Deferred Care for Adults with Musculoskeletal Complaints

Published in: Effective Clinical Practice, v. 4, no. 2, Mar./Apr. 2001, p. 65-72

Posted on on December 31, 2000

by Donna L. Washington, Paul G. Shekelle, Carl Stevens

Read More

Access further information on this document at

This article was published outside of RAND. The full text of the article can be found at the link above.

CONTEXT: Many ambulatory care facilities do not have resources to provide same-day care for all walk-in patients. Yet, there are few guidelines that identify patients for whom care can be safely deferred. OBJECTIVE: To describe the development and implementation of deferred-care guidelines for adults with musculoskeletal complaints. DESIGN: Consensus process and field test. GUIDELINE DEVELOPMENT: After an eight-member multidisciplinary physician panel identified critical factors that necessitate same-day care, the authors created 34 clinical scenarios to consider for deferred care. In 22 scenarios, the panel members agreed that deferred care was safe. These were formatted into screening guidelines for back, neck, isolated extremity, and generalized muscle pain. IMPLEMENTATION: In reliability testing between two nurses reading 40 patient scenarios, interrater agreement for deferred care was nearly perfect (K=0.95). The guidelines were then applied to 448 patients presenting with musculoskeletal complaints to a Veterans Administration ambulatory care triage station. One hundred seven (24%) patients met guidelines for deferred care. Seventy-six patients agreed to have their care deferred, of which 66 kept their return appointment. CONCLUSIONS: Our guidelines suggest that a substantial proportion of patients with musculoskeletal complaints can have their care deferred. Most patients were willing to do so and kept their follow-up appointment. Use of these guidelines could help decompress ambulatory settings with limited resources to provide nonemergency same-day care.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.