Direct access use by experienced therapists in states with direct access.

Direct access use among experienced therapists practicing in states with 3 years' experience with direct access was studied, as were differences between therapists who had and had not practiced through direct access. A questionnaire was mailed to 250 members of the North Carolina, Nevada, and Utah chapters of the American Physical Therapy Association. Almost half (44,5%) of the respondents had practiced through direct access; an estimated 10.3% of their caseload was seen through direct access. Reasons for not practicing through direct access were that the employer does not permit direct access practice (49,1%), insurance does not reimburse for direct access practice (43.6%), no patients have been seen without referral (25.5%), and personal preference to treat by referral only (23.6%). Therapists who had treated patients through direct access were significantly more likely to believe that direct access had benefited them professionally and benefited their patients than were therapists who had not practiced through direct access. [Domholdt E, Durchholz AG. Direct access use by experienced therapists in states with direct access. Phys Ther. 1992;72:569-574.]

Key Words: Direct access, Legislation, Professional autonomy, Professional issues.

As of March 1992, physical therapists in 26 states may evaluate and treat patients without a referral from another practitioner such as a physician or a dentist. In 15 additional states, physical therapists may evaluate, but not treat, patients without a referral. Thus, in 41 states, consumers are able to consult physical therapists without a referral from another health care practitioner. The availability of practice without referral has increased dramatically in the United States during the last two decades. Twenty-one of the 24 states in which evaluation and treatment without referral is permitted gained this status in the 1980s.[1]

The first mode of practice without referral, permitting both evaluation and treatment without referral, has become known as "direct access." In states with direct access, therapists may evaluate patients without referral and make autonomous decisions about subsequent patient management. Options include treatment by the physical therapist, referral to another practitioner for further evaluation, or determination that no physical therapy intervention or other follow-up is indicated. In this article, "direct access" refers to either evaluation only or both evaluation and treatment without a referral.

Direct access laws vary markedly from state to state and often place restrictions on the nature of practice without referral. Common restrictions include requiring that the patient have a diagnosis before coming to physical therapy, that the physical therapist refer the patient to a physician if treatment continues for longer than a specified period of time, that the physical therapist meet certain experiential or educational requirements, or that direct access practice be limited to certain settings.2

Despite the fact that physical therapists in more than half the states can evaluate and treat without physician referral, there is surprisingly little published, data-based information about the impact of direct access on the practice of physical therapy in these states. Much of the information that exists is anecdotal. For example, Lott[3] noted that two private practitioners in California report that fewer than 5% of their patients are seen without referral. She further reported that a major barrier to treating more patients without referral is that insurance companies do not reimburse if the patient starts physical therapy via direct access. This insurance information, like the proportion of patients seen through direct access, is based on the experiences of just a few therapists.

There are, however, five data-based reports[4-8] that begin to examine the phenomenon of direct access in a systematic way. Three studies44 examined the extent of direct access practice; two studies7,8 examined the effectiveness of controlled programs of first-contact physical therapy care.

The three studies of the extent of direct access practice examined very different samples of physical therapists. In 1987, the American Physical Therapy Association (APTA) surveyed a random sampling of member physical therapists from around the country to obtain broad-based information about the characteristics of members. The sample included therapists in direct access and non-direct access states. Results of two questions about practice without referral showed that 30% of the respondents had evaluated patients without referral and that 13% had treated patients without referral.4

In the second report on the extent of direct access practice, Jette and Davis5 studied practice patterns in hospitalbased and private practice settings in the United States. When they examined the referral status of discharged outpatients in both settings, they found that 19.7% of the hospital sample and 10.8% of the private practice sample had been either evaluated or treated, or both, without referral.

In the third report on the frequency of direct access practice, Dennis6 studied private practitioners in Victoria, Australia. She found that over 90% of the private practices studied had seen patients through direct access. The most frequent estimates of the percentage of patients seen without referral were 30%, 10%, and 20%, in order of decreasing frequency.

Thus, available information about the incidence of practice without referral in the United States is limited to a study conducted across all jurisdictions, irrespective of direct access status, and to a study of two types of practice settings, and information about the incidence of practice without referral in Australia is limited to a study of selected private practitioners.

The remaining data-based studies related to direct access report on actual care delivered through direct access for patients with low back pain. Both studies used algorithms to guide therapist treatment and referral decisions. James and Stuart7 found that patients, physicians, and physical therapists were all pleased with physical therapy screening of patients who have low back pain. Overman et al8 found no negative outcomes related to acts of commission or omission on the part of physical therapists, and they found that patients with more severe disabilities showed greater improvement when managed by physical therapists than by physicians. The major limitation of both of these studies is that the systematic, algorithm-based practice described is probably not representative of the majority of direct access practice settings.

Thus, the limitations of these five studies4-8 leave major knowledge gaps about direct access practice. There are little data about the extent of direct access practice or about characteristics associated with therapists or patients participating in direct access care. The purpose of this study was to begin to close this information gap by collecting preliminary data on the extent of direct access practice by experienced therapists in three states that received direct access in 1985, 3 years before the beginning of the study. In addition to determining the extent of direct access practice, we collected information related to the characteristics of patients being treated through direct access and the opinions of therapists about the benefits of direct access practice.

Method

Experience with direct access practice, that is, either evaluation only or both evaluation and treatment without referral, was ascertained through a mailed questionnaire distributed in early 1989. Therapists in the states of North Carolina, Utah, and Nevada were studied. Direct access laws were passed in these three states in 1985. We felt that 3 years of direct access availability was enough time to allow for practice changes in response to the law, while still giving us access to reasonable numbers of experienced therapists who had practiced under both direct access and referral-only situations.

Instrument

A pilot study was conducted with 15 therapists located in the three selected states. The therapists who received the pilot questionnaire were encouraged to make suggestions regarding improvement of the questionnaire. Based on the pilot questionnaire, one item was added and minor wording and design changes were made to other items.

The first item ascertained whether therapists had practiced under both direct access and non-direct access conditions. If they had not, the questionnaire indicated that they were done and requested that the questionnaire be returned in the envelope provided. If they had practiced under both conditions, they were instructed to complete the remainder of the questionnaire and return it in the envelope provided. We eliminated those therapists who had not practiced under both conditions based on the assumption that most of those who had practiced under direct access only would be new graduates who would be unlikely to see patients without referral early in their career. In addition, several later items required that respondents assess the changes in various aspects of their practice since the initiation of direct access within their state. These items could only be answered by individuals with experience under both practice conditions.

Eight items collected demographic, educational, and employment information. Six items were related to whether the therapist had "treated patients without referral" since the passage of the direct access law; 1 question was to be answered by all respondents, 1 by those who had not practiced through direct access, and the remaining 4 by those who had seen patients via direct access. Four items were related to the impact of direct access on liability insurance rates and claims. One item asked whether the therapist had had difficulty collecting insurance payments for direct access services. Four opinion items ascertained whether therapists believed their entry-level education prepared them adequately for direct access practice (strongly agreestrongly disagree); whether communication with physicians had become better, had become worse, or remained unchanged with direct access practice; whether direct access had benefited the therapist professionally (yes, no); and whether patients had benefited from the availability of direct access (yes, no).

Sample

The sample consisted of 250 randomly selected physical therapists who were members of the Utah (n=47), Nevada (n=36), and North Carolina (n= 167) chapters of the AgrA. These members represented 22% of the APTA membership in each state, a proportion we hoped would yield responses from at least 10% of the population of 1,136 APTA members in these states, as recommended by Gay.9

Procedure

A survey package containing a cover letter; the questionnaire; and a stamped, addressed reply envelope was sent to each physical therapist in the sample. All survey packages were sent by first-class mall in February 1989; the completed questionnaire was to be returned by mid-March 1989.

Data Analysis

Means, medians, standard deviations, and frequencies were calculated, as appropriate, for each state and for the total group. Two additional variables were derived from responses to one or more items. The first was the estimate of the percentage of patients seen through direct access for those therapists who had treated patients without referral. Each therapist's estimate of the number of patients seen per week was multiplied by 52 to obtain the number of patients seen per year. Each therapist's estimate of the number of patients seen per month through direct access was multiplied by 12 to obtain the number of patients seen through direct access yearly. The number of patients seen through direct access yearly was divided by the total number of patients seen yearly and multiplied by 100 to obtain the percentage of patients seen through direct access.

The second derived variable was the ranking of patient types (orthopedic, neurologic, chronic pain, preventive care, pediatric, work hardening, wound care, cardiopulmonary, and sports medicine) seen through direct access. The surveyed therapists were asked to rank from 1 to 7 the frequency with which they had seen various types of patients directly, with a ranking of 1 indicating the type of patient seen most frequently. These rankings were given a point value reflecting how often the various patient types were seen without referral. A ranking of 1 received 7 points; a ranking of 7 received 1 point. Rankings between 1 and 7 were given points in one-integer increments between the two extremes. The overall ranking for each patient type was determined by totaling the points across respondents. The diagnostic category with the most points was ranked first; the category with the least points was ranked last.

Chi-square analyses were used to test whether therapists who had or had not practiced through direct access had different opinions about whether direct access had benefited the profession and patients. The alpha level for each test was set at .05.

Results

Return Rate

The overall return rate was 137 survey questionnaires, or 54.8% of the sample. This return rate represented 12% of the population we sampled. The return rate was greater from North Carolina (n=I02 [61.1%]) than from either Utah (n=20 [42.6%]) or Nevada (n=15 [41.7%]). Of the 137 returned survey questionnaires, 99 were from therapists who had practiced in both direct access and non-direct access settings. These 99 questionnaires (75 from North Carolina, 12 from Utah, and 12 from Nevada) were analyzed. Results will be presented in the aggregate, but it should be recognized that these results are, overall, dominated by the greater number of responses from North Carolina because of the low numbers of usable responses from Utah and Nevada.

1Demographics/Education

The mean age of the respondents was 36.2 years; 71.7% of the respondents were women. The median year of graduation from physical therapy school was 1978; 81.8% of the respondents had entry-level bachelor's degrees, 11.1% had certificates in physical therapy, and 7.1% had master's degrees. The bachelor's degree was the highest eamed degree for 77.8% of the respondents; the remainder had master's degrees. Over 60% of the respondents attended one to two continuing education courses per year; 24% attended three to five courses per year.

Work Information The median time spent in non-direct access practice was 6.0 years; in direct access practice, the median was 3.0 years. The outpatient clinic was the most frequent work setting indicated (51.5%), followed by hospital (22,2%), home health care (17,2%), consulting (17.2%), nursing home (14.1%), school system (12.1%), rehabilitation center (5.1%), and university (1%). The work-setting percentages total more than 100% because respondents could indicate more than one work setting.

Extent of Direct Access Practice

Almost half of the respondents had seen patients through direct access (44.5%); an average of 10.3% of their caseload was seen through direct access. Of patients seen through direct access, 40.7% were estimated to be referred by the therapist to another practitioner. By multiplying the proportion of respondents who see patients through direct access by the estimated proportion of their patients seen directly, we obtained an estimate that 4.6% of all patients seen by all physical therapists in these states are seen without referral.

Reasons given for not treating via direct access included employer does not permit direct access practice (49.1%), insurance does not reimburse for direct access practice (43.6%), no patients have been seen without referral (25.5%), personal preference to see patients through referral only (23.6%), and "other" (25.5%). The "other" responses were as follows: 7 respondents noted that, until recently, Medicare-certified facilities were prohibited from receiving any patients without referral; 3 respondents cited hospital or nursing home policies prohibiting direct access practice; 1 respondent was employed by a physician; and 1 respondent was concerned that physician referrals might stop if patients were seen via direct access. The ranking of which patients were seen most frequently was as follows, in descending order: orthopedic, neurologic, chronic pain, preventive care, pediattic, work hardening, wound care, cardiopulmonary, and sports medicine.

Impact 01 Direct Access on Liability Insurance Costs and Claims

We asked questions about the cost of liability insurance and the number of claims before and after direct access. A significant number of respondents were unable to answer the question about liability insurance costs, and the number of liability claims was so low both before and after direct access that no conclusions could be drawn from this information.

Reimbursement for Direct Access Practice

Almost one third (31.8%) of the respondents indicated that they had problems with insurance reimbursement for direct access practice. All respondents were asked to answer this question, so the percentage includes both those who had treated patients through direct access and presumably had tried to be reimbursed for their services and those who had not treated patients through direct access but may have inquired about the eligibility of such services.

Opinions

Most respondents (84.5%) felt that communication with physicians was unchanged after direct access, and 43.4% indicated that direct access had benefited the profession. Over half of the respondents (52.5%) indicated that they believed that direct access had benefited patient care. With respect to the adequacy of entry-level education, 11.1% of the respondents strongly agreed, 34.4% agreed, 31.3% disagreed, 14.1% strongly disagreed, and 8.1% were undecided about whether their entry-level education had provided adequate preparation for direct access practice. Those who had practiced through direct access were significantly more likely than those who had not practiced through direct access to believe that direct access had benefited the profession and had benefited patients (Table).

Discussion

Fears that direct access will mean separation from the traditional medical model seem unfounded, based on the results of this study. Fewer than half of therapists saw patients without referral; those who did saw small percentages of their caseloads without referral, and approximately 40% of those patients were referred back to some other practitioner.

The stated reasons for practicing only by referral may not represent true barriers to direct access practice, but may reflect the inertia of therapists used to practicing in a more dependent mode. The relatively low use of direct access practice documented in our study may counter some of the reasons therapists gave for not treating patients through direct access. For example, employers might be willing to change policies requiring referral if they see direct access as an occasional service to particular patients rather than a routine mode of practice. Therapists who have a stated preference to see patients by referral only might also change their views if they see direct access as an appropriate option for a very selected portion of their practice.

The finding that therapists who had practiced through direct access were significantly more likely to agree that direct access benefited patients and the profession than therapists who had not practiced through direct access should provide reassurance to therapists uncertain about whether to accept patients without referral. This information goes beyond mere rhetoric about the positive effects of direct access practice and documents the positive views of therapists who have actually practiced in this mode. Future research to determine whether physicians and patients share this positive view will strengthen these results.

Several limitations should be considered when interpreting the results of this study. First, the sample was selected from APTA members, who may have different views and may practice differently than nonmembers. Second, although we exceeded our goal of receiving responses from 10% of the population of APTA members in the three states, the response rate was still somewhat less than ideal, particularly as 27% of the respondents did not meet the inclusion criteria of having practiced under both direct access and non-direct access conditions.

Despite the low response rates for two of the three states sampled, we believe there was minimal overall response bias because our respondents were similar to the overall APTA membership reported in the 1987 Active Member Profile.4 For example, compared with the 1987 Agra member survey, our respondents were slightly older (36.2 years versus 35.7 years); included a slightly lower percentage of women (71.7% versus 74.6%); had somewhat more experience as physical therapists, as expected by our elimination of those with experience only under direct access (median, 11 years versus 9 years); and had more entry-level baccalaureate degrees (81.8% versus 74.3%). Our survey and the 1987 APTA member survey also had almost equal percentages of respondents with the bachelor's degree as the highest degree (77.8% versus 76.3%).

Differential returns were seen from the three states, with the highest rate of return from North Carolina. In general, the responses from North Carolina were more positive about direct access than were the responses from Utah and Nevada. We believed, however, that there was limited generalizability to the entire states of Utah and Nevada because of the low number of responses from those two states (12 from each state). We considered eliminating the responses from Utah and Nevada and only presenting the North Carolina responses. We believed that eliminating those responses would give a distorted, overly positive view of practice since the implementation of direct access. Therefore, we presented all results in the aggregate, without differentiating among the states. Readers should consider that the results represent responses from experienced therapists in states with 3 years' experience with direct access, rather than being representative of a particular geographic area. In addition, the three states studied are more rural than many other states and represent only the southern and western portions of the country. Thus, generalizability to urban states and other regions may be limited.

The extent of direct access practice has been documented by others in terms of the proportion of practices that accept patients via direct access (90% of practices in Victoria, Australia)6; the proportion of therapists who have evaluated or have evaluated and treated patients without referral (30% and 13%, respectively, of a sample of APTA members across states)4; and the proportion of patients evaluated or treated, or both, without referral (19.7% and 10.8% of patients seen in hospital and private practice settings, respectively, across states).5 Direct comparison of these earlier results with ours is difficult because of differences in the proportion of interest, the way in which direct access was defined, and the method of data collection.

The 44.5% of our respondents who saw patients through direct access includes therapists who may evaluate but not treat without referral as well as those who both evaluate and treat without referral. The APTA study4 separates "evaluate and treat" from "evaluation"; presumably, the percentage of therapists who evaluate and treat without referral (13%) is a subset of the percentage who evaluate without referral (30%). Predictably, our proportion of therapists practicing through direct access is higher than either of the APTA proportions because that sample included therapists from all states, not just from states with direct access.

Our estimate that 4.6% of patients are seen through direct access is low compared with the 19.7% and 10.8% found in hospital and private practice settings by Jette and Davis.5 They used retrospective data collected at the point of discharge to determine their percentages. The discrepancy between the two studies may be explained by weaknesses in the data-collection methods of both studies. In our study, we relied on therapists' estimates of their caseloads and of the number of patients seen without referral, providing opportunities for both overreporting and underreporting direct access cases. The Jette and Davis study may be limited by overreporting of practire without referral in instances in which the written referral was missing or a verbal referral was not recorded. In addition, almost all of the direct access practice reported by Jette and Davis consisted of evaluation only; both evaluation and treatment without referral represented only 0.8% and 1.5% of patients seen in hospital and private practice settings, respectively.

Further research should be conducted to clarify some issues that were answered in a cursory fashion by this study. We would suggest repeating the study in different states with a modified questionnaire. Items about setting and patient type should be changed to determine more precisely where and with whom direct access is used. As noted previously, determining the satisfaction of patients and physicians with direct access practice is needed to balance the views of the physical therapists who participated in this study. It would also be useful to conduct a study of the character of direct access practice rather than simply documenting its extent.

Summary

The majority of therapists (44.5%) in states with 3 years' experience with direct access had seen patients directly; an average of 10.3% of their patients were seen directly. Therapists who had treated patients through direct access were far more likely than those who had not treated patients through direct access to indicate that direct access had benefited the profession and patients.

References

1 Case for Direct Access. Alexandria, Va: American Physical Therapy Association; 1990.

2 Taylor TK, Domholdt E. Legislative change to permit direct access to physical therapy services: a study of process and content issues. Pbys Ther. 1991;71:382-389.

3 Lott D. Physical therapists and physicians: autonomy and control. Rehab Management. 1989;2(1):44-49. 4 1987 APTA Active Membership Profile Survey. Alexandria, Va: American Physical Therapy Association; 1987.

5 Jette AM, Davis KD. A comparison of hospital-based and private outpatient physical therapy practices. Phys Ther. 1991;71:366-381.

6 Dennis JK. Decisions made by physiotherapists: a study of private practitioners in Victoria. Australian Journal of Physiotherapy. 1987; 30:181-191.

7 James JJ, Stuart RB. Expanded role for the physical therapist: screening musculoskeletal disorders. Phys Ther. 1975;55:121-132.

8 Overman SS, l.arson JW, Dickstein DA, Rockey PH. Physical therapy care for low back pain: monitored program of first-contact nonphysician care. Phys Ther. 1988;68:19%207.

9 Gay LR. Educational Research: Cornpetencies for Analysis and Application. 3rd ed. Columbus, Ohio: Merrill Publishing Co; 1987:114-115.