Change in diagnosis among orthopedists compared to non-orthopedists in themanagement of acute knee injuries

Objective. Uncertainty regarding diagnosis is associated with lower patient satisfaction and can lead to delays in definitive treatment and to inappro priate use of resources. We sought to compare change in diagnosis among ort hopedists and non-orthopedists caring for a community based cohort of indiv iduals with incident acute knee injuries. Methods. We conducted a longitudinal investigation of a population based co hort of Olmsted County residents with their First episode of acute knee inj ury occurring between January 1, 1993, and December 31, 1995. We reviewed t he entire (inpatient and outpatient) medical records for these patients and collected extensive clinical data on all diagnoses made (including possibl e and probable) and the specialty of the attending physician(s) making them . Diagnoses were categorized as: (1) meniscus injury, cruciate injury, or o steochondral fracture; (2) ligament injury, patellar instability, patellar injury; or (3) sprain, strain, injury (unspecified). Diagnostic switches we re defined as changes from one diagnostic category to another, or the addit ion or subtraction of a diagnostic category. We then examined the quality o f the documented evidence supporting meniscal, ligamentous, and cruciate di agnoses (at initial evaluation) by comparing the clinical evidence to the r ecommendations outlined by the American Academy of Orthopaedic Surgeons cli nical algorithm on acute knee injury. Analyses were conducted comparing (1) the number elf diagnostic switches and (2) the quality of the documented e vidence among those cases initially cared for by orthopedists and those car ed for by non-orthopedists, using logistic regression analysis adjusting fo r age sex and injury severity. The influence of these variables on costs of care was also examined. Results. There were 664 patients (361 men and 303 women) in our study popul ation, with an average age of 36.0 years (minimum 17, maximum 87). Of these , 324 were excluded because they only had one clinical encounter for their acute knee injury. Of the remaining 340, 59 (17.4%) were initially cared fo r by an orthopedist and 211 (62.1%) were cared for by an orthopedist at som e time during their care. Diagnostic switcher were significantly less frequ ent in the group who were cared for by orthopedists (55% vs 74%, p < 0.001) . This result persisted after adjusting for age, sex, and severity (P = 0.0 03). The proportion of cases whose diagnoses were supported by evidence was significantly higher among the group whose first attending physician was a n orthopedist (63.0% vs 37.6%, p = 0.002). Both change in diagnosis (p < 0. 001) and physician specialty (p < 0.001) were statistically significant pre dictors of costs of care. Conclusion. Compared to non-orthopedic care, orthopedic care for acute knee injury was associated with fewer changes in diagnosis, and diagnoses made by orthopedists were more likely to be supported by evidence. However, even after adjusting for severity, orthopedic care remained significantly more costly than non-orthopedic care.