
==== Front
BMC Health Serv Res
BMC Health Serv Res
BMC Health Services Research
1472-6963
BioMed Central London

11519
10.1186/s12913-024-11519-6
Research
Evaluating diagnostic and management agreement between physiotherapists and ear, nose and throat specialist in a primary contact physiotherapy-led vestibular clinic: A prospective blinded inter-rater agreement pilot study
http://orcid.org/0000-0003-4552-7343
Smith Tamsin Tamsin.Smith@health.qld.gov.au

1
http://orcid.org/0000-0002-7446-5383
Eakin Jennifer 2
http://orcid.org/0000-0002-4633-6074
Payten Christopher L. 3
http://orcid.org/0000-0001-6044-7902
Noonan Fritha 4
http://orcid.org/0000-0002-5042-1925
Weir Kelly 56
http://orcid.org/0000-0002-9762-5749
Stewart Vicky 1
1 https://ror.org/05eq01d13 grid.413154.6 0000 0004 0625 9072 Department of Physiotherapy, Gold Coast Hospital and Health Service, Southport, Gold Coast, Qld Australia
2 https://ror.org/05eq01d13 grid.413154.6 0000 0004 0625 9072 Department of Speech Pathology and Audiology, Gold Coast Hospital and Health Service, Southport, Gold Coast, Qld Australia
3 https://ror.org/05eq01d13 grid.413154.6 0000 0004 0625 9072 Department of Speech Pathology and Audiology, Gold Coast Hospital and Health Service, Gold Coast, QLD Australia
4 https://ror.org/05eq01d13 grid.413154.6 0000 0004 0625 9072 Department of ENT, Gold Coast Hospital and Health Service, Gold Coast, QLD Australia
5 https://ror.org/02sc3r913 grid.1022.1 0000 0004 0437 5432 Health Sciences & Social Work, Griffith University, Gold Coast, Qld Australia
6 https://ror.org/01ej9dk98 grid.1008.9 0000 0001 2179 088X Department of Audiology and Speech Pathology, The University of Melbourne, Parkville, VIC Australia
19 9 2024
19 9 2024
2024
24 10947 12 2022
2 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Dizziness and vertigo are common referrals to Ear Nose Throat (ENT) outpatient services however these services have long waitlists for assessment. Primary contact physiotherapy-led vestibular clinics are recognized as improving access to care. This pilot study investigated agreement between physiotherapists and an ENT medical practitioner for diagnostic and management decisions in patients attending a primary contact physiotherapy-led vestibular clinic.

Methods

Prospective blinded inter-rater agreement study undertaken in an ENT primary contact physiotherapy-led vestibular clinic. Participants were adults referred to ENT from general practitioners, triaged (Category 2 or 3) to the primary contact physiotherapy-led vestibular clinic with clinical symptoms consistent with vestibular disorder. Primary outcome measures included agreement of diagnoses and management decisions made by an ENT medical practitioner and Physiotherapist based on a vestibular physiotherapy assessment. Adverse events were reviewed 11 months post data collection. Gwet’s first order agreement co-efficient (AC1) calculated inter-rater reliability between physiotherapy and ENT.

Results

Fifty-one participants were recruited consecutively from the primary contact physiotherapy-led vestibular clinic. Physiotherapy and ENT had a substantial agreement (AC1 0.613) on diagnosis. AC1 between physiotherapy and ENT for recommending Magnetic resonance imaging (0.810) and computerized tomography (0.935) both indicated near perfect agreement. There was moderate to near-perfect agreement regarding management recommendations between physiotherapy and ENT. Substantial agreement (AC1 0.720) was found for recommendations for ENT input, near perfect agreement (AC1 0.933) for neurology input and moderate agreement (AC1 0.574) for physiotherapy input. There were no adverse events from physiotherapist’s management decision, based on final recommendations undertaken 11-months post data collection.

Conclusions

Physiotherapists and ENT medical practitioner made comparable diagnostic and management decisions, based on physiotherapy and audiology hearing assessment, for adults with signs of vestibular dysfunction, within an ENT primary contact physiotherapy-led vestibular clinic. This study provides support for this type of Physiotherapy-led service in managing patients referred to an ENT service with vestibular dysfunction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11519-6.

Key points

1. This is the first study investigating interprofessional agreement between physiotherapists and an ENT medical practitioner in the diagnosis and management of patients within an ENT primary contact physiotherapy-led vestibular clinic (recommendations were based on a vestibular physiotherapy assessment as participants were not directly assessed by ENT).

2. Physiotherapists and ENT agreement on diagnosis was substantial.

3. Agreement between physiotherapy and ENT on requesting MRI brain and CT head were near perfect; and agreement between physiotherapy and ENT for onward management to ENT, neurology or physiotherapy was moderate to near perfect.

4. There were no adverse events from physiotherapy’s management decision, based on the final recommendations.

5. This paper provides support for the competency of physiotherapists in managing patients referred to ENT with vestibular dysfunction and the safety of ENT primary contact physiotherapy-led vestibular clinics, albeit the presence of bias given the recommendations were based on a vestibular physiotherapy assessment only.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11519-6.

Keywords

Ear
Nose and Throat
Vestibular
Vertigo
Dizziness
Primary Contact
Agreement
Physiotherapy
Audiology
Agreement
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

Dizziness and vertigo are common referrals to Ear Nose Throat (ENT) medical specialist outpatient services however these services have long waitlists for assessment [1]. Vertigo presentations are often related to peripheral vestibular disorders [2, 3], frequently requiring assessment and treatment by vestibular physiotherapy to alleviate symptoms [2, 4, 5]. The burden of vestibular conditions can be devastating on individuals and society including reduced quality of life [6], and high health expenditure [6].

People wait longer than clinically recommended for specialist outpatient assessment in the public health system [7–13]. Governments have supported redesign of service delivery [14] aiming to increase access to cost effective, high-value health care. Expanded roles for allied health practitioners (AHP) are gaining popularity with research supporting the benefits of Allied Health Primary Contact Service (AH PCS) models to reduce medical wait lists [10, 12, 13, 15, 16] and bridge the service-demand gap. Specifically, the Queensland government committed $30 million of non-recurrent funding to address the expanding ENT wait lists with the aim of developing a sustainable model for eliminating ENT outpatient long waits [17].

A primary contact physiotherapy-led vestibular clinic at the Gold Coast University Hospital (GCUH) was developed in 2016 in response to the long waitlist for outpatient ENT services. The usual pathway in most outpatient ENT services is referral from primary care to ENT for medical assessment. In this new model of care, category 2 and 3 referrals to ENT are triaged by ENT medical practitioners to the physiotherapy-led vestibular clinic according to symptomatic criteria consistent with vestibular dysfunction. These patients are initially seen by an audiologist for a hearing test including pure tone audiometry (PTA), tympanometry, acoustic reflexes, and speech discrimination before being seen by the physiotherapist for vestibular and balance assessment. This primary contact physiotherapy-led vestibular clinic reduced the average initial appointment wait time from 583 to 52 days, with only 26% of patients requiring review by an ENT medical practitioner [1].

Allied health primary contact service (AH PCS) models of care are recognized as a successful strategy for improving access to care that is cost effective and with improved patient outcomes [8, 10, 11, 15, 18–24]. They are interdisciplinary, collaborative models of care that can have a positive impact on the efficiency of the health care system in terms of service provision and patient satisfaction. Some studies have investigated diagnostic and management accuracy by way of a concordance evaluation in the area of orthopaedics [18, 25, 26] and musculoskeletal in ED [27], comparing outcomes of physiotherapy versus medical practitioner. To date there is little evidence in the literature regarding the diagnostic and management agreement as the primary research outcome in the area of dizziness and ENT. This study aimed to explore the agreement between vestibular physiotherapists and an ENT medical practitioner on diagnosis and management plans for adults referred into the vestibular pathway for dizziness concerns. Of note, the diagnostic and management recommendations were made based on information from a hearing and vestibular physiotherapy assessment and patients were not seen face to face by the ENT medical practitioner. When a disagreement occurred, the nature of the disagreement was examined to determine the impact on clinical outcomes and patient safety. While each discipline brings a different perspective and expertise to the patient assessment process, both professions utilize similar subjective and objective information (including oculomotor, positional and vestibular-ocular reflex (VOR) assessments information) to guide diagnosis and decision making for best practice management for these patients. The hypothesis is that the agreement between one ENT medical practitioner and three vestibular physiotherapists regarding diagnosis and management will be essentially equivalent such that the proposed management of a patient would not differ.

Methods

Study design and site

A prospective cohort inter-rater agreement investigation was undertaken as a pilot study between July 2018 and April 2019 at Gold Coast University Hospital (GCUH) in the Allied Health Primary Contact Service AH PCS Vestibular clinic in Allied Health Outpatients. The study was conducted with reference to the STROBE (Strengthening-the-Reporting-of-Observational-Studies-in-Epidemiology) [28] and the Guidelines for reporting reliability and Agreement Studies (GRRAS) [29].

Sample size

A sample size of 50 participants was determined for this study. It was hypothesized that there should be at least substantial agreement between the physiotherapists and ENT medical practitioner. The minimum value expected for AC1 was set at 0.7, that is, the middle of the “substantial” agreement category on the Landis and Koch (1977) scale [30] and a sample size was set to detect a true level of agreement of 0.9 (“almost perfect”). The sample size was calculated to allow an estimated AC1 to be accurate to within the bounds of one of the higher Landis and Koch categories. A sample size estimation of 49 was calculated based on comparisons of 4 to 10 categories for a power of 80% and type 1 error of 0.05 using the published tables of Bujang and Baharum (2017) [31].

Participants

There were 51 participants who met the inclusion and exclusion criteria of the study and attended the AH PCS during the data collection period. This included adults (18 years or older) who were referred to the ENT medical outpatient service at GCUH from a general practitioner (GP), triaged (Category 2 or 3) to the primary contact physiotherapy-led vestibular clinic (refer to the clinic inclusion/ exclusion criteria Fig. 1). Consecutive clients who were seen in the clinic were invited to participate to reduce any selection bias and provided written consent.

Fig. 1 ENT primary-contact vestibular physiotherapy pathway (ENT: Ear Nose Throat; ENT-PCS: Ear Nose Throat Primary contact Specialty; OAE: Otoacoustics emissions; AH: Allied Health; Ax: Assessment; MRI: Magnetic Resonance Imaging; PT: Physiotherapy; GP: General Practitioner.)

Study inclusion criteria

All referrals received by the ENT medical specialist service were reviewed by an ENT medical practitioner to determine a category of urgency and suitability of the referral for the AH PCS according to the details provided by the GP on the referral. Only category 2 (seen within 90 days) and 3 (seen with 365 days) referrals are directed to the AH PCS. The triage criteria were dizziness, vertigo, balance disorders, possible benign paroxysmal positional vertigo (BPPV), possible Meniere’s disease. Participants were required to provide informed consent prior to physiotherapy assessment to be included in the study.

Study exclusion criteria

Patients were excluded if their original ENT referral came from another ENT medical practitioner, they had been assessed by an ENT medical practitioner prior to being seen by the Vestibular Physiotherapist, if the referral did not meet the eligibility criteria, or if the patient did not provide consent.

Assessors

Assessors included three advanced allied health practitioners (AHP’s) with between five to eleven years vestibular physiotherapy experience and a senior ENT registrar with over 10 years ENT medical specialty experience.

Ethics

Ethics approval was gained from the Gold Coast Hospital and Health Service Human Research Ethics Committee (HREC/17/QGC/121). The authors report there are no competing interests to declare.

Clinical assessment

The AH PCS vestibular clinic pathway (Fig. 1) was developed in consultation with an ENT-Allied Health steering committee. Participants seen in the study underwent assessment and management in line with this agreed clinical pathway. Physiotherapy and audiology hearing assessments were performed as appropriate, including a comprehensive subjective case history, oculomotor assessment, vestibulo-ocular assessment using video Frenzel goggles and video head impulse testing, positional testing, functional balance and gait assessment, and same day audiology hearing assessment including pure tone audiometry, tympanometry, acoustic reflexes and speech audiometry. Where patients did not undergo a complete assessment due to a medical contraindication or the patient declined due to symptom provocation, they were not excluded to maintain a real-life context of the management decisions. Physiotherapy treatment commenced immediately following the assessment as appropriate.

Data collection

Following completion of the patient assessment, the physiotherapist completed a data collection form, including up to 10 differential diagnostic options and relevant management options that were recommended. More than one diagnostic option could be selected to allow for conditions that could not be differentiated without further investigations. The diagnosis options from which the AHPs and ENT medical practitioner were able to choose included benign paroxysmal positional vertigo, unilateral vestibular hypofunction, bilateral vestibular hypofunction, Meniere’s disease, persistent postural perceptive dizziness, postural hypotension, vestibular migraine, central, Other (including cervicogenic dizziness), no diagnosis. The management options included further imaging (including MRI brain and CT head), physiotherapy treatment, medical practitioner review (including ENT or Neurology) or discharge from clinic.

The ENT medical practitioner independently completed the same data collection form as described above using information from the subjective and objective hearing and vestibular physiotherapy assessment, and excluding any information about treatment commenced. The study was conducted within the bounds of the existing clinical pathway, therefore the ENT medical practitioner did not see the patients themselves. This is the main limitation of this study and also the main difference between this study design and previous study protocols. This design selection was driven by staffing and clinic limitations, but also reflects the clinical pathway for these patients where the ENT medical practitioner does not see the patient unless escalation is clinically required and actioned by the allied health practitioner. As a result, the ENT medical practitioner reviewed and utilised relevant clinical information including: patient age and gender, referral letters, case history, previous investigations, questionnaires and physiotherapy and audiology assessment notes (excluding impression, diagnosis, recommendations for management and treatment commenced). Raters were blinded to each other’s decisions until after data collection was finalized and sealed in an envelope. Once data collection was completed, disagreements were discussed. There were no changes required in the clinical management plan after discussion. Medical chart reviews were completed 11 months (March 2020) after completion of initial assessment to record final diagnoses, management undertaken and outcomes (see Supplemental Table 1). Table 1 Participant demographics and initial assessment characteristics

Participant characteristic on initial assessment	No	Result	
Age years, mean (SD, range)	51	58.1 (SD 12.7, 30.0–89.0)	
Gender female %	51	66.7	
Dizziness Handicap Inventory ( /100), mean	29	33.1	
Vestibular Rehabilitation Benefit Questionnaire ( /132), mean	43	41.0	
Functional Gait Assessment ( /30), mean	39	26.59	
Wait-time prior initial assessment days, mean	51	51.6	
Chronicity of symptoms

- Acute symptoms 0–2 weeks %

- Sub-acute symptoms 2 weeks – 3 months %

- Chronic > 3 symptoms months %

	51

0

7

44

	0

13.7

86.3

	
SD Standard Deviation

Data collection also included demographics (age, gender) and patient-reported measures on initial assessment including the Dizziness Handicap inventory (where scores 61–100 indicate severe [32] and the Vestibular Rehabilitation Benefit Questionnaire (where 100% indicates significant deficit [33]).

Outcome measures

Primary outcome measures included diagnoses, and recommendations for management. The diagnoses were grouped into categories as specified in Supplemental Table 1. Primary vestibular diagnosis was used for categorization when multiple diagnoses were made. The questions for recommendations, recorded as a dichotomous response (yes/ no), were “Should an MRI (Magnetic Resonance Imaging) brain /CT (Computerised Tomography) head be requested?”, “Is ENT/ neurology/ vestibular physiotherapy recommended?”. Assessors also recorded the urgency for ENT medical practitioner review, categorised as not applicable, routine, priority, or urgent.

Data analysis

Data was analysed using Stata (IC 15.1). Demographics, patient reported measures and wait times were analysed using descriptive statistics. Gwet’s first order agreement co-efficient (AC1) was used as the measure of inter-rater agreement using the kappaetc command of Stata. Percentage agreement is also presented but does not take into consideration agreement by chance. Cohen’s Kappa coefficient was considered since it corrects for chance agreement and is the most used measure of agreement between categorical outcomes. Cohen’s Kappa is, however, affected by a high (or low) prevalence of the trait of interest or by the existence of bias between raters in the proportion of positive ratings given [34, 35]. Alternatively, Gwet’s AC1 has been found to be less affected by prevalence and marginal probability differences than Cohen’s Kappa and is recommended for use in inter-rater reliability analysis [35]. We also applied the scale by Landis and Koch as recommended by Gwet (2014) [36] to interpret the level of agreement indicated by AC1 values: < 0.2 poor, 0.21–0.41 fair, 0.41–0.6 moderate, 0.61–0.8 substantial, 0.81–1 near perfect agreement. While the best estimate of the level of agreement is determined by the benchmark interval that the AC1 estimate falls into, it does not take into consideration the variability of the estimate and may overestimate actual agreement. As such, a more conservative interpretation is also presented which, as suggested by Gwet (2014) [36], is the benchmark interval for which we are > 95% certain that the actual level of agreement is at least as good as.

The diagnostic comparisons were performed using a concordance matrix. Since some discrepancies between AHP and ENT diagnoses could not be considered as “discordant” as others, a weighted AC1 was calculated based on a concordance matrix constructed by independent practitioners. For example, if exactly the same diagnoses were recorded, an agreement weighting of 1 was used whereas two very different diagnoses, such as vestibular migraine and postural hypotension, were weighted as 0 for agreement. However, vestibular migraine and Meniere’s disease were considered very similar diagnoses and weighted at 0.8 for agreement. The full concordance matrix that was used in the weighted AC1 estimate is shown in Supplementary Table 1.

The frequencies and a descriptive analysis of disagreements between physiotherapy and ENT medical practitioner were also presented to explain the agreement statistics and are found in the supplementary Table 2.

Results

Fifty-one participants were recruited consecutively from the physiotherapy-led vestibular clinic, their characteristics are detailed in Table 1.

Diagnosis

There was ‘substantial’ agreement (AC1 of 0.613) between physiotherapy and ENT medical practitioner on diagnosis (Table 2) with greater 95% certainty that the agreement is ‘moderate” or better.. The frequencies and agreement with which each assessor recorded primary diagnosis in each diagnostic category are detailed in Table 3. Peripheral vestibular dysfunction was the most common primary diagnosis category. A detailed breakdown of final diagnosis and outcomes of management for all disagreements can be found in Supplementary Table 2. Table 2 Calculated agreement coefficients for the level of agreement between physiotherapy and ear nose throat medical practitioner (N = 51)

	% agreement	95% CI	AC1	95% CI	Benchmark interval#	Cumulative probability	Benchmark interval*	
Diagnosisa	71.6	60.1	-83.1	0.613	0.448	-0.779	substantial	0.994	moderate	
MRI requestedb	86.2	76.5	-96.1	0.810	0.659	-0.961	near perfect	0.989	substantial	
CT requestedc	94.1	87.4	-100	0.935	0.857	-1.000	near perfect	1.000	near perfect	
Ear Nose Throat recommendedd	82.3	71.5	-93.2	0.738	0.554	-0.921	substantial	0.997	moderate	
Ear Nose Throat urgencye	82.3	71.5	-93.2	0.720	0.527	-0.913	substantial	0.997	moderate	
Neurology recommendedf	94.1	87.4	-100	0.933	0.852	-1.00	near perfect	1.000	near perfect	
Physiotherapy recommendedg	72.0	59.1	-84.9	0.574	0.334	-0.813	moderate	0.998	fair	
# Benchmark interval for AC1 correction

*Benchmark interval with probabilistic correction

aDiagnosis: 10 groups: benign paroxysmal positional vertigo, unilateral vestibular hypofunction, bilateral vestibular hypofunction, Meniere’s disease, persistent postural perceptive dizziness, postural hypotension, vestibular migraine, central, Other (including cervicogenic dizziness), no diagnosis

bMRI requested: Yes / No

cCT requested: Yes / No

dEar Nose Throat recommended: Yes/ No

eEar Nose Throat urgency: 1. Not applicable, 2. Routine, 3. Priority, 4. Urgent

fNeurology Recommended: Yes/ No

gPhysiotherapy Recommended: Yes/ No

SEM Standard error of the mean, CI Confidence interval, AC1 Gwet's first order agreement coefficient, MRI Magnetic Resonance Imaging, CT Computerised Tomography

Table 3 Diagnosis decisions comparing Ear Nose Throat medical practitioner and Physiotherapy

Ear Nose Throat specialist	
Physiotherapists	Diagnosis 1: Peripheral vestibular dysfunction	
	Yes	No	Total	
Yes	27	4	31	
No	4	16	20	
Total	31	20	51	
Diagnosis 2: No vestibular diagnosis	
	Yes	No	Total	
Yes	3	3	6	
No	5	40	45	
Total	8	43	51	
Diagnosis 3: Vestibular migraine	
	Yes	No	Total	
Yes	4	3	7	
No	1	43	44	
Total	5	46	51	
Diagnosis 4: Central	
	Yes	No	Total	
Yes	6	1	7	
No	1	43	44	
Total	7	44	51	

Management recommendations

There was ‘moderate’ to ‘near-perfect’ agreement regarding management recommendations between ENT medical practitioner and physiotherapist (Table 2) with frequencies of recommendations and agreement between assessors detailed in Table 4. A breakdown of disagreements on management recommendations is detailed in Table 5, including physiotherapists reasons, adverse events, and final recommendations undertaken. Table 4 Management recommendation decisions comparing Ear Nose Throat medical practitioner and Physiotherapist

Ear Nose Throat	
Physiotherapists	Magnetic Resonance Imaging Brain recommended	
	Yes	No	Total	
Yes	6	3	9	
No	3	39	42	
Total	9	42	51	
Computerised Tomography head recommended	
	Yes	No	Total	
Yes	1	3	4	
No	0	47	47	
Total	1	50	51	
Ear Nose Throat recommended	
	Yes	No	Total	
Yes	7	4	11	
No	4	36	40	
Total	11	40	51	
Neurology recommended	
	Yes	No	Total	
Yes	2	3	5	
No	0	46	46	
Total	2	48	51	
Physiotherapy recommended	
	Yes	No	Total	
Yes	32	12	44	
No	2	5	7	
	Total	34	17	51	

Table 5 Physiotherapists’ management decisions detailed and management undertaken

Physiotherapist decision	No	Reasons provided by Physiotherapist	Adverse events	Recommendation undertaken	
Not recommending MRI when ENT did	3	Nil migraine history/ central signs (n = 2)

Audiology monitoring deterioration for mild asymmetrical sensorineural hearing loss (n = 1)

	0	Nil MRI (n = 2)

Audiology repeated finding deterioration to significant asymmetrical sensorineural hearing loss, therefore MRI ordered (normal result) (n = 1)

	
Recommending MRI when ENT did not	3	Central signs (n = 1)

Migraine (n = 1)

Investigate for vestibular paroxysmia (n = 1)

	0	MRI brain normal (n = 2)

MRI brain found temporal lobe abnormality, assessed by neurosurgery, not for surgery (n = 1)

	
Recommending CT when ENT did not	3	Signs of SCD (n = 3)	0	Nil CT head completed (n = 1). CT normal (n = 1)

CT demonstrated sinus disease requiring surgery (n = 1)

	
Not recommending ENT when ENT did	4	Assessment consistent with diagnosis of vestibular migraine (n = 1)

Meniere’s disease (stable) (n = 1)

BPPV (n = 2)

	0	Nil ENT and symptoms resolved (n = 3)

ENT for Meniere’s disease, discharged as symptoms stable (n = 1)

	
Recommending ENT when ENT did not	4	Otalgia (n = 1)

Possible SCCD (n = 1)

Aural fulness (n = 1)

Meniere’s disease (n = 1)

	0	Nil ENT (n = 3)

ENT review for aural fullness symptoms diagnosed with mild otitis externa (n = 1)

	
Recommending neurology when ENT did not	3	Central objective signs (n = 2)

Vestibular migraine (n-1)

	0	Neuro diagnosis neurodegenerative disease CANVAS (n = 1)

Neuro referred to opthamology (diplopia surgery) (n = 1)

GP to consider referral to neurology for migraine (n = 1)

	
Not recommending PT when ENT did	2	No vestibular signs/ symptoms (n = 1), possible vestibular migraine (n = 1)	0	Nil PT (n = 2)

Sinus disease requiring ENT surgery (n = 1)

	
Recommending PT when ENT did not	12	Possible/ probable vestibular migraine (n = 4)

Meniere’s disease (n = 2)

BPPV (n = 3)

Unilateral vestibular hypofunction (n = 2)

Central (n = 1)

	0	PT treatment (n = 10) however education only on initial assessment (n = 2)

Symptoms resolved/ improved (n = 8)

Self-discharge PT (n = 1). Nil PT (n = 1)

Palliative care -metastatic cholandiocarcinoma (n = 1)

	
PT Physiotherapy, ENT Ear Nose Throat, MRI Magnetic Resonance Imaging, CT Computerised Tomography, BPPV Benign Paroxysmal Positional Vertigo, SCCD Semicircular Canal Dehiscence, CANVAS Cerebellar Ataxia, Neuropathy, Vestibular Areflexia Syndrome

MRI brain recommended

There was ‘near perfect’ agreement between physiotherapist and ENT medical practitioner (AC1 of 0.810) regarding recommending MRI brain (Table 2) with 95% certainty that the agreement is ‘substantial” or better. There were six cases of disagreement (Table 4), however, there were no adverse MRI findings or outcomes where physiotherapy did not recommend MRI brain and ENT medical practitioner did (Table 5). Two participants did not require an MRI as symptoms resolved. Another participant had an MRI brain ordered after a 6-month follow-up audiogram showed a deterioration in unilateral sensorineural hearing loss. The report showed no abnormalities. This highlights the importance and effectiveness of the allied health monitoring process.

CT head recommended

Recommendation for requesting CT head revealed ‘near perfect’ agreement (AC1 of 0.935) between physiotherapy and ENT medical practitioner (Table 2). In 47 out of 51 cases both physiotherapy and ENT medical practitioner agreed that CT head investigations were not required (Table 4). Physiotherapy always recommended CT when ENT medical practitioner recommended CT. Physiotherapy was more cautious and recommended CT in an additional three cases when ENT medical practitioner did not (Table 5).

ENT medical practitioner review recommended

There was ‘substantial’ agreement between physiotherapy and ENT medical practitioner (AC1 of 0.719) regarding recommending ENT medical practitioner management (Table 2). There were eight cases of disagreement, four of which ENT medical practitioner said yes when physiotherapy said no to recommending ENT medical practitioner review. The physiotherapists reasons for not recommending ENT medical practitioner review were due to a peripheral vestibular dysfunction appropriate for physiotherapy management (n = 3) and stable Meniere’s disease (n = 1). On review of these four participants, symptoms resolved without ENT medical practitioner review (Table 5). Additionally, the four participants recommended by physiotherapy to be managed by ENT medical practitioner did not require or undergo an ENT medical practitioner review (Table 5). The participants that were recommended for ENT medical practitioner review were all deemed as routine urgency by both physiotherapy and ENT medical practitioner.

Neurology medical practitioner review recommended

Recommendation for neurology medical practitioner review revealed ‘near perfect’ agreement between physiotherapy and ENT medical practitioner (AC1 of 0.933) (Table 2). There were two cases that physiotherapy recommended a neurology medical practitioner review and the ENT medical practitioner did not, which resulted in an important diagnosis of a neurodegenerative disorder, and ophthalmology surgery post neurology review (Table 5).

Physiotherapy review recommended

There was ‘moderate’ agreement between physiotherapy and ENT medical practitioner (AC1 of 57.4) regarding recommending physiotherapy management (Table 2). Physiotherapy management was the most frequent treatment recommendation, made by the ENT medical practitioner in 34 cases and by physiotherapy in 44 cases, with agreement in 32 cases (Table 4). Conversely, there were 12 cases where physiotherapy recommended physiotherapy management, but the ENT medical practitioner did not, with 10 of these cases undergoing physiotherapy management (Table 5). Additionally, there were two cases that the ENT medical practitioner recommended physiotherapy management when physiotherapy did not, with neither undergoing physiotherapy management on the final review (Table 5).

Adverse events

There were no adverse events from physiotherapy’s management decision, based on the final recommendations undertaken 11-months post the completion of data collection (Table 5). It is also supported by an evaluation of the discrepancies between the Physiotherapist and ENT medical practitioner (see supplementary Table 2) which revealed that there were no cases where the ENT medical practitioner over-ruled the recommendations made by the Vestibular Physiotherapist.

Discussion

Innovative AHP primary contact models of care are increasingly being utilised in public health systems to improve patient access to timely and appropriate care. These models of care utilise experienced AHPs operating at an advanced scope of practice to undertake specific tasks usually performed by a medical specialist. Physiotherapists are well positioned to provide an initial point of contact for patients with vestibular dysfunction referred to an ENT medical outpatient service. Physiotherapists working at full scope are responsible for diagnosing and providing treatment for specific vestibular disorders, arranging audiological assessment, identifying risk factors for conditions that require ongoing monitoring, recommending further medical investigation and management, and facilitating onward referral to other professionals for further intervention such as ENT medical practitioner review, neurology medical practitioner review, psychology, and general practitioner.

The success of Allied Health Primary Contact Service (AH PCS) models of care is facilitated by a supportive and positive relationship between the AHPs and medical practitioners [13]. While the AHPCS pathways are expected to have an important role in providing value-based care and meeting growing service demands, there is no agreed approach to measuring safety and quality [37]. To our knowledge, this is the first study investigating inter-rater agreement between physiotherapists and ENT medical practitioner in diagnostic and management of patients within ENT primary contact physiotherapy-led vestibular clinic. In this study, we used a measure of concordance between the advanced vestibular physiotherapist and ENT medical practitioner on diagnosis and management to examine decision making competence. This methodology was based on publications from orthopaedic and musculoskeletal services showing high level of agreement between medical practitioners and physiotherapists working in primary contact models [18, 19, 23, 38] but was modified due to staffing and clinic limitations (further discussed in limitations section). This study found that advanced vestibular physiotherapists made comparable decisions to an ENT medical practitioner regarding diagnosis and onward management of vestibular disorders, based on information obtained from a hearing and vestibular physiotherapist assessment. This study provides support for this type of Physiotherapy led service in managing patients referred to an ENT service with vestibular dysfunction.

Previous research has shown that the AH-PCS pathway significantly reduces the time patients with vestibular dysfunction wait for their first appointment, thus improving timely access to care [1]. The shorter waiting time allows for earlier and an additional triage point to be able to identify conditions that benefit from early assessment to exclude or diagnose central pathology such as stroke, tumours (including acoustic neuroma) or multiple sclerosis; or early management of conditions such as vestibular neuritis and BPPV to prevent falls or the development of chronic dizziness such as PPPD [39].

In this current study we found that physiotherapists and ENT medical practitioner agreement on diagnosis was substantial. The primary contact physiotherapy-led initial appointment is extensive, including a comprehensive subjective history, objective outcome measures for balance and functional gait, vestibular assessment utilising video Frenzel goggles and video head impulse test, and same day audiology assessment including pure tone audiometry, tympanometry, acoustic reflexes and speech audiometry. An ENT initial appointment under the traditional medical model does not have the time or resources to complete such a comprehensive vestibular assessment. ENT medical practitioner would commonly refer to physiotherapy and audiology for such assessment to be completed after the ENT medical practitioner initial assessment, further delaying diagnosis and treatment. In addition to the shorter waiting times to attend the primary contact physiotherapy-led vestibular clinic, physiotherapy treatment commences immediately, further improving timely access to diagnosis and treatment.

Agreement between physiotherapist and an ENT medical practitioner on requesting MRI brain and CT head were near perfect. Whilst there were discrepancies in ordering an MRI brain there were no adverse MRI findings or outcomes where physiotherapy did not recommend MRI brain. One brain MRI requested by a physiotherapist but not the ENT, found an abnormality requiring neurosurgery monitoring. Another case involved repeat audiology examination that indicated a deterioration in SNHL which prompted an MRI brain. The report revealed normal findings. Additionally our findings show Physiotherapy was more cautious in recommending CT head.

Agreement for onward management to ENT medical practitioner review, neurology medical practitioner review or physiotherapy for treatment was moderate to near perfect, according to the current study. There was variability in recommending ENT medical practitioner review however a chart audit post study completion found physiotherapists recommendations for onward management to an ENT medical practitioner was appropriate without adverse outcomes. An acknowledged limitation of the study is that the ENT medical practitioner did not assess the patient in person and were required to make management decisions based on written information from hearing and vestibular physiotherapy assessment. This may have hindered the ENT medical practitioner in exploring some of the more subjective factors that influence recommendations or led to overcaution in forming a diagnosis. However this can also be considered reflective of usual clinical practice when an ENT medical practitioner refers on for additional assessments and management.

Clear communication pathways are essential between physiotherapy and the ENT medical practitioner to accommodate changes to onward management plans during physiotherapy monitoring and treatment. Case discussion with the ENT medical practitioner should be routine when symptoms are not resolving with physiotherapy management, as ENT medical practitioners are best placed to consider factors such as medical management for Meniere’s disease, and coexisting ENT conditions such as middle ear conditions. Agreement between physiotherapy and the ENT medical practitioner for onward management to neurology was near perfect with physiotherapy recommending neurology medical practitioner review more frequently, resulting in important diagnostic findings (which would have led to serious adverse clinical outcomes for the patients if they had received the traditional model of care with the associated long wait) and two required neurology medical practitioner reviews. Experienced physiotherapists are well positioned to identify subtle neurological deficits accounting for the bias to referring to neurology. Clear referral pathways to neurology is recommended for an ENT primary contact physiotherapy model. Physiotherapists were more likely to recommend ongoing physiotherapy management compared to the ENT medical practitioner. Physiotherapist’s and ENT medical practitioner’s bring different perspectives to the assessment accounting for the variability.

Results of this study supports a primary contact physiotherapy-led vestibular clinic and a multi-disciplinary team approach between Physiotherapy, ENT medical practitioner and Audiology. The concept of a multidisciplinary approach to effectively manage vestibular dysfunction and dizziness is not new and supported my multiple studies, although the approach can vary. Several models have been described. Similar clinics in the United Kingdom described a physiotherapy-led vestibular clinic that included audiology assessment with close ENT medical practitioner access [15, 8]. They reported that vestibular physiotherapy is essential to a primary contact ENT model and with value in the collaborative approach with access to medical review as required, with decreased wait times and improved patient outcomes Trinidade et al. [40] describes an ENT consultant-led balance clinic that included an initial assessment by an otologist with referrals to audiology and physiotherapy assessment and management as required. They highlight the importance of a thorough assessment which can be achieved by multiple team members increasing efficiency and improving outcomes for patients. Bath et al. [41] describes a combined otolaryngology and neurology clinic. They reported that most patients seen in their multidisciplinary clinic were diagnosed with peripheral vestibular disorders and central causes of dizziness were relatively uncommon. Regardless, central causes need to be considered and managed in a timely manner. Timely referral to a neurologist may suffice rather than having a neurologist as part of the clinic [40]. We believe a multi-disciplinary approach to assessment and management of patients with dizziness is required, however may best be achieved via a physiotherapy-led primary contact service, with communication and referral links to audiology, ENT medical practitioner and neurology medical practitioner. Further research may be warranted to determine the cost-effectiveness comparisons of such services.

An acknowledged limitation of this study that has previously been mentioned is that the ENT medical practitioner did not assess the patient in person, leaving the ENT medical practitioner to make diagnostic and management decisions based on written information from the audiology hearing and the vestibular physiotherapy assessments. It should be considered that this may lead to inadequate assessment due to the lack of additional information and lower the diagnostic accuracy. The main reason for this design selection was that this was a pragmatic study utilising existing staffing and clinic limitations that did not allow for a face-face assessment by the ENT medical practitioner. It is the main difference between this study and other concordance studies. The recommendations by assessors were based on the same information. However, the study would have been stronger if both the Physiotherapist and ENT assessors has been provided with written notes and reports of the assessment in a blinded manner. In support of this study design, whilst people are commonly referred to ENT for dizziness, an ENT medical practitioner vestibular assessment would generally not be as comprehensive as a vestibular physiotherapist. Patients are often referred to a vestibular physiotherapist or audiologist for more specialist testing, and the results are then provided in a written report to the ENT medical practitioner to assist in diagnosis and recommendations. It is possible that the diagnostic review bias and incorporation bias may have reduced the variability in the recommendations between raters. Future studies may look at reducing these biases with an approach involving a standard reference and blinding. Furthermore, in the present study, it was assumed that both physiotherapists and ENT medical practitioners are fully trained to perform clinical assessment of patients with vertigo symptoms. Further assessment of the comparative competency between physiotherapist and ENT physicians in assessing patients with vertigo symptoms should be validated.

Another limitation is that the recommendation for further audiology vestibular assessment was not captured. Audiology vestibular function tests, such as caloric testing, vestibular evoked myogenic potentials, and videonystagmyography are commonly utilised by both physiotherapists and ENT medical practitioner to assist with vestibular diagnosis and are frequently utilised in our service, however the recommendation for such testing was not captured as part of this study and could be considered for future research. Furthermore, decisions from 3 physiotherapists were compared to that of a single ENT medical practitioner due to staffing limitations of the clinic. Further study of a single rater vs single rater assessment may be beneficial to assess between disciplines and within disciplines, and a greater sample size may also be of benefit. Because of the small sample size and the abovementioned limitations in the methodology, this paper should be considered a pilot study that investigates this issue with no firm conclusions. Further research investigating the ENT primary contact physiotherapy-led vestibular clinic may include patient re-presentation rates, cost effectiveness, patient reported satisfaction and longer-term outcomes.

Conclusion

This pilot study showed a high level of inter-professional agreement between advanced vestibular physiotherapists and ENT medical practitioner in the diagnosis and management of patients within an ENT primary contact physiotherapy-led vestibular clinic, based on information from audiology hearing and vestibular physiotherapy assessment. Our provisional findings indicated that the physiotherapists and ENT medical practitioner made comparable diagnostic and management decisions for patients referred to an ENT medical outpatient service. The preliminary findings offer reassurance about the competency of physiotherapists to identify vestibular disorders and make appropriate onward management decisions. This model is successfully being used to help manage lengthy ENT medical wait lists and allow patients with vestibular dysfunction earlier access to effective assessment and management options.

Supplementary Information

Supplementary Material 1.

Supplementary Material 2.

Acknowledgements

The authors would like to acknowledge Dr Ian Hughes, biostatistician Gold Coast Hospital and Health Service and Professor Robert Ware, biostatistician Griffith University, for statistical support. We would also like to acknowledge small grant funding support received from Gold Coast Hospital and Health Service SERTA seeding grants and Allied Health Research Clinical Backfill Grant to support protected time for research (TS, CP, VS, JE).

Authors' contributions

Vicky Stewart: Conduct, analysis, report write up, critical review. Jennifer Eakin: Design, conduct, analysis, critical review. Christopher Payten: Design, conduct, analysis, critical review. Fritha Noonan: Design, conduct. Kelly Weir: Design, critical review. Tamsin Smith: Design, conduct, report write up, critical review.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and /or publication of this article: This work was support by the Gold Coast hospital and Health Service SERTA seeding grants.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Declarations

Ethics approval and consent to participate

The authors confirm that all experiments were performed in accordance with the Declaration of Helsinki. Participants were unblinded to the profession of their assessor and provided written informed consent. Gold Coast University Hospital and Health Service Human Research Ethics Committee approved this study. The authors report there are no competing interests to declare.

Consent for publication

Not applicable.

Competing interests

The authors declare that there is no conflict of interest.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Payten CL Eakin J Smith T Stewart V Madill CJ Weir KA Outcomes of a multidisciplinary Ear, Nose and Throat Allied Health Primary Contact outpatient assessment service Clin Otolaryngol 2020 45 6 904 913 10.1111/coa.13631 32780943
Payten CL, Eakin J, Smith T, Stewart V, Madill CJ, Weir KA. Outcomes of a multidisciplinary Ear, Nose and Throat Allied Health Primary Contact outpatient assessment service. Clin Otolaryngol. 2020;45(6):904–13. 32780943
2. Hall CD Herdman SJ Whitney SL Cass SP Clendaniel RA Fife TD Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION Journal of neurologic physical therapy : JNPT 2016 40 2 124 155 10.1097/NPT.0000000000000120 26913496
Hall CD, Herdman SJ, Whitney SL, Cass SP, Clendaniel RA, Fife TD, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION. Journal of neurologic physical therapy : JNPT. 2016;40(2):124–55. 26913496
3. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015;1(1):CD005397
4. Ricci NA Aratani MC Doná F Macedo C Caovilla HH Ganança FF A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults Braz J Phys Ther 2010 14 361 371 10.1590/S1413-35552010000500003
Ricci NA, Aratani MC, Doná F, Macedo C, Caovilla HH, Ganança FF. A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults. Braz J Phys Ther. 2010;14:361–71.
5. Tsukamoto Heloísa Freiria de Souza Pinho Costa Viviane da Silva Rubens Alexandre Pelosi Gislaine Garcia de Moraes Marchiori Luciana Lozza Sanches Vaz Cláudia Regina Effectiveness of a Vestibular Rehabilitation Protocol to Improve the Health-Related Quality of Life and Postural Balance in Patients with Vertigo International Archives of Otorhinolaryngology. 2015 19 3 238 47 10.1055/s-0035-1547523 26157499
Tsukamoto Heloísa Freiria, de Souza Pinho Costa Viviane, da Silva Rubens Alexandre, Pelosi Gislaine Garcia, de Moraes Marchiori Luciana Lozza, Sanches Vaz Cláudia Regina, et al. Effectiveness of a Vestibular Rehabilitation Protocol to Improve the Health-Related Quality of Life and Postural Balance in Patients with Vertigo. Int Arch Otorhinolaryngology. 2015;19(3):238–47.26157499
6. Agrawal Y Pineault KG Semenov YR Health-related quality of life and economic burden of vestibular loss in older adults Laryngoscope Investig Otolaryngol 2017 3 1 8 15 10.1002/lio2.129 29492463
Agrawal Y, Pineault KG, Semenov YR. Health-related quality of life and economic burden of vestibular loss in older adults. Laryngoscope Investig Otolaryngol. 2017;3(1):8–15. 29492463
7. Victorian Goverment. Access to specialist outpatient care. In: Auditor General V, editor. http://www.audit.vic.gov.au/publications/2006/20060601-Access-to-Specialist-Medical-OutPatient-Care.pdf2006.
8. Burrows L Lesser TH Kasbekar AV Roland N Billing M Independent prescriber physiotherapist led balance clinic: the Southport and Ormskirk pathway J Laryngol Otol 2017 131 5 417 424 10.1017/S0022215117000342 28202097
Burrows L, Lesser TH, Kasbekar AV, Roland N, Billing M. Independent prescriber physiotherapist led balance clinic: the Southport and Ormskirk pathway. J Laryngol Otol. 2017;131(5):417–24.28202097
9. Department of Health. Wait Time Strategy Statewide Consultation Handbook, State of Queenland (Queensland Health); 2015.
10. Howard Z Jackman A Bongers M Corcoran K Nucifora J Weir K Outcomes of a physiotherapy-led pelvic health clinic Australian & New Zealand Continence Journal 2018 24 43 50
Howard Z, Jackman A, Bongers M, Corcoran K, Nucifora J, Weir K, et al. Outcomes of a physiotherapy-led pelvic health clinic. Australian & New Zealand Continence Journal. 2018;24:43–50.
11. Kasbekar AV, Mullin N, Morrow C, Youssef AM, Kay T, Lesser TH. Development of a physiotherapy-led balance clinic: the Aintree model. J Laryngol Otol. 2014;128(11):966–71
12. Mutsekwa RN Canavan R Whitfield A Spencer A Angus RL Dietitian first gastroenterology clinic: an initiative to reduce wait lists and wait times for gastroenterology outpatients in a tertiary hospital service Frontline Gastroenterol 2019 10 3 229 235 10.1136/flgastro-2018-101063 31281623
Mutsekwa RN, Canavan R, Whitfield A, Spencer A, Angus RL. Dietitian first gastroenterology clinic: an initiative to reduce wait lists and wait times for gastroenterology outpatients in a tertiary hospital service. Frontline Gastroenterol. 2019;10(3):229–35.31281623
13. Stute M Moretto N Raymer M Banks M Buttrum P Sam S Process to establish 11 primary contact allied health pathways in a public health service Aust Health Rev 2018 42 3 258 265 10.1071/AH16206 28483033
Stute M, Moretto N, Raymer M, Banks M, Buttrum P, Sam S, et al. Process to establish 11 primary contact allied health pathways in a public health service. Aust Health Rev. 2018;42(3):258–65.28483033
14. Queensland Government. Ministerial Taskforce on health practictioner expanded scope of practice: final report. In: Queensland AHPOo, editor. www.health.qld.gov.au/ahwac2014.
15. Lee A Jones G Corcoran J Premachandra P Morrison GA A UK hospital based multidisciplinary balance clinic run by allied health professionals: first year results J Laryngol Otol 2011 125 7 661 667 10.1017/S0022215111000624 21481295
Lee A, Jones G, Corcoran J, Premachandra P, Morrison GA. A UK hospital based multidisciplinary balance clinic run by allied health professionals: first year results. J Laryngol Otol. 2011;125(7):661–7.21481295
16. Leong AC Barker F Bleach NR Primary assessment of the vertiginous patient at a pre-ENT balance clinic J Laryngol Otol 2008 122 2 132 138 10.1017/S0022215107007797 17470305
Leong AC, Barker F, Bleach NR. Primary assessment of the vertiginous patient at a pre-ENT balance clinic. J Laryngol Otol. 2008;122(2):132–8.17470305
17. Queensland Health. Queensland Budget 2015–2016 Service Delivery Statement. In: Government Q, editor. online at www.budget.qld.gov.au2015.
18. Alice B. Aiken, Mary Ann McColl. Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon - A pilot study. Journal of Interprofessional Care. 2008;22(3):253–61.
19. Desmeules F Roy JS MacDermid JC Champagne F Hinse O Woodhouse LJ Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review BMC Musculoskelet Disord 2012 13 107 10.1186/1471-2474-13-107 22716771
Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review. BMC Musculoskelet Disord. 2012;13:107.22716771
20. Hattam P The effectiveness of orthopedic triage by extended scope physiotherapists Clin Gov Int J 2004 9 244 252
Hattam P. The effectiveness of orthopedic triage by extended scope physiotherapists. Clin Gov Int J. 2004;9:244–52.
21. Mutsekwa RN Larkins V Canavan R Ball L Angus RL A dietitian-first gastroenterology clinic results in improved symptoms and quality of life in patients referred to a tertiary gastroenterology service Clin Nutr ESPEN 2019 33 188 194 10.1016/j.clnesp.2019.05.016 31451260
Mutsekwa RN, Larkins V, Canavan R, Ball L, Angus RL. A dietitian-first gastroenterology clinic results in improved symptoms and quality of life in patients referred to a tertiary gastroenterology service. Clin Nutr ESPEN. 2019;33:188–94.31451260
22. Napier C McCormack RG Hunt MA Brooks-Hill A A Physiotherapy Triage Service for Orthopaedic Surgery: An Effective Strategy for Reducing Wait Times Physiother Can 2013 65 4 358 363 10.3138/ptc.2012-53 24396164
Napier C, McCormack RG, Hunt MA, Brooks-Hill A. A Physiotherapy Triage Service for Orthopaedic Surgery: An Effective Strategy for Reducing Wait Times. Physiother Can. 2013;65(4):358–63.24396164
23. Oldmeadow LB Bedi HS Burch HT Smith JS Leahy ES Goldwasser M Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care Med J Aust 2007 186 12 625 628 10.5694/j.1326-5377.2007.tb01079.x 17576177
Oldmeadow LB, Bedi HS, Burch HT, Smith JS, Leahy ES, Goldwasser M. Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Med J Aust. 2007;186(12):625–8.17576177
24. Saxon RL Gray MA Oprescu FI Extended roles for allied health professionals: an updated systematic review of the evidence J Multidiscip Healthc 2014 7 479 488 10.2147/JMDH.S66746 25342909
Saxon RL, Gray MA, Oprescu FI. Extended roles for allied health professionals: an updated systematic review of the evidence. J Multidiscip Healthc. 2014;7:479–88.25342909
25. Décary S Fallaha M Pelletier B Frémont P Martel-Pelletier J Pelletier JP Diagnostic validity and triage concordance of a physiotherapist compared to physicians’ diagnoses for common knee disorders BMC Musculoskelet Disord 2017 18 1 445 10.1186/s12891-017-1799-3 29137611
Décary S, Fallaha M, Pelletier B, Frémont P, Martel-Pelletier J, Pelletier JP, et al. Diagnostic validity and triage concordance of a physiotherapist compared to physicians’ diagnoses for common knee disorders. BMC Musculoskelet Disord. 2017;18(1):445.29137611
26. Lowry V Bass A Lavigne P Léger-St-Jean B Blanchette D Perreault K Physiotherapists' ability to diagnose and manage shoulder disorders in an outpatient orthopedic clinic: results from a concordance study J Shoulder Elbow Surg 2020 29 8 1564 1572 10.1016/j.jse.2019.11.030 32199757
Lowry V, Bass A, Lavigne P, Léger-St-Jean B, Blanchette D, Perreault K, et al. Physiotherapists’ ability to diagnose and manage shoulder disorders in an outpatient orthopedic clinic: results from a concordance study. J Shoulder Elbow Surg. 2020;29(8):1564–72.32199757
27. Matifat E Perreault K Roy JS Aiken A Gagnon E Mequignon M Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department BMC Emerg Med 2019 19 1 67 10.1186/s12873-019-0277-7 31707978
Matifat E, Perreault K, Roy JS, Aiken A, Gagnon E, Mequignon M, et al. Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department. BMC Emerg Med. 2019;19(1):67.31707978
28. von Elm E Altman DG Egger M Pocock SJ Gøtzsche PC Vandenbroucke JP The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies J Clin Epidemiol 2008 61 4 344 349 10.1016/j.jclinepi.2007.11.008 18313558
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9.18313558
29. Kottner J Audigé L Brorson S Donner A Gajewski BJ Hróbjartsson A Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed J Clin Epidemiol 2011 64 1 96 106 10.1016/j.jclinepi.2010.03.002 21130355
Kottner J, Audigé L, Brorson S, Donner A, Gajewski BJ, Hróbjartsson A, et al. Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed. J Clin Epidemiol. 2011;64(1):96–106.21130355
30. Landis JR Koch GG The measurement of observer agreement for categorical data Biometrics 1977 33 1 159 174 10.2307/2529310 843571
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.843571
31. Bujang Mohamad Adam Baharum Nurakmal Guidelines of the minimum sample size requirements for Cohen’s Kappa Epidemiology Biostat Public Health 2017 14 e12267 1
Bujang Mohamad Adam, Baharum Nurakmal. Guidelines of the minimum sample size requirements for Cohen’s Kappa. Epidemiology Biostat Public Health. 2017;14:e12267–1.
32. Whitney S, Wrisley D, Brown K, Furman J. Is perception of handicap related to functional performance in persons with vestibular dysfunction? Otol Neurotol. 2004;25(2):139–43.
33. Morris AE Lutman ME Yardley L Measuring outcome from vestibular rehabilitation, part II: refinement and validation of a new self-report measure Int J Audiol 2009 48 1 24 37 10.1080/14992020802314905 19173111
Morris AE, Lutman ME, Yardley L. Measuring outcome from vestibular rehabilitation, part II: refinement and validation of a new self-report measure. Int J Audiol. 2009;48(1):24–37.19173111
34. Gwet KL Computing inter-rater reliability and its variance in the presence of high agreement Br J Math Stat Psychol 2008 61 Pt 1 29 48 10.1348/000711006X126600 18482474
Gwet KL. Computing inter-rater reliability and its variance in the presence of high agreement. Br J Math Stat Psychol. 2008;61(Pt 1):29–48.18482474
35. Wongpakaran N Wongpakaran T Wedding D Gwet KL A comparison of Cohen's Kappa and Gwet's AC1 when calculating inter-rater reliability coefficients: a study conducted with personality disorder samples BMC Med Res Methodol 2013 13 61 10.1186/1471-2288-13-61 23627889
Wongpakaran N, Wongpakaran T, Wedding D, Gwet KL. A comparison of Cohen’s Kappa and Gwet’s AC1 when calculating inter-rater reliability coefficients: a study conducted with personality disorder samples. BMC Med Res Methodol. 2013;13:61.23627889
36. Gwet KL. Intrarater Reliability. In: Balakrishnan N, Colton T, Everitt B, Piegorsch W, Ruggeri F, Teugels JL, editors. Wiley StatsRef: Statistics Reference Online. 2014.
37. Mutsekwa RN Byrnes JM Larkins V Canavan R Angus RL Campbell KL Role substitution of specialist medical doctors with allied-health professionals: A qualitative exploration of patients' experiences and perceptions of healthcare quality J Eval Clin Pract 2022 28 6 1096 1105 10.1111/jep.13691 35470945
Mutsekwa RN, Byrnes JM, Larkins V, Canavan R, Angus RL, Campbell KL. Role substitution of specialist medical doctors with allied-health professionals: A qualitative exploration of patients’ experiences and perceptions of healthcare quality. J Eval Clin Pract. 2022;28(6):1096–105.35470945
38. MacKay C Davis AM Mahomed N Badley EM Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage J Eval Clin Pract 2009 15 1 178 183 10.1111/j.1365-2753.2008.00979.x 19239599
MacKay C, Davis AM, Mahomed N, Badley EM. Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage. J Eval Clin Pract. 2009;15(1):178–83.19239599
39. Sealy A Vestibular assessment: a practical approach Occup Med 2014 64 2 78 86 10.1093/occmed/kqt153
Sealy A. Vestibular assessment: a practical approach. Occup Med. 2014;64(2):78–86.
40. Trinidade A Yung MW Consultant-led, multidisciplinary balance clinic: process evaluation of a specialist model of care in a district general hospital Clin Otolaryngol 2014 39 2 95 101 10.1111/coa.12236 24612936
Trinidade A, Yung MW. Consultant-led, multidisciplinary balance clinic: process evaluation of a specialist model of care in a district general hospital. Clin Otolaryngol. 2014;39(2):95–101.24612936
41. Bath AP Walsh RM Ranalli P Tyndel F Bance ML Mai R Experience from a multidisciplinary "dizzy" clinic Am J Otol 2000 21 1 92 97 10.1016/S0196-0709(00)80081-2 10651441
Bath AP, Walsh RM, Ranalli P, Tyndel F, Bance ML, Mai R, et al. Experience from a multidisciplinary “dizzy” clinic. Am J Otol. 2000;21(1):92–7. 10651441
