Referral decisions and its predictors related to orthopaedic care.  A retrospective study in a novel primary care setting

Autoři: Esther H. A. van den Bogaart aff001;  Marieke D. Spreeuwenberg aff001;  Mariëlle E. A. L. Kroese aff001;  Mark W. van den Boogaart aff003;  Tim A. E. J. Boymans aff003;  Dirk Ruwaard aff001
Působiště autorů: Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands aff001;  Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands aff002;  Department of Orthopaedic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands aff003
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article


Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81–0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient’s diagnosis and the period (p ≤ 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.

Klíčová slova:

Diagnostic medicine – Magnetic resonance imaging – Orthopedic surgery – Osteoarthritis – Outpatients – Primary care – Surgeons – Ultrasound imaging


1. Storheim K, Zwart JA. Musculoskeletal disorders and the Global Burden of Disease study. Ann Rheum Dis. 2014;73(6):949–50. Epub 2014/05/03. doi: 10.1136/annrheumdis-2014-205327 24790065.

2. Gillum R. Global health care: Issues and policies. J Health Care Poor Underserved. 2008;19(3):1013–4. WOS:000258350700031.

3. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ. 2003;81(9):646–56. WOS:000185876300006. 14710506

4. WHO. The burden of musculoskeletal conditions at the start of the new millennium: report of a WHO scientific group. Millennium WSGotBoMCatSotN, editor. Geneva: World Health Organization; 2003.

5. Andersson G, American Academy of Orthopaedic Surgeons. The burden of musculoskeletal diseases in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons. 2008.

6. Bevan S. Economic impact of musculoskeletal disorders (MSDs) on work in Europe. Best Pract Res Clin Rheumatol. 2015;29(3):356–73. Epub 2015/11/28. doi: 10.1016/j.berh.2015.08.002 26612235.

7. Leveille SG. Musculoskeletal aging. Curr Opin Rheumatol. 2004;16(2):114–8. doi: 10.1097/00002281-200403000-00007 WOS:000189285400006. 14770095

8. MacKay C, Canizares M, Davis AM, Badley EM. Health care utilization for musculoskeletal disorders. Arthritis Care Res (Hoboken). 2010;62(2):161–9. Epub 2010/03/02. doi: 10.1002/acr.20064 20191514.

9. Lubeck DP. The costs of musculoskeletal disease: health needs assessment and health economics. Best Pract Res Clin Rheumatol. 2003;17(3):529–39. Epub 2003/06/06. doi: 10.1016/s1521-6942(03)00023-8 12787516.

10. Trends [Trends] Bilthoven: RIVM; 2017 [cited 2017 16 November]. Available from:

11. Kosten van zorg voor artrose [Cost of care for osteoarthritis] 2017 [cited 2017 16 November]. Available from:

12. Verheij RA, van Dijk CE, Abrahamse H, Davids R, Wennekes L, van den Hoogen H, et al. Landelijk Informatie Netwerk Huisartsenzorg (LINH): Kerncijfers 2008 [National Information Network General Practice Care (LINH): Key figures 2008]. Utrecht: NIVEL, 2010.

13. NIVEL. Meeste consulten bij huisarts voor klachten aan het bewegingsapparaat [Most consultations with general practitioner are related to complaints of the musculoskeletal system]. Infographic. Utrecht: NIVEL, 2018.

14. Brekke KR, Nuscheler R, Straume OR. Gatekeeping in health care. J Health Econ. 2007;26(1):149–70. doi: 10.1016/j.jhealeco.2006.04.004 WOS:000243808700008. 16890313

15. Speed CA, Crisp AJ. Referrals to hospital-based rheumatology and orthopaedic services: seeking direction. Rheumatology (Oxford). 2005;44(4):469–71. doi: 10.1093/rheumatology/keh504 15716322.

16. Roland MO, Porter RW, Matthews JG, Redden JF, Simonds GW, Bewley B. Improving care: a study of orthopaedic outpatient referrals. Br Med J (Clin Res Ed). 1991;302(6785):1124–8. doi: 10.1136/bmj.302.6785.1124 2043784.

17. Roberts C, Adebajo AO, Long S. Improving the quality of care of musculoskeletal conditions in primary care. Rheumatology (Oxford). 2002;41(5):503–8. doi: 10.1093/rheumatology/41.5.503 12011372.

18. van Rhijn L, Spreeuwenberg M, Ruwaard D. Orthopedie gebaat bij anderhalvelijnszorg [Orthopaedic care benefits from Primary Care Plus]. Medisch Contact. 2013;68:283–5.

19. Goodwin N, Curry N, Naylor C, Ross S, Duldig W. Managing people with long-term conditions. London: The King's Fund, 2010.

20. Ruwaard D, Spreeuwenberg M, Kroese M, Steevens J, Ouwens M, Hilbink M, et al. Triple Aim en de toepassing in de regionale proeftuinen ‘Populatiemanagement’ van VGZ en CZ [Triple Aim and the application in the regional pioneer sites 'Population management' by VGZ and CZ]. Maastricht; Nijmegen: Maastricht University, Health Services Research, Maastricht University; Radboudumc, IQ Healthcare., 2014.

21. van Hoof SJ, Spreeuwenberg MD, Kroese ME, Steevens J, Meerlo RJ, Hanraets MM, et al. Substitution of outpatient care with primary care: a feasibility study on the experiences among general practitioners, medical specialists and patients. BMC Fam Pract. 2016;17:108. Epub 2016/08/11. doi: 10.1186/s12875-016-0498-8 27506455.

22. Wildeboer JA, van de Ven ART, de Boer D. Substitution of care for chronic heart failure from the hospital to the general practice: patients’ perspectives. BMC Fam Pract. 2018;19(1):8. doi: 10.1186/s12875-017-0688-z 29316896

23. Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, et al. Chapter 7, Moving care from hospital into the community: international experiences (substudy 5). In: Library NJ, editor. Outpatient services and primary care: scoping review, substudies and international comparisons. No. 4.15. Southampton (UK): Health Services and Delivery Research; 2016.

24. Vierhout WP, Knottnerus JA, van OA, Crebolder HF, Pop P, Wesselingh-Megens AM, et al. Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders. Lancet. 1995;346(8981):990–4. doi: 10.1016/s0140-6736(95)91686-5 7475592.

25. ZIO. Jaarverslag [Annual report]2015. Available from:

26. Enthoven AC, van de Ven WP. Going Dutch—managed-competition health insurance in the Netherlands. N Engl J Med. 2007;357(24):2421–3. Epub 2007/12/14. doi: 10.1056/NEJMp078199 18077805.

27. Schellevis FG, Westert GP, De Bakker DH. The actual role of general practice in the dutch health-care system. Results of the second dutch national survey of general practice. Journal of Public Health. 2005;13(5):265–9. Epub 2005/10/13. doi: 10.1007/s00063-005-1090-5 16220254.

28. van Hoof SJ, Kroese ME, Spreeuwenberg MD, Elissen AM, Meerlo RJ, Hanraets MM, et al. Substitution of Hospital Care with Primary Care: Defining the Conditions of Primary Care Plus. The International Journal of Integrated Care. 2016;16(1):12. Epub 2016/09/13. doi: 10.5334/ijic.2446 27616956.

29. Bailey JJ, Black ME, Wilkin D. Specialist Outreach Clinics in General-Practice. Br Med J. 1994;308(6936):1083–6. doi: 10.1136/bmj.308.6936.1083 WOS:A1994NH48900027. 8173432

30. Stolk EA, Rutten FF. The "health benefit basket" in the Netherlands. The European Journal of Health Economics. 2005;6(Suppl 1):53–7. Epub 2005/11/05. doi: 10.1007/s10198-005-0319-9 16270209.

31. World Health Organization. ICD-10: international statistical classification of diseases and related health problems / World Health Organization. Geneva: World Health Organization; 2004.

32. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3:17. Epub 2008/12/18. doi: 10.1186/1751-0473-3-17 19087314.

33. Pedhazur EJ, Schmelkin LP. Measurement, design, and analysis: an integrated approach1991.

34. Nagelkerke NJD. A Note on a General Definition of the Coefficient of Determination. Biometrika. 1991;78(3):691–2. doi: 10.1093/biomet/78.3.691 WOS:A1991GJ30600024.

35. McBride D, Hardoon S, Walters K, Gilmour S, Raine R. Explaining variation in referral from primary to secondary care: cohort study. Br Med J (Clin Res Ed). 2010;341:c6267. doi: 10.1136/bmj.c6267 21118873.

36. Katz JN. Patient preferences and health disparities. JAMA. 2001;286(12):1506–9. doi: 10.1001/jama.286.12.1506 11572745.

37. Walters K, Iliffe S, Orrell M. An exploration of help-seeking behaviour in older people with unmet needs. Fam Pract. 2001;18(3):277–82. doi: 10.1093/fampra/18.3.277 WOS:000169151900008. 11356734

38. Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Kreder HJ, et al. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg. 2008;51(6):428–36. WOS:000261176000003. 19057730

39. Maempel JF, Riddoch F, Calleja N, Brenkel IJ. Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients. Acta Orthop. 2015;86(4):451–6. doi: 10.3109/17453674.2015.1040304 25885004.

40. Becker SJE, Teunis T, Blauth J, Kortlever JTP, Dyer GSM, Ring D. Medical Services and Associated Costs Vary Widely Among Surgeons Treating Patients With Hand Osteoarthritis. Clin Orthop Relat Res. 2015;473(3):1111–7. doi: 10.1007/s11999-014-3912-3 WOS:000349242200051. 25171936

41. Lipitz-Snyderman A, Bach PB. Overuse of Health Care Services When Less Is More … More or Less. Jama Internal Medicine. 2013;173(14):1277–8. doi: 10.1001/jamainternmed.2013.6181 WOS:000324160100001. 23712254

42. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. Lancet. 2017;390(10090):156–68. doi: 10.1016/S0140-6736(16)32585-5 WOS:000404976600033. 28077234

43. Vegting IL, van Beneden M, Kramer MHH, Thijs A, Kostense PJ, Nanayakkara PWB. How to save costs by reducing unnecessary testing: Lean thinking in clinical practice. Eur J Intern Med. 2012;23(1):70–5. doi: 10.1016/j.ejim.2011.07.003 WOS:000298148800024. 22153535

44. Gupta DM, Boland RJ Jr., Aron DC. The physician's experience of changing clinical practice: a struggle to unlearn. Implement Science. 2017;12(1):28. Epub 2017/03/02. doi: 10.1186/s13012-017-0555-2 28245849.

45. Singh D. Making the shift, key success factors. A rapid review of best practice in shifting hospital care into the community. Birmingham: University of Birmingham Health Services Management Centre, 2006.

46. Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database Syst Rev. 2004;(1):CD003798. Epub 2004/02/20. doi: 10.1002/14651858.CD003798.pub2 14974038.

47. Bentsen BG. International classification of primary care. Scand J Prim Health Care. 1986;4(1):43–50. Epub 1986/02/01. doi: 10.3109/02813438609013970 3961309.

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