Final r eport
Pilot Study Podiatric Triage
Pilot Foot Triage SAG Conducted by Stichting LOOP (LOOP Foundation) Project management on behalf of LOOP: A. Boek. Participating triage podiatrists: R. Wonink, A. Voorhorst, T. van Loon, P. Fahner and E. Sluijter. Participating orthopaedic surgeons: I.V van Dalen, H.A.F. Luning and K.M. Veenstra. Locations: Bergman clinic in Naarden, St. Maartens clinic in Woerden, Diaconessenhuis in Meppel. Under the guidance and advice of M. te Riele and I. Westera on behalf of Achmea. September 2013
Content TOC Introduction ............................................................................................................................................ 3 Methods .................................................................................................................................................. 4 Participants ......................................................................................................................................... 4 Measuring instruments ....................................................................................................................... 4 Procedure and data processing ........................................................................................................... 4 Additional methods ............................................................................................................................. 5 Results ..................................................................................................................................................... 5 Total Results ........................................................................................................................................ 5 Results per team ................................................................................................................................. 9 Saving on costs: ................................................................................................................................. 10 Added value of ultrasound ................................................................................................................ 11 Effect of waiting lists and agenda of the orthopaedist ..................................................................... 11 Effect of unnecessarily approaching the second -‐line care ............................................................... 12 Effects on client satisfaction ............................................................................................................. 12 Conclusion ............................................................................................................................................. 16
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Introduction This final report describes the results of the pilot study of podiatric triage, initiated by Achmea and Agis health insurers in cooperation with the Stichting LOOP. The pilot was launched in October 2012 and all information supplied up to and including June 2013 has been processed. The reason for the pilot study of the podiatric triage concerns the successful cooperation between the orthopaedist and the registered podiatrist as triage podiatrist in the Bergman clinic in Naarden, thereby functioning as a central point for clients with foot complaints. In most other settings such a central point is missing and there is a shortage of health-‐care providers who can fulfil a referential role in foot care. For clients, referrers, insurers and care providers, it is often unclear as to where the client can receive the most adequate and suitable treatment for his specific foot complaint, thereby causing more clients to visit and be treated by the orthopaedist than is necessary. This leads to dissatisfaction among clients and unnecessarily high health care consumption. The podiatric triage pilot is aimed at reducing the high health-‐care expenses and establishing a more efficient means of foot care, with ultrasound diagnostics playing an important role. The pilot is limited to commissioning a few triage podiatrists with an important referential function such as an intramural assistant for the orthopaedist. The question that the pilot should provide the answer to is: "What effect does the triage podiatrist and the use of ultrasound diagnostics have on second-‐line podiatric health care with regard to care efficiency and care consumption?" It is expected that with the entry of the triage podiatrist and the use of ultrasound, the diagnosis of foot complaints will improve, clients with foot complaints will receive adequate care from the correct care provider, the claims load reduced and unnecessarily high care consumption in the second-‐line care will be reduced. Furthermore the expectation of better patient flow in less time. Sequentially, this report covers the research method, the research results and the conclusion. The questionnaires, financial responsibility and a vision on podiatric triage in the future included as supplements.
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Methods To be able to answer the question, a pilot study has been started in which podiatric triage is made use of on a small scale. In this way the effects and side effects of the intervention by the triage podiatrist can be assessed quickly and easily. It concerns an empirical quantitative study in which the results are made more comprehensible by means of figures and percentages. The data is collected by means of predetermined questions that have been answered during a baseline measurement in the course of the pilot study.
Participants For the purpose of the survey data has been collected from a total of 2867 clients with foot complaints that are being treated by the participating orthopaedic surgeons and triage podiatrists. Four specialists associated with different hospitals, were willing to cooperate. Each specialist is connected with a triage podiatrist or a small team of triage podiatrists. All triage podiatrists are experienced paramedics specializing in diagnosis of foot and ankle problems by means of ultrasound and physical examination. They have completed the module Advanced Practitioner MSU foot and ankle of the MIRT training in Haarlem. The triage podiatrists have extensive knowledge of all conservative treatment options of foot and ankle pathology. During the preliminary phase of the pilot one of the participating specialists withdrew as it was not possible to organise the pilot study over the short term within the institution concerned. Due to this, the information provided in this final report is supplied by three orthopaedic surgeons and the cooperating triage podiatrists. The participating teams are: -‐ -‐ -‐
Dr. IV van Dalen and register podologists R. Wonink, E. Sluijter and P. Fahner of Bergman clinic in Naarden; Dr. K.M. Veenstra and triage podiatrist T. van Loon of the St. Maartens clinic in Woerden; Dr. H.A.F. Luning and triage podiatrist A. Voorhorst of the Diaconessenhuis in Meppel.
Measuring instruments At baseline prior to the pilot, existing data was made use of i.e. data that been recorded previously by the participating orthopaedic surgeons. The period in which they are recorded is called the Mirror period. The corresponding questionnaire is included in Annex 1. After the start of the pilot a type of written interview was used as a method of measurement, that is a triage questionnaire to be filled in by the triage podiatrist. This questionnaire is included in Annex 2. During the pilot a client satisfaction survey was conducted among 177 clients, of which 137 were also asked about the effect of the treatment. The related questionnaire is included in Annex 3.
Procedure and data processing The initial situation is determined with the help of the baseline based on the data prior to the entry of the triage podiatrist. The questionnaire for the baseline survey was completed by the orthopaedic surgeons based on the dossiers of clients with foot complaints. The most important questions are focused on how diagnostic imaging was carried out with these clients (MRI, CT, X-‐ray or bone scan), and which treatment was applied (conservative or operative).
Pilot Study Podiatric Triage4
During the pilot study the participating triage podiatrists perform their duties as diagnostician and referrer. In practice, this means that clients with foot complaints whom the GP has referred to the specialist, are first seen by the triage podiatrist in the hospital or clinic. The triage podiatrist examines the client by means of ultrasound and a physical examination and makes his diagnosis concerning the functionality and deviation of the foot. At the end of the consultation the orthopaedic surgeon will also see the client shortly (approx. 10 minutes) and indicate if he agrees with the assessment made by the triage podiatrist, with regard to the diagnosis, supplementary examination and method of treatment. The triage podiatrist is required to work with a triage form. Also here, the applied diagnostic imaging is requested as well as the suggested treatment for the client. The supplied data are processed in Excel worksheets. From these, the charts and tables are generated that compare the data of the baseline with the data of the pilot study.
Additional methods In addition to performing quantitative research, an answer to the question concerning the study has been looked at in a previous study carried out abroad in the field of orthopaedics and (podiatric) triage. A study with clear relevance is: Homeming L.J., Kuipers, P., Aneel Nihal A. (2012). Orthopaedic podiatry triage: process outcomes of a skill mix initiative. Australian Health Review, 36 (4), 457-‐460. The purpose of this pilot study was to reduce the long waiting lists for orthopaedic surgery concerning clients with foot and ankle problems. It is based on the recognition that many referrals for orthopaedic surgery can be identified early and treated conservatively with podology, so that more expensive and invasive surgical procedures can be avoided. In the period prior to the pilot an estimate of the costs was drawn up describing the potential savings with the introduction of ultrasound. In the report, the results obtained have been associated with the estimated savings that can be determined. Finally, the experiences of the triage podiatrists and orthopaedic surgeons involved, as well as the feedback received from clients during this pilot are included in this report.
Results To display the results in this report the data from the pilot (November 2012 up to and including June 2013) are compared to the data collected in the Mirror period (October 2011 to July 2012) prior to the baseline.
Total Results Because a different number of new clients with foot complaints are attended to by the orthopaedic surgeons and triage podiatrists in the mirror period and in the pilot period, and also that the number of examined /treated clients per team varies considerably, it was decided to calculate the ratio of the amounts to 100 clients per institution providing healthcare. The tables and charts on the following pages show an overall decline in medical imaging techniques and surgical procedures since the deployment of the triage podiatrists. In terms of percentage the
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decrease in the use of MRI is 71%, because the number of MRIs has dropped from 14 per 100 clients to 4 per 100 clients (Table 3 and Table 4). In CT scans and X-‐ray diagnostics the reduction is 90% and 65%, respectively. The percentage of bone scans remains unchanged. In terms of percentage the decline of a surgical procedure is 26%. In terms of percentage there is an increase of 8% in conservative treatment. There is also a percentage of clients that remained untreated, or first for further examination, or are eligible for referral to another specialist / hospital. It also occurred that clients were given a “non-‐medical” advice for treatment and that they, for example, were helped by being referred to an approved shoe retailer. This group is not broken down any further and is categorised under “not treated / other”. This percentage has increased significantly in relation to the mirror period. Data Mirror period: baseline
Bergman clinic
St. Maartens Diaconessen clinic huis
Totals Percentage
10 11 21 42 9 7 13 29 100 94 40 234 2 0 1 3 50 33 45 128 50 67 38 155 0 0 17 17 Table 1: The data per 100 new clients, who for purposes of the baseline, are provided by the orthopaedists of the health care providers involved. Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
14% 10% 78% 1% 43% 52% 6%
Data total pilot period
Bergman clinic
St. Maartens Diaconessen clinic huis
Totals Percentage
3 3 6 12 4% 1 1 1 3 1% 26 33 22 82 27% 0 0 4 4 1% 35 29 33 97 32% 57 54 58 169 56% 8 19 10 38 13% Table 2: The data per 100 new clients, which are provided during the pilot, are provided by the triage podiatrists of the included health care institutions. Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
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Mirror Period
Pilot Period
Difference
Medical imaging
14% 4% -‐10% MRI: 10% 1% -‐9% CT: 78% 27% -‐51% X-‐Rays 1% 1% 0% Bone scan Medical Treatment 43% 32% -‐11% Intervention 52% 56% 4% Conservative treatment 6% 13% 7% Untreated / other * Table 3: The difference in the application of medical imaging and treatment since the start of the pilot, expressed in percentages. Increase / decrease Medical imaging
-‐71% MRI: -‐90% CT: -‐65% X-‐Rays 0% Bone scan Medical Treatment -‐26% Intervention 8% Conservative treatment 117% Untreated / other * Table 4: The percentage of increase and decrease of the applied medical imaging and treatment per 100 clients.
Chart 1: Change in applied imaging. Pilot Study Podiatric Triage7
Chart 2: Change in applied method of treatment.
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Results per team Bergman clinic
Mirror Period
Pilot Period
Difference
10% 3% -‐7% 9% 1% -‐9% 100% 26% -‐74% 2% 0% -‐2% 50% 35% -‐15% 50% 57% 7% 0% 8% 8% Table 5: Change in application of medical imaging and treatment in the Bergman clinic. Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
St. St. Maartens clinic
Mirror Period
Pilot Period
Difference
11% 3% -‐8% 7% 1% -‐6% 94% 33% -‐61% 0% 0% 0% 33% 29% -‐4% 67% 54% -‐13% 0% 19% 19% Table 6: Change in application of medical imaging and treatment in the St. Maartens clinic. Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
Diaconessenhuis
Mirror Period
Pilot Period
Difference
21% 6% -‐15% 13% 1% -‐12% 40% 22% -‐18% 1% 4% 2% 45% 33% -‐12% 38% 58% 20% 17% 10% -‐7% Table 7: Change in application of medical imaging and treatment in the Diaconessenhuis. Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
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Saving on costs: The amounts mentioned in Table 8 are estimates for medical imaging and treatment. All clients are currently still being seen by the orthopaedist after each consultation with the triage podiatrist. The hospital fees including those of the orthopaedist add up to an amount of approximately € 380, -‐ also if it does not lead to an intervention, or if treatment is cancelled. The total estimated cost savings on the investigated medical imaging and methods of treatment amounts to € 44.260,-‐ per 100 clients (Table 9). It should be noted that the costs for triage (€ 60, -‐ per client) are not yet included in the calculation, just as in the interim report. The above shown saving in costs is realised by a strong decline in the amount of operations since using podiatric triage, and a clear decrease in diagnoses due to expensive imaging techniques. In the future, the triage podiatrist will fulfil a more independent role in second-‐line care and it is expected that the triage podiatrist can also take over more control patients from the orthopaedist, which will yield an extra reduction in consultation fees of the orthopaedist. Costs diagnosis and treatment Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
Estimated amount € 400,00 € 320,00 € 60,00 € 400,00 € 3.500,00 € 380,00 € 380,00
Table 8: Estimated cost medical imaging and treatment. Savings per 100 clients
Difference in clients
Medical imaging MRI: CT: X-‐Rays Bone scan Medical Treatment Intervention Conservative treatment Untreated / other *
Total estimated savings per 100 clients: Table 9: Estimated cost savings per 100 clients.
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-‐10 -‐9 -‐51 0 -‐11 4 7
Savings € 4.000,00 € 2.880,00 € 3.060,00 € -‐ € 38.500,00 € -‐1.520,00 € -‐2.660,00
€ 44.260,00
Added value of ultrasound In addition to the numerical results of the pilot until now, the orthopaedists and the triage podiatrists involved were asked what they considered as added value of triage supported by ultrasound. Below are the summaries of their experiences. The orthopaedist and triage podiatrist of St. Maartens clinic report that the added value of triage is the greater possibility of a “live” diagnosis by means of ultrasound. An ultrasound is not necessarily a substitute for other means of examination, but actually is a supplement to the existing possibilities. Thanks to ultrasound a diagnosis is made in less time, among others, because planning appointments with the radiologist in many cases becomes superfluous. This alone creates a reduction in care consumption. The orthopaedist and triage podiatrist experience the collaboration and the possibility of exchanging knowledge as very positive. The orthopaedist prefers to have this working process implemented. According to expectations the triage podiatrist is of greater value in second-‐line care due to the close collaboration with the specialist. The triage podiatrist of the Bergman Clinic states that MRI has become superfluous when dealing with disorders such as peritalar tendon problems and neuromas, that can be diagnosed very well using ultrasound. In the past when MRI was used to “see what the problem is”, and thereafter decide for conservative therapy. MRI now has been given a specifically pre-‐operative character in the course of diagnostics. MRI is used when ultrasound diagnostics is inadequate, in particular to accentuate the bone diameters in relation to the surrounding joints and soft tissue. In certain cases it is best suited to use MRI after ultrasound as the echo results showed that there is a joint defect and thereby indicated for surgical treatment. Thanks to ultrasound diagnostics MRI is now being used with greater awareness and more effectively. Ultrasound is also of added value for corticosteroid injections, since the physician can not only inject more accurately using ultrasound guidance, but can also confirm hypervascularization better, making it easier for him to conclude if an injection would be appropriate. The orthopaedist of Diaconessenhuis likes to discuss the status of a client with the triagist as a “skilled professional” and exchange thoughts concerning the client. Ultrasound did not contribute to diagnosis or treatment in all cases. It also occurred that the orthopaedist and triage podiatrist differed in opinion, with the orthopaedist giving preference to a consultation prior to carrying out an ultrasound.
Effect of waiting lists and agenda of the orthopaedist Data on the agenda of the orthopaedist in the mirror period Waiting time of referral to first consultation with the surgeon (in weeks) Waiting time for an intervention (in weeks) Scheduled time per new patient in the agenda of the surgeon (minutes)
Average 7 15 12
Table 10: Data with regard to the agenda of the orthopaedist d uring the mirror period.
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The pilot study still shows no changes in the agenda of the orthopaedist. The waiting lists are currently unchanged, and in this pilot study the orthopaedist will diagnose the client at the end of each triage consultation for approximately 10 minutes. Regarding this point, the participating caregivers expressed their expectations. The orthopaedist and triage podiatrist of St. Maartens clinic believe that the use of podiatric triage will have a positive effect on the waiting list and the agenda of the orthopaedist, if the triage podiatrist carries out his work (even) more independently, and also caters for more checkup patients. At the start it will be it an investment in time to organize the agenda of the orthopaedist so that a correct distribution is made between the clients to be seen first by the triage podiatrist and clients who can go directly to the orthopaedist. In due course people will get used to this and it will result in a better flow. An earlier study carried out abroad shows the following: An Australian study in which podiatrists were used as triage podiatrists for foot and ankle problems, the chief purpose being to reduce the waiting lists for the orthopaedist, resulted in a reduction of the non-‐urgent part of the waiting list by 23.3% to 49.7%, in the three hospitals. The study showed an improved flow of clients (L.J. Homeming et al, 2012). Here it should be noted that in the study it is not mentioned whether the triage podiatrist made use of ultrasound as a means of diagnosis or not. The triage podiatrist examined people who already had been on the waiting list of the orthopaedist. Because a large proportion of clients with non-‐urgent problems could be assisted by conservative treatment, thanks to the triage, the waiting list was reduced noticeably.
Effect of unnecessarily approaching the second -‐line care Prior to the pilot, the expectation was that by commissioning the triage podiatrist unnecessary access to second-‐line care would be restricted. This particularly would be the case if the triage podiatrist were to be positioned in first-‐line care, so that an early correct diagnosis would prevent unnecessary referrals to the orthopaedist. As it has been decided to use triage podiatrists alongside the orthopaedist during the pilot period, it can not be proved at the moment, to which extent the unnecessary workload of the second -‐line care is reduced. All clients participating decidedly made use of the second-‐line. Based on the outcome of the pilot in which among others, the percentage of operations is reduced and the percentage of conservative treatment has risen the expectation still remains that when the triage podiatrist is commissioned for first-‐line care, this will reduce the use of second-‐line care, probably because more clients can be helped by means of a conservative treatment instead of undergoing an operation. With the use of triage podiatrists in the first-‐line the expectation is that clients with foot complaints will have direct access to triage podiatrists, thereby avoiding unnecessary visits to the G.P. In supplement 4 we will go into more detail of our view on podiatric triage in the future.
Effects on client satisfaction One hundred and seventy seven clients participated in our survey on client satisfaction. This survey covered pain reduction, effects of treatment and the satisfaction concerning intervention by the triage podiatrist as well as the treatment in general. In 137 of the 177 cases the treatment had
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already taken place. In the remaining 40 cases the clients were on the waiting list for an operation or some other treatment, or they were given a “non-‐medical” treatment advice, although they already had seen the triage podiatrist. The pain reduction was measured by asking about the amount of pain prior to and after treatment in which 0 meant “no pain” and 10 which meant “unbearable pain” (NRS-‐11 pain score). Both clients who had undergone surgery as well as clients who had conservative treatment reported a reduction of pain after treatment (expressed with a minus sign). The average reduction of pain of all 137 clients treated was -‐3,91 (Table 11). 2% of the clients treated indicated that the pain worsened somewhat after the treatment, 19% indicated that there was no recovery despite having been treated, the remaining 79% of the clients experienced the recovery after treatment as “somewhat better to complete recovery” (Table 12).
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Pain Reduction
Avg. pain reduction
Number of clients
Total number of clients treated
137
-‐3,91
Medical Treatment Intervention 50 -‐4,96 Conservative treatment 85 -‐3,33 Surgery and conservative treatment 2 -‐2,50 Table 11: Average pain reduction of treated clients measured by the NRS-‐11 pain scale score. Recovery after treatment
Number of clients
Total number of clients treated Recovery after treatment was experienced as: Complete recovery Far better Somewhat better No recovery Somewhat worse Much worse Worse than ever Table 12: Recovery after treatment
Percentage
137
100%
15 68 25 26 3 0 0
11% 50% 18% 19% 2% 0% 0%
On the intervention of the triage podiatrist, the 177 clients asked were predominantly positive. 7% had no opinion, 20% were positive and 73% were very positive about the triage podiatrist (Table 13).The reason for this may be due to the following: The experience of the triage podiatrist of Bergman clinic is that a feeling of dissatisfaction experienced by the client can be prevented by the triage podiatrist taking time, and by means of ultrasound, also give the client insight and information about the problem. Then clearly discuss the various treatments possible. Like this podiatric triage has an even greater value in communicating with the client. The orthopaedist of Diaconessenhuis noticed that clients generally appreciated the extra attention given to their problem. Feedback from clients supports this line of thought; below a selection of their comments: It was very nice that I also came into contact with a podiatrist / sonographer. By having an ultrasound it immediately became clear why I had problems with my toes, which were almost dislocated with every step I took. I had never been aware of this, and now the examination has contributed to me being able to understand the recommended method of treatment a lot better. The reason that I'm so positive about the ultrasound is that you get better (visual) insight concerning the problem, so that before the actual consultation, I already have a better idea of the situation and the adjustments that are discussed.
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A preliminary examination by the podiatrist / sonographer is very effective, because the orthopaedist (in my case) immediately has a “clear picture” of the status. One can not simply see the internal parts of a foot. So, very positive. Intervention triagist
Number of clients
Total number of clients interviewed
Percentage
177
100%
experienced as: The intervention of the triage nurse was Very Negative 0 0% Negative 0 0% No opinion 12 7% Positive 36 20% Very positive 129 73% Table 13: Experiences related to the intervention of the registered podiatrist as triage podiatrist. The overall customer satisfaction of the complete treatment is somewhat less positive, and yet 21% of the clients asked were satisfied and 61% very satisfied with the treatment (Table 14). As for the clients who were dissatisfied or had no opinion, it can not be excluded that there are other factors that would influence an objective assessment. For example, on arrival at the hospital a client may have great expectations of undergoing an operation that would solve the the problems with his feet. But during the triage it seems that the course of treatment would be changed and an operation would not be necessary. This can have a negative influence on client satisfaction. However, there is no further data concerning this. Satisfaction
Number of clients
Total number of clients interviewed
177
The client's opinion of the treatment: Very dissatisfied Dissatisfied Somewhat dissatisfied No opinion Somewhat satisfied Satisfied Very satisfied Table 14: General client satisfaction
3 0 3 25 0 38 108
Percentage 100% 2% 0% 2% 14% 0% 21% 61%
Although there is currently insufficient data available to show a relation between saving on costs and client satisfaction, the expectation is that a high level of customer satisfaction will have a positive effect on the total cost savings. The triage podiatrist of the Bergman clinic comments: We can expect that some of the dissatisfied clients will request a second opinion and / or a new consultation by way of the GP with a referral for further follow-‐up examinations and treatments. A high level of customer satisfaction will limit the procedures and strongly reduce the costs involved.
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Conclusion The use of triage podiatrists and echo diagnostics within the second-‐line foot care has a positive effect on care efficiency and care consumption. Because the number of clients in the pilot study differs from the number of clients on the baseline, we have determined the percentage increase or decrease per 100 clients. The percentage decrease in diagnosis by means of MRI, CT scans and X-‐rays can be considered as significant, with 71%, 90% and 65% respectively. The implementation of bone scans remained relatively unchanged (percentage decrease 0%). There is a decline of surgical procedures expressed in percentage at 26% and an increase in conservative treatments expressed in percentage at 8%. The percentage increase of clients that were not treated, were referred to another specialist / hospital for follow-‐up examination, or a “non-‐medical” advice such as a referral to a good shoe supplier, amounts to 117%, because this has increased from 6 per 100 clients to 13 per 100 clients. On basis of the registered data and the current working method the estimated cost saving on the examined medical imaging and methods of treatment is € 44.260, per 100 clients (Table 9), and therefore € 442,60 per client. During the pilot period 1096 clients were seen, which, in eight months time yielded a saving of more than € 485.000,. It should also be noted that the triage costs have not yet been included in this calculation. In the future, the savings will result in more than was expected because the triage podiatrist will fulfil a more independent role in second-‐line care. This means a reduction of the costs for an orthopaedic consultation. In addition, the triage podiatrist will take over more control patients of the orthopaedist. This makes the second-‐line foot care even more efficient and equipped for saving costs. A reduction of the unnecessary approach to second-‐line care has not yet been shown, because the triage podiatrist was only used for second-‐line care during the pilot study, and all participating clients were making use of this care. The involved triage podiatrists and orthopaedists experienced the cooperation as constructive and in the interest of the client. This is also evident from the data of the client satisfaction survey: 93% of the 177 clients asked were positive to very positive about the intervention of the triage podiatrist , and 82% were satisfied to very satisfied with the course of the treatment. Also an average pain reduction was indicated by -‐3.91 and 79% of the 137 clients treated who were interviewed, experienced an improvement to some extent and others complete recovery. The orthopaedists as well as the triage podiatrist involved have positive expectations that waiting lists will be shortened. Currently no figures are yet available. A study in Australia however, shows that triage with foot and ankle problems prior to a consultation or orthopaedic surgery, resulted in waiting lists being shortened and an improved flow of clients (Homeming L.J. et al, 2012).
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