Abstract
The project, ‘Best practice pathway for knee osteoarthritis –Implementing an advanced musculoskeletal pre-surgical triage and assessment clinic’ was instituted in response to Canberra Health Service (CHS) identifying delays to access consultants in orthopaedics and asking University of Canberra (UC) to develop and conduct a collaborative project to address the issues by implementing best practice solutions. A structured project was developed collaboratively to investigate factors contributing to extended waits for patients with knee osteoarthritis referred for orthopaedic consultation at Canberra Hospital, guide changes to care and evaluate outcomes. The project was funded by a Translation Grant from HCF Foundation for a 3-year period from July 2022 to June 2025.
Key Findings
ü Wait times improved: wait times to clinician consultation in 2023 were 14%, and in 2024 10% of comparable 2022 wait times.
ü The APPs saw more patients: from 20% in 2022, to 81% in 2023 and 76% in 2024.
ü Patients seen first in the APP clinic risked less delays than those seen only in the surgical clinic (APP clinic IRR: 0.55; 95%CI: 0.43, 0.72); and if seen in both APP and surgical clinics incidence rate ratio (IRR): 0.54; 95%CI:0.41, 0.70).
ü Risk of delays outside of clinical recommendations for patients reduced in 2023 and 2024 (AOR: 0.11; 95% CI: 0.04, 0.31; AOR: 0.02; 95% CI: 0.004, 0.09).
ü Less patients referred to orthopaedics were listed for knee replacement: from 46% to 38% then 35%.
ü As a measure of adverse response, people referred-back to see a surgeon by their GP after APP consultation were counted, but there was no difference between the years.
ü The surgeons saw more patients ready for surgery: a patient examined by a surgeon in 2023-2024 was 1.9 times more likely to be listed for surgery than a patient in 2022 (Odds Ratio 1.9, Chi2 = 6.5, p = 0.011).
Conclusions
Positive changes can be attributed to:
• Significantly reduced wait to see a clinician,
• An increased proportion of people with knee osteoarthritis being seen by APP,
• Digital health records reducing the risk of lost referrals,
• Availability of community exercise and education programs (GLA:D),
• Efficient use of consultant time,
• Compliance with the clinical standards for management of knee osteoarthritis.
Care has improved for patients following these improved pathways.
There is now an urgent imperative to expand this model of care to patients with other conditions in Orthopaedics and to other specialist clinics across CHS where it has been identified that advanced clinical practitioners would benefit access to care. An example is patients with chronic shoulder pain where strong evidence supports non-surgical interventions, but at present community care does not have capacity to treat this number of patients, which would be essential.
Resourcing and planning are needed for APPs to provide these additional services. APP clinics can improve access to care and efficiency of the surgical clinics, in that the patients in surgical clinics are more likely to be ready for surgery. However, there are insufficient APPs trained, and it is very difficult to recruit them from elsewhere. The interviews showed that GPs referring a patient to orthopaedics are seeking a specialist consultation for their patient; they are not necessarily seeking surgery for this patient and the consultation with the APP met their needs. Surgeons, however, prefer to see patients ready for surgery, except where complex conditions require specialist expertise.
Key Findings
ü Wait times improved: wait times to clinician consultation in 2023 were 14%, and in 2024 10% of comparable 2022 wait times.
ü The APPs saw more patients: from 20% in 2022, to 81% in 2023 and 76% in 2024.
ü Patients seen first in the APP clinic risked less delays than those seen only in the surgical clinic (APP clinic IRR: 0.55; 95%CI: 0.43, 0.72); and if seen in both APP and surgical clinics incidence rate ratio (IRR): 0.54; 95%CI:0.41, 0.70).
ü Risk of delays outside of clinical recommendations for patients reduced in 2023 and 2024 (AOR: 0.11; 95% CI: 0.04, 0.31; AOR: 0.02; 95% CI: 0.004, 0.09).
ü Less patients referred to orthopaedics were listed for knee replacement: from 46% to 38% then 35%.
ü As a measure of adverse response, people referred-back to see a surgeon by their GP after APP consultation were counted, but there was no difference between the years.
ü The surgeons saw more patients ready for surgery: a patient examined by a surgeon in 2023-2024 was 1.9 times more likely to be listed for surgery than a patient in 2022 (Odds Ratio 1.9, Chi2 = 6.5, p = 0.011).
Conclusions
Positive changes can be attributed to:
• Significantly reduced wait to see a clinician,
• An increased proportion of people with knee osteoarthritis being seen by APP,
• Digital health records reducing the risk of lost referrals,
• Availability of community exercise and education programs (GLA:D),
• Efficient use of consultant time,
• Compliance with the clinical standards for management of knee osteoarthritis.
Care has improved for patients following these improved pathways.
There is now an urgent imperative to expand this model of care to patients with other conditions in Orthopaedics and to other specialist clinics across CHS where it has been identified that advanced clinical practitioners would benefit access to care. An example is patients with chronic shoulder pain where strong evidence supports non-surgical interventions, but at present community care does not have capacity to treat this number of patients, which would be essential.
Resourcing and planning are needed for APPs to provide these additional services. APP clinics can improve access to care and efficiency of the surgical clinics, in that the patients in surgical clinics are more likely to be ready for surgery. However, there are insufficient APPs trained, and it is very difficult to recruit them from elsewhere. The interviews showed that GPs referring a patient to orthopaedics are seeking a specialist consultation for their patient; they are not necessarily seeking surgery for this patient and the consultation with the APP met their needs. Surgeons, however, prefer to see patients ready for surgery, except where complex conditions require specialist expertise.
| Original language | English |
|---|---|
| Publisher | University of Canberra |
| Number of pages | 9 |
| Publication status | Published - 27 Jun 2025 |