Intermediate Care pathways for musculoskeletal conditions - Are they working? A systematic review

Background: Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services. Objectives: This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence. Data sources: PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013. Study selection/eligibility criteria: Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded. Results: Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists' clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction. Limitations: These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services. Funding: Part funded by EPSRC and AXA-PPP. Conclusion: Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients.