe Ting, Claire Low, Bernice Liu, Cindy Ng, Rachel Chin Yu Lian.
References
Footnotes
Contributors Conceptualisation: LRHT, YH; Methodology: WW, LRHT, YH; Formal analysis: WW, CHS, HYK; Resources: WW, LRHT, YH; Writing – original draft preparation: WW, CHS, HYK; Writing – review and editing: LRHT, YH; Supervision: LRHT, YH; Project administration: WW. All authors have read and agreed to the published version of the manuscript. YH is the guarantor and is responsible for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.