Low back pain (LBP) is recognised as the foremost contributor to global disability. It is a common condition experienced by most people at some point in their lives. In 2020, LBP accounted for 8.1% of all-cause years lived with disability globally. This equates to approximately one out of every 13 individuals (total of 619 million) who were afflicted with LBP. Projections suggest an escalation in LBP incidences to approximately 843 million by 2050, predominantly in the African and Asian regions, attributed to demographic expansion and enhanced life expectancy [3, 4]. This poses several challenges to the orthopaedic service in Ireland.

Individuals presenting with a spectrum of lumbar region-related pathologies constitute a substantial segment of the referrals directed towards orthopaedic surgeons [5,6,7]. GP referrals of back pain are naturally very common. Spine centres do not have the capacity to review all referrals nationally. Most of these patients are not considered surgical candidates, contributing significantly to consultation wait times for surgery for those who need it. The majority can be assessed locally by MSK triage service and opinions by non-spine orthopaedic surgeons so that tertiary referral centres are not overwhelmed.

At a local non-spinal orthopaedic level, minimising non-surgical consultations within a surgeon’s caseload can abbreviate wait periods for surgical candidates potentially benefiting from spinal procedures and expedite redirecting non-operative cases to alternative treatment modalities [5]. Based on demographic data from European countries with established conservative spinal treatment pathways, it is estimated that there is an annual need for spinal intervention in approximately 1000 cases per million population. In Ireland, this equates to approximately 5000 cases per year [8].

From a national orthopaedic framework point of view, the National Model of Care for Trauma and Orthopaedic Surgery in Ireland identifies three major spine centres in Dublin, Cork & Galway. These centres, located at Mater Misericordiae University Hospital, Cork University Hospital, and University Hospital Galway, respectively, have seen an overwhelming volume of patients requiring outpatient assessments and surgeries. This has limited the number of spine cases performed at hospitals outside these highly specialised, high-volume centres.

Furthermore, with the evolution of sub-specialisation[9], increased surgical complexity and rising patient expectations[10], the “general” orthopaedic surgeon who does some minor spine surgery is no longer within the remit of practice for Irish orthopaedic surgeons without spinal subspecialty training. Furthermore, spine surgery is concentrated in high-volume units, and as a result, the number of orthopaedic units offering spine surgery has significantly decreased. This has led to the referral of routine and low-complexity spinal cases to regional or national centres [8].

The physiotherapy musculoskeletal (MSK) triage service, established in 2012, consists of experienced physiotherapists working closely with orthopaedic surgeons. Patients are given appointments based on how long they have been waiting for care. Approximately 85% of these patients are managed without being referred to a consultant orthopaedic clinic. Of the 15% referred for surgical evaluation, about 5% undergo spinal surgery [8]. Nonetheless, The current process for accessing care for these conditions is lengthy, with patients first consulting their primary care physician and possibly receiving analgesia, anti-inflammatories, and an exercise programme before being referred for an MRI if their condition does not improve. Depending on the results of the MRI, onward referrals are made via two main pathways: patients may be referred to a physiotherapy musculoskeletal triage clinic for non-urgent degenerative conditions or to a local non-spinal orthopaedic specialist for assessment and further workup. In cases where symptoms or neurological deficits persist, an additional wait for an appointment at a tertiary referral centre may be necessary [8].

A faster mechanism for that spinal surgical opinion is necessary when regional centres, such as UHW, are fundamentally under-resourced. There are currently over 11,700 patients waiting for Orthopaedic surgery and 76,000 waiting for an Orthopaedic outpatient appointment nationally. In addition, the Report of the National Task Force on Medical Staffing (Hanly report) from 2003 stipulated that Ireland requires a minimum of four Orthopaedic Consultants per 100,000 population to maintain a basic standard of care [2]. As of 2022, Ireland has only 2.4 orthopaedic consultants per 100,000 population, starkly contrasting to the UK and New Zealand, where the figure exceeds six orthopaedic consultants per 100,000 individuals [1]. Ideally, increasing consultant numbers is the key solution to address the lengthy outpatient waitlists. While sufficient investment in our regional orthopaedic centres is still lacking, novel pathways and virtual MDTs have become a valuable necessity to help bridge the gap.

The economic evaluation of this Rapid Access Spine pathway needs to be explored more, as it represents a significant void in evidence considering the substantial expenses related to back pain for individuals and society. Before engaging in cost-effectiveness analyses, it is crucial to have a comprehensive grasp of the health service delivery mechanisms and pathways, notably within multidisciplinary healthcare settings [11,12,13]. Although virtual MDTs are not resource-neutral, as the burden of monthly discussion takes clinician and specialist time at regional centres and tertiary sites, it is a low-cost alternative to appointing more surgeons in the interim.

The growing adoption of multidisciplinary care essentially took place following the recommendations of the Calman-Hine report in 1995 [14]. A concerted push for integrating multidisciplinary teams (MDTs) to guarantee the prompt and fitting delivery of care given the multiple facets of orthopaedic care. By promoting enhanced coordination and communication, MDTs have significantly improved the decision-making processes among specialists, resulting in substantial advantages for patient care, as substantiated by numerous studies [15, 16]. These teams encompass diverse healthcare professionals, each offering unique expertise to enhance patient outcome [17, 18]. This virtual spine MDT clinic includes a spinal surgeon and spinal clinical specialist physiotherapist, in addition to the non-spinal orthopaedic consultants, clinical specialist physiotherapists and pain specialists from the offsite referring hospital. Implementing this new referral pathway also stems from the forced virtualisation of MDTs by the unprecedented strain from the COVID-19 pandemic, allowing for remote specialist care delivery to a certain extent.

The quantitative and qualitative results of the patient satisfaction survey demonstrated very high satisfaction levels with the rapid access pathway/virtual spine clinic in our study. Satisfaction in healthcare is a complex entity, where individuals might appreciate some aspects of their care yet find others lacking. The parameters commonly included in standardised assessments of satisfaction within healthcare contexts cover a range of factors: the manner of personal interactions, technical excellence, accessibility and convenience, financial implications, the efficacy and outcomes of care, continuity of service, the physical environment of care facilities, and service availability [19].

PSQ-18 is comprised of 18 items with seven dimensions which measure general satisfaction (two items), technical quality (four items), interpersonal manner (two items), communication (two items), financial aspects (two items), time spent with the doctor (two items), and accessibility and convenience (four items). These items were scored on a five-point Likert scale ranging from one (strongly agree) to five (strongly disagree). Each dimension that explores tangible priorities and patient experience regarding health service satisfaction is evaluated through different related questions that identify a particular area for improvement. Some PSQ-18 items are worded so that agreement reflects satisfaction with medical care, whereas other items were worded so that agreement reflects dissatisfaction with medical care. We reversed the scores of items worded that reflected disagreement with medical care to tabulate the total satisfaction score. A higher score reflected greater satisfaction with medical care. After item scoring, items within the same subscale were averaged to create the seven subscale scores [20]. We have adapted the PSQ-18 for context as healthcare services were publicly funded by the Health Service Executive (HSE) in Ireland. Therefore, two questions concerning the transactional nature of self-funded healthcare were omitted—“I have to pay for more of my medical treatment than I can afford” and “Healthcare providers act too impersonal, business-like towards me”. However, the mean score for accessibility and convenience was lower than the other subsections as most of our data points originate from existing long-time list waiters who have been brought into the Rapid Access Spine pathway.

Integrating open-ended and closed-ended queries is advocated to garner a comprehensive insight into patient satisfaction and experiences. Slade et al. differentiate between “satisfaction” and “experience” surveys within the patient context. Satisfaction surveys, characterised by closed-ended questions, evaluate elements deemed significant by researchers and healthcare providers. Conversely, experience surveys, employing open-ended questions, position healthcare consumers, particularly those managing chronic conditions, as authorities in evaluating service quality based on their firsthand experiences [5, 21]—this study’s semi-structured interview section aimed to capture the patient experience within the Rapid Access Spine pathway.

Some limitations of this cohort study must be acknowledged. Firstly, the sample size of 44 patients may limit the generalizability of the findings to broader populations, as it may not capture the diverse experiences and outcomes of a larger patient group. Additionally, the study’s design as a cohort study may introduce selection bias, given that participants were not randomly selected, potentially affecting the representativeness of the results. The average and median waiting time, a critical measure of the pathway’s effectiveness, did not show a significant reduction. This outcome can be attributed to the fact that patients incorporated into this pathway had already experienced extended wait times before its initiation. This prior waiting period could skew the data, presenting a temporal malalignment in accurately assessing the impact of the rapid access pathway on reducing wait times. The pre-existing wait times before the introduction of the pathway may also influence patient satisfaction scores, as initial expectations may not align with the actual speed of service delivery experienced under the new system.