What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia.

OBJECTIVES: To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions. DESIGN: We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting. SETTING: Australian primary care. PARTICIPANTS: Registered physiotherapists who are members of a practice-based research network (n=31). RESULTS: The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application. CONCLUSION: High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Pre-hospital lowest recorded oxygen saturation independently predicts death in patients with COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) results in hypoxia in around a fifth of adult patients. Severe hypoxia in the absence of visible respiratory distress ('silent hypoxia') is increasingly recognised in these patients. There are no published data evaluating lowest recorded pre-hospital oxygen saturation or pre-hospital National Early Warning Score 2 (NEWS2) as a predictor of outcome in patients with COVID-19. METHODS: In this retrospective service evaluation, we included adult inpatients with laboratory confirmed COVID-19 who were discharged from hospital or who died in hospital between 12 March and 28 April 2020 (n = 143). Pre-hospital and in-hospital data were extracted and analysed to explore risk factors associated with in-hospital mortality to inform local triage and emergency management. RESULTS: The lowest recorded pre-hospital oxygen saturation was an independent predictor of mortality when controlling for age, gender and history of COPD. A 1% reduction in pre-hospital oxygen saturation increased the odds of death by 13% (OR 1.13, p < 0.001). Lower pre-hospital oxygen saturation predicted mortality after adjusting for the pre-hospital NEWS2 (OR for a 1% reduction in pre-hospital oxygen saturation 1.09, p = 0.02). The pre-hospital NEWS2 was higher in those who died (Median 9; IQR 7-10; n = 24) than in those who survived to discharge (Median 6; IQR 5-8; n = 63). CONCLUSION: This service evaluation suggests that the lowest recorded pre-hospital oxygen saturation may be an independent predictor of mortality in COVID-19 patients. Lowest pre-hospital oxygen saturation should be recorded and used in the assessment of patients with suspected COVID-19 in pre-hospital and emergency department triage settings.