Telephone-based triage and diagnostic accuracy of spinal pathologies

Purpose

Advanced Level Physiotherapy (ALP) is a term used to describe a level of practice for a physiotherapist to be working at. It includes utilising a combination of advanced skills, knowledge and clinical reasoning to successfully and safely manage patients, recognising where a clinical presentation is outside an individual's scope, and taking appropriate action. Utilising advanced clinical reasoning and making appropriate radiology referrals enables physiotherapists to exclude serious pathology and determine the appropriate pathway for a patient. Being able to safely triage and direct patients to conservative management or escalate to an orthopaedic review where suitable is the cornerstone of a clinically-effective service, and highlights the benefits of having experienced physiotherapists on hand to guide patients appropriately. Many studies have looked at whether the diagnostic accuracy of physiotherapists is comparable to orthopaedic consultants, but the diagnostic accuracy of a telephone based ALP triage service has not previously been investigated. The aim of this study was to audit the diagnostic accuracy of radiology investigations performed for spinal pain (cervical, thoracic, lumbar and sacroiliac) by a telephone based ALP triage service.

80% overall imaging diagnostic accuracy
against confirmed radiological findings via a telephone based ALP triage service

Approach

All radiology referrals made for spinal pain that were sent from September 2016 to December 2016 by the telephone based ALP service were included in this study (n=276). An audit was performed which retrospectively compared the reported radiological findings against the suspected pathology post initial ALP telephone triage assessment. Diagnostic accuracy can be calculated by comparing the clinical diagnosis from the telephone assessment, with pathology or findings confirmed from the radiological investigation. These were then grouped as either 1) correct diagnosis or 2) incorrect diagnosis. The percentage of onward referrals to a consultant based on the symptoms and diagnostic findings was also determined.

Outcomes

276 patient radiology referrals for spinal pain were included in this study. Correct diagnosis was seen in 220 cases, incorrect diagnosis totalled 56. Therefore, telephone based ALP assessment of spinal pain demonstrated an overall imaging diagnostic accuracy of 80% against confirmed radiological findings. From the results, disc pathology and nerve root impingement were the most common pathologies suspected (151 cases), and correctly diagnosed (137 cases), displaying a 91% accuracy. Of the 276 spinal cases referred for diagnostics, 117 were referred on for consultant review (42.5%) based on the findings. Over the space of four months, two cases of cauda equina syndrome (CES) were successfully identified and treated via the NHS, and one case of multiple metastases was identified and referred swiftly back to the patient's GP.

Cost and savings

There were no costs attached to this study, as it was all carried as part of normal working practice. The de-escalation rates of successfully diagnosing and de-escalating clients led to fewer onward referrals to consultants, which in term made the process more clinically effective for patients and cost effective for their PMI.

Implications

This telephone based ALP triage services was able to demonstrate a very high diagnostic accuracy with requested radiological investigations for spinal pain, and an appropriate onward referral rate based on symptoms and the findings. This suggests that the high number of patients assessed and investigated via the telephone based ALP service are not only appropriately investigated, but also a high percentage are safely kept in conservative management.

These results support the notion that the telephone based ALP service is both clinically effective and safe.

Top three learning points

  • Clinical reasoning and differential diagnoses can be effectively utilised via a telephone triage of a spinal patient
  • This study demonstrated a high diagnostic accuracy rate (80%) when comparing the clinical suspicion and the MRI results in spinal patients
  • Telephone triage can be safe and clinically effective when utilised in spinal patients

Fund acknowledgements

This study was part of the normal working practice of the Advanced Level Physiotherapy telephone triage service, undertaken by Nuffield Health. Funding was not sought from anyone else.

Additional notes

This work was presented at Physiotherapy UK 2017.

For more information, please contact the author at: Christine.Hutchinson@nuffieldhealth.com