Outpatient views on direct access to physical therapy in Indiana.

Outpatient Views on Direct Access to Physical Therapy in Indiana

The purpose of this study was to determine the opinions of outpatients receiving physical therapy in Indiana about physical therapy evaluation and treatment without referral (direct access). Subjects were 361 individuals being treated at one of 25 privately owned clinics. Each subject completed a 15-item questionnaire. Results showed that 82.8% of the respondents supported direct access to physical therapy. A majority indicated they would seek physical therapy services without referral if they were available. Physical therapists were cited as frequently as all other health care professionals combined as the practitioners providing the most thorough evaluation. Physical therapists were cited far more often than other health care professionals combined as the practitioners providing the best information about the control of symptoms. Subjects who had received more treatments than others were significantly more likely to support direct access (p [is less than] .05). Conclusions were that individuals who have received physical therapy at private outpatient physical therapy clinics in Indiana are supportive of direct access to physical therapy services. [Durant TL, Lord LJ, Domholdt E: Outpatient views on direct access to physical therapy in Indiana. Phys Ther 69:850-857, 1989]

Key Words: Interprofessional relations; Physical therapy profession, professional issues; Referral and consultation.

Physical therapy in the United States had its beginning in World War I with the establishment of training programs for rehabilitative personnel to treat wounded servicemen.[1] By the early 1970s, physical therapists were recognized as licensed professionals in all 50 states.[2] Until recently, most state practice acts required that patients be referred to a physical therapist by another health care practitioner. Depending on the state, the referring practitioner may be a physician, osteopath, dentist, podiatrist, chiropractor, naturopath, or psychologist.[3] In this article, the term "practitioner" will refer to any of these referral sources. The American Physical Therapy Association's position on direct access is that mandatory referral

does not recognize the professional

training and expertise of the licensed

physical therapist nor does it serve the

needs of those patients who require

physical therapy but find they must

first be seen by a physician.[4]

Since 1968, 21 states have passed laws enabling physical therapists to evaluate and treat patients without a practitioner's referral.[4-7] This legislation gives consumers "direct access" to the services of physical therapists. Therapists in states with longstanding direct access have apparently functioned effectively with minimal restrictions on their practices. In contrast, recent direct-access legislation in several states has imposed restrictions on the implementation of physical therapy evaluation and treatment without referral. Common restrictions include requiring individual therapists to complete one to two years of practice with practitioner referral before seeing clients directly, requiring mandatory continuing education for all practitioners with physical therapy licenses, and requiring practitioner review and referral of individual clients after 30 days of physical therapy without referral.[5],[6]

Two studies have investigated patient care outcomes when physical therapists have acted as first-contact providers of services for patients with low back pain. A 1975 study of physical therapists in the US Army revealed that patients and orthopedic surgeons were pleased with a physical therapy-based back screening program.[8] In a 1988 study of first-contact nonphysician care in a hospital-based ambulatory physical therapy clinic, the outcomes of physical therapy-based care were found to be equal to or better than those of primary care internists.[9] Although both studies support direct access to physical therapy services for patients with low back pain, it must be noted that both studies used treatment algorithms to assist the therapist in making decisions about whether to refer the patient to a physician, and both studies concluded that specialized training was needed to prepare the physical therapists for their expanded roles.

Many physical therapists support the APTA's position that direct access to physical therapy will improve the health care system both by decreasing health care costs and by reducing the delay before beginning physical therapy. Other groups, including individual physical therapists, physicians, and chiropractors, oppose direct access and express the concern that physical therapists may diagnose and treat beyond their level of competency. They believe that injury because of inappropriate or unsupervised treatment and decreased communication between the practitioner and the physical therapist may result from the direct-access practice of physical therapy.[4],[10],[11] The APTA's response to these concerns is that

physical therapists are also well

qualified to recognize when patients

demonstrate conditions, signs and

symptoms that should be evaluated by other

health care professionals before

therapy is instituted and they recognize

when it is appropriate to refer patients

to these other health care professionals

for consultation.[4]

Although the conflicting views of health care professionals have been documented, only one formal study has been conducted to determine public opinion on direct access. A statewide public-opinion survey performed for the Minnesota Chapter of the APTA revealed that 57.2% of those surveyed supported direct access, 28.7% did not, and 14.1% had no opinion. The survey also revealed that those who agreed with direct access were more likely than those who disagreed to be young (25-40 years of age), male, liberal, and Democratic.[12]

The Texas Chapter of the APTA has collected direct patient input on this topic via comment cards provided to patients in an educational brochure. On these cards, patients cited "cost, inconvenience, and poor health care" as the consequences of mandatory referral.[13](p16) Several patients reported delaying seeking health care or choosing alternate, less traditional forms of health care in an attempt to avoid the cost and inconvenience inherent in obtaining an "unnecessary" practitioner referral to begin physical therapy. In the conclusion of the Texas Chapter's report, patients stated that by delaying appropriate medical care, they risked exacerbating their physical disability and damaging their health.[13]

Many state chapters of the APTA are presenting direct-access proposals to their state legislatures. Testimony from health care professionals can be expected to influence legislators' opinions, and ultimately their votes, on direct-access legislation. It can be expected, however, that the opinions of the lay public, the legislators' constituents, will be equally influential. Given the paucity of information about the views of the public, the specific aim of this study was to determine the opinions about physical therapist evaluation and treatment without practitioner referral of out-patients receiving physical therapy in privately owned clinics in Indiana.

Method

Instrument

Patient opinion about direct access to physical therapy was determined via a questionnaire that was distributed to privately owned physical therapy clinics in Indiana. The questionnaire consisted of 15 questions that sought to determine the type of patients who responded to the survey, their previous and present experiences with physical therapy, their opinions about whether they would use direct access if it were available, their opinions on how some physical therapy services compared with those provided by other practitioners, and their level of support of direct access to physical therapy.

A pilot study consisting of a questionnaire survey of 10 patients was performed at an independently owned physical therapy clinic in central Indiana. The specific purpose of the pilot study was to determine whether the respondents would understand the physical therapy procedures indicated on the questionnaire and whether they could understand the assumptions related to the opinion items. The pilot group completed the questionnaires appropriately, indicated receiving all but one of the listed treatment procedures, and responded to the opinion items consistently. Two items on the pilot questionnaire were either eliminated or reworded for the final questionnaire based on responses that indicated misinterpretation of the items.

Clinics

Clinics were identified through the Private Practice Special Interest Group of the Indiana Chapter of the APTA and through telephone listings of physical therapy centers in Indiana. Each clinic owner was contacted via telephone to determine whether the clinic met the criteria for inclusion in the study. These criteria included having registered physical therapists on staff, being a physical therapist-owned center not affiliated with a hospital, and having a patient population appropriate for completing a questionnaire survey. Thirty-two clinics met the inclusion criteria and agreed to participate in the study. Because of the political nature of the questions, we assumed that the owners or administrators of physician-owned clinics or clinics based in hospitals would not likely be willing to participate in the survey. The owners of the 32 privately owned clinics were instructed to distribute questionnaires to the first 20 patients who had received five or more treatments and agreed to participate in the survey, to assure the patients that their participation was voluntary, to permit the patients to complete the questionnaires in private, and to instruct the patients to seal their completed questionnaires in the envelopes provided by the researchers. Because all respondents were adults and participation was voluntary, completion of the questionnaire was considered to constitute the giving of informed consent. The final version of the questionnaire was distributed to the clinics during March 1988. Follow-up telephone calls to clinics from which surveys were not returned by the initial deadline revealed that most had used a secretary or receptionist to distribute the survey, removing the therapist from a position of influence over the patients' responses. When all 20 questionnaires were completed or the return deadline had passed, each clinic owner or secretary returned the questionnaires in their sealed envelopes to the researchers in one packet.

Data Analysis

The overall responses were tabulated, and means, medians, standard deviations, and frequencies were calculated as appropriate. Three additional variables--age, geographic location, and level of exposure to physical therapy--were sorted into categories for later analysis. First, the respondents were assigned to one of three age groups: young adults ([is less than or equal to] 30 years of age), adults (31-50 years of age), and old adults ([is greater than or equal to] 51 years of age). Next, the respondents were separated according to their clinic location and categorized as being from central, northern, or southern Indiana. The respondents were also assigned to one of three groups on the basis of total number of physical therapy treatments received: low exposure ([is less than or equal to] 10 treatments), moderate exposure (11-30 treatments), and high exposure ([is greater than or equal to] 31 treatments). In addition, the percentage of positive responses to the direct-access opinion item was calculated for each individual clinic. Finally, a chi-square analysis was performed to examine the subgroup difference on the direct-access opinion item. The Statistics with Finesse software program(*) was used to tabulate and analyze the data.

Results

Twenty-five of the 32 clinics (78.1%) that met the inclusion criteria returned completed questionnaires. A total of 361 completed questionnaires were received and used in the data analysis.

Demographics 

The survey respondents ranged from 18 to 90 years of age (X [bar] = 42.5, s = 15.1). Other data concerning the demographic and diagnostic composition of the respondents are shown in Table 1. The respondents were predominately women who were being treated for extremity disorders and who indicated no other complicating diagnoses.

The treatment procedures received by the respondents are tabulated in Table 2. The procedures are listed in descending frequency under each category. We were surprised at the specificity with which respondents listed their treatments--many have apparently picked up on the jargon of physical therapy because they differentiated between manual techniques such as joint mobilization and soft tissue manipulation. Each respondent received an average of 3.6 different treatment procedures during the course of their most recent episode of physical therapy.

Table 3 presents the respondents' experiences with physical therapists and physicians. Although medians, means, and standard deviations are presented, the median provides the best measure of central tendency for these data because a few extreme values distorted both the means and standard deviations. The respondents had received a median total of 14 physical therapy visits, and most had no previous exposure to physical therapy. It should be noted that some respondents had received fewer than the five treatments that were part of the initial criteria for completion of the questionnaire; we chose to retain them in the data analysis and to examine the question of whether the number of visits was related to direct-access opinion. Respondents had been seen by a median of two physicians for a median of four visits related to their current episode of physical therapy.

Opinions

Table 4 shows the respondents' opinions concerning direct-access legislation and their anticipated usage of evaluation and treatment without referral if they were permitted by law. A large majority (82.8%) responded that physical therapists in Indiana should be allowed direct access for evaluation and treatment. The Figure depicts the number of clinics that had a given percentage of affirmative responses to the question concerning direct-access opinion. In only one clinic (Clinic 20) did fewer than 60% of the respondents express positive opinions about direct access. A demographic profile of this clinic in relationship to the profile of the total sample is provided in Table 5.

For the questions concerning anticipated usage of direct access, the survey participants were instructed to assume that legislation allowing direct access in Indiana had passed, that they had finished their current episode of treatment, and that they had remained without symptoms for six months. Most respondents (71.5%) indicated that they would seek evaluation and treatment directly from their physical therapist if they were to experience the same symptoms again. A smaller majority (59.6%) indicated that they would seek direct evaluation and treatment if they were to experience different symptoms that they knew were treated by physical therapists. Respondents' opinions concerning which health care professional was most thorough in evaluation and which was the best source of information regarding the control of symptoms are shown in Table 6. With respect to evaluation, respondents cited physical therapists as their best source of evaluation (44.6%) about as frequently as they did all other health care professionals combined (42.7%). With respect to information provided to control and prevent recurrence of symptoms, physical therapists were cited as the best source far more frequently (74.0%) than all other health care professionals combined (15.5%).

Subgroup Analysis 

Chi-square analyses were performed to determine whether various demographic, diagnostic, usage, and opinion variables had an effect on direct-access opinion. Table 7 reveals the chi-square values and significance levels of each of these subgroup analyses. The relationship between the total number of physical therapy visits and direct-access opinion was the only chi-square value significant at the .05 level. Table 8 provides the data used to calculate the chi-square value for that relationship.

Discussion

There are several limitations to this study that prevent the results from being generalized to the general population. Because the individuals surveyed were strictly defined as outpatients who were currently receiving physical therapy at privately owned clinics in Indiana and who met our inclusion criteria, their opinions cannot be regarded as general public opinion. Some of the clinics that qualified for inclusion in the study did not return all of the questionnaires provided, and some returned none. The sample was affected further by the method of distribution at each clinic. Although all clinics were provided with identical instructions for survey distribution and collection, the researchers had no control over respondents selection or the influence of the therapists' opinions on respondents' opinions. The nonrandom nature of our sample may explain the more positive results of this study (82.8% favored direct access) compared with those of the Minnesota study (57.2% favored direct access).[12] It also should be noted, when considering the responses to the direct-access opinion questions, that our selection procedure ensured that all respondents had consulted at least one referral source and had visited a physical therapist. We had no knowledge, however, of how many respondents had exposure to each type of practitioner. For this reason, Table 6 combines the data for all practitioners to allow better comparison with the data for physical therapists. The results indicate that the physical therapists provided comparable evaluations and far superior information.

Review of the results led us to hypothesize that respondents who had more experience with physical therapy would be more likely to believe that consumers should be allowed direct access to physical therapists. Chi-square analysis revealed a significant relationship between those respondents who were in favor of direct access and those who had made a larger number of total visits to physical therapy. These total visits included those of the present episode of physical therapy, where treatment was given in private clinics, and those of any previous episodes of physical therapy, where treatment may have been given in different settings. Interestingly, those who had received physical therapy previously did not show different opinions than those who had not had a previous episode. We attribute this finding to the fact that the previous episodes may have been very brief (ie, one or two visits as an inpatient, followed by the current episode as an outpatient). Thus, the total number of visits seemed to be the better means of quantifying total exposure to physical therapy.

Initial review of the data also led us to believe that responses to the direct-access opinion item were related to the clinic of origin. After calculating the percentage of positive responses at each clinic, however, it was apparent that the responses from only one clinic (Clinic 20) were substantially less positive about direct access than the responses from the overall group. At Clinic 20, the percentage of patients responding positively to the anticipated usage questions was also lower than the total sample. To search for an explanation of this result, we compared the demographic profile of the respondents from Clinic 20 with that of the total sample. The clinic's respondents were within one standard deviation of the total for mean age, number of physical therapy visits for the current episode of physical therapy, number of practitioner visits, number of practitioners seen, and number of physical therapy visits for previous episodes. Fewer respondents at Clinic 20 as compared with the overall sample reported receiving previous physical therapy, and this lack of experience may have affected their opinions. Clinic 20 contained a higher percentage of male respondents than the other clinics, although the overall results indicate that sex does not influence direct-access opinion. "Other" diagnoses were more frequently reported at Clinic 20, but diagnosis was not found to be related to direct-access opinion for the total sample. These results may indicate a poor relationship between the therapists and clients at this particular clinic, inadequate delivery of physical therapy services at this clinic, or a clientele with very traditional views about the respective roles of physicians and other health care providers.

The survey also assessed the experiences of the respondents with their referring practitioners. The respondents made a median of 4 visits to 2 practitioners, with values as high as 130 visits and 24 practitioners. We believe that direct access to physical therapy can provide an alternate means of entry into the health care system that could reduce the number of practitioner visits and thus decrease medical expenses. First, direct evaluation by a physical therapist may result in referral to an appropriate specialist practitioner and may decrease the number of different practitioners seen. Second, patients with chronic, progressive, or recurrent pathological conditions that have previously been diagnosed could seek treatment from their physical therapist without first requiring office visits to a practitioner to obtain referral.

In the final section of the questionnaire, the respondents were given the opportunity to express their opinions concerning direct-access legislation and the health care professionals providing services to them. In response to the question regarding which health care provider was most thorough in evaluating their condition, the percentage of respondents indicating physical therapists was comparable to the percentage indicating all other health care professionals combined. This finding suggests that patients were at least as satisfied with the evaluative services provided by their physical therapists as they were with the evaluative services provided by their physicians, dentists, or chiropractors.

In response to the question regarding which health care professional was the best source of information for decreasing the severity of their symptoms and preventing their recurrence, a great majority of the respondents indicated that their physical therapists had been their best source of information. When physical therapy can only be obtained through practitioner referral, these practitioners control the access of patients to the very treatment that was noted to be most effective in controlling and preventing symptom recurrence.

Further research could expand upon these data to give a broader view of consumer opinions about direct access to physical therapy services. First, the types of settings studied could be broadened to determine whether clients being seen in other settings are equally positive about seeing their physical therapists without practitioner referral. Second, more information about the therapists treating the patients could be collected to determine whether there are therapist-specific factors such as length of time in practice, level of education, and extent of continuing education that influence opinions about direct access to physical therapy services.

Conclusion

It has been suggested that "no other health professional has patient access to its services so severely limited, and few other health professions are so demonstrably well qualified for practice without referral."[4] The respondents in this survey expressed confidence in their physical therapists' evaluation skills and knowledge of how to control their symptoms. A majority indicated support of direct access and a willingness to use physical therapy services without referral. These results indicate that people who have been exposed to physical therapy in private outpatient settings in Indiana favor legislation allowing physical therapists in Indiana to evaluate and treat clients without referral. [Tabular Data 1 to 8 Omitted] [Figure 1 Omitted]

References

[1]Granger FB: The development of physiotherapy. Phys Ther Rev 3(2):14--19, 1923 [2]Mathews J: A profession on the move: Physical therapy's dramatic progress. Progress Report of the American Physical Therapy Association 17(8):10, 1986 [3]State Licensure Reference Guide. Alexandria, VA, American Physical Therapy Association, Department of Practice, 1986 [4]Direct Access to Physical Therapy. Alexandria, VA, American Physical Therapy Association, Division of Professional Relations, June 1987 [5]Yohn J: Direct access gets green light in New Hampshire, Vermont. Progress Report of the American Physical Therapy Association 17(6):3, 1988 [6]Phillips P: 1988 has been most productive year for direct access to PT legislation. Progress Report of the American Physical Therapy Association 17(7):18, 1988 [7]Minnesota becomes 18th state with direct access. PT Bulletin 3(15):3, 1988 [8]James JJ, Stuart RB: Expanded role for the physical therapist: Screening musculoskeletal disorders. Phys Ther 55:121--131, 1975 [9]Overman SS, Larson JW, Dickstein DA, et al: Physical therapy care for low back pain: Monitored program of first-contact care. Phys Ther 68:199--207, 1988 [10]Dorste T: Physical therapists: Green light on direct access. Hospitals 61(15):113, 1987 [11]Yohn J: Washington, Colorado join growing ranks of direct access states. Progress Report of the American Physical Therapy Association 17(5):1, 1988 [12]Sims Research Associates, Inc: Statewide Public Opinion Survey. Proprietary Section, Minnesota Chapter of the American Physical Therapy Association, 1988 [13]Physical therapy patients calling for direct access. Synergy (publication of the Texas Chapter of the American Physical Therapy Association) 43(3):16, 1987

T Durant, MS, PT, is Staff Physical Therapist, Methodist Hospital of Indiana, Inc, 1701 N Senate Blvd, Indianapolis, IN 46206. L Lord, MS, PT, is Staff Physical Therapist, Sunnyview Hospital and Rehabilitation Center, 1270 Belmont Ave, Schenectady, NY 12308. E Domholdt, EdD, PT, is Dean, Krannert Graduate School of Physical Therapy, University of Indianapolis, 1400 E Hanna Ave, Indianapolis, IN 46227 (USA). Address all correspondence to Dr Domholdt. Mrs Durant and Ms Lord were students in the master's degree program, Krannert Graduate School of Physical Therapy, when this study was completed in partial fulfillment of the requirements for their master's degrees.