Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services: national data audit

Background: Many people with musculoskeletal (MSK) disorders wait several months or years for Consultant Doctor appointments, despite often not requiring medical or surgical interventions. To allow earlier patient access to orthopaedic and rheumatology services in Ireland, Advanced Practice Physiotherapists (APPs) were introduced at 16 major acute hospitals. This study performed the first national evaluation of APP triage services. Method: Throughout 2014, APPs (n = 22) entered clinical data on a national database. Analysis of these data using descriptive statistics determined patient wait times, Consultant Doctor involvement in clinical decisions, and patient clinical outcomes. Chi square tests were used to compare patient clinical outcomes across orthopaedic and rheumatology clinics. A pilot study at one site identified re-referral rates to orthopaedic/rheumatology services of patients managed by the APPs. Results: In one year, 13,981 new patients accessed specialist orthopaedic and rheumatology consultations via the APP. Median wait time for an appointment was 5.6 months. Patients most commonly presented with knee (23%), lower back (22%) and shoulder (15%) disorders. APPs made autonomous clinical decisions regarding patient management at 77% of appointments, and managed patient care pathways without onward referral to Consultant Doctors in more than 80% of cases. Other onward clinical pathways recommended by APPs were: physiotherapy referrals (42%); clinical investigations (29%); injections administered (4%); and surgical listing (2%). Of those managed by the APP, the pilot study identified that only 6.5% of patients were re-referred within one year. Conclusion: This national evaluation of APP services demonstrated that the majority of patients assessed by an APP did not require onward referral for a Consultant Doctor appointment. Therefore, patients gained earlier access to orthopaedic and rheumatology consultations in secondary care, with most patients conservatively managed.</p

Expression of NKRs CD94, NKG2A, CD161 and CD57 in patients maintaining or withdrawing therapy.

<p>Graphs illustrate (<b>A</b>) CD94 and NKG2A expression and (<b>B</b>) CD161 and CD57 expression at baseline (▴) and three months (○) in patients maintaining or withdrawing TNF inhibitor therapy. (C) Representative dot plots of two patients withdrawing TNF inhibitor therapy. Patient (I) remained in clinical remission for the study duration and maintained expansion of CD94 and NKG2A; Patient (II) had a flare in disease activity 6 months after withdrawal of therapy with loss of expansion of CD94 and NKG2A at 3 months (i.e. prior to clinical relapse). *p<0.05 significantly different.</p

Clinical, laboratory and functional assessments in patients cohorts maintaining and withdrawing TNF inhibitor therapy.

<p>*p<0.05 vs baseline.</p

Expression of NKRs CD94 and NKG2A in active RA, Remission RA and healthy controls.

<p>(A) Representative dot plots of CD94 and NKG2A expression on healthy control, patient with active RA and patient in remission following TNF inhibitor therapy. (B) CD94 and NKG2A expression on CD3+CD56− cells in healthy controls (▴), patients with active RA (○) and patients in remission following TNF inhibitor therapy (▪). *p<0.05 significantly different.</p

Total CD3+, Total CD56+ and CD3+CD56− T cell populations in patients maintaining or withdrawing therapy.

<p>Graphs illustrate total CD3+, Total CD56+ and CD3+CD56− T cell populations (expressed as a percentage of the lymphogate) in patients maintaining or withdrawing therapy at baseline (▴) and three months (○). *p<0.05 significantly different.</p

Baseline characteristics of patients in remission following TNF inhibitor therapy and in patients with active rheumatoid arthritis.

<p>*p<0.05 remission cohort significantly different from active RA cohort.</p

PsA patients have higher levels of IL-15 in their synovial tissue, providing an environment wherein NK cells are primed to the effector stage.

<p>(<b>A</b>) IL-15 is upregulated in the synovial tissue of patients with PsA but not AS, as shown by immunohistochemical staining using an anti-IL-15 mAb. Staining of a PsA tissue preparation with an isotype control antibody is shown on the left. Images are representative of at least three independent experiments. (<b>B</b>) Stress ligand levels are higher in the synovial tissue of PsA patients compared to patients with AS, as shown by immunohistochemical staining using an anti-MIC mAb. An isotype control is shown on the left as in (A). Images are representative of at least three independent experiments.</p

Expression of CD161, HLA-DR and CD57 in active RA, Remission RA and healthy controls.

<p>(A) Representative dot plots of CD161, HLA-DR and CD57 expression on healthy control, patient with active RA and patient in remission following TNF inhibitor therapy. (B) CD161, HLA-DR and CD57 expression on CD3+CD56− cells in healthy controls (▴), patients with active RA (○) and patients in remission following TNF inhibitor therapy (▪). *p<0.05 significantly different.</p

Associations between clinical disease activity and NKG2A expression.

<p>(A) Flare in disease activity (Increased DAS28) is associated with reduction in NKG2A expression on CD3+CD56− cells. (B) Negative correlation between DAS28 and T cell expression of *p<0.05 significantly different.</p

T cell, NK and NKT cell populations in active RA, Remission RA and healthy controls.

<p>Graph illustrating T cell, NK and NKT cell populations in healthy controls (N = 15) (▴), patients with active RA (n = 18) (○) and patients in remission following TNF inhibitor (n = 15)(▪). *p<0.05 significantly different.</p