Introduction

Integrated Regional Orthopaedic (MSK) Assessment clinics (ROAC) are now mandated in many provinces for the assessment and triage of patients referred for total joint arthroplasty (TJA). Their introduction underscores the lack of means for Primary Care Physicians (PCP) to appropriately refer patients for surgical consideration. Thus, problems arise when patients who are clear candidates for surgery are subject to a significant extra step in the care pathway by attending a ROAC while those who have insufficient problems are also seen, contributing to costs and crowding the access portal.  We postulated that a patient reported outcome measure, decision aid combined with a validated
grading of a weight bearing knee X-ray would provide an inexpensive yet effective tool to significantly improve the referral process for Knee OA (compared with the current mechanism).

Method:
To date we have enrolled two hundred and forty-five consenting patients in the study, all referred by their PCP to the
ROAC with a diagnosis of symptomatic Knee Osteoarthritis. All patients were evaluated as per the current ROAC
protocol which included a medical history, physical examination and an X-ray (standing AP, lateral, and patella-femoral
skyline). Prior to the visit, subjects were sent a copy of a patient decision aid, Oxford Knee Score (OKS), and
requested to answer whether their current clinical status described as Patient Acceptable Symptom State (PASS2) was acceptable. All radiographs were analyzed and scored for OA severity using the validated grading from 0 – 13.

Results:
Of the 245 cases, 200 completed OKS and PASS2 questionnaires and had standing X-rays for evaluation (only 120
completed the decision aid and these were left out of this report). Of the 200 included cases, 104 were referred from
the ROAC to see a surgeon. In analysis, we found that a self-reported PASS 2 answer NO and an AP X-ray graded at
6 or above predicted over 75% of those patients that were referred. This represents a 3.4 greater likelihood of referral using this simple analysis. The OKS did not modify this prediction.

Conclusion:
Thus, use of a validated grading of a standing AP X-ray along with a response, ‘readiness for surgery’ indicated 75 %
of patients appropriate for surgical consideration. Patients with less severe gradings are likely being unnecessarily
referred to ROAC leading to overuse of scarce resources, crowding the access and adding to costs; others, who score higher, are being needlessly delayed. The ability to discreetly screen for the best possible candidates should be a continued focus of ROAC and will lead to improved use of expensive resources, overall patient care and satisfaction and the provision of tools to the PCP for appropriate referral.