title: Intermediate care pathways for musculoskeletal conditions--are they working? A systematic review.
abstract: BACKGROUND
  Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services.
  
  
  OBJECTIVE
  This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence.
  
  
  METHODS
  PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013.
  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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  Part funded by EPSRC and AXA-PPP.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Centre for Sports and Exercise Medicine, Bart's and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London E1 4DG, UK.
authors.forename: A
authors.initials: A
authors.lastname: Hussenbux
authors.affiliation: Centre for Sports and Exercise Medicine, Bart's and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London E1 4DG, UK; Physiotherapy Department, Bart's Health NHS Trust, London, UK. Electronic address: d.morrissey@qmul.ac.uk.
authors.forename: D
authors.initials: D
authors.lastname: Morrissey
authors.affiliation: Centre for Sports and Exercise Medicine, Bart's and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London E1 4DG, UK.
authors.forename: C
authors.initials: C
authors.lastname: Joseph
authors.affiliation: Academic Department of Emergency Care, Adult Emergency Department, Bristol Royal Infirmary, University Hospitals NHS Foundation Trust, Bristol BS28HW, UK.
authors.forename: C M
authors.initials: CM
authors.lastname: McClellan
mesh_terms: D019091:Critical Pathways / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D059352:Musculoskeletal Pain / Q000175:diagnosis / Q000534:rehabilitation*; D010147:Pain Measurement; D010349:Patient Compliance / Q000706:statistics & numerical data; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D010808:Physical Examination; D026741:Physical Therapy Modalities; D011379:Prognosis; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014218:Triage; D006113:United Kingdom; D014850:Waiting Lists
keywords: Appropriate referral; Effectiveness; Musculoskeletal clinical assessment and treatment service; Patient outcome; Physiotherapy triage; Waiting times