Evaluating the outcomes of Australia’s first all-age public hospital Sport and Exercise Medicine Outpatient Clinic: a retrospective cross-sectional study

Study design

This was a single-centre retrospective cross-sectional study of patient and clinic records that were collected from a SEMOC that commenced in January 2023. The SEMOC was based within the orthopaedic department of the Cairns Hospital in Far North Queensland, Australia. Twenty-nine SEMOCs were conducted between March and October 2023 (i.e. the study period) (Fig. 1). Patient and clinic records from these clinics were reviewed in December 2023, and these records formed the basis of the current study. The reporting of information in this study followed the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement.¹⁴

Fig. 1.

Flowchart of patients who attended a Sport and Exercise Medicine (SEM) Outpatient Clinic in Far North Queensland, Australia, March 2023–October 2023.

Patient selection

All patients in the SEMOC were referred to the Orthopaedic Outpatient Department of the Cairns Hospital by medical practitioners in the community or the local hospital and health service. These referrals were triaged by an orthopaedic consultant and/or asport and exercise medicine (SEM) physician at the Cairns Hospital to determine appropriateness for initial management in the SEMOC (see Fig. A1). Referral to the SEMOC was a clinical decision, with reference to Queensland Health Clinical Prioritisation Criteria for Orthopaedics.⁶ The category of triage allocated was based on these criteria, which consider the acuity of the condition, the referral information, and nature of the condition, as is standard practice for Queensland Health outpatient orthopaedic clinics.⁷

Patients referred to SEMOC were placed on a waitlist, and then allocated an appointment. Patients were reviewed in-person, or via telehealth, by an SEM registrar or consultant. The details of care provided to all patients at the SEMOC were documented in their records.

The patient records for the current study were selected in two stages. First, the records for all new patients who were seen since the establishment of the SEMOC (January 2023) and had a follow up during the study period (March to October 2023) were included in the initial number of allocated appointments (Fig. 1). Second, the analysis of clinical outcomes was limited to only new patients who had their first consultation during the study period. The decision to limit analysis of clinical outcomes to the study period was to accommodate for the clinic operating procedures being established prior to the study period. From this point onward, the patient care pathways and outcomes were considered as an accurate representation of the clinic going forward.

Patient records that were incorrectly documented and duplicate records were excluded from analyses (Fig. 1). There were no other inclusion or exclusion criteria.

Data collection

Patient data for the study were sourced from Cairns Hospital casemix records and the Integrated electronic medical record system. This included personal identifiers, demographics, and clinic outcomes. Feedback was collected via Google Forms. Data were securely stored on Queensland Health servers, de-identified for analysis, and anonymised in publications.

Outcome measures

The primary outcome measures of this study were the total number of SEMOC appointments allocated in the study period, the number of patients reviewed, the characteristics of these patients (age, sex, and Aboriginal and Torres Strait Islander status), and rurality of residence. Clinic outcomes included number of patients seen by categories of triage (urgent, semi-urgent, and non-urgent) and percentage of patients seen within the Queensland Health recommended guidelines. To account for semi-urgent (Category 2) and non-urgent (Category 3) patients who had referrals that pre-dated the SEMOC, this category was sub-divided into two levels, 2A and 2B and 3A and 3B respectively. The patients in 2A and 3A had been referred directly to the SEMOC and triaged during the study period. The patients in 2B and 3B had an existing referral to the orthopaedic department outpatient waitlist prior to the commencement of the SEMOC. These patients had already been waiting for their appointment allocation and were re-triaged by the SEM physician when the clinic commenced.

Additional clinic information included inward referral patterns (GP, hospital emergency department (ED), or peripheral centre), onward referral patterns (orthopaedics, conversion from orthopaedic referral to surgery), discharge rates from the SEMOC, injury patterns (i.e. area of body), and patient travel distance from residence to clinic for face-to-face appointments (kilometres, km).

Rurality was measured using a seven-point scale based on the Modified Monash Model (MMM) of remoteness.¹⁵ Each patient was allocated an MMM category (i.e. 1–7) based on their postcode and suburb of residence. The available MMM categories included metropolitan areas (1), regional centres (2), large rural towns (3), medium rural towns (4), small rural towns (5), remote communities (6), and very remote communities (7). Distance travelled was calculated using Google Maps and Microsoft 365 Excel. First, each patient’s postcode was entered into Google Maps and the distance by road was calculated from the centre of that postcode to the address of the Cairns Hospital. The total distance travelled per patient was calculated from the face-to-face in-person appointments. Telehealth and no-show appointments were excluded.

Patient self-reported outcome measures were collected via six questions to the electronic-based patient feedback survey. The questions were measures of satisfaction on five-point Likert scales, from ‘strongly disagree’ to ‘strongly agree’. Additional qualitative questions were in free-text short-answer format, which allowed for collection of both quantitative and qualitative data.

Statistical analysis

All data analyses were performed using Microsoft Excel 365. Proportions were calculated as a total of categories. Means and standard deviations (s.d.) were used to describe the dispersion of normally distributed continuous variables, and medians and interquartile ranges used otherwise.

Ethics approval

Participant consent for study was waived through the quality assurance process of the CHHHS. This approval was provided by the Far North Queensland Human Research Ethics Committee [EX/2023/QCH/103308 (Nov ver 2) – 1777 QA].

Patient characteristics

Among the 270 new patients, 61.5% were male, the average age was 37.0 years (range 11–81), with the 25–34 year age group accounting for the largest number of patients (20.0%) (Table 1). Almost a quarter (23.7%) of patients identified as Aboriginal and Torres Strait Islander peoples. Most patients (68.1%) were from regional centres (MMS = 2), the remainder were from rural, remote, or very remote towns/communities (MMS = 4–7).

Clinic outcomes

Among the 270 new patient referrals, over half (58.9%) were from community GPs, with the remainder (28.5%) from the Cairns Hospital ED, a peripheral hospital ED (8.9%), or an outpatient hospital specialist (3.7%) (Table 2).

Over half the 270 new patients were triaged as urgent (Category 1) (67.8%) at an average of 1.8 appointments per patient and wait time of 19.0 days (s.d. = 12.9) (Table 2). Most of these patients (88.0%) were seen within Queensland Health recommended guidelines. A smaller proportion of referrals were deemed semi-urgent (n = 38, 14.1%) (Category 2). On average, these patients waited 121.3 days to be seen, with 71.1% seen within recommended timeframes with 1.8 appointments per patient. Most of these Category 2 patients were referred during the study period (2A, n = 32), with the majority (n = 27, 84.4%) seen in the recommended timeframe. The 49 non-urgent (Category 3) patients were evenly distributed into 3A and 3B categories. All Category 3A patients, who were referred and triaged during the study period, were seen in the recommended time, while none in the Category 3B met the recommended timeframe. When analyses were limited to the 239 patients who were referred during the study period (i.e. Categories 1, 2A, and 3A), 88.7% were seen within the recommended timeframe.

There were 240 patients who attended face-to-face appointments. Although half (47.9%) only travelled a 30-km round trip or less to attend their appointment, a third (32.5%) necessitated travel over 100 km (range 0–1996) (Table 2). Almost all of the 270 new patients seen in the SEMOC within the study period were discharged from the SEMOC service (89.3%), including referral to orthopaedics, with only a small portion (10.7%) remaining within the SEMOC for further review and assessment.

A quarter of the 270 new patients were referred to orthopaedics for consideration or surgical management (24.4%) (Table 2). Most of these patients were reviewed during the study period (i.e. 47, 71.2%) and among these, almost all (44) were booked for surgery. At the end of the study period, 19 patients had yet to be reviewed by orthopaedics. Among the 240 patients who had at least one face-to-face appointment during the study period (Table A1), the most frequent injury regions were the knee (62.1%), shoulder (20%), and foot or ankle (9.2%).

Feedback survey

All 240 patients who had a face-to-face appointment were sent feedback surveys and 51 (21%) returned a response (Table 3). Almost all these patients (96.1%) rated the overall service as good to excellent, were satisfied with the quality of treatment (90.2%) and treatment outcome (82.3%), and would return to the clinic for a similar injury (94.1%). Their average likelihood of recommending the service to a friend or family member was 8.9 out of 10.

Clinical implications

Over 29 clinics, one SEM registrar and consultant reviewed over 15 patients per clinic. These clinics reached a higher proportion of Aboriginal and Torres Strait Islander patients compared to other specialist outpatient CHHHS clinics (24.5 and 20% respectively),¹¹ and a large proportion of patients from small rural towns (16.3%) and remote communities (9.3%). Aboriginal and Torres Strait Islander peoples face considerable systemic barriers to accessing appropriate health care.¹⁶ Our SEMOC provides a potential model for addressing some of these inequities.

The SEMOC also saw almost 90% of patients within the recommended Queensland Health guideline wait times, after excluding those who had already breached their recommended wait time at referral. After this exclusion, the proportion of our Category 1, 2, and 3 patients who met the recommended timeframes (88.0, 88.4, and 100% respectively) was higher than the CHHHS (74.0, 50.0, and 58% respectively) and the Queensland Health targets. These results suggest that our SEMOC model has the potential to reduce wait times to be seen by a clinician, for all levels of clinical priority.

Our clinic was efficient in terms of the low number of patient appointments required before discharge, high patient satisfaction, and the high proportion of successful orthopaedic surgery referrals. Most of our patients (88%) were discharged within the study period, with less than two appointments per patient, indicating that issues were addressed and resolved promptly. Given that respondents to our study overwhelmingly rated the SEMOC as positive, these results suggest that the patients had a positive experience from their level of care. More than 90% of our patients who were referred to an orthopaedic surgeon for opinion were subsequently booked for surgery. This rate of successful conversion is higher compared to Queensland Health orthopaedic data, where surgery following specialist referral ranged from 14 to 41%.⁹ Our higher conversion rate suggests that appropriate onward referrals were being made.

The study found a 20% non-attendance rate for appointments, lower than the 25% for other Queensland Health specialist outpatient appointments.³ Reduced non-attendance can lower healthcare costs. Travel over 100 km for a third of our patients may have affected attendance, leading to the use of Telehealth, which is now widely accepted practice, but lacks practical examination capabilities.¹⁷