Identifying the Pathway to Conservative Pelvic Floor Physiotherapy in a Tertiary Public Hospital in Australia: A Retrospective Audit

Introduction: Incontinence and/or pelvic organ prolapse symptoms are prevalent in women in Australia, and the estimated healthcare cost is considerable. Internationally accepted best practice evidence supports a trial of conservative physiotherapy treatment with a physiotherapist trained in the management of pelvic floor dysfunction before surgical options should be considered. Existing referral pathways in the tertiary healthcare system to access conservative physiotherapy treatment require direct referral from gynaecology staff. Objective: To identify the pathway to conservative pelvic floor physiotherapy for women referred to a tertiary hospital in Australia with incontinence and/or pelvic organ prolapse symptoms following existing referral pathways. Results: Attendance data for the period January to June 2015 identified 63 women as being primarily referred for incontinence and/or pelvic organ prolapse by their local healthcare provider. Half of these 63 women (n = 31) were referred on to physiotherapy for conservative management; the other half were not. The time between local healthcare provider referral to specialist gynaecology appointment ranged from 49 days to 351 days (average 169.6 days). Of the 31 women referred to physiotherapy, the majority (n = 22, 70.9%) were referred on the day of their initial gynaecology consultation; the 9 remaining women waited between 2 to 126 days for physiotherapy referral. The shortest pathway from local healthcare provider referral to physiotherapy consultation was 64 days; the longest pathway was 402 days. Of the 31 women who were not referred to physiotherapy, 18 (58%) proceeded directly to surgery. Conclusion: This audit demonstrates that existing referral pathways for women referred with incontinence and/or pelvic organ prolapse create lengthy delays between local healthcare provider referral and access to physiotherapy services. Only half of those women who would be appropriate for a trial of conservative therapy are being referred to physiotherapy, which is in direct contrast to the widely accepted best practice guidelines for the management of pelvic floor dysfunction mandating conservative therapy as a first line approach for these conditions. The opportunity to implement an advanced scope model of care that promotes more timely access and earlier commencement of conservative physiotherapy for these women would significantly improve the clinical care pathway for this cohort of patients in the tertiary healthcare setting. INTRODUCTION Incontinence (urinary and/or anal) and pelvic organ prolapse symptoms are prevalent in women in Australia, and these conditions can significantly impact a woman’s health and wellbeing. Urinary incontinence affects up to 37% and faecal incontinence affects up to 13% of Australian women and up to 1 in 2 women who have had children will have some degree of pelvic organ prolapse on vaginal examination.1,2 The lifetime risk of surgery for incontinence and pelvic organ prolapse symptoms in women has been shown to be 11.8% to age 80, meaning that approximately 1 in 10 women will require surgical intervention for these conditions.3 While both incontinence and pelvic organ prolapse represent a significant economic burden on the nation, most literature focuses on the impact of incontinence in particular. The total financial cost of incontinence was estimated to be $42.9 billion in 2010, with an additional $23.8 billion if the cost of the burden of disease was also considered.4 Internationally accepted best practice evidence strongly supports the role of physiotherapy in the management of pelvic floor dysfunction and, by way of Grade A recommendations using the Oxford Centre of Evidence Based Medicine level of evidence system, mandates the involvement of physiotherapy in the clinical care pathway for these conditions:5 Identifying the Pathway to Conservative Pelvic Floor Physiotherapy in a Tertiary Public Hospital in Australia: A Retrospective Audit 2 © The Internet Journal of Allied Health Sciences and Practice, 2017  Supervised pelvic floor muscle training should be offered as first line treatment for urinary incontinence (Grade A recommendation)  Conservative physiotherapy management can reduce pelvic organ prolapse symptoms and reduce patient-reported symptom severity (Grade A recommendation) The existing referral pathway at the Women’s and Children’s Hospital (WCH; Adelaide, South Australia) for women with incontinence and/or pelvic organ prolapse symptoms to access conservative physiotherapy management requires referral from their local medical caregiver (often a general practitioner (GP)) to the specialist gynaecology outpatient clinics. These referrals are triaged by senior medical staff in the Gynaecology Department as low priority “P3” for an initial consultation appointment (despite being a high priority for physiotherapy input), and thus, may wait in excess of 6 months for an appointment with the Gynaecology Team, at which point the patient must choose to “opt in” to the service. Once they have been seen in the Gynaecology Clinic, if appropriate, they are then referred to Women’s Health Physiotherapy to a trial period of conservative treatment (usually 4-6 months of therapy, which generally equates to 5-6 occasions of service). At this point, surgical management may be considered in such cases where it appears that conservative management has failed, and symptom severity and bother have not improved sufficiently from the patient’s perspective. The pilot Gynaecology Physiotherapy Assessment Service (GPAS) was implemented in October 2015, an initiative designed to improve the clinical care pathway for women referred to the Gynaecology Department at the WCH with symptoms of incontinence (urinary and/or anal) and pelvic organ prolapse, or a combination of these conditions. The GPAS model of care aims to facilitate more timely access to appropriate care in the tertiary healthcare system, while ensuring better utilisation of medical staff time and resources. By implementing a physiotherapy-led assessment service, women referred with mild or moderate pelvic floor dysfunction symptoms can be diverted from the existing waitlist to see a gynaecologist and instead be seen in a much timelier manner by a physiotherapist trained in the assessment and management of pelvic floor dysfunction. The GPAS model allows those women who are responding favourably to conservative management to be removed from the gynaecology waitlist, while also allowing those who require specialist medical review and/or surgical opinion to keep their place on the waitlist to see the gynaecologist. As a result, this pathway helps to ensure that gynaecology clinics are appropriately booked with patients who will require the Gynaecology Team’s specialist medical knowledge and/or surgical opinion, thereby improving the utilisation of specialist medical staff time and resources. The GPAS clinic is the first of its kind to run in the public sector in South Australia and is the first advanced scope role for physiotherapy in the Women’s and Babies’ Division at the WCH. An advanced scope role is defined as “a role that is within the currently recognised scope of practice for a profession, but that through custom and practice, has been performed by other professions. The advanced role may require additional training as well as significant professional experience and competency development.”6 The GPAS clinic model closely resembles similar advanced scope clinics operating in other Australian states. Informal correspondence with the lead physiotherapists for some of these clinics suggest that the roles have resulted in more timely access to conservative management, reduced symptom severity, reduction in patients on the gynaecology waitlist, improved patient flow through the health services, and high patient satisfaction since their inception. Identifying the Pathway to Conservative Pelvic Floor Physiotherapy in a Tertiary Public Hospital in Australia: A Retrospective Audit 3 © The Internet Journal of Allied Health Sciences and Practice, 2017 Identifying the Pathway to Conservative Pelvic Floor Physiotherapy in a Tertiary Public Hospital in Australia: A Retrospective Audit 4 © The Internet Journal of Allied Health Sciences and Practice, 2017 Method A retrospective audit was conducted to determine the pathway for a cohort of women who met GPAS inclusion criteria but who followed the existing referral pathway prior to the establishment of the GPAS pilot. GPAS inclusion criteria were defined as incontinence (urinary and/or anal symptoms), pelvic organ prolapse (grade I – III), or a mixed presentation of incontinence and/or pelvic organ prolapse symptoms. Ethics approval for this audit was granted by the WCH Human Research Ethics Committee in July 2015 (Audit 797A). A review of the hospital’s Clinical Information Systems (CIS) data showed 498 occasions of service provided by gynaecology staff to patients triaged as “P3” between Jan 1st and June 30th 2015. A list of these occasions of service was generated by CIS personnel, including patient name, date of birth, hospital identifier number, date of GP/medical caregiver referral, and date of Gynaecology Clinic presentation. Each of the medical records for these identified patients were recalled and reviewed, with key information recorded on an Excel spreadsheet.  Would the patient have been appropriate for GPAS (based on GP/medical caregiver referral letter detail) – yes or no? o If no, was the patient referred to physiotherapy for a relevant secondary symptom (that was not flagged on the original GP/medical caregiver referral letter)? o If yes, was the patient referred to physiotherapy – yes or no?  If yes, when did this referral to physiotherapy occur date?  If yes, did the patient attend their physiotherapy appointment – yes or no?  If yes, what has been the patient journey since referral to physiotherapy – free text e.g., attending for ongoing physiotherapy treatment, failed to attend subsequent appointments, pursued surgical intervention?  If no, what has been the patient journey since presentation to the Gynaecology Outpatient Clinic – free text e.g., proceeded to surgery? The time difference (days) between referral from GP/medical caregiver to the Gynaecology Outpatient Clinic appointment for those patients who would have met GPAS inclusion criteria was calculated. For those patients who were then subsequently referred to physiotherapy, the time difference (days) between gynaecology appointment and referral to physiotherapy, as well as the time difference (days) between date of referral to physiotherapy and initial consultation with the physiotherapy service, were also calculated. Results Data obtained via the WCH Clinical Information Service indicated 498 occasions of service to women triaged as “P3” were provided through the outpatient Gynaecology Clinics for the period January 1 to June 3