Musculoskeletal diseases are the most common chronic problems in the adult European population.1 In Spain, the EPISER 20002 study showed that 44.8% of the population has suffered from back pain in the past 6 months, 10.2% suffers from knee osteoarthritis, 6.2% of hand osteoarthritis, 3.4% osteoporosis, 2.4% fibromyalgia and 0.5% rheumatoid arthritis. According to the Health Survey of Catalonia 2006,3 musculoskeletal disorders are the most prevalent chronic problems associated to a poor perception of health and a high consumption of health resources, and are the leading cause of functional restriction.4 Rheumatic processes are also a common cause of disability.5

The Spanish public health system has as its main feature a strong presence in primary care (PCP), which usually acts as a gateway to specialist care (SC), mostly in hospitals. The main problems in the functioning of the system are the burden of care, waiting lists and lack of coordination between the PC and SC.6 The PC level receives more inquiries regarding locomotor7 pathologies which are expected to increase with the aging of the population. These processes are usually derived to 4 specialties: orthopedic surgery and trauma (TOS), rheumatology (RMT), physical medicine and rehabilitation (PMR) and pain units (PUs). However, the poor implementation of clinical practice guidelines on musculoskeletal care problems, poor definition of the interconsultation criteria, and the lack of coordination between levels and causes specialty mismatches in referral to SC.8,9 It has also been postulated that the lack of training in these diseases received by PC has a negative effect on the appropriateness of referrals to SC.10

The “European Parliament declaration on rheumatic diseases” urges governments to promote plans to improve care and research on them, with the goal of reducing associated economic and social costs.11 To this end, the Department of Health of the Generalitat of Catalonia designed the Master Plan for Rheumatic Diseases and Locomotor Apparatus.12,13 In this context, and as an aid to planning, it was considered useful to have the views of professionals on different aspects related to musculoskeletal diseases and their care process by designing a survey of medical professionals. The objective of this paper is to describe, from the results of this survey, the professionals’ opinions on the major problems perceived in the care of these diseases.

Study design: Descriptive study based on a survey designed by the authors (available upon request), one of whom (LB) is a sociologist and an expert in questionnaire design. The survey was overseen and approved by the Department of Health of the Generalitat de Catalunya. There were 9 versions of the survey prior to the final version. There was a pre-test validation process with 3 professionals who self-administered the questionnaire and collected comments. The first 80 questionnaires (40 specialists and 40 primary) underwent a pilot test for undetected problems in understanding or interuser agreement, inconsistencies or accumulation of negative answers.

Sample and data collection: 2 questionnaires were sent, one to GPs and another to hospital specialists. We previously conducted a random sampling of primary care centers, selecting 114 (102 publicly owned and 12 privately run) of 362 existing centers where a total of 1250 PC physicians work. In addition, the questionnaire was sent to 61 specialist hospitals of the Catalan public network, in which 1036 specialists work (645 TOS, RMT 138, 123 and 130 PRM). Questionnaires were sent to the professionals’ workplace, who were able to answer on paper or electronically. The information was collected between June and December 2009 and a specific database was created. Participation was voluntary and with the survey an explanatory letter was sent about the study objectives and the commitment to maintain confidentiality.

Variables: The 2 questionnaires were common and had some specific points. Sociodemographic data and clinical activity. The diseases studied were peripheral joint osteoarthritis, back pain, osteoporosis, tendonitis, fibromyalgia and arthritis, inflammatory rheumatism, as well as sprains and bruises. Questions were made on the allocation of care (proportion of time devoted to musculoskeletal pathology) and order of frequency of the 7 diseases analyzed (scoring from 1 to 7 for each disease based on their high to low presence in the query), the self-reported skill level, the referral process, the existence of mechanisms for coordination and evaluation of a series of 15 problems described in the literature or selected by experts. Table 1 shows the survey questions and the scale of measurement of the different variables.

Statistical analysis: The margin of error for the survey was obtained by applying the calculation for finite samples (less than 100000 subjects) for a confidence level of 95.5% with p=q=0.5 (statistically the worst outcome); a descriptive analysis was performed using measures of central tendency and dispersion for quantitative variables and distribution of percentages for qualitative variables.

The PCP respondents spend nearly a third of their time treating diseases of the musculoskeletal system. This figure puts the relative weight of this group of disorders on primary care over something known in other countries.14,15 Also in SC, the time devoted to the care of musculoskeletal diseases is significant, even in specialties or cross disciplines as PMR and PU. The skill level declared by the PCP for each condition was better for the more frequent processes in daily practice, and these were also the least common processes referred to specialists. The case of fibromyalgia would be an exception, as it is perceived as a rare condition in consultation with AP, with lower levels of skill and greater percentage of referrals. This is in line with the results of a survey of primary care physicians performed in Great Britain.8

There are different perceptions by GPs and hospital specialists regarding the management of musculoskeletal diseases, starting with the review of the adequacy of the referral. While the PCP was concerned with the problems that deserved to be referred to these specialties, especially RMT and TOS, experts believed that there was inadequacy in the referral to hospitals and specialties. Consistent with the latter, PCP themselves recognize that they derive the majority of cases of back pain, tendinitis, sprains, bruises, and arthritis to TOS but they had less success in non-traumatic pathologies, where the proposal is to increase the referrals to other specialties such as rheumatology (especially in the case of osteoarthritis). In the same vein, some scholars claim that TOS also openly assumes a more specific reference to the surgical unit.16 This excess referral toward the orthopedic specialist also has been described in other countries.9

GPs referral derives a small percentage of the most prevalent diseases; however, experts perceive this rate as excessive, attributing it to a lack of resolution capability, containment and inadequate specific training. Although the “ideal” referral rate is not set, it seems clear that this is valued differently in the 2 health care settings. From the perspective of PCP, the very high morbidity of these processes, their chronic nature, the burden of care and the willingness of patients to obtain a specialized assessment are factors that probably influence the rate of referral to SC. On the other hand, it is clear that more training or some specific professional dedication for PCP in an area of knowledge reduce referral to the corresponding specialized level.17 Mismatched referral to different specialties may be related to their historical development in the health care in our country (with a clear predominance of TOS), the lack of definition of the burden of each specialty and the deficiency in the mechanisms for coordination. Finally, there is a lack of satisfaction with the transfer of information between levels, making it difficult to prioritize patients in SC18 and insure continuity of care.

For the PCP, the main problem in the management of these diseases is the SC waiting list, a widespread problem in western health systems.19,20 As a second problem, the lack of feedback from the hospitals is highlighted. From the standpoint of the specialist, its own burden of care is followed by inefficient information systems that are the elements that determine the quality of care. Note that in Catalonia there are different PCP service providers and hospitals, many of which are publicly owned and do not share their information systems. The current development of Shared Medical History of Catalonia as a tool for interoperability of information systems will improve access to all information professionals regarding patients.21

A limitation of our study is the low rate of responses from GPs despite repeated contacts with heads of departments requesting their participation. This was probably influenced by the time of year the questionnaires were sent, which coincided with the holiday season and the alarm generated by the first influenza A epidemic. Moreover, the data referred on the prevalence of each disease in the clinic and referral to a specialty were based exclusively on the opinion of the physician and have been compared with objective referral data and activity logs. However, the qualitative data presented, taking into account these limitations, sheds some light on the opinions and practice. We should also mention the different response rates of the participating specialties. Among these specialties, the most numerous in Catalonia, the orthopedic surgeons, represent more than half of all respondents. Still, except in very specific issues, their opinion does not differ greatly between the 4 specialties and is representative of the views of specialists dedicated to the musculoskeletal system of our public health system.

In conclusion, the waiting lists for SC as well as gaps in the information systems sharing and coordination mechanisms are the elements of greatest concern to the professionals who care for musculoskeletal diseases. The marked discrepancy in the perception of GPs and specialists in some ways reflects the existence of deficits in the definition and organization of health services involved in the care of chronic musculoskeletal problems.

Department of Health, Generalitat de Cataluña, Spain.

The authors have no conflicts of interest to declare.