Quality of care can be evaluated by collecting adequate, reliable, and valid data using patient-reported outcome measures [35]. Real-time information is critical to determining the quality of care a patient receives, and can provide a complete description of the patient’s clinical pathway. Such information can be utilized to evaluate and improve current healthcare system processes [23, 36]. Two instruments were used to collect such information: the HAPSQ and the RC-QOL. This study is the first step towards evaluating quality of care at a provincial level for patients presenting to the healthcare system with chronic, full-thickness tears of the rotator cuff.
Accessibility
Accessibility was measured using waiting times and distance. Lengthy waiting times to healthcare services and procedures serve as a barrier to care for many Albertans. According to the Government of Alberta’s Wait Time Registry, 95% of patients requiring interventions of the shoulder experienced a mean waiting time of 315 days for surgery [37]. In this study, patients requiring surgery experienced a mean waiting time of 370 days. The largest delay occurred while waiting for consultation with a surgeon. Group 1 patients experienced a mean waiting time of 157 days, while Group 2 patients experienced a mean waiting time of 172 days.
Another contributing factor to unnecessary waiting times occurred for patients waiting for MRI. Patients in this study spent a mean waiting time of 103 days before undergoing an MRI in the public system; however, this is likely an underestimation as the reported wait time from the Alberta Wait Times Reporting Website currently shows an average wait time of 280 days [37]. The ideal standard of care begins with standardized shoulder x-rays [33]. If additional investigations are warranted, an ultrasound should be obtained to assess the status of the rotator cuff [33] Patients in this study spent a mean waiting time of 28 days waiting for ultrasound; an average difference of 75 days. An MRI is unwarranted in most occasions and should ideally be requested by a surgeon for surgical planning [33]. Ultrasound is the cost-effective investigation for defining full and partial-thickness rotator cuff tears, and is comparable to MRI in both sensitivity and specificity [38]. More importantly, surgical treatment of chronic, full-thickness rotator cuff tears is not always necessary. In fact, non-operative treatment using physical therapy protocols have been previously demonstrated as an effective treatment for chronic rotator cuff tears [19]. It is crucial that primary care physicians and complementary allied medical providers managing patients with chronic, full-thickness rotator cuff tears recognize that a trial of non-operative treatment should be started at the time of the initial clinical presentation, and that MRI and referral to a surgeon be reserved for ‘non-responders’ to the initial line of treatment [33]. Surgery is an invasive procedure and is not always the best option for patients. Prescription and adherence to an early non-operative program can result in successful treatment of chronic, full-thickness rotator cuff tears and serve as an alternative to surgery [17,18,19,20], which can reduce utilization of healthcare resources, reduce inappropriate surgical referrals, and save costs to both the healthcare system and the patient.
The services available to rural populations are often very different compared to those available in urban areas [39]. Specifically, access to specialist health service providers and surgical procedures are often restricted to larger medical centres and hospitals found in cities such as Calgary and Edmonton. As such, 17 patients (10%) travelled from rural areas to seek care from specialists.
Acceptability
Healthcare systems have recently sought to not only achieve a balance in clinical effective and evidence-based care, but also provide services which are judged by patients as acceptable and beneficial [40]. In this study, patient satisfaction with respect to the quality of care received and the length of time spent waiting for physician care were used to evaluate acceptability. Overall, patients were not satisfied with either the quality of care or waiting time of emergency room physicians. In contrast, patients were satisfied with both the quality of care and waiting time of general practitioners/family physicians and sport medicine physicians. Although patients were satisfied with the quality of care received from surgeons, they were unsatisfied with the time spent waiting for care. Patients were the least satisfied when asked about waiting for MRI in the public system.
Efficiency
Efficiency was evaluated through healthcare utilization and its associated costs. To our knowledge, this is the first study to have measured the direct costs of chronic, full-thickness rotator cuff tears in patients in Alberta. The cost of chronic rotator cuff tears to society is multi-dimensional. Costs to the province made up more than half of the total aggregate costs. The two main cost drivers were diagnostic imaging and physician visits. An ultrasound is the cost-effective investigation for diagnosing rotator cuff pathology [33]. In Alberta, an ultrasound costs approximately $160 [26], whereas a MRI costs approximately $530 [25]; a difference of $370. In this study, 117 patients received an ultrasound; 159 patients received MRI; and 56 patients received both an ultrasound and MRI. This resulted in provincial spending of $113,950.00 for MRI costs compared to $27,680 for ultrasound. This study also demonstrated that patients sought care from an average of two or more physicians before receiving adequate treatment for their problem, with one patient having received care from seven different physicians. Most patients received care from multiple physicians over numerous visits, similar to another study that also found the current state of care to be plagued with an overuse of too many practitioners at the primary care level [14]. Since physician visits are publicly funded in Alberta, healthcare expenditures will continue to rise with the overuse of healthcare resources. Currently, Alberta spends more on physician services than most other provinces and territories in Canada [41].
Effectiveness
Effectiveness was measured using the RC-QOL to obtain baseline quality-of-life scores as a quantitative measure of the current state of care for patients with chronic, full-thickness rotator cuff tears. Such information can be used to assess the effectiveness of alternative clinical pathways in future studies. As part of this study, baseline quality-of-life scores were obtained for both groups of patients. Mean baseline quality-of-life scores were similarly low at 44 (SD: 22) for Group 1 patients and 41 (SD: 21) for Group 2 patients.
Appropriateness
Appropriateness of the healthcare system must be measured relevant to user needs. According to this study, patient needs were not met with respect to waiting time. Patients expected significantly lower waiting times from sport medicine physicians and surgeons. Patients also expected significantly lower waiting times for ultrasound and public MRI. With respect to utilization of healthcare resources, MRI and physician services were over-utilized.
Safety
Patient safety is the cornerstone of high quality healthcare [42]. This corresponds to receiving treatment from the appropriate healthcare providers within the right timeframe to achieve optimal clinical outcomes. Ideally, the most direct clinical pathway should be the most appropriate and safest pathway. The most direct clinical pathway begins when a patient decides to seek medical care for their shoulder complaint and enters the primary healthcare system [33]. Usually they seek care from an emergency room physician or a general practitioner/family physician. If the primary care physician does not feel confident in their clinical assessment skills, they should refer the patient to an expert (e.g., sport medicine physician or non-physician expert) [15]. At this time, it is recommended that all patients with chronic, full-thickness rotator cuff tears be prescribed a 12 week non-operative, physical therapy program (home or supervised) [33]. Patients unable to achieve pain-free status with improved range-of-motion after 6 weeks should be provided additional means of pain control (i.e., oral NSAID medication and/or injectable corticosteroids) [33]. If the patient fails non-operative treatment, they should be referred to a surgeon. If the surgeon and patient collectively decide that surgery is the best option, the patient should receive surgery. Immediate operative repair within 3 months from the onset of symptoms has been proposed to result in better post-operative patient outcomes, earlier return-to-work, and decreased costs [43]. In this study, 38 patients (22%) experienced care that was inconsistent with ideal clinical pathway algorithms. Furthermore, only 40 patients (46%) received surgery within the ideal timeframe. Similarly, studies have shown that conservative treatment of chronic, full-thickness rotator cuff tears results in better outcomes if treatment is started within 6 months of the onset of symptoms [44]. Only one patient (1%) met the standard of care for non-operative treatment. Although no complications were reported in this study, only 24% of all patients received care within appropriate benchmark timeframes.
Implications
RCD can be long-lasting, debilitating, and costly. As Alberta’s population continues to age, the prevalence of these conditions will increase, thus placing a large economic burden on the already strained healthcare system [45]. The results of this study suggest that the current state of healthcare delivery is fragmented through a complex system, whereby patients are seeking medical care from different physician providers. This presents challenges in providing appropriate care and coordinating access for patients with chronic, full-thickness rotator cuff tears. Ideal clinical pathway algorithms, along with waiting time benchmarks that detail stepwise care for patients throughout primary, secondary, and tertiary healthcare settings, were recently published [33]. The objective of creating such pathways was to ensure that patients were safely and appropriately managed within acceptable timeframes without wasting healthcare resources and worsening health outcomes. Adherence to clinical pathway algorithms will help in decision-making processes and improve patient care.
Recently, there has been a surge in the development of clinical pathways in Alberta focusing on addiction and mental health, cancer care, cardiovascular health and stroke, critical care obesity, diabetes, digestive health, emergency medicine, renal health, respiratory health, seniors’ health, and safer surgical procedures [46]. Although bone and joint health has been designated another priority area, no projects on RCD have been studied. This is the first study to evaluate the current state of healthcare for patients with chronic, full-thickness rotator cuff tears presenting to primary, secondary, and tertiary healthcare settings in Alberta. This study generated important knowledge about the quality of care patients received and identified areas in need of improvement. The findings are similar to those previously studied with respect to patients presenting with acute knee injuries; which found the current state of care to be plagued with lengthy waiting times, unsatisfied patients, bottlenecks for specialist services, inappropriate use of MRI, and a clinical care pathway that utilizes too many medical service providers [14, 15].
Limitations
This study is not without limitations. The use of convenience sampling may limit the extent to which the results can be generalized to the population of interest; however, patients were recruited from the two largest academic centers in Alberta in an attempt to obtain a representative sample of the population. Overall, the results of this study show similar trends in the quality of care when compared to other reports published across Canada [41, 47].
Another limitation involved sampling bias as all patients in this study were recruited from sport medicine clinics and seen by an orthopedic surgeon. Therefore, information for patients with chronic, full-thickness rotator cuff tears that presented to other physician provider groups or complementary allied medical providers was not captured in this study. The fact that all patients in this study were seen by a surgeon may have also led to response bias and potentially impacted patient satisfaction with respect to the quality of care provided by a surgeon, which was significantly higher than the other physician provider groups. This needs to be further studied given the limited number of surgeons used in this study.
Another sampling bias occurred with patient inclusion criteria. The spectrum of RCD is broad, however, the sample population for the study was limited to patients presenting with chronic, full-thickness rotator cuff tears. This clinical presentation was chosen because anecdotal evidence had suggested this sample of patients to experience difficulty accessing care. It was also selected because an ideal clinical pathway algorithm had previously been developed for this clinical presentation, which allowed the comparison of the current state to the ideal. Therefore, the results presented in this study may not be representative of patients presenting with other RCD such as partial-thickness tears or acute, traumatic tears of the rotator cuff.
Furthermore, it is important to highlight the difference in response rates between Calgary and Edmonton (76 and 60% respectfully), which has the potential to introduce non-response bias to the study. This occurred because more Calgary patients received completion requests in person during subsequent follow-up visits; whereas more Edmonton patients were followed-up over email. This finding is consistent with previous studies that found face-to-face requests to be more successful than email requests [48]. A future sensitivity analysis could be performed to further examine the impact of this difference; however, bias resulting from non-response in surveys is difficult to assess since information about non-responders is rarely available. It is important to note that non-response bias in this study would have been greater had the response rates been lower. The response rates, however, were moderately high compared to those published in the literature, which suggest benchmark response rates of 35 to 50% [49]. Nevertheless, this may reflect further concerns regarding the generalizability of the information.
Finally, patient recall was used to create a history of care throughout the patients’ continuum of care. Although there is some skepticism about the reliability and validity of self-report and patient recall, many studies have found patient recall of healthcare events to be reliable [50, 51]. The HAPSQ and the RC-QOL permitted patients to provide information that was tangible and unique. Currently, this presents an inexpensive and efficient method for communicating both clinical and cost information.