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 refer rals 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-Fellowsh ip junior orthopaedic surgeons, or by specially trained physiotherapists wo rking in an extended role (orthopaedic physiotherapy specialists). Main outcome measures-Patient centred measures of pain, functional disabili ty 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, physioth erapist n=237) were similar at baseline. Baseline and follow up questionnai res 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 statisticall y or clinically important difference between arms was in a measure of patie nt satisfaction, which favoured the physiotherapist arm. A cost minimisatio n 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 = pound 256, n=232), as the y were less likely to order radiographs and to refer patients for orthopaed ic surgery than were the junior doctors (mean cost per patient in arm =poun d 498, n=238). Conclusions-On the basis of the patient centred outcomes measured in this r andomised 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 ortho paedic departments, and generate lower initial direct hospital costs.