Contents lists available at ScienceDirect Musculoskeletal Science and Practice journal homepage: www.elsevier.com/locate/msksp Professional issue The effects of a new Tendo-Achilles Pathway (TAP) on an orthopaedic department– A quality improvement study Anne-Marie Hutchison a,* , Hamish Laing b , Paul Williams c , Owen Bodger d , Claire Topliss e a Physiotherapy Department, ABMU HB, Morriston Hospital, Swansea, SA6 6NL, UK b Medical Directors Department, ABMU HB, Port Talbot, UK c Orthopaedic Department, ABMU HB, Swansea, UK d Swansea University, UK e Orthopaedic Department, AMBU HB, Swansea, UK ABSTRACT Background: Achilles tendinopathy is a common pathology that is considered difficult to treat. At a time of austerity in the NHS it is essential to have carefully designed pathways that are monitored in terms of cost and effectiveness. However, a paucity of evidence exists for what the “best value” dedicated “joined up” pathway of care is for this difficult condition. Objectives: Design, implement and evaluate the impact of a new therapist lead pathway for Tendon- Achilles Pain (TAP). Methods: Process mapping, driver diagrams, stakeholder analysis and a series of Plan-Do-Study-Act cycles were used to design and implement TAP. To assess the impact of TAP, data was compared on whole system measures for 46 patients treated with referral to the traditional service (without TAP) and 46 patients managed according to the newly designed pathway (with TAP). A cost analysis was also conducted. Results: A quality improvement approach led to the successful design and implementation of a therapist lead TAP. The impact of TAP included positive effects on patient satisfaction, a decrease in duplication of treatments, investigations and inappropriate reviews with consultants. No safety concerns were found. TAP was also £44,000 cheaper per annum than the previous service. Conclusion: Collaboration between orthopaedic and therapy services has resulted in a standardised pathway of care for patients with an Achilles tendinopathy. It has removed unwanted variation, provided an opportunity to monitor the outcomes of treatments and resulted in decreased cost for the health board. 1. Problem Achilles tendinopathy is characterised by pain and stiffness in the Achilles tendon. It is a common pathology, affecting approximately 150,000 people in the UK each year (Riley, 2008). Although not fully understood the pathology is thought to occur because of degeneration and a failed healing response of the tendon (Riley, 2004; Khan et al., 2002). Many modalities are used in the management of this tendon pa- thology and new innovative treatments are frequently emerging (Hutchison et al., 2011). Patients and clinicians face a range of non- operative treatment options such as exercise, insoles, electrotherapy and injections. Surgery is usually only considered if conservative treatments fail (Alfredson and Cook, 2007; Hunter, 2000; Paavola et al., 2000). Although these modalities are in routine clinical use, only a few controlled clinical trials have been performed. In most cases there is little or no evidence of therapeutic effectiveness of treatment, especially long term. Clinicians are essentially reliant on anecdotal evidence and experience when treating this condition and it is therefore considered difficult to treat. In our health board there was no defined pathway or co –ordination of patients care for this condition. Resulting in the order of interven- tions and investigations being haphazard and potentially not cost ef- fective. At a time of austerity in the NHS it is essential to have carefully designed pathways of care, which are monitored in terms of effective- ness and cost (Roberts, 2014). It is also important to have equality and no disparities in the healthcare provided (Aylward et al., 2013) and make best use of the skills of each clinician. The approach for this condition was therefore not satisfactory. 2. Available knowledge A search of the electronic data bases: Medline, CINAHL, EMBASE, AMED and PEDro (physiotherapy evidence database) identified a pau- city of evidence for organisations reporting what the “best value” dedicated “joined up” pathway of care for this condition is. At the British Orthopaedic Foot and Ankle Society (BOFAS) https://doi.org/10.1016/j.msksp.2018.11.002 Received 10 May 2018; Received in revised form 28 August 2018; Accepted 9 November 2018 * Corresponding author. E-mail address: Anne-Marie.hutchison@wales.nhs.uk (A.-M. Hutchison). Musculoskeletal Science and Practice 39 (2019) 67–72 2468-7812/ © 2018 Published by Elsevier Ltd. T