ABSTRACT
OBJECTIVE To describe referral mechanisms for referral to orthopedic surgery for isolated limb injuries in a public health care system and to identify factors affecting access.
DESIGN Cross-sectional survey.
SETTING Orthopedic surgery service in a level 1 trauma centre in Montreal, Que.
PARTICIPANTS We conducted a prospective study of 166 consecutive adults (mean age 48 years) referred to orthopedic surgery for isolated limb injuries during a 4-month period.
MAIN OUTCOME MEASURES Self-reported data on the nature of the trauma, the elapsed time between injury and orthopedic consultation, the number and type of previous primary care consultations, sociodemographic characteristics, and the level of satisfaction with care.
RESULTS Average time between the injury and orthopedic consultation was 89 hours (range 3 to 642), with an average of 68 hours (range 0 to 642) for delay between primary care consultation and orthopedic consultation. A total of 36% of patients with time-sensitive diagnoses had unacceptable delays to orthopedic consultation according to the Quebec Orthopaedic Association guidelines. Lower limb injury, consulting first at another hospital, living far from the trauma centre, patient perception of low severity, and having a soft tissue injury were associated with longer delays.
CONCLUSION Identifying gaps and risk factors for slower access might help improve referral mechanisms for orthopedic consultation.
Serious isolated limb injury requiring medical care affects 9% to 13% of adults annually.1 The incidence of fracture is 8.5 per 1000 adults and the incidence of dislocation is 1 per 1000 adults.2 Approximately 10% of all referrals from emergency department physicians are to orthopedic surgery, which is more than any other specialty.3 The large number of patients affected by traumatic orthopedic lesions makes them a challenge for public health care systems with limited resources. A basic tenet of the Canadian system is universal access to health care. However, accessing specialists can be problematic. In the case of traumatic orthopedic injury, prompt access is important to prevent potentially serious complications.4,5 In order to access an orthopedic surgeon, a patient must obtain a referral requisition. Therefore, access to an orthopedic surgeon is dependent on access to primary care, subsequent recognition of the need for referral, and availability of an orthopedic team. Factors related to access and health care use include patients’ predisposing characteristics, enabling resources, and patient needs.6
To our knowledge, no one has characterized access to ambulatory orthopedics services for isolated limb injuries. The objective of this study was to describe referral mechanisms for orthopedic surgery consultations for isolated limb injuries and to identify factors affecting access. The secondary objective of this study was to evaluate patient satisfaction with the referral mechanism.
METHODS
Study design and setting
This cross-sectional survey was conducted in a 420-bed tertiary care level 1 trauma centre in Montreal, Que. The orthopedic service is composed of 9 orthopedic surgeons specializing in trauma. There is no screening system for injury referral; thus, access depends on prompt referral by primary care physicians. Also, ambulatory injured patients might put off attending the orthopedic clinic for various reasons. In our centre, urgent referrals can be seen the same day by the team on call and nonurgent cases are typically referred to the next day‘s trauma clinic. The institution’s Research Ethics Committee approved the study.
Study patients
Patients were included in the study if they were ambulatory adult patients referred to the orthopedic service with isolated limb injuries. Patients were excluded if they were unable to speak French or English or if their injuries had occurred more than 3 months earlier. Referrals came from the emergency department in the same hospital, different hospitals, local community health centres, and family medicine clinics.
Data collection and measures
Following the first orthopedic visit for an injury, any patient meeting the inclusion criteria was recruited by a research nurse who administered questionnaires after obtaining written consent. Patients answered a questionnaire on sociodemographic characteristics, injury history, past medical history, initial primary care treatment, time of injury, and time of each medical consultation. We also asked participants about consumption of tobacco, alcohol, and drugs. A second questionnaire was completed by the orthopedist, addressing type of injury, quality of immobilization, adequacy of referral diagnosis, and type of treatment offered. The “Arbeitsgemeinschaft für Osteosynthesefragen” (AO) classification for fractures was used.7 Soft tissue injuries were described by the anatomic structure injured. A third questionnaire was completed by the patient regarding pain relief treatment, immobilization, and walking aids, as well as an evaluation of pain using a scale (0 to 10).8 Patient satisfaction with the process of care was assessed with the Visit Satisfaction Questionnaire, a validated, 9-item questionnaire.9,10
Analysis
Access to an orthopedic surgeon was defined as the time elapsed from the injury until the orthopedic consultation. The time between injury and each primary care physician visit was calculated in hours according to patient self-report. We defined 3 time intervals (Figure 1). We compared the time to referral to the orthopedic service with the norms published by the Quebec Orthopaedic Association.4,5 We also documented the number of consultations before orthopedic consultation. To assess patients’ proximity to the hospital, we calculated the distances between patients’ home and the hospital using their postal codes, with the aid of MapQuest (www.mapquest.ca).
Diagram defining time interval in referral mechanism: A interval represents time between injury and the first primary care visit; B interval represents time between first primary care visit and the consultation in orthopedic surgery; AB interval represents the total delay between the time of injury and the orthopedic consultation.
We sought to identify factors affecting the number of primary care consultations, the amount of time elapsed before seeing an orthopedic surgeon (B interval in Figure 1), and patient satisfaction. Bivariate analyses of continuous variables were performed using the Student t test. The χ2 test was used for dichotomous variables. We used multiple logistic regression for the dichotomous outcomes and multiple linear regression models for continuous data.
RESULTS
A total of 201 ambulatory patients were referred for orthopedic surgery for isolated limb injuries during the 4-month period following September 1, 2006. Of 178 eligible patients, 166 (93%) agreed to complete all questionnaires. Mean age of the sample was 48 years (SD 19 years, range 18 to 88 years) and slightly more than half were female (n = 85, 51%). Most (n = 150, 90%) declared that they were in good to excellent health before their injuries. On average, participants had 14 years of schooling (SD 4.5, range 2 to 37). The mean distance between home and the hospital was 15.9 km (SD 55.5 km, range 0 to 616 km, median 5.7 km). Sociodemographic characteristics are described in Table 1.
Descriptive data: A total of 166 respondents completed the survey, but not all respondents answered all questions.
Most patients (n = 142, 86%) were diagnosed with fractures; 24 (14%) were diagnosed with soft tissue injuries. The severity of their injuries was graded by patients on a 5-point Likert scale (Table 1). The most common physical site of injury was upper limbs (n = 107, 64%).
Referral mechanism
Sources of referral varied: 76 (46%) patients were referred from the same hospital, 67 (40%) from family medicine clinics, 13 (8%) from other hospitals, and 6 (4%) from community health centres. Mean time from injury to orthopedic consultation (AB interval in Figure 1) was 89 hours (SD 108 hours, range 3 to 642 hours, median 45 hours, interquartile range [IQR] 372 hours). The average time from injury to the first medical visit (A interval) was 21 hours (SD 49 hours, range 0 to 412 hours, median 4 hours, IQR 23 hours). The average time from the first medical consultation to the visit with an orthopedic surgeon (B interval) was 68 hours (SD 94 hours, range 0 to 642 hours, median 29 hours, IQR 385 hours). In the bivariate analysis, 5 variables were significantly associated with longer time between the first primary care visit and the orthopedic consultation (B interval) (Figure 2). In the multivariate analysis, 2 independent predictors were associated with shorter B intervals: high severity of injury according to the patient (P < .001) and having a fracture instead of a soft tissue injury (P = .003, R2 = 0.379).
Results of bivariate analysis for delays (in hours) between initial primary care visit and consultation in orthopedic surgery
Although most (n = 127, 77%) patients saw only 1 primary care doctor, there were 39 patients (23%) who saw 2 or more primary care doctors before consulting the orthopedic service. In bivariate analyses, 7 variables were significantly associated with multiple primary care consultations (Table 2). Also, seeing 2 general practitioners or more was associated with longer B intervals for these patients compared with patients who had seen 1 physician (128 hours vs 49 hours, P < .001). In the multivariate analysis, the 2 independent predictors of multiple consultations were lower limb injury (odds ratio [OR] 3.30, 95% confidence interval [CI] 1.41 to 7.68, P = .006) and consulting first in another health care centre (OR 13.50, 95% CI 4.36 to 41.5, P < .001).
Bivariate analysis of factors associated with multiple previous consultations
According to Quebec guidelines,4,5 42 (25%) patients had time-sensitive pathologies. Of these, 15 (36%) cases were seen after unacceptable delays (Table 3). Among the 15 cases with longer times to consultation, 7 saw more than 1 doctor before getting orthopedic referrals. Longer distance between patients’ homes and the hospital (18.6 km vs 9.0 km; P = .03) was associated with not being seen within the recommended time.
Cases with referral times exceeding those recommended by the Quebec Orthopaedic Association
Patient satisfaction
Results obtained with the Visit Satisfaction Questionnaire indicated that global satisfaction of patients was 82.4% (SD 12.1%, range 47.5% to 100%, median 83%, IQR 17%). Only 16 (9.9%) patients rated the time to see the orthopedic surgeon as poor or fair. Satisfaction with time to consultation or number of primary care visits before seeing an orthopedic surgeon was not associated.
DISCUSSION
The mean time from injury to orthopedic consultation was approximately 3.5 days. However, 36% of those patients with time-sensitive diagnoses were not seen by orthopedic surgeons within the acceptable delay time. Referral from another hospital or clinic, lower limb injury, low self-assessment of injury severity, and having a soft tissue injury were all independent predictors of delayed access to orthopedic consultation.
These findings have potential explanations. Although the waiting time for orthopedic consultation was for the most part acceptable, there were some problems. In our level 1 trauma centre, there is 24-hour access to the orthopedic team on call. Nevertheless, communication with this team can be difficult because there is no specific protocol for new consultations from other centres. Patients with lower limb injuries might experience more difficulty finding transportation to a medical facility. Patients who perceive their injuries as more severe are more likely to consult physicians sooner. Having soft tissue injuries, as opposed to fractures, was associated with longer delay, as they are often regarded as less urgent than bony injuries.11
A substantial number of patients (n = 39, 23%) with isolated limb injury saw 2 or more doctors before receiving referral for orthopedic consultation. In the context of limited financial resources for health care, this situation is unacceptable. In addition, 36% of patients with time-sensitive injuries4,5 did not consult orthopedic surgeons within the appropriate time frame. This was associated with longer distance between patients’ homes and our hospital. A recent study showed that patients often bypass the nearest hospital for orthopedic care, despite longer delays in the farther health centre, if they believe that it delivers better care.12 There might be problems at the primary care level, as suggested by results from another Canadian study that showed deficits in care of acute orthopedic conditions13 and other musculoskeletal diseases14 by primary care physicians, possibly owing to inadequate medical training in this area.15 Other studies have found that sex and social status were associated with access to health care.16 Our analysis showed that male patients typically had longer delays before orthopedic consultation, although it was no longer significant in the multivariate analysis. No association was found between socioeconomic status and access to orthopedics, unlike results found by other researchers.17–24 This might be the result of universal health insurance in Canada.
In this study, patient satisfaction with the care they received was high, and it was not related to access to care, as was the case in another study.22 Completing the questionnaire immediately following the visit (as in our study) as opposed to filling it out later might increase the level of satisfaction.25,26
Limitations
Our study has several limitations. First, participants might have been those who were most likely to have shorter delays to consultation, fewer previous consultations, and higher levels of satisfaction. This would represent a selection bias. This study was done in a single health care centre in the context of a public health care system. Results on elapsed time to consultation might not be generalizable to other hospitals.
Conclusion
Injury type, patient self-assessment of severity, and type of first health care resource used by the patient are factors influencing access to orthopedic consultation. Substantial rates of multiple primary care consultations before obtaining orthopedic consultation and long delays for time-sensitive injuries underscore the necessity of improving primary care physician training in the area of musculoskeletal injuries. Orthopedic surgeons should get involved in teaching first-line care and must improve communication to accept referrals. Development of clear guidelines for referral is also needed to improve referral mechanisms.27
Notes
EDITOR’S KEY POINTS
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Access to orthopedic surgeons is dependent on access to primary care and subsequent recognition by primary care physicians of the need for orthopedic consultation.
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This study describes referral mechanisms for orthopedic surgery consultation for isolated limb injuries and identifies factors affecting access.
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The mean time from injury to orthopedic consultation was 89 hours or approximately 3.5 days, and half the sample consulted an orthopedist within 45 hours. However, 36% of those with time-sensitive diagnoses were not seen by orthopedic surgeons within the acceptable time frame.
POINTS DE REPÈRE DU RÉDACTEUR
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L’accès aux chirurgiens orthopédiques dépend de l’accès aux soins primaires et de la reconnaissance subséquente par le médecin de première ligne de la nécessité d’une consultation orthopédique.
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Cette étude décrit les mécanismes pour demander une consultation orthopédique pour une blessure isolée à un membre et identifie les facteurs qui nuisent à l’accès à ce service.
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Il s’est écoulé en moyenne 89 heures, ou environ, 3,5 jours, entre la blessure et la consultation orthopédique, et la moitié des patients étudiés ont été vus par l’orthopédiste en moins de 45 heures. Toutefois, 36 % des patients avec un diagnostic où le temps est un facteur limitant n’ont pas été vus par un chirurgien orthopédiste dans un délai acceptable.
Footnotes
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This article has been peer reviewed.
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Competing interest
None declared
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Contributors
All authors contributed substantially to the concept and design of the protocol, analysis and interpretation of the data, and drafting the article or revising it critically for important intellectual content. Dr Rouleau collected the data.
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*Full text is available in english at www.cfp.ca.
- Copyright© the College of Family Physicians of Canada
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