disadvantages of direct access in physical therapydisadvantages of direct access in physical therapy

Despite the growing body of scientific literature in support of consumer direct access to physical therapy, the only systematic review that, in part, evaluated the impact of physician referral versus direct access on outcomes and costs was published in 1997 by Robert and Stevens.4 The review4 found that the main advantages for direct referral to physical therapy were significant reductions in waiting times, convenience, and reduced costs for the patient. This also cuts costs of unnecessary doctor's appointments and gives the patient additional time . In addition, a visit to the doctor's may result in X-rays and prescriptions for pain relievers that do not tackle a patient's ailment directly. In contrast, in our review, we investigated a group of physical therapists, the majority of whom were not practicing in advanced practice roles (7 out of 8 studies exclusively focused on physical therapists without any special training reported who largely held master's or bachelor's degrees), and still found advantages in terms of treatment effectiveness, use of resources, economic costs, and patient satisfaction over initial physician care. Because of the conceptual heterogeneity in dependent variable measurements and lack of reports of variability around point estimates, we were unable to pool data and calculate effect sizes. Grooving evidence suggests that patients could have Direct Access (DA) to physiotherapy. As different jurisdictions passed laws and regulations that granted varying degrees of access, the terms "unrestricted access," "patient access with provisions," and "limited patient access," became three main categories used to identify a state's level of direct access to PT services. A point was awarded if the hypothesis aim or objective of the study was implicitly or explicitly indicated anywhere in the article. Table 2 lists characteristics of each study included in this review and the level of evidence using the CEBM criteria (levels ranged from 3 to 4). Heidi A. Ojha, Rachel S. Snyder, Todd E. Davenport, Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review, Physical Therapy, Volume 94, Issue 1, 1 January 2014, Pages 1430, https://doi.org/10.2522/ptj.20130096. 3 studies (2 level 3 studies, 1 level 4 study) show improved discharge outcomes for direct access vs physician referral; Is the hypothesis/aim/objective of the study clearly described? There is evidence across level 3 and 4 studies (grade B to C CEBM level of recommendation) that physical therapy by direct access compared with referred episodes of care is associated with improved patient outcomes and decreased costs. The site is secure. Databases of CINAHL (EBSCO) (restricted to humans, January 1990July 2013), Web of Science (restricted to articles, 1990 and later), and PEDro (1990 and later) were searched last on July 5, 2013. Fritz Was adherence to the intervention reliable? Please check with your insurance company to determine if you can use your benefits to cover direct access for physical therapy care. Twelve states and the . As what they say, "respect is a two-way street", if you do not show respect then you will not be afforded the same respect. Individuals typically seek physical therapy services through either direct access or physician referral. Furthermore, these results do not indicate that patients seen through direct access received more visits or achieved inferior outcomes compared with those who were referred by physicians. 2022 Nov 1;100(11):669-675. doi: 10.2471/BLT.22.288339. The question was answered with "unable to determine" if the number of patients lost to follow-up were not reported or could not be deduced from the outcome data (le, initial and final sample sizes not indicated). , Stevens A. Kelly AM All searches were restricted to 1990 to present because we wanted to specifically focus on more recently published literature to improve generalizability of results, reflecting changes in modern practice patterns and updated interpretations of the search terms direct access and open access. We searched the databases using combinations of the key words direct access, primary care, physical therapy, physiotherapy, and open access. In addition to these key words, we searched Ovid MEDLINE (1990 and later) using a comprehensive list of Medical Subject Headings (MeSH) terms related to our topic. Four studies9,11,13,15 reported on cost differences between direct access and physician referral groups, and all reported lower costs (to the patient, insurance company, or health system) in the direct access group during the participants' episode of care. JM Were the main outcome measures used accurate (valid and reliable)? Have the characteristics of patients lost to follow-up been described? Grabs bus for burst transfers Disadvantages: if done badly, hard to use (you want an unlimited address/length pair list). However, in this report, the terms direct access and open access seem to have been defined as expeditious physical therapy referrals from generalist physicians, such as on-demand physical therapy clinics, which reflects a gatekeeping model, with the GP initiating the physical therapy referral. Mitchell and de Lissovoy9 reported fewer radiology claims (P<.01), Hackett et al15 reported 8% less imaging ordered in the direct access group (no statistical tests run), and Holdsworth et al13 showed 6% less imaging ordered in the direct access group (P<.001). We decided that criterion 17 (In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients, or, in case-control studies, is the time period between the intervention and outcome the same for cases and controls?) was not a good evaluation of quality because the follow-up period in many studies was initial evaluation to discharge, which was influenced by one of our primary outcome measures (number of physical therapy visits). Mitchell and de Lissovoy9 reported there were significantly fewer drug claims in the direct access group (P<.01), Hackett et al15 reported fewer medications were prescribed in the direct access group (P<.001), and Holdsworth et al13 reported 12% less took nonsteroidal anti-inflammatory drugs or analgesics in the direct access group (P<.0001). Budtz CR, Rnn-Smidt H, Thomsen JNL, Hansen RP, Christiansen DH. Due to limitations inherent in study design, differences in number of participants between groups, and other potentially confounding variables, we believe our most relevant findings are that patient and health care costs were not greater in the direct access group compared with the physician referral group. E For crossover study designs, a point was awarded when participants were randomly allocated in the order in which treatments were received. A point. We hypothesized that policies permitting patients to seek physical therapy directly would result in decreased health care costs and similar patient outcomes. The authors of this tool indicated that this question should be answered "yes" where there were no losses to follow-up or where losses to follow-up were small that findings would have been unaffected by their inclusion. It also showed that . Imaging rules depend on the state. F BL Not to mention the opportunity that each patient is given with direct access when it comes to choosing who their physical therapy provider should be. The direct access, as opposed to the indirect access which requires a referral from a general physician, has several merits including better quality, timeliness, cost effectiveness of treatment and better probability of preventing acute conditions from turning into chronic ailments. Ho-Henriksson CM, Svensson M, Thorstensson CA, Nordeman L. BMC Musculoskelet Disord. We used the Oxford 2011 Centre of Evidence-Based Medicine (CEBM) recommendations to rate each article's level of evidence16 and the Downs and Black checklist17 to assign a methodological quality score to each article because all of our included studies were nonrandomized. If the distribution of the data (normal or not) was not described, it was assumed that the estimates used were appropriate, and a point was awarded. Two points were awarded if a study reported any possible confounders (eg, sex ratios, age, comorbidities, severity of injury) that might account for differences between groups clearly in table format. Of note, compared with the other studies in this review that involved civilian physical therapists, the large majority of physical therapists in this study were military physical therapists, with 8% civilian physical therapists, many with specialized training. Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. Direct access is the removal of the physician referral. L The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). A point was awarded only when the intervention was clear and specific. A point was awarded if quantitative data were reported for all of the main outcome measures indicated in the introduction or "Method" section. , Jutai JW, Strong G, Russell-Minda E. Samoocha , Webster V, McFadyen A. Webster Data from the included studies supported a grade D (inconsistent) recommendation that patients in the direct access group saw their general practitioner (GP) or other consultants less than in the physician referral group, suggesting that patients maintain contact with other medical providers despite seeking direct access to physical therapy. 2022 Oct 14;19(20):13276. doi: 10.3390/ijerph192013276. and T.E.D.). In response to the growing literature supporting physical therapy's role in primary care, 47 out of 50 states (United States) currently have legislation that provides for some form of direct access to physical therapy. Direct access to physiotherapy in primary care: Now?and into the future? All 3 studies 9,13,15 investigating imaging showed significant differences between groups. The https:// ensures that you are connecting to the A point was not awarded if at least one of the primary outcome measures in the study was not valid or reliable or if this information was not reported or could not be determined (ie, a questionnaire without reported validity or reliability). There is no evidence that self-referral to physical therapy puts patients at increased risk. CA Physical therapy by way of direct access may contain health care costs and promote high-quality health care. The primary characteristics were extracted from each study. Criteria are based on Downs and Black checklist (Appendix 1): Y (yes)=criterion met, N (no) =criterion not met P=criterion partially met, and U=criterion unable to determine from the study manuscript. [Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: A narrative review]. Unauthorized use of these marks is strictly prohibited. Publication types English Abstract MeSH terms Cost-Benefit Analysis Delivery of Health Care / economics Although adverse events were outcome measures extracted from the studies in this review, we believed that they also were indicative of comprehensive reporting. In the United States, the Commission on Accreditation in Physical Therapy Education (CAPTE) criteria support the ability of all physical therapists to engage in the delivery of physical therapy through direct access. 63-13-303- Most Recent Update Policy for Approved and Pre-Approved Dry Needling Courses Criminal Convictions and R.S.S.) Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial. Similar to our findings, the review found advanced practice care may be as (or more) beneficial than usual care by physicians in terms of treatment effectiveness, use of health care resources, economic costs and patient satisfaction. SJ A platform presentation of this research was given at the Combined Sections Meeting of the American Physical Therapy Association; February 2124, 2013; San Diego, California. Direct access allows a patient to go to a physical therapist to receive an evaluation and treatment without a referral. In the analysis, account for any medical or payment policy that influences referral patterns by physicians or ability of patients to self-refer for physical therapy. Effects of Exercise Training on Cognitive Function in Individuals with Heart Failure: A Meta-Analysis, Comparison of High-Intensity Interval Training to Moderate-Intensity Continuous Training for Functioning and Quality of Life in Survivors of COVID-19 (COVIDEX): Protocol for a Randomized Controlled Trial, Do Physical Therapists Practice a Behavioral Medicine Approach? Two of the 8 included studiesHoldsworth et al13 and Webster et al14investigated different outcomes from the same population and cohorts, so this review summarized the results from 7 datasets reported across the 8 included studies. In summary, findings from this systematic review support the safety, efficacy, and cost-effectiveness of physical therapist services by way of direct access compared with physician-referred episodes of care. Accordingly, we were able to obtain 8 studies in full text that met our inclusion criteria. If claims are date-spanned, as may occur when analyzing outpatient hospital physical therapy claims, determine reasonable number of CPT codes or units of service per visit to calculate the number of visits in the date-spanned period. Achieving direct access has been a major initiative for APTA and its chapters. Advanced Physical Therapy Center participates with most insurance plans. HHS Vulnerability Disclosure, Help Title: Microsoft Word - Direct Access.doc Before Direct selection. Request an initial evaluation appointment by filling out the form below or calling (713) 521-0020 or (888) 301-8477. Would you like email updates of new search results? G Out of 3 studies12,14,15 reporting on frequency of GP consultation services, only Holdsworth and Webster12 found a significant difference (P=.0113), with 29% of the direct access group having at least one contact with their GP for the same diagnosis 3 months after physical therapy versus 46% in the physician referral group (for other mean differences, see Tab. D is included to provide an appropriate balance to the patients right to direct access. Given that patients in the direct access group received fewer medications and less imaging while achieving similar or superior discharge outcomes, the results from this review suggest a relative decreased risk of harm in the direct access group, potentially due to fewer side effects of medication or less exposure to imaging radiation. In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients, or, in case-control studies, is the time period between the intervention and outcome the same for cases and controls. MeSH An estimated 53.9 million people in the United States report having 1 or more musculoskeletal disorders, with per capita medical expenditures averaging more than $3,578.1 As musculoskeletal conditions represent some of the leading causes of restricted activity days,2 many of these individuals seek care from or are referred to a physical therapist. Otherwise, a point was not awarded (eg, a point was not awarded when all participants from the physician referral group received care at clinic A and all participants in the direct access group received care at clinic B, because they could have represented 2 distinct populations). Dr Ojha and Dr Davenport provided concept/idea/research design, writing, data collection, project management, and fund procurement. Full texts were obtained for any article that could not be ruled out based on the specified inclusion criteria. Direct Access and Medicare. Home safety. The advantages and disadvantages of using technology in hand injury evaluation. Keywords: Kentucky State Board of Physical Therapy 9110 Leesgate Road, Suite 6 Louisville, KY 40222-5159 502/327-8497 Fax: 502/423-0934 . JH Data from the included studies supported a grade B recommendation that costs to patient or insurance companies per physical therapy episode of care were less when patients saw a physical therapist directly versus through physician referral, likely due to less imaging ordered, injections performed, and medications prescribed. Efficient disk space utilization. Ont Health Technol Assess Ser. In this commentary the authors share their experiences on the design and implementation of community-centered early intervention programs in Prince George's County, MD. J File Volatility. Reply to Moretti et al. 3 for a description of each grade of recommendation). National Library of Medicine After scoring, any disagreements were resolved by discussion (T.E.D.). They may not be able to afford time away from work for the physician visit and then for the appointment with the physical therapist. , Holdsworth L, McFadyen A, Little H. Hackett , McMillian DJ, Rosenthal MD, Weishaar MD. , de Lissovoy G. Moore Direct access means that if patients feel they have an issue that may benefit from physical therapy, they may contact a PT office and make an appointment without a referral. official website and that any information you provide is encrypted Background Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system . Careers. We have attached a chart it prepared on the topic (Attachment 1). "Health organizations are providing virtual appointments and are expanding their . A point was awarded as long as the number of dropouts lost to follow-up accounted for less than 10% of the initial number of total participants or a maximum of 5% from each group. Results of a national trial, Self-referral, access and physiotherapy: patients' knowledge and attitudesresults of a national trial, Management of joint and soft tissue injuries in three general practices: value of on-site physiotherapy, Oxford Centre for Evidence-Based Medicine Levels of Evidence Working Group, The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions, Systematic review of hip fracture rehabilitation practices in the elderly, Age-related macular degeneration and low-vision rehabilitation: a systematic review, Effectiveness of web-based interventions on patient empowerment: a systematic review and meta-analysis, The abuse of power: the pervasive fallacy of power calculations for data analysis, Evaluation of a direct access and fast track route to physiotherapy at primary healthcare centers in Singapore, Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders, Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise, Primary care referral of patients with low back pain to physical therapy: impact on future healthcare utilization and costs, Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial, Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review, Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers, Direct access: factors that affect physical therapist practice in the state of Ohio, 2014 American Physical Therapy Association. Direct Access to Physical Therapy Treatment This Question and Answer document is provided as a guideline to inform you about the new law and regulations that deal with physical therapists providing treatment without a referral from a physician, dentist, podiatrist or nurse practitioner. Medications=nonsteroidal anti-inflammatory drugs and analgesics. Likewise, if half of the articles that reported on an outcome measure showed a significant difference and the other half did not reach significance, the results were considered inconsistent. The authors thank Eugene Komaroff and Elizabeth Frank for reviewing the manuscript. Were the statistical tests used to assess the main outcomes appropriate. Da Ros A, Paci M, Buonandi E, Rosiello L, Moretti S, Barchielli C. Bull World Health Organ. Were losses of patients to follow-up taken into account? Patients pay fewer copays and can see savings upward of $500 with direct access. Wand 2005;5(8):1-91. V Direct access in physical therapy: a systematic review The findings suggest that DA to physiotherapy is feasible considering the clinical and economic point of view. Old tape drives use sequential access while hard drives use direct access to read and write to files. Primary limitations were lack of group randomization, potential for selection bias, and limited generalizability. Your policy may require a referral to physical therapy by your primary care physician. This approach is relevant because, in addition to potentially limiting inferences that can be made regarding cause and effect based on the evidence, there is a possibility for the influence of uncontrolled selection bias among individuals who self-refer for physical therapy through direct access. This study was funded by the Health Services Research Pipeline established through the American Physical Therapy Association to cover basic supplies and conference fees related to the research. There were statistically significant and clinically meaningful findings across studies that satisfaction and outcomes were superior, and numbers of physical therapy visits, imaging ordered, medications prescribed, and additional nonphysical therapy appointments were less in cohorts receiving physical therapy by direct access compared with referred episodes of care. who were blinded to each other's results. The proportion of those asked who agreed to participate or responded should be stated. , Black N. Chudyk Moore Cost Savings - Direct access eliminates unnecessary physician visits and copays. Percent satisfied=percent satisfied or very satisfied. Consider diagnoses on the physician claims when looking for visits with a primary diagnosis that agreed with the diagnosis used by the physical therapist. Convenience - Direct access eliminates the need for a physician's referralproviding you the convenience to start physical therapy sooner. The Figure lists our search strategy, also referenced in the Results section of the article. Data from the included studies indicated a grade C recommendation that individuals seen by a physical therapist in a direct access capacity did not result in harm because only one level 4 study reported on this outcome measure. Finishing treatment in fewer visits results in less therapy copays and more savings in your pocket. 2). The study did not receive a point unless the participants were randomly allocated and the methods for ensuring random allocation were specified. Similar to other previously published reviews,1820 the tool was slightly modified for use in our study by dropping 2 checklist items from our analysis. 2. Were the staff, places, and faculties where the patients were treated representative of the treatment the majority of patients receive? The study was not awarded a point if it was prospective and failed to mention whether the patients had knowledge of whether they were assigned to the direct access or physician referral group. Four studies8,12,13,15 reported on discharge outcomes, and although all of the studies showed improved outcomes in the direct access group, the differences reached significance in 2 studies8,12 (one level 3, one level 4). Webster et al14 showed 5% more of the participants in the direct access group were satisfied or very satisfied (P<.001). Aggregate physical therapy claims for each member by defining the start of the episode as the date of the physical therapy initial evaluation code (ie, CPT 97001). Was there adequate adjustment for confounding in the analyses from which the main findings were drawn? Finally, despite self-referring for physical therapy, it appears that patients continue to be engaged with physicians throughout their course of care; thus, it is unlikely that widespread implementation of direct access to physical therapy will reduce demand for seeking care from other practitioners. . Because of the conceptual heterogeneity in dependent variable measurements and lack of reports of variability around point estimates, we were unable to pool data and calculate effect sizes. GC Of the 1,501 articles that were screened, 8 articles at levels 3 to 4 on the CEBM scale were included. No adverse events resulting from PT dx or management, no state licenses modified or revoked for disciplinary action, no litigation cases filed against US government. GP-suggested referral group results excluded. Mitchell and de Lissovoy9 found that paid claims per episode of care were $1,232 less in the direct access group for all services and drugs per episode of physical therapy care (P<.001). Limits were not placed on language when conducting all searches because we did not want to exclude articles written in the Spanish language, one author's second language. Purpose . The precise method of randomization need not be specified. Included studies compared data from physical therapy by direct access with physical therapy by physician referral, studying cost, outcomes, or harm. An official website of the United States government. If the majority of articles showed a statistically significant difference between groups, the results were considered consistent across studies for that outcome measure.
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