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Singapore Med J
Singapore Med J
SMJ
Singapore Med J
Singapore Medical Journal
0037-5675
2737-5935
Wolters Kluwer - Medknow India

34688234
SMJ-65-471
10.11622/smedj.2021178
Short Communication
Are primary care referrals to the paediatric orthopaedic speciality clinic always clinically indicated?
Nashi Nazrul MBBS, MMed 1
Choo Selena Xueli BMedSc (Hons), BMBS 1
Doshi Chintan MBBS, DOrtho 1
Wong Keng Lin Francis MBBS, FRCSEd 2
Lim Kean Seng Andrew MBBS, FRCSEd 1
1 University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore
2 Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore
Correspondence: Dr. Nazrul Nashi, Registrar, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, 1E Kent Ridge Road, 119228, Singapore. E-mail: nazrulnashi@gmail.com
8 2024
24 10 2021
65 8 471475
18 5 2020
20 8 2020
Copyright: © 2024 Singapore Medical Journal
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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pmcINTRODUCTION

Musculoskeletal conditions are increasingly prevalent in the primary care setting, comprising up to 20% of visits to primary care physicians (PCPs).[123] There are also more children presenting with such complaints to PCPs, making up one-third of the total population.[3] This has led to an increase in primary care referrals to paediatric orthopaedic surgeons.[4]

Based on current literature, up to 95% of referrals were for common musculoskeletal conditions or normal variants manageable at the primary care setting.[5] Majority of the referred conditions do not warrant surgery, with surgical rates ranging between 3% and 10%.[5] In addition, increasing referrals on top of a stretched paediatric orthopaedic workforce lead to longer waiting times, which may affect those requiring an earlier review or intervention.[6]

The American Academy of Pediatrics (AAP) Surgical Advisory Panel (SAP) has published a set of guidelines attempting to identify diagnoses that should be referred to paediatric orthopaedic surgeons.[7] However, these guidelines listed conditions requiring a paediatric orthopaedic specialist referral, but not general orthopaedic management. Therefore, to include conditions requiring the latter, the American Board of Pediatrics (ABP) referral criteria are utilised as well to delineate between conditions that can be managed at the primary care setting versus those requiring a general or paediatric orthopaedic specialist review.[8] However, even with such guidelines in place, only 35%–53% of referrals to the paediatric orthopaedic surgeons were considered appropriate.[2910]

In the local population, there is a lack of guidelines to determine appropriateness of referrals to paediatric orthopaedic speciality clinics by PCPs. As such, there is concern regarding an increasing number of inappropriate referrals made. The primary aim of this study was to determine how many referral cases seen by the paediatric orthopaedic surgeons in our outpatient clinics were manageable by PCPs based on the AAP SAP and ABP guidelines. The secondary aim of this study was to identify commonly referred conditions by PCPs to the specialists, and this would help to identify potential knowledge gaps.

METHODS

A retrospective review of the clinical data of successive first-visit paediatric patients (aged ≤18 years) referred to our paediatric orthopaedic specialist clinics between January 2018 to June 2018 was conducted. Only patients referred from PCPs to the specialist clinics were included in the study. Patients referred from the children’s emergency department or from overseas physicians were excluded. This study was approved by the National Healthcare group domain specifc review board (reference 2017/01248).

To determine if a condition referred to the paediatric orthopaedic specialist was considered a paediatric and/or general orthopaedic condition, we utilised the AAP SAP and ABP guidelines.[78] The list of conditions under the AAP SAP guidelines includes malignant and benign bone tumours, congenital deformities of the upper extremity, limb malformations, metabolic bone disease, hip dysplasia, bone and joint infections, slipped capital femoral epiphysis, scoliosis, complex fractures and dislocations, and growth arrest. Examples of conditions under the ABP guidelines include long cast application of upper or lower extremity fractures, treatment of displaced fractures, scaphoid fractures, compartment syndrome, presence of a nerve or vascular injury and lesions, developmental anomalies or any condition requiring advanced diagnostic evaluation, complex reduction or surgical treatment.[789] A condition was considered a primary care problem if it is not included in either guidelines.

Data entry was performed using a spreadsheet application (Excel 2003; Microsoft Corporation, Redmond, WA, USA). All variables were presented in frequency tables and as descriptive statistics (mean, standard deviation or median where appropriate). Categorical variables were presented as proportions and continuous variables were presented as mean. Chi-square test and Fisher’s exact test were used for comparison between categorical variables. Statistical significance was set at P ≤ 0.05, and data analysis was performed using IBM SPSS Statistics version 16 (IBM Corp, Armonk, NY, USA). Univariate and multivariate logistical regression was used to analyse the significance between age groups and various factors.

RESULTS

A total of 522 first-visit paediatric patients aged ≤18 years were referred to our paediatric orthopaedic speciality clinic by PCPs between January 2018 to June 2018. Of these patients, 305 (58.4%) were male, 510 (97.7%) were subsidised and 12 (2.3%) were not subsidised (private). There were 106 (20.3%) patients referred from PCPs, who were discharged from the specialist clinic after their first visit.

Of the 522 patients, 357 (68.4%) referred had an accompanying referral diagnosis, whereas 165 (31.6%) did not. Out of the 357 patients with an established referral, 122 (34.2%) had an inappropriate referring diagnosis when compared to the final paediatric orthopaedic specialist diagnosis. The most common group of conditions leading to an inappropriate referring diagnosis were those affecting the hip, knee and leg (n = 40, 32.8%). Of the 165 patients who did not have any referring diagnosis, 49 (29.7%) had conditions involving the foot and ankle. Table 1 shows the breakdown of inappropriate primary care referrals based on the group of conditions for those with and without a referring diagnosis. There was no significant difference in inappropriate referral diagnosis and whether a referring diagnosis was made or otherwise when compared against the patients’ age, gender or paying category. Of the 522 patients reviewed, only 24 (4.6%) required advanced diagnostic investigation in the form of imaging (computed tomography scans or magnetic resonance imaging) before a final diagnosis was reached. Seven (1.3%) patients were scheduled for advanced diagnostic imaging, but defaulted follow-up. The remaining 491 (94.1%) patients did not require further diagnostic evaluation before a final diagnosis was reached.

Table 1 Inappropriate primary care referrals based on group of conditions for patients with or without a referring diagnosis.

Diagnosis	n (%)	
	
With (n=122)	Without (n=165)	
Infection	4 (3.3)	2 (1.2)	
Tumour	1 (0.8)	2 (1.2)	
Spine conditions	10 (8.2)	10 (6.1)	
Shoulder and elbow conditions	8 (6.6)	14 (8.5)	
Hand conditions	7 (5.7)	25 (15.2)	
Hip, knee and leg conditions	40 (32.8)	47 (28.5)	
Foot and ankle conditions	29 (23.8)	49 (29.7)	
Physiological variants	23 (18.9)	16 (9.7)	

The appropriateness of referral was evaluated based on the AAP SAP and ABP guidelines[78]; 58 (11.1%) and 75 (14.4%) patients were deemed to have been referred appropriately based on the AAP SAP and ABP guidelines, respectively. In total, out of the 522 patients, only 133 (25.5%) patients referred from PCPs were deemed appropriate, whereas the remaining 389 (74.5%) patients had conditions that can be managed at the primary care setting. The most common diagnosis for referral based on the AAP SAP and ABP guidelines was scoliosis (14/58, 24.1%) and ganglions (12/75, 16%), respectively. The lists of appropriate referral diagnoses by PCPs as per the AAP SAP and ABP guidelines are reflected individually in Tables 2 and 3, respectively. There was no significant difference found on comparing appropriateness of referral to the patients’ age, gender or paying category. Interestingly, 389 (74.5%) patients could have been managed by PCPs [Table 4]. The most common primary care condition referred was under the umbrella of ligamentous and soft tissue injuries (145/389 patients, 37.3%), mostly those affecting the hip, knee and leg (66/145, 45.5%). Sprains and strains form the bulk of the diagnosis under ligamentous and soft tissue injuries (59/145, 40.7%). Table 5 shows the breakdown of the various ligamentous and soft tissue injuries based on anatomical groupings. Other commonly referred conditions include non-displaced/angulated fractures (52/389, 13.4%) and flexible pes planus (48/389, 12.3%). None of the inappropriately referred patients were referred back to PCPs.

Table 2 Appropriate diagnoses based on the AAP SAP guidelines (N=58).

Diagnosis	n (%)	
Scoliosis	14 (24.1)	
Complex fracture dislocation	9 (15.5)	
Developmental dysplasia of the hip	7 (12.1)	
Benign bone tumours	7 (12.1)	
Congenital deformity of the upper limb	2 (3.4)	
Limb malformations	13 (22.4)	
Spinal anomalies	2 (3.4)	
Othersa	4 (6.9)	
aOther conditions, (n=1, 1.7%): slipped capital femoral epiphysis, malignant bone tumour, growth arrest and kyphosis. AAP: American academy of pediatrics, SAP: Surgical advisory panel

Table 3 Appropriate diagnoses based on the ABP referral criteria (N=75).

Diagnosis	n (%)	
Displaced single upper limb fracture	2 (2.7)	
Displaced lower limb fractures	2 (2.7)	
Torticollis	5 (6.7)	
Bilateral pathological genu varum	3 (12.1)	
Tight heel cord	5 (6.7)	
Knee injury (patella dislocation)	8 (10.7)	
Osteochondritis dissecans (talus)	4 (5.3)	
Ankle injury (anterior talofibular ligament tear)	6 (8)	
Medial plica syndrome	9 (12)	
Hallux valgus	2 (2.7)	
Ganglion	12 (16)	
Othersa	16 (21.3)	
aOther conditions, (n=1, 1.3%): displaced both upper limb fractures, neurovascular injury, intramuscular haemangioma, pathological internal tibial torsion, synostosis, knee cyst, syndactyly, fibular hemimelia, arteriovenous malformation of the hand, congenital talipes equinovarus, bilateral tibia vara, ulna subluxation, under-riding fifth toe, knee injury (anterior cruciate ligament tear), Scheuermann’s disease, and partial gastrocnemius tear. ABP: American board of pediatrics

Table 4 Conditions that can be managed by primary care physicians (N=389).

Diagnosis	n (%)	
Pes planus (flexible)	48 (12.3)	
Non-displaced/angulated phalanx fractures	52 (13.4)	
Femoral anteversion	2 (0.5)	
Chronic low back pain	11 (2.8)	
Non-displaced single bone fracture (upper limb)	26 (6.7)	
Radius buckle fracture	29 (7.5)	
Normal exam	28 (7.2)	
Physiological torsion or angular deformity	8 (2.1)	
Ligamentous and soft tissue injuries	145 (37.3)	
Ingrown toenail	11 (2.8)	
Viral wart (foot)	5 (1.3)	
Sebaceous cyst	3 (0.8)	
Undisplaced lower limb fracture	8 (2.1)	
Paronychia	2 (0.5)	
Coccydynia	3 (0.8)	
Accessory navicular	3 (0.8)	
Subungual haematoma	2 (0.5)	
Other conditions, (n=1, 0.3%): pes planus (rigid), callus and mallet finger.

Table 5 Breakdown of ligamentous and soft tissue injuries based on anatomical groups (N=145).

Diagnosis	n (%)	
Spine		
 Strain/sprain	10 (6.9)	
Shoulder and elbow		
 Contusions	2 (1.4)	
 Strain/sprain	8 (5.5)	
 Tendinitis	6 (4.1)	
Hand		
 Contusion	6 (4.1)	
 Strain/sprain	5 (3.4)	
Hip, knee and leg		
 Osgood–Schlatter disease	8 (5.5)	
 Anterior knee pain syndrome	11 (7.6)	
 Contusion	22 (15.2)	
 Strain/sprain	12 (8.3)	
 Tendinitis	10 (6.9)	
 Shin splint	3 (2.1)	
Foot and ankle		
 Strain/sprain	24 (16.6)	
 Tendinitis	17 (11.7)	
 Tight tendoachilles tendon	2 (1.4)	

Only 36 (6.9%) patients were offered surgery; of these patients, 27 (75%) ultimately underwent a procedure, whereas the remaining nine (25%) defaulted follow-up. The remaining 486 (93.1%) patients were managed conservatively. Table 6 shows the list of conditions for which patients were offered surgery.

Table 6 Conditions that were offered surgical treatment (N=36).

Diagnoses	n (%)	
Osteochondral lesion	2 (5.6)	
Medial patellofemoral ligament disruption	3 (8.3)	
Sebaceous cyst	2 (5.6)	
Gastrocnemius and tendoachilles tightness	2 (5.6)	
Ingrown toenails	3 (8.3)	
Angulated phalanx fractures	3 (8.3)	
Medial plica	4 (11.1)	
Medial meniscus tear	2 (5.6)	
Bilateral pathological genu varum	2 (5.6)	
Othersa	13 (36.1)	
aOther conditions, (n=1, 2.7%): slipped capital femoral epiphysis, tumour, anterior talofibular ligament tear, anterior cruciate ligament tear, pes planus (rigid), pathological genu varum, arteriovenous malformation of the hand, prolapsed intervertebral disc, synostosis, calcaneonavicular coalition, syndactyly, ulna subluxation and ganglion.

DISCUSSION

Based on the existing literature, most referred conditions from PCPs to paediatric orthopaedic specialists can be managed at the primary care setting.[259] Out of the 522 patients referred from PCPs to the paediatric orthopaedic specialist, 389 (74.5%) were considered inappropriate based on the AAP SAP and ABP guidelines. This is much higher than what is reported in the literature. In Hsu et al.’s[9] study, it was found that 47% of the patients referred to the paediatric orthopaedic specialist had, in fact, primary care conditions. Reeder et al.[2] also found that 41.6% of referrals were inappropriate based on the referral diagnosis. In the study by Balazs et al.[10] in 2019, it was reported that 48% of referrals made were inappropriate even within a closed healthcare system where physicians are protected from malpractice liability, patients do not have to pay for subspeciality care and surgeons are paid a constant salary regardless of productivity. A plausible reason why the local population has a much higher rate of inappropriate referrals may be the lack of local guidelines for reference. Hsu et al.’s[9] and Reeder et al.’s[2] study populations were from the USA, where physicians may be more aware of the AAP SAP and ABP guidelines. Other potential reasons could be inadequate knowledge by the referring physicians or due to parental insistence. Fallatah et al.[11] reported in their study that 87.3% of their sampled participants consisting of paediatricians and general practitioners had inadequate knowledge of common paediatric orthopaedic conditions. The majority of physicians also tend to make specialist referrals when there was parental insistence. Our study, however, did not look at these potential factors. We hope that a set of local guidelines as well as targeted education sessions for PCPs may reduce the rate of inappropriate referrals.

In this study, 122 (34.2%) out of 357 patients who were referred to the paediatric orthopaedic specialist with a referring diagnosis had an inappropriate one when compared to the final paediatric orthopaedic specialist diagnosis. Most of the conditions that had been referred inappropriately involved those affecting the hip, knee and leg (40/122, 32.8%). Among those without a referring diagnosis, most of the patients had conditions related to the foot and ankle (49/165, 29.7%). While it is reassuring that our PCPs were able to identify most cases that required a specialist review and provide an appropriate referral diagnosis (235/357, 65.8%), barriers to making an appropriate diagnosis should be identified for improvement and to reduce the number of referrals without a referring diagnosis. There are no studies that demonstrates the potential knowledge gaps faced by PCPs in dealing with musculoskeletal conditions. In our study, we found that conditions surrounding the lower limb, in general, lead to either an inappropriate referring diagnosis or no attempt at making a diagnosis for some patients. By identifying these knowledge gaps, we can tailor future musculoskeletal teaching programmes to PCPs to focus more on conditions that they may not be familiar with and increase their confidence in managing these conditions. Paediatric orthopaedic specialists and PCPs should also work together to improve the primary healthcare landscape.

Interestingly, we found that 39 (13.5%) out of 287 patients who had been referred with the wrong diagnosis or none made at all had normal physiological variants. For these patients to be referred, they must have been viewed as pathological by PCPs, especially if a wrong diagnosis was made. The PCPs should be aware of physiological variants in a developing child to avoid unnecessary referrals to the specialists and causing anxiety to the patients and family members. The study by Roberts and Conner[12] found that more than half of the referrals made to the paediatric orthopaedic specialist clinic consisted of either normal or benign conditions. To avoid making inappropriate referrals for physiological variants, PCPs should keep themselves updated with such knowledge. Continuing medical education seminars can be conducted to reinforce this. At the same time, a review of the orthopaedic education for family medicine residency training may be required as well. The PCPs should also be able to allay parental concerns, rather than referring the patients to the specialists, as this places unnecessary stress on the parents as well as the healthcare system.

Only 36 out of 522 (1/15 new patients, 6.9%) patients were offered surgery. Of the 36 patients, 27 (75%) ultimately underwent a procedure, whereas the remaining nine (25%) defaulted follow-up. The remaining 486 (93.1%) patients were managed conservatively. The low percentage of patients undergoing surgery is consistent with the literature.[5] The Paediatric Orthopaedic Society of North America Practice Management Committee found that paediatric orthopaedic surgeons saw 13 patients for every one scheduled surgery, compared to adult orthopaedic surgeons (2.7 patients), general surgery (4.1 patients) and neurosurgery (3.2 patients).[5] This demonstrates that the majority of cases seen by paediatric orthopaedic surgeons are, in truth, primary care problems. To reduce the burden on our paediatric orthopaedic specialists in managing primary care musculoskeletal conditions, PCPs should be empowered to manage simple musculoskeletal conditions such as undisplaced fractures. Our PCPs are mostly equipped with modalities such as X-rays and cast equipment; yet up to 30% of referred cases [Table 5] involve undisplaced fractures of the upper and lower limb, radius buckle fractures and non-displaced/angulated phalanx fractures, which could have been managed at the primary care setting. Greater change may be instituted at the ministry level and by the Academy of Medicine to introduce courses and certification to empower PCPs to manage such primary care orthopaedic conditions. Another potential solution to reduce the burden on specialist clinic, as demonstrated successfully by Belthur et al.,[13] is the creation of physiotherapy clinics to review patients with non-urgent musculoskeletal conditions.

This study has limitations. The lists of specialist conditions reflected in the ABP and AAP SAP guidelines are not exhaustive, although they are the only guidelines available and were used previously in other studies. Therefore, we had to assume that any cases not reflected in either guidelines were considered manageable by PCPs. We did not evaluate the PCPs’ capacity and credentials in managing paediatric musculoskeletal conditions, as we wanted only to identify primary care orthopaedic conditions. In addition, we were not able to sieve out data regarding other potential factors for referral, such as parental request or previous litigation against PCPs causing them to have a lower threshold in referring patients. However, this study does give us an idea of our local referring practice as well as potential knowledge gaps that can be addressed.

In conclusion, we found that 74.5% of patients referred to our paediatric orthopaedic specialists from PCPs were considered inappropriate, a rate much higher than what is available in the literature. Lower limb conditions were often referred with either a wrong or lack of diagnosis. The PCPs should be empowered to deal with simple musculoskeletal conditions and should receive support from the ministry and the Academy of Medicine in the form of courses and certification. This will not only address potential knowledge gaps, but also instil confidence in patients and parents to allow continuity of care at the primary healthcare setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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