OBJECTIVE:Effective general practitioner (GP) referral and timely orthopaedic surgical decisions are essential for health service productivity and quality patient care, yet efficiency in this pathway is not well understood. This study evaluated GP public orthopaedic referrals up to the point of surgical determination. Aims were to estimate GP-level variability in referral volumes, types, orthopaedic resource usage, surgical conversion rates and the time and costs of orthopaedic care, up to surgical decision. METHODS:This study involved a retrospective observational cohort with cost and outcomes analysis. The 2-year cohort included all GP orthopaedic referrals to a large regional Australian public health service, orthopaedic-led care provision and costs incurred up to surgical determination (or discharge). Survival analysis used the Kaplan-Meier estimator for right censored data, with inverse probability censoring for inflation adjusted costs, expressed in Australian dollars from the health service perspective. RESULTS:A total of 18,901 referrals were identified. Referral volume was highly variable, ranging from 1 to 238 per GP. Time to surgical decision was often lengthy (mean = 520 days) and highly variable (1 week-4 years). Mean pre-surgical health service costs per referral were $785 (s.e. 11.89) and the surgical conversion rate was low (25%). Longer time periods and surgical listings were associated with greater costs. CONCLUSIONS:This large, single-centre evaluation revealed high GP referral variability, prolonged non-surgical orthopaedic care, low surgical conversion and high drop-out rates. Further research is needed to better understand the reasons behind variation in GP referral parameters and to explore ways to more efficiently align referral goals and non-surgical care across primary care and orthopaedics.

Adherence to compression stocking wear is essential for reducing venous leg ulcer recurrence, yet adherence rates remain low. This study examined the relationship between a novel digital clinical decision-aid (the Personalized and Multidimensional Compression Assessment and Intervention [PAMCAI]), clinician practice, and patient adherence with compression stocking use, by embedding a prospective comparative cohort study within a pilot randomized controlled trial. The clinical notes of occupational therapists using PAMCAI were compared with those not using PAMCAI on their documentation of adherence and frequency of wear, identification of patient-specific barriers and attempts to address barriers. The relationship between higher documentation scores and patient adherence was also explored. Thirty-six medical records from 18 patients demonstrated significantly higher documentation scores when PAMCAI was used for all three categories (p < 0.001). Improvements in adherence were positively associated with documentation quality in the targeted categories (p < 0.001). These findings indicate that PAMCAI supports practice changes that translate to improved patient adherence, highlighting the potential value of clinician-focused decision-aids in venous leg ulcer care.

OBJECTIVE:This systematic review assessed trial-based economic evaluations to provide empirical evidence on the cost-effectiveness of non-drug interventions (NDIs) that are currently recommended within the Royal Australian College of General Practitioners Handbook of Non-Drug Interventions (HANDI). METHODS:Medline, CINAHL and PsycINFO along with clinical trial registries (clinicaltrials.gov and WHO International Clinical Trials Registry Platform) were searched from inception to 1 July 2025. Randomised controlled trials (RCTs) that reported cost effectiveness for a prescribed non-drug intervention (NDI) from HANDI were included in the study. The primary outcome was the incremental cost-utility ratio (ICUR) derived from cost-utility analyses (CUAs). RESULTS:A total of 11 187 citations were identified, from which 156 RCTs were included. These RCTs enrolled a total of 66 926 participants (median=214, IQR 139-342), with a median follow-up duration of 12 months (IQR 6-12 months). Over half of the CUA NDIs were for mental health conditions (n=81; 54.0%), one-third were for were for musculoskeletal conditions (n=44; 29.3%), while only 16.0% (n=24) were for those with cardiovascular/metabolic conditions. Out of the 150 NDIs that reported CUAs, 40% were deemed to be in the south-east (SE) quadrant (cheaper and more effective) and 49.3% fell in the north-east (NE) quadrant (more costly but more effective), with 70% considered cost effective against a £25 000/quality-adjusted life-year (QALY) willingness to pay threshold. The overall median ICUR was £2400/QALY (IQR -18 986 to 20 027). CONCLUSIONS:Most of the HANDI NDIs that were included within this systematic review are cost-effective compared with a variety of alternatives including usual care or waiting list controls. HANDI NDIs warrant use as a first line of treatment when clinically appropriate.

Venous leg ulcer recurrence can be prevented with daily compression stocking wear; however, stocking effectiveness is often hindered by poor patient adherence. The 'Personalised and Multi-dimensional Compression Assessment and Intervention' (PAMCAI) is a multidimensional decision aid, delivered by clinicians via an iPad application, designed to improve adherence. This study piloted the methodology and feasibility of PAMCAI's efficacy and cost-effectiveness for evaluation in a larger randomised controlled trial (RCT). Using a two-arm, single-blinded pilot RCT with cost-utility analysis, PAMCAI was compared with usual care in a tertiary hospital occupational therapy outpatient clinic. The primary outcome was adherence to wearing compression stockings, measured on a 4-point scale. Twenty participants were randomised to receive PAMCAI (n = 10) or usual care (n = 10). Recruitment and pilot methodology appear feasible for use in a larger study. Compression stocking adherence was greater with PAMCAI compared to usual care (p = 0.002) and PAMCAI is likely cost-effective, with an incremental cost-effectiveness ratio of $3379.36 per quality-adjusted life year (QALY) gained. Resolution of identified barriers to stocking adherence was positively associated with improvements in patient adherence. These findings support further investigation of PAMCAI in a larger RCT and its potential to improve patient adherence and the cost-effectiveness of compression therapy for venous leg ulcer prevention.

A novel mobile app decision-aid was developed to improve patient adherence to compression stockings and was tested in a tertiary hospital outpatient clinic, demonstrating improved adherence in the intervention group compared to usual care. The successful integration of new technology into clinical practice depends on clinician acceptance of the technology. The objective of this research was to investigate clinicians’ acceptance of the mobile app decision-aid, exploring their experiences and perceptions regarding its use in clinical practice. A qualitative descriptive approach was used in this two-phased study: (a) capturing clinician perceptions throughout the conduct of the main study and (b) semi-structured interviews guided by the Technology Acceptance Model (TAM). Themes were analyzed using NVIVO-12 software. Nine clinicians participated in the first phase, with four completing follow-up interviews in the second phase. Key themes, organized using TAM constructs (ease of use, perceived usefulness, attitudes, and behavioural intentions), highlighted the integration of the technology into practice, emphasizing efficiency, benefits, and challenges. The mobile app decision-aid may have gently guided clinicians and patients towards certain evidence-based choices, while allowing for clinicians to override recommendations based on their professional judgement and experience. Clinicians reported that the decision-aid supported a non-judgmental approach, strengthening the therapeutic relationship with the patient, challenged assumptions, provided structure, facilitated skill-development, and encouraged persistence in identifying and addressing patient barriers. Clinicians positively perceived the mobile app delivering the decision-aid, emphasizing its ease of use and benefits for patients as key factors supporting its adoption in clinical practice to improve compression stocking adherence. These findings suggest that the mobile app decision-aid could be a feasible and effective resource for improving adherence, with opportunities for tailoring and broader applicability to other patient populations in the future. Further research is warranted to explore its long-term impact and scalability. The research is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) 12,620,000,544,976. Ethical Approval was granted through the Gold Coast Hospital and Health Service Human Research Ethics Committee and Bond University Human Research Ethics Committee HREC/2020/QGC/62,843 and SSA/2020/QGC/62,843.

Background: Efficient musculoskeletal care is important for health services and society. Surgical conversion rates are a common measure of efficiency, yet normal values and the impact of referrer type are unclear. This information could assist musculoskeletal care, service benchmarking and redesign. Methods: A systematic review with meta-analysis was undertaken with PubMed, CINAHL and EMBASE databases searched from inception to 12th of October 2024, to identify studies from which musculoskeletal surgical conversion rates could be extracted. Data were categorised according to the professional group responsible for referral (all doctors, general practitioners, sports physicians, allied-health/physiotherapy-led screening services) and methodology used to define surgical conversion. Meta-analysis of pooled data was undertaken. Results: Twenty-eight studies with a combined total of 5358 patients were included. Pooled data revealed surgical conversion rates of 23% for referrals from all types of doctors (0.23, 95% CI 0.18-0.27), 28% from general practitioners (0.28, 95% CI 0.12-0.52), 61% from allied health physiotherapy-led screening services (0.61, CI 0.50-0.70) and 70% from sports physicians at (0.70, CI 0.64-0.75). A variety of methodological factors impacted surgical conversion rate reporting and heterogeneity. Conclusions: Musculoskeletal services seeking to improve efficiency through higher surgical conversion rates, should include sports physician and/or physiotherapy-led models of care for referral generation or management.

BACKGROUND:Patient and clinician expectations of benefit from recommended management approaches may potentially impact the success of managing musculoskeletal conditions. METHODS:This was a multisite study in an advanced practice musculoskeletal service across Queensland, Australia. Relationships between patient and clinician (advanced physiotherapy practitioner) expectations of benefit, patient characteristics, and clinical outcome recorded 6 months later were explored with regression analysis in 619 patients undergoing non-surgical multidisciplinary care for either knee osteoarthritis (n = 286), low back pain (n = 249) or shoulder impingement syndrome (n = 84). RESULTS:Patient and clinician expectation ratings had a weak positive association (standardized coefficient (β) 0.28, adjusted R2 0.09). Higher patient expectation ratings were associated with higher readiness for change scores (β 0.31, model adjusted R2 = 0.18), while higher clinician expectation ratings were associated with the condition managed, higher patient education level, lower potential presence of neuropathic pain or yellow flags, and more favourable radiological findings (model adjusted R2 0.4). Patient expectations and self-reported engagement with care were poorly correlated. Higher patient (β 0.33, adjusted R2 0.12) and clinician (β 0.32, adjusted R2 0.14) expectations were associated with better clinical outcomes. This positive association was stronger when patient and clinician expectation ratings were congruent. CONCLUSIONS:Findings suggest that expected benefits from recommended care may impact outcomes and should be considered in the initial phases of management. In particular, congruence between patient and clinician expectations appears to have relevance to outcomes.

OBJECTIVES: The primary objective was to compare sensory processing measures in people attending specialist orthopaedic consultation for management of persistent shoulder pain with control participants. The secondary objective was to compare the groups' sociodemographic, clinical, general health and lifestyle, and psychological characteristics. DESIGN: Observational cross-sectional. METHODS: Participants with shoulder pain for >= 3 months, who attended a public hospital orthopaedic department (n = 119), and community participants without shoulder pain (n = 44) underwent a standardized quantitative sensory testing protocol, measuring pressure pain threshold, temporal summation, and conditioned pain modulation. Sociodemographic, clinical, general health and lifestyle, and psychological characteristics were also collected. RESULTS: Participants with shoulder pain had significantly lower pressure pain thresholds at all sites (ie, local and widespread mechanical hyperalgesia) and significantly decreased conditioned pain modulation effect (ie, descending inhibition of nociception) than control participants. There was no significant difference between groups for temporal summation. Participants with shoulder pain had decreased general health and function, less healthy lifestyles, and poorer psychological health compared with controls. CONCLUSION: People referred to specialist orthopaedic care for management of persistent shoulder pain had clinical signs of altered sensory processing and poor health outcomes. J Orthop Sports Phys Ther 2024;54(10):647-656. Epub 25 July 2024. doi:10.2519/ jospt.2024.12512

BACKGROUND Musculoskeletal shoulder pain is a common problem and its symptoms often become persistent. The experience of pain is multidimensional, and therefore, a range of patient characteristics may influence treatment response. An altered sensory processing has been associated with persistent musculoskeletal pain states and may contribute to outcomes in patients with musculoskeletal shoulder pain. The presence and potential impact of altered sensory processing in this patient cohort is not currently known. The aim of this prospective longitudinal cohort study is to investigate if baseline sensory characteristics are associated with clinical outcomes in patients presenting to a tertiary hospital with persistent musculoskeletal shoulder pain. If found, a relationship between sensory characteristics and outcome may lead to the creation of more effective treatment strategies and improvements in risk adjustment and prognosis. METHODS This is a single-centre prospective cohort study with 6-, 12- and 24-month follow-up. A total of 120 participants aged ≥18 years with persistent musculoskeletal shoulder pain (≥3 months) will be recruited from an Australian public tertiary hospital orthopaedic department. Baseline assessments, including quantitative sensory tests and a standardised physical examination, will be performed. In addition, information will be obtained from patient interviews, self-report questionnaires and medical records. Follow-up outcome measures will comprise information from the Shoulder Pain and Disability Index and a six-point Global Rating of Change scale. ANALYSIS Descriptive statistics will be used to report baseline characteristics and outcome measures over time. Change in outcome measures at the primary endpoint of six months from baseline will be calculated using paired t-tests. Associations between baseline characteristics and outcomes at a 6-month follow-up will be reported using multivariable linear and logistic regression models. DISCUSSION Understanding the relationship between sensory profile and the variable response to treatment in people with persistent musculoskeletal shoulder pain may enhance our understanding of the mechanisms contributing to the presentation. In addition, through better understanding of the contributing factors, the results of this study may contribute to the development of an individualised, patient-centred approach to treatment for people with this highly prevalent and debilitating condition.

Background This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions. Methods PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English. Results 214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep’s role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy’s limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation. Conclusions The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required. Pre-registration OSF : https://osf.io/erh9m

Background: Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery. Design: prospective prognostic cohort study. Methods: Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaes-thetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks. Results: Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks. Conclusion: Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection re-sponses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings. Registration: Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.

Introduction: The burden of Musculoskeletal disorders (MSD) is large. Surgery is an important management option but the factors that shape patients' surgical decisions are not well understood. As prior reviews have explored only single data types or conditions, a mixed methods appraisal across the musculoskeletal spectrum was undertaken. Methods: A mixed-methods systematic, convergent segregated approach was used, with PubMed, Cumulated Index to Nursing and Allied Health Literature (CINHAL), Embase and PsycINFO searched to identify studies of adult patients' decisions about whether to undergo surgery. A narrative synthesis was conducted, with identified themes integrated across quantitative, qualitative and mixed-methods studies. Results: Forty-six studies were included (24 quantitative, 19 qualitative and three mixed methods), with four decision-making themes identified (symptoms, sociodemographic and health factors, information and perceptions). Decision-making involves a complex interaction of individual sociodemographic, health and symptom information, integrated with individual perceptions of candidacy and surgical expectations. While most studies investigated hip and knee surgery, across all included conditions, patients are more likely to favour surgery if symptoms and/or dysfunction are higher, and if perceptions of surgical candidacy and processes (outcomes, inconvenience, and risk) are favourable. Other factors including age, general health, race, financial context, professional and non-professional communication, and information sources also impact decision-making but exert a less consistent impact upon the propensity to prefer surgery. Conclusion: Patients are more likely to choose surgery for MSD when they have higher levels of symptoms or dysfunction and positive perceptions of surgical suitability and expectations. Other factors important to individuals, have a less consistent impact upon the propensity to prefer surgery. These findings have potential to aid the efficient referral of patients to orthopaedics. More research is needed to validate these findings across the spectrum of MSD.

Purpose:Poor patient adherence to compression stockings remains a difficult and pervasive problem for clinicians, with costly repercussions for patients and health-care systems. The purpose of this paper was to describe the application of behavior change theory to the systematic development of a suite of resources, aimed at improving patient adherence to wearing compression stockings.Methods:Employing a non-empirical approach, behavior-change theory was used to develop an innovative intervention as part of a multi-phase project. Target behaviors, barriers and potential enablers were identified in relation to stocking adherence. An impact-likelihood matrix for behavior prioritization was used to identify possible areas for intervention within occupational therapy outpatient clinics. Selection of suitable resources and their consequent development were based on a narrative and problem-solving process by a panel of clinical experts.Results:Of 14 potential domains embedded in the Theoretical Domains Framework, the key target behaviors and barriers were associated with eight domains. Michie's Behavior Change Wheel revealed recommendations in six subdivisions and of these, four intervention functions were selected by the panel, based on their potential impact and likelihood of adoption in clinical practice. Findings led to the development of a suite of resources comprising a new questionnaire, a clinical decision tree, augmented by clinical answer sheets corresponding to each of the barriers.Conclusion:Application of behavior change theory informed the design of a behavior change intervention comprising an integrated suite of resources for novice and experienced clinicians.Practice Implications:These novel resources have potential to improve patient adherence to compression stockings and consequently generate health-care savings through reduced need for wound care products, and medical interventions with translation to other settings and conditions requiring compression stockings. Patient outcomes will likely be improved with reduced pain, improved quality of life and earlier resumption of usual occupations.

OBJECTIVE:To determine whether differences exist for older persons presenting to Emergency Departments (EDs) with lower back pain (LBP) in terms of management, health service resource use and cost when compared to younger patients with LBP.METHODS:Retrospective analysis of routinely collected electronic medical record data from January 2015 to July 2021. Data from 11,098 adults presenting with LBP to two large regional Australian EDs were analysed over a 5-year period. Rates of presentation, investigation, medication use, spinal surgery and cost were assessed for all participants with respect to age groups (over or under 65 years of age), diagnosis and time. Multivariable logistic regression analysis was employed to assess the contribution of presentation characteristics to the risk of inpatient admission and to investigate the variable effect of patient age.RESULTS:Older people represented 23% (n = 2565) of all LBP presentations, with a growing proportion of presentations over time. More than 1 in 4 patients over 65 were admitted (n = 703, 27%), with CT imaging being proportionately three times more prevalent (24% vs. 6%), and average cost double (AU$3973 vs. $1671) that of the younger population. Consultation by an ED physiotherapist was associated with lower admission risk across all adult presentations (OR 0.52, 95% CI [0.40 to 0.67]).CONCLUSIONS:Older persons are over-represented amongst gradually increasing rates of LBP presentations to EDs and associated with escalating cost of care and hospital resource use. Older patients present a different clinical and economic profile to younger patients, supporting the provision of individualised management recommendations.

Introduction: While the efficacy of telehealth in musculoskeletal physiotherapy has been supported, its cost effectiveness has not been established. Therefore, the objective of this review was to ascertain the health economic impact of outpatient musculoskeletal physiotherapy delivered by telehealth and describe methodology utilized to date. Methods: Electronic searching of PubMed, CINHAL, PEDro, and Web of Science databases was undertaken alongside handsearching for publications comprising: population: adults with musculoskeletal disorders managed in any type of outpatient ambulatory setting; intervention: physiotherapy delivered by telehealth comparison: traditional in-person physiotherapy; and, outcomes: economic analyses reporting costs and consequences. Appraisal was undertaken with the Downs and Black Questionnaire and the Consolidated Health Economic Evaluation Reporting Standards Checklist. Results: Eleven studies of mixed methodological quality were included. Most were conducted in the public sector, from the economic perspective of the health service funder. Telehealth consistently produced health outcomes akin to in-person care. In all but one, telehealth was less costly, with savings achieved by reducing in-person consultations and travel costs. Conclusion: Telehealth is as effective and cheaper than in-person physiotherapy for musculoskeletal disorders in public hospital outpatients. Further health economic research is needed to clarify the economic impact of telehealth upon non-government providers of musculoskeletal physiotherapy.

PURPOSE:Patient adherence to wearing compression stockings in the management of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is low. Poor adherence with compression stockings contributes to recurrence and impaired healing of VLUs. As such, the purpose of this review was to report on the scientific evidence related to adherence and explore modifiable factors which impact adherence with compression stockings. METHODS:A systematic search was conducted from inception to 31 October 2019. Following the PRISMA-ScR Checklist, PubMed, Medline, CINAHL, Cochrane, Embase, OT Seeker and Web of Science were explored using search terms: compression/compression stocking/compression garment/compression sock/stockings/garments and adherence/compliance/concordance. RESULTS:We identified 2613 papers of which 125 full text papers were assessed for eligibility and 69 met inclusion criteria. Papers were grouped and charted by concepts relevant to the research questions and narratively synthesized. Several dominant themes emerged, and a conceptual framework was developed incorporating modifiable variables, adherence itself, and outcomes related to adherence. Specifically considering interventions to improve adherence, only five of 14 randomized controlled trials were able to demonstrate improvements in adherence through unidimensional approaches. All nine of the case studies/series demonstrated a positive impact on adherence, eight of which described a personalized multidimensional approach. A lack of consensus around defining, measuring, and quantifying adherence with compression stockings was identified, resulting in wide variation in reported adherence rates. CONCLUSION:Inconsistency in the definition and measurement of adherence limits meaningful interpretation of the literature. No individual intervention has consistently demonstrated improved adherence. Multidimensional interventions show promise but require further investigation with high-quality trials. Improving adherence appears to improve health outcomes in VLU /CVI populations but there is a lack of information directly linking improved adherence with cost outcomes. TRIAL REGISTRATION:Open Science Framework: ACTRN12620000544976p.

1Department of Occupational Therapy, Bond University, Faculty of Health Science and Medicine, Queensland, Australia; 2Department of Physiotherapy, Bond University, Faculty of Health Science and Medicine, Queensland, Australia Purpose: Patient adherence to wearing compression stockings in the management of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is low. Poor adherence with compression stockings contributes to recurrence and impaired healing of VLUs. As such, the purpose of this review was to report on the scientific evidence related to adherence and explore modifiable factors which impact adherence with compression stockings. Methods: A systematic search was conducted from inception to 31 October 2019. Following the PRISMA-ScR Checklist, PubMed, Medline, CINAHL, Cochrane, Embase, OT Seeker and Web of Science were explored using search terms: compression/compression stocking/compression garment/compression sock/stockings/garments and adherence/compliance/concordance. Results: We identified 2613 papers of which 125 full text papers were assessed for eligibility and 69 met inclusion criteria. Papers were grouped and charted by concepts relevant to the research questions and narratively synthesized. Several dominant themes emerged, and a conceptual framework was developed incorporating modifiable variables, adherence itself, and outcomes related to adherence. Specifically considering interventions to improve adherence, only five of 14 randomized controlled trials were able to demonstrate improvements in adherence through unidimensional approaches. All nine of the case studies/ series demonstrated a positive impact on adherence, eight of which described a personalized multidimensional approach. A lack of consensus around defining, measuring, and quantifying adherence with compression stockings was identified, resulting in wide variation in reported adherence rates. Conclusion: Inconsistency in the definition and measurement of adherence limits meaningful interpretation of the literature. No individual intervention has consistently demonstrated improved adherence. Multidimensional interventions show promise but require further investigation with high-quality trials. Improving adherence appears to improve health outcomes in VLU /CVI populations but there is a lack of information directly linking improved adherence with cost outcomes. Trial Registration: Open Science Framework: ACTRN12620000544976p.

Objective The aim of this study was to calculate the societal economic burden of shoulder pain in patients on the orthopaedic waiting list at an Australian public hospital and calculate the cost (from the government’s perspective) of care delivered by the hospital for those patients. Methods A cost-of-illness analysis was undertaken in a cohort of 277 orthopaedic patients on the Gold Coast in Australia. Outcomes included a health care costs and impacts questionnaire, work absenteeism, presenteeism questionnaires (Work Limitations Questionnaire (WLQ) and Work Productivity and Activity Impairment Questionnaire (WPAI)) and hospital care provision over a 2-year period. Results The mean societal cost of healthcare and domestic support was AU$20.72 per day (AU$7563 annually) per patient on the orthopaedic waiting list. When absenteeism and presenteeism were included, the cost per patient who was employed was AU$38.04 per day (AU$13 885 annually) calculated with the WLQ and AU$61.31 per day (AU$22 378 annually) calculated with the WPAI. The mean per-patient cost to government of public hospital care was AU$2622 in Year 1 and AU$3835.78 (s.d. 4961.28) over 2 years. The surgical conversion rate was 22%, and 51% of hospital care cost was attributable to outpatient services. Conclusions Public orthopaedic shoulder waiting lists create a large economic burden for society; few referrals require surgery and just over half the hospital care costs are for out-patient services. New models of care that better manage shoulder pain and identify surgical candidates before orthopaedic referral could reduce this burden. What is known about the topic? Little is known about the cost of shoulder pain in Australia, or the cost of patients referred for public orthopaedic care. What does this paper add? This article quantifies the costs of shoulder pain and the value of lost production from shoulder pain. The time spent waiting for public hospital orthopaedic appointments and the costs associated with waiting demonstrate that the time spent on a waiting list is a key driver of the economic burden. What are the implications for practitioners? Greater resourcing to reduce public orthopaedic shoulder waiting lists may be helpful, but system change is also required. Earlier and more accurate identification of surgical cases could reduce inefficient referrals and improve hospital productivity. Collaboration between clinicians and policy makers is needed to design more economically efficient shoulder care.

BACKGROUND:There is large variation in models-of-care involving the professional substitution of doctors with physiotherapists.OBJECTIVE:To establish the impact upon patients and health services, of substituting doctors with physiotherapists in the management of common musculoskeletal disorders.DATA SOURCES:Medline, CINAHL and ABI Complete databases, and hand-searching of related studies.STUDY SELECTION:Randomised and non-randomised clinical trials, inter-rater reliability and comparative studies comparing the outcomes of usual care from doctors, with outcomes when the doctor was substituted with a physiotherapist.STUDY APPRAISAL AND SYNTHESIS METHODS:Two reviewers evaluated all studies using the Downs and Black Instrument. Meta-analysis was not possible due to study heterogeneity. A descriptive review was undertaken.RESULTS:14 studies of moderate to low quality met the inclusion criteria. Professional substitution with a physiotherapist causes no significant change to health outcomes and inconsistent variation in the use of healthcare resources. There is insufficient health economic data to determine overall efficiency. In the selected presentations studied, physiotherapists made similar diagnostic and management decisions to orthopaedic surgeons and patients are as, or more satisfied with a physiotherapist.LIMITATIONS:Further high quality health and economic research is needed, in less selective patient populations, to determine the optimal role for physiotherapists.CONCLUSION AND IMPLICATIONS OF KEY FINDINGS:Physiotherapists provide a professional alternative to doctors for musculoskeletal disorders but the health economic implications of this model are presently unclear. Systematic Review Registration Number PROSPERO (Registration number CRD42015027671).