This clinical audit evaluated the effects of introducing an experienced podiatrist to initiate the triage, assessment and management of patients referred to an orthopaedic outpatient unit with a foot or ankle condition. The findings of this study indicate that two-thirds of the patients who had an appointment at the podiatry-led assessment service were removed from the orthopaedic waitlist without requiring a surgical consultation. These findings are similar, albeit greater, to previous studies involving podiatrists performing assessment and triage roles where 41-45% of patients were discharged without requiring surgical management [8],[14]. Current literature suggests allied health professionals, including podiatrists, can ease demands placed on orthopaedic outpatient services [8],[9],[14],[16]. Importantly, as `Category 3’ patients generally wait the longest for a surgical consultation, the assessment and triage service allows those considered likely to benefit from non-surgical interventions to be redirected, in many cases earlier, for effective treatment.
The triage of referrals is intended to ensure patients receive appropriate and timely care, yet this process is highly reliant on referrals being accurate and informative. The results from this study indicate that almost half of the referrals received provided a non-specific diagnosis or one that wasn’t agreed upon by the triaging podiatrist. Although many of the diagnostic disagreements between the referrer and the assessing podiatrist are likely to be true differences in opinion, there is the possibility that in some cases the condition may have changed in the time between the date of the referral and initial appointment. When disagreement is present, it often remains uncertain which diagnosis is most accurate as a definitive diagnosis is not always established. With this in mind, it should be noted that the triaging podiatrist was more likely to provide a more specific diagnosis than that contained on the referrals. Although all patients provided an appointment at the podiatry-led assessment service were considered likely to benefit from non-surgical intervention based on their referral, approximately 20% were directly referred to a surgeon following their initial assessment. In addition, nearly half of all patient referrals to receive an appointment with a surgeon were found to have a non-specific diagnosis or one that wasn’t agreed upon by the podiatrist. This demonstrates the propensity for a referral lacking detail and/or accuracy to delay appropriate surgical treatment when indicated. Based on our findings, we recommend referrers ensure they provide informative and specific referrals to maximise triage efficiency and accuracy.
A novel aspect of the present study is it reported the specific conditions seen at the podiatry-led assessment service and the proportion of these conditions that were discharged with and without requiring a surgical opinion. This information can potentially be used in several ways. First, referrers could be advised that specific foot conditions, such as plantar fasciitis, should be referred for non-surgical management as a first-line of care as supported by this study and, more importantly, high quality clinical trials and clinical practice guidelines [4],[17],[18]. This would allow patients to receive appropriate, timely care and reduce unnecessary referrals to orthopaedic services, with the latter further reducing demand on surgical services. In contrast, for conditions such as hallux rigidus, it would be reasonable for referrers to strongly consider a surgical referral if the condition remains recalcitrant following non-surgical management [5],[19]. Second, when all new referrals are being triaged, conditions likely to benefit from non-surgical and surgical interventions could be identified and the most appropriate treatment options and referrals could be established. Importantly, this information could be applied at various stages of triage including the initial entry points into a public health service. If these changes were implemented it could potentially improve the efficiency of how foot and ankle referrals are triaged and managed.
Although the preliminary findings of this audit are promising, further service efficiencies are likely and should be considered. As triage prioritisation systems have been shown to have issues with reliability [20],[21], podiatrists could potentially triage all referrals with foot and ankle conditions to assist with identifying prioritisation categories and provide patients with early intervention where possible. By reducing the demands of triage on orthopaedic surgeons, it could potentially allow surgeons more time to consult patients already triaged and identified as requiring their surgical skills.
The findings of this audit should be considered in light of several limitations. First, and most importantly, the lack of a comparison group introduces uncertainty around whether the results reported are the effect of the new podiatry-led assessment service or unrelated factors. In addition, as assessment and patient care was not controlled, the results of this audit may be influenced by the individual clinicians rather than the new initiative itself. Nevertheless, in light of the limitations, the findings of this audit can be viewed as additional evidence to support the introduction of podiatry-led assessment services in orthopaedic units. In addition to addressing the aforementioned limitations, future research should consider measuring outcomes such as cost-benefit, waiting times, patient and referrer satisfaction and validated measures of changes in pain, function and psychological well-being.
