Moore and colleagues10 retrospectively compared harm between direct access and physician referral groups. 2022 Nov 1;100(11):669-675. doi: 10.2471/BLT.22.288339. , Bradway LF. Oxford University Press is a department of the University of Oxford. It saves time and can be repeated. A point was awarded if quantitative data were reported for all of the main outcome measures indicated in the introduction or "Method" section. Results were summarized qualitatively by outcome measures (included below) and are presented in further detail in Table 2. A grade C recommendation was suggested by data from the included studies that patients receiving physical therapy through direct access versus referral had better outcomes at discharge. Direct access means reduced wait times and access to immediate care and treatment. The https:// ensures that you are connecting to the CJ Published data regarding clinical outcomes, practice patterns, utilization, and economic data were used to characterize the effects of direct access versus physician-referred episodes of care. Hackett et al15 reported the mean number of days of work missed due to the condition was 17 days less in the direct access group compared with the physician referral group, although statistical analyses were not reported for this difference. Results of the direct access and physician referral groups from each study were extracted for outcomes of interest at all time frames (most studies collected outcomes during the course of physical therapy, at discharge, or both). FOIA Telemedicine, which enables video or phone appointments between a patient and their health care practitioner, benefits both health and convenience. Among all articles read in full text, studies were excluded if they were written in a language that the authors did not speak (all languages except English and Spanish). Are the main outcomes to be measured clearly described in the introduction or "Method" section? At a minimum, the results presented in this report show no evidence of greater costs or increased number of visits or harm when patients self-refer directly to a physical therapist. Some studies have suggested that early or direct access to physical therapy can reduce waiting time, improve convenience, reduce costs for the patient and health care system, and improve recovery time.46 The results of these studies directly support recent health care reform efforts in which legislators and health care providers have sought to provide efficient care through cost reduction and optimizing patient outcomes. Please check for further notifications by email. The 13 states that have introduced or are considering introduction of compact legislation are Alaska, Connecticut, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Mexico, New York, Rhode Island, and Vermont. of articles located in database, Two rural practices, ~42% spinal injuries, the rest extremity injuries(> 95% msk), 2.3% had GP consultations, 2.5% referred to specialists, 1.5% had GP consultations, 8.2% referred to specialists. Subsequently, Leemrijse and colleagues8 reported as the results of a logistic regression analysis that individuals in the Netherlands (n=10,519) who are younger, with higher educational attainment, nonspecific spine symptoms, recurrent symptoms, and prior treatment by a physical therapist were significantly more likely to have direct access to physical therapist services than individuals who were referred by a physician. We believe our review was able to more directly focus on results of direct access physical therapy defined by the consumer self-referring for physical therapy. A point was awarded unless the effect of the main confounders was not investigated or confounding was demonstrated, but no adjustment was made in the final analyses. One reason for this limitation is that most third-party payers do not compensate physical therapists for evaluation and management of patients who self-refer for physical therapy. In addition, direct access is unrecognized as a covered route of access to physical therapy in the United States at the federal level. Titles and abstracts were screened by the authors (H.A.O. , Webster V, McFadyen A. Webster Maselli F, Piano L, Cecchetto S, Storari L, Rossettini G, Mourad F. Int J Environ Res Public Health. Studies had to satisfy all of the following criteria to be included in this review: (1) included patients with greater than 85% musculoskeletal injuries treated by a physical therapist in an outpatient setting, (2) included original quantitative data of at least one group that received physical therapy through direct access or direct allocation to a physical therapist without seeing a physician, (3) included original quantitative data for at least one group that received physical therapy through physician referral, (4) greater than 50% of the patients in both groups had to have received physical therapy, and (5) included assessment of at least one of the following: outcomes of physical therapy (improvement or harm), cost, or outcome measures that would affect cost or outcomes (use of imaging, pharmacological interventions, consultant appointments, and patient satisfaction). Webster et al14 found that the number of GP consultations 1 month after physical therapy was approximately the same in both groups (not significant, P=.219). File Volatility. Description of grades of recommendation are according to the Centre for Evidence-Based Medicine criteria: A, consistent level 1 studies; B, consistent level 2 or 3 studies or extrapolations from level 1 studies; C, level 4 studies or extrapolations from level 2 or 3 studies; D, level 5 evidence or troublingly inconsistent or inconclusive studies of any level. For the purposes of this review, this question was omitted due to reasons previously stated. There is evidence across level 3 and 4 studies (grade B to C CEBM level of recommendation) that physical therapy by direct access compared Bethesda, MD 20894, Web Policies 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. 2. and costs per subject were lower. Have all of the important adverse events that may be a consequence of the intervention been reported? 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. Criteria 17 and 27 were omitted due to reasons explained in the Quality Assessment section. [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]. 166 Hargraves Drive, Suite C-400-148. SRK 2. However, there was little evidence in the published literature at that time to make conclusions about recovery time, outcomes, or cost to the health system. A team approach to the treatment of musculoskeletal injuries suffered by navy recruits: a method to decrease attrition and improve quality of care, A controlled study of the effects of an early intervention on acute musculoskeletal pain problems, Physical therapy as primary health care: public perceptions, Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy, A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy, Risk determination for patients with direct access to physical therapy in military health care facilities, A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. 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. A physical therapist who has completed a doctor of physical therapy program approved by the Commission on Accreditation of Physical Therapy Education or who has obtained a certificate of authorization to 54.1-3482.1 2 ( according to 18VAC112-20-81, Requirements for Direct Access Certification. 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). . 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. Starting therapy sooner can lead to a faster recovery and fewer visits. Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. In the United States, the large majority of physical therapist programs are doctor of physical therapy programs; however, a comparatively low percentage of physical therapists practice in a direct access capacity due to these various barriers. A point was awarded if inclusion or exclusion criteria, or both, were indicated. If the majority of articles showed a statistically significant difference between groups, the results were considered consistent across studies for that outcome measure. There was one article22 that, from the title, seemed to meet our inclusion criteria; however, we were unable to obtain the abstract or full text to determine eligibility for inclusion, and no contact information was available for the authors. Are the interventions of interest clearly described? A point was awarded if the study identified the source population for patients and described how the patients were selected. The Figure lists our search strategy, also referenced in the Results section of the article. Of note, both studies conducted in the United States9,11 that collected data on number of visits showed a significant difference between groups. 2010 Dec;8(4):256-8. doi: 10.1111/j.1744-1609.2010.00177.x. 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. 3 for a description of each grade of recommendation). Your policy may require a referral to physical therapy by your primary care physician. Publication types English Abstract MeSH terms Cost-Benefit Analysis Delivery of Health Care / economics Accessibility Were the main outcome measures used accurate (valid and reliable)? No point was awarded if the proportion of those asked who agreed to participate or responded was not stated. We developed guidelines, specific to our study type, to improve agreement between raters (Appendix 1). There may be limitations regarding the number of visits you can receive. Benefits of Telemedicine. Would Moving Forward Mean Going Back? A point was awarded if the patients were not aware of, or would have no way of knowing (as in the case of retrospective studies), which intervention they received. 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). Primary Care Physical Therapists' Experiences When Screening for Serious Pathologies Among Their Patients: A Qualitative Study. 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. Similar to the results of this review, Robert and Stevens found improved waiting time, recovery time, convenience, and costs among patients receiving physical therapy through direct or open access. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Background There are two primary ways of accessing physiotherapy for service users around the world. . , Shamus E, Hill C. Leemrijse "Health organizations are providing virtual appointments and are expanding their . Contiguous Allocation. Classify as physician-referred if one or more claims from any physician provider on the list occurred within 30 days prior to the initial physical therapist evaluation. 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. , Goss DL, Baxter RE, et al. Validation that the sample was representative would include demonstrating that the distribution of the main confounding factors was the same in the study sample and the source population (eg, if the demographics and diagnoses of the patients were considered representative of a typical outpatient moo practice, the study was awarded a point). A point was not awarded it the main outcome to be measured was first mentioned in the "Results" section. Were study participants randomized to intervention groups? However, more research is still needed due to the low evidence of the reviewed studies and to explore the clinical safety of DA. A program provided entirely via real-time video achieved outcomes comparable to in-person treatment, researchers say. Are the characteristics of the patients included in the study clearly described? Physical therapists should take advantage of the. HHS Vulnerability Disclosure, Help Objectives This study was designed to ascertain whether direct access to physical therapy placed military health care beneficiaries at risk for adverse events related to their management. Was the randomized intervention assignment concealed from both patients and health care team until recruitment was complete and irrevocable? If you're interested in finding relief through physical or occupational therapy, the therapists at Memorial Hermann are here to help. 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. Bookshelf Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial. 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. 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? What are the benefits of direct access physical therapy? Purpose . 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. 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. Pennsylvania is one of 26 states that allow direct patient access to PT with some provisions. 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. These outcomes of interest were: cost-effectiveness, number of physical therapy visits, discharge outcomes, imaging use, medication use, patient or physician satisfaction, number of additional referrals, additional care sought, or evidence of harm to the patient, physical therapist, or facility. Many of these 47 states limit direct access to certain physical therapists' qualifications, specialty areas, or condition/diagnostic codes. Federal government websites often end in .gov or .mil. Unable to load your collection due to an error, Unable to load your delegates due to an error. 2014 Jan;94(1):14-30. doi: 10.2522/ptj.20130096. 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. The flowchart outlines the search strategy. 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. Physical Therapy is the one of the most important thing a person may need when recovering from an injury or disease. , Bundred P, Hutton J, et al. is included to provide an appropriate balance to the patients right to direct access. Fewer than half of the included studies (3 out of 8) were conducted in the United States, which is relevant because of the unique payer arrangements and practice regulations involving physical therapists in the US health care market. PF The PI project utilized research that shows a projected cost savings of $1,543 per patient over the next year for those who entered physical therapy through direct access. For crossover study designs, a point was awarded when participants were randomly allocated in the order in which treatments were received. The allocation methods define how the files are stored in the disk blocks. L These legislators and payers should consider the potential for improved patient outcomes and significant health care cost savings by facilitating more widespread direct access to physical therapist services. V Efficient disk space utilization. 2022 May 5;102(5):pzac026. , Roy JS, Macdermid JC, et al. Examples of Search Words and Medical Subject Headings (MeSH) Terms Used in Ovid MEDLINE. Regarding hospital admissions, only the study by Mitchell and de Lissovoy9 investigated this outcome measure and showed significantly fewer mean hospital admissions in the direct access group (P<.01). Opioid's side effects include depression, overdose, addiction, and withdrawal symptoms. DA showed less number of physiotherapy treatments, visits to physician, imaging performed and required fewer non-steroidal anti-inflammatory drugs and secondary care. Home safety. More health care providers are offering to "see" patients by computer and smartphone. The previous systematic review on this topic by Robert and Stevens published in 19974 examined a related question, reporting results from studies largely conducted within the National Health Service of the United Kingdom. Brindisino F, Scrimitore A, Pennella D, Bruno F, Pellegrino R, Maselli F, Lena F, Giovannico G. Int J Environ Res Public Health. 2005;5(8):1-91. This preliminary support for improved outcomes in the direct access group potentially could be due to earlier initiation of physical therapy. Data Synthesis. Full texts were obtained for any article that could not be ruled out based on the specified inclusion criteria. High satisfaction and better outcomes. The Downs and Black checklist scores are reported in Table 4 and ranged from 13 to 22 out of a total of 26 points. Levels of evidence are based on the Oxford 2011 CEBM levels of evidence: level 1=systematic review of randomized trials or n=1 trial; level 2=randomized trial or observational study with dramatic effect; level 3=nonrandomized controlled cohort/follow-up study; level 4=case-series, case-control, or historically controlled studies; level 5=mechanism-based reasoning. , Nilsson B, Moller M, Gunnarsson R. Desmeules Was an attempt made to blind those measuring the main outcomes of the intervention? and T.E.D.). JH Epub 2013 Sep 12. The purpose of this study was to conduct a systematic review of the literature on patients with musculoskeletal injuries and compare health care costs and patient outcomes in episodes of physical therapy by direct access compared with referred physical therapy. Direct access to physical therapy evaluation but not treatment is legal in 44 states. 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. 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. , DiAngelis T. Modified Downs and Black Criteria and Scoring Guidelinesa, For original criteria, refer to Downs and Black.17, One Method of Calculating Differences in Cost Between Direct Access and Physician-Referred Episodes of Care. Quasi-randomization allocation procedures, such as allocation by bed availability, did not satisfy this criterion. For all conversions, we used Great Britain sterling pound to US dollar, Bank of England daily rate as of August 15, 2013 (http://www.bankofengland.co.uk/boeapps/iadb/Rates.asp). Included articles were hand searched for additional references. Ultrasound therapy uses the head of the ultrasound probe that is placed in direct contact with your skin via a transmission coupling gel, ultrasonic energy forces the medication through the skin, Ultrasound therapy can help stimulate the healing process by increasing blood flow and decreasing pain and inflammation. Contrary to this conception, Moore et al cited samples of diagnoses identified by physical therapists in the study, which included Ewing sarcoma, Charcot-Marie tooth disease, fractures, nerve injuries (long thoracic, suprascapular, and spinal nerve root injuries), posterior lateral corner sprain, osteochondritis dessicans, ankylosing spondylitis, tarsal coalition, compartment syndrome, and scapholunate instability. 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. The validity of studies using a between-group comparison was evaluated by 2 authors not blinded to authors or journals. However, physical therapists are trained to diagnose injuries and diseases related to the musculoskeletal system. It is commonly thought that physical therapists seeing patients in a direct access capacity would result in overlooking serious diagnoses that could mimic musculoskeletal presentations, thereby putting the patient's health at risk. No harms were reported. Little previous work has been conducted to critically evaluate and synthesize the literature related to physical therapy clinical management obtained through direct access. 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. Does the study provide estimates of the random variability in the data for the main outcomes? I=intervention group, C=comparison group, D&B=Downs and Black checlist (see Appendix 1 for criteria), NH =National Health Service, BCBS=Blue Cross Blue Shield, pts=patients, CEBM=Centre for Evidence- Based Medicine, dx=diagnosis, DC=discharge, PT=physical therapist, msk=musculoskeletal, peds=pediatrics, 95% CI=95% confidence interval, GP-general practitioner, NR=not reported, NS=not significant. A point was awarded if the primary outcome measures were thought to be valid and reliable (eg, number of physical therapy visits per chart report), regardless of whether reliability or validity was reported. Hackett et al15 investigated the frequency of GP visits during the course of physical therapy care and found patients, on average, saw their GP for 2 visits in both groups. Kentucky State Board of Physical Therapy 9110 Leesgate Road, Suite 6 Louisville, KY 40222-5159 502/327-8497 Fax: 502/423-0934 . Conclusion: For example, in the early 1990s the following limitations on practice in physical therapy (physiotherapy) direct access models applied in different US states: diagnosis requirements, eventual . 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. Then the application of mechanical stretching in stem cell therapy for cardiovascular disease, including . There are two important features of file: 1. 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. Direct access to networks was first time introduced in windows server 2008, then in Windows 7 and Windows 8. The mean NOS score for study quality was 6.4 1.4 out of a possible total score of nine points. Were the staff, places, and faculties where the patients were treated representative of the treatment the majority of patients receive? Interrater reliability for the Downs and Black checklist scoring (H.A.O. Run analyses on only those members who were continuously enrolled for at least 6 months before until 2 months after treatment. Direct Access and Medicare. In conclusion, this review suggests that physical therapists practicing in a direct access capacity have the potential to decrease costs and improve outcomes in patients with musculoskeletal complaints without prescribing medications and ordering adjunctive testing that could introduce harm to the patient. Was there adequate adjustment for confounding in the analyses from which the main findings were drawn? Copyright 2023 American Physical Therapy Association. Were study participants in different intervention groups (trials and cohort studies), or were the cases and controls (case-control studies) recruited over the same period of time? Included studies compared data from physical therapy by direct access with physical therapy by physician referral, studying cost, outcomes, or harm. 1593 articles were initially identified, and thirteen studies met the inclusion criteria.

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