Final report Pilot Study Podiatric Triage

                    Final   r eport   Pilot  Study  Podiatric   Triage                 Pilot  Foot  Triage  SAG       Conducted  by  Stichting  LOO...
Author: Philippa Norman
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                    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    

Pilot  Study  Podiatric  Triage2  

 

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.    

Pilot  Study  Podiatric  Triage3  

 

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  

Pilot  Study  Podiatric  Triage5  

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  *  

   

Pilot  Study  Podiatric  Triage6  

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.    

Pilot  Study  Podiatric  Triage8  

 

 

 

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  *  

 

Pilot  Study  Podiatric  Triage9  

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.  

   

Pilot  Study  Podiatric  Triage10  

        -­‐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.  

Pilot  Study  Podiatric  Triage11  

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  

Pilot  Study  Podiatric  Triage12  

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).    

Pilot  Study  Podiatric  Triage13  

 

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.    

Pilot  Study  Podiatric  Triage14  

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.  

Pilot  Study  Podiatric  Triage15  

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).  

Pilot  Study  Podiatric  Triage16  

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