Occupational Therapists, Physiotherapists and Orthopaedic Surgeons Agree on the Decision for Carpal Tunnel Surgery

Background: Therapist-led pathways have been proposed as waitlist management strategies prior to surgery for conditions such as carpal tunnel syndrome (CTS) in public hospitals. These models of care typically shift the initial care of patients and decision-making from surgeons to therapists and, have been shown to reduce the number of patients requiring surgery and improve wait-times. This occurs despite limited evidence of surgeon-therapist agreement on key decisions, such as the need for surgery. The purpose of this was study was to assess the agreement between therapists and orthopaedic surgeons regarding the need for surgery for patients who have CTS. Methods: This blinded inter-rated agreement study was embedded in a multicentre randomised parallel groups trial of 105 patients with CTS referred to four orthopaedic departments and waitlisted for an appointment. The trial evaluated the effect of a therapist-led care pathway on the need for surgery and outcomes related to symptoms and function. Patients were randomised to either remain on the orthopaedic waitlist or receive group education, a splint and home exercises. The decision on the need for surgery at 6 months was made by a member of the orthopaedic consultant team or by one of the 14 participating therapists. The therapists and surgeons were blinded to each other’s decision. Agreement was determined using percentage agreement, kappa coefficients (k), prevalence-adjusted and bias-adjusted kappa (PABAK), and Gwet’s first-order agreement coefficient (AC1). Results: Substantial agreement was seen between therapists and surgeons regarding the need for surgery (PABAK=0.74 (0.60-0.88)). Agreement was significantly associated with experience (P=.02). Therapists with advanced experience and scope of practice demonstrated perfect agreement with surgeons (PABAK=1.00 (95% CI: 1.00-1.00)). Mid-career therapists demonstrated substantial agreement (PABAK=0.67 (95% CI: 0.42-0.91)) and early-career therapists demonstrated fair agreement (PABAK=0.43 (95% CI: -0.04-0.90)). Conclusion: Therapists with advanced scope of practice make decisions that are consistent with orthopaedic surgeons.