Physical therapists' opinions and practices regarding direct access.

Key Words: Direct access, Opinion, Practice, Referral, Stipulations.

Until 1957, every state required a physician's referral for all patients needing physical therapy.[1] The American Physical Therapy Association's (APTA) current policy is that physician 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."[2] Direct access is defined as the evaluation and treatment of patients by physical therapists without referral from a physician or other health care practitioner.[1] As of March 1997, only 31 states permit direct access to physical therapy services. In 13 additional states and the District of Columbia, physical therapists may evaluate patients to determine whether physical therapy may be beneficial, but they may not initiate treatment without physician referral. Thus, in only 6 states are patients restricted by law from consulting a physical therapist without the referral from a physician. Table 1 provides a listing of states' current direct-access status.

Table 1.
Direct-Access Status by State

States That Permit   States That Permit   States That Require
Physical Therapy     Physical Therapy     Physician Referral
Evaluation and       Evaluation Only      for Physical Therapy
Treatment Without    Without Physician    Evaluation and
Physician Referral   Referral             Treatment

Alaska               Connecticut          Alabama
Arizona              Georgia              Indiana
Arkansas             Hawaii               Missouri
California           Kansas               Ohio
Colorado             Louisiana            South Carolina
Delaware             Michigan             Virginia
Florida              Mississippi
Idaho                New Jersey
Illinois             New York
Iowa                 Oklahoma
Kentucky             Pennsylvania
Maine                Tennessee
Maryland             Washington, DC
Massachusetts        Wyoming
Minnesota
Montana
Nebraska
Nevada
New Hampshire
New Mexico
North Carolina
North Dakota
Oregon
Rhode Island
South Dakota
Texas
Utah
Vermont
Washington
West Virginia
Wisconsin

Proponents believe that direct access will be advantageous to the health care system for a variety of reasons.[1] According to APTA publications, direct access can (1) provide an additional entry point into the health care system for consumers, (2) reduce health care costs by permitting patients to consult with physical therapists without the cost of paying a physician to make a referral, (3) decrease the time between initial onset of symptoms and actual treatment, thereby increasing treatment success, (4) promote the prevention of health care problems because physical therapists could serve as health care screeners, (5) allow early intervention and on-site treatment in both schools and industries, resulting in decreases in lost wages, absenteeism, and injuries, (6) decrease the long-term care of individuals due to easier access to necessary services, and (7) increase job satisfaction experienced by physical therapists.

Opponents of direct access argue that patients may be harmed by physical therapists and placed at a greater risk because physical therapists are not trained to make medical diagnoses.[3] Consequently, some opponents believe that if physical therapists treat patients without a referral, some medical conditions will be left undetected or physical therapists may provide care that is inappropriate or contraindicated.[3] Another potential criticism of direct access,is that physical therapists cannot typically refer patients directly for diagnostic testing (eg, radiographs) or other laboratory tests. Patients needing these procedures must then be referred to a physician.

Another concern is that direct access will increase health care costs. It is feared that the cost of insurance premiums and the rates of malpractice claims will increase with direct access. This concern has not been supported by the limited data available.[4] Two major liability insurers for licensed physical therapists reported that the removal of the referral requirement has not caused any increase in physical therapy liability costs or claims (letter from DE Boyce to JA Brannon, June 3, 1991, and letter from DF Lang to M Lane, July 12, 1990). Direct access may also increase patient costs due to an overutilization of physical therapy services.[4] Mitchell and de Lissovoy,[4] however, recently reported that direct-access episodes had fewer treatments and lower costs than physician-referred episodes.

Domholdt and Durchholz[5] surveyed physical therapists practicing in three states with direct access legislation to determine their opinions regarding direct access. They found that 43.4% of the respondents believed that direct access benefited the profession, whereas 52.5% of the respondents believed that direct access benefited patient care. They estimated that only 4.6% of all patients seen by physical therapists in the states studied were seen without a physician's referral. Therapists who had treated patients through direct access were more likely than those who had not to believe that direct access benefited the profession and the patients. Domholdt and Durchholz indicated that physical therapists did not practice direct access because of employer policies (49.1%), lack of insurance reimbursement (43.6%), patients without a physician's referral not presenting themselves for physical therapy (25.5%), and personal preference (23.6%). Concerns about the potential costs associated with malpractice liability have also been investigated, but the number of events were so low that no conclusions have been reached.[5]

One purpose of our study was to investigate differences in opinions and practices between physical therapists practicing in Massachusetts (a state that has permitted direct access since 1984) and physical therapists practicing in Connecticut (a state that does not permit full direct access). A second purpose was to examine the practices of physical therapists practicing in a direct-access state. This information would add to the data presented by Domholdt and Durchholz[5] and would allow the assessment of the use of direct access in a state that has experienced recent increases in managed care. Direct access, in its purest form, includes both evaluation and treatment by a physical therapist without a referral from a physician or other health care practitioner.[1] Although Connecticut permits physical therapists to perform evaluations without referral, legislation does not permit treatment without referral from a medical practitioner.[6] Connecticut, therefore, does not permit "true" direct access according to this definition. We decided to compare the opinions and practices of physical therapists practicing in Massachusetts and Connecticut because these states share a similar geography, population, socioeconomic structure, and reimbursement pattern. We believed that these similarities would help to reduce variables that we could not control.

We had several a priori hypotheses. We hypothesized that there would be no difference in the demographic data between the two states. We hypothesized that the therapists in a direct-access state (Massachusetts) would feet more positively than the therapists in Connecticut about the practice of direct access, be more satisfied and challenged by their career, and feel more positive about the effects of direct access on the profession, physical therapy practice, and patient care. We anticipated finding no difference between the therapists in the two states regarding their opinions about entry-level competence to evaluate and treat a referred patient in a safe and effective manner. We hypothesized that the therapists in Massachusetts would be more likely to report that physical therapists and physicians did not change their communication patterns with direct access. We hypothesized that the therapists in Massachusetts would cite the need for fewer stipulations on direct access practice than would the therapists in Connecticut. Finally, we hypothesized that the use of direct access in Massachusetts would be less than that estimated by Domholdt and Durchholz[5] because of the increased use of managed care.

Method

Sample

Sample size calculations were determined a priori, assuming a 10% loss for nonusable questionnaires and a 50% response rate. The calculations were conducted using the technique for chi-square analyses described by Cohen.[7] Using this technique, we needed a total of 133 returned questionnaires to obtain a power of .8. A mailing of 300 survey instruments and a projected response rate of 50%, theoretically, should have provided the 133 questionnaires needed. We mailed 500 questionnaires to ensure a sample of 133 respondents, even if the actual return rate was as low as 30%. The number of survey instruments mailed to each state was weighted by the ratio of all licensed physical therapists in each state (34% in Connecticut versus 66% in Massachusetts). Thus, 171 therapists in Connecticut and 329 therapists in Massachusetts were randomly selected through the use of a table of random numbers from a mailing list of current APTA members in each state.

Instrument

A questionnaire designed by the researchers was used to obtain data. There were two forms of the questionnaire. The questionnaire used to survey therapists in the direct access state of Massachusetts contained 39 items. A 36-item questionnaire was used to survey therapists in the non-direct-access state of Connecticut. The additional three questions contained in the Massachusetts survey instrument asked about direct access practices. Both survey instruments included items eliciting demographic, educational, and employment information. Therapists in Massachusetts were asked about their current career, their opinions regarding direct access, and stipulations in relation to direct access that they believed were necessary to better document current clinical access practices. Therapists were also asked questions regarding referrals, physical therapy assessment, and estimated payment. Aside from the items that requested demographic data or numerical values, all responses were in the form of Likert-type responses using a five-point scale, from "strongly agree" to "strongly disagree."

Procedure

To improve the content validity of the survey, a pilot study was conducted during March 1993 in Maine (a state permitting direct access) and Virginia (a state not permitting direct access). For the pilot study, survey instruments were mailed to 58 licensed physical therapists (20 therapists in Maine and 38 therapists in Virginia), and 49 of the therapists responded (a response rate of 84.5%). In addition to the questionnaire, a cover letter soliciting feedback about content and form of the instrument was mailed to each therapist. The suggestions received from these physical therapists were incorporated into the final wording of the questionnaire and the response scale.

For the actual research study, a cover letter explaining the purpose of this study, a questionnaire, and a stamped, addressed reply envelope were mailed to each therapist. The data collected were held in confidence and were used only for the purposes of this study.

Data Analysis

All data were coded and entered into the Mystat statistical program(*) for analyses. Means, maximum values, minimum values, ranges, and standard deviations were calculated for all descriptive data. Independent group t tests were performed for all noncategorical data to determine whether differences existed between the responses of physical therapists practicing in a direct access state and the responses of physical therapists practicing in a non-direct-access state. Chi-square analyses were conducted for all categorical data to determine whether differences existed between therapists practicing in a direct access state and those practicing in a non-direct-access state. For each of the statistical analyses, the alpha level was set at .05.

Results

Return Rate

From the sample of 500 survey instruments mailed, 293 questionnaires were returned. Nine of the returned questionnaires were from therapists who were no longer practicing. These questionnaires were unusable because a majority of the questions were left blank. Twenty questionnaires were returned as undeliverable and without a forwarding address. Thus, the usable response was 284 questionnaires received from a sample of 471 subjects, for an adjusted response rate of 60.3%. The adjusted response rate was for 65.5% (n=176) for Massachusetts and 57.9% (n=108) for Connecticut.

Demographics

The demographic data grouped by state are presented in Table 2. The majority of the respondents were female, had an entry-level bachelor degree, and stated that they attended three continuing education courses per year. The average age was 37.2 years (SD=10.4, range= 20-81). The mean number of years practicing physical therapy was 13.1 (SD=9.5, range=0-45). The majority of the respondents were staff-level therapists practicing in an outpatient orthopedic setting. The only demographic factor that differed between therapists in Massachusetts and Connecticut was the entry-level degree. More therapists in Massachusetts (n=23 [13.1%]) had an entry-level master's degree than did therapists in Connecticut (n=7 [6.5%]).

Table 2.
Demographic Data for Respondents(a)

                         Massachusetts   Connecticut   Overall
                         (n=175)         (n=108)       (n=283)
Age (y)
  X                      36.8            37.9          37.2
  SD                                                   10.4
  Range                                                20-81
Female [%)               82.9 (145)      79.6 (86)     81.7 (231)
Entry-level degree (%)
  Bachelor's             83.4 (146)      84.4 (91)     83.7 (237)
  Master's(b)            13.1 (23)        6.5 (7)      10.6 (30)
  Certificate             9.3 (6)         3.4 (10)      5.7 (16)
Highest degree (%)
  Bachelor's             61.7 (108)      61.1 (66)     61.5 (174)
  Master's               34.3 (60)       32.4 (35)     33.6 (95)
  Certificate             2.3 (4)         4.6 (5)       3.2 (9)
  Doctorate               1.9 (3)         1.7 (2)       1.8 (5)
No. of continuing
 education per year
  X                       3.0             2.7           2.9
  SD                                                    3.4
  Range                                                 0-50
No. of years in
 practice
  X                      13.1            13.2          13.1
  SD                                                    9.5
  Range                                                 0-45

(a) Absolute values shown in parentheses.

(b) Significant difference between states (chi-square analysis, P [is less than] .05, df=2).

Opinions About Career, Practice, and Direct Access

Opinions concerning how direct access affects patient care and the profession did not differ between the two states. The following data are combined from both states (all respondents). The majority of the therapists (96.4%) were satisfied with their career. More than 87% of the therapists indicated that they felt challenged in their current job position. Nearly 75% of the therapists supported direct access. Similarly, 73.6% of the therapists believed that direct access is important to the development of the profession. For 70.4% of the therapists, the decision to practice in a particular state was not influenced by the presence of direct access in that state. Fewer than 20% of the therapists reported that they believe entry-level education prepares students to practice direct access immediately after graduation. Fewer than 40% of the therapists stated that they believed communication with physicians would decrease while practicing under a direct-access mode of care. Only 38.2% of the therapists stated that they agreed that direct access would enhance patient care. Table 3 provides these data by state.

Table 3. Opinions About Career and Direct Access (Expressed as Percentages)

                              Massachusetts   Connecticut   Overall
                              (n=175)         (n=109)       (n=284)

Satisfied with career(a)
  Agree                          97.7            94.4        96.4
  Neutral                         1.7             4.7         2.9
  Disagree                        0.6             0.9         0.7
Challenged with career(a)
  Agree                          87.6            85.9        87.1
  Neutral                         8.9            12.7        10.0
  Disagree                        3.6             1.4         2.9
Support direct access(a)
  Agree                          77.7            70.4        74.9
  Neutral                        17.1            21.3        18.7
  Disagree                        5.1             8.3         6.4
Direct access enhances
 develop of profession(a)
  Agree                          70.3            78.7        73.6
  Neutral                        19.2             9.3        15.4
  Disagree                       10.5            12.0        11.1
Direct access influenced
 practice in particular
 state(a)
  Agree                           5.3            00.0         3.3
  Neutral                        28.4            22.9        26.3
  Disagree                       66.3            77.1        70.41
New graduate preparation(a)
  Agree                           9.2             3.7         7.1
  Neutral                        11.6             7.4        10.0
  Disagree                       79.2            88.9        82.9
Communication with
 physicians decreases(a)
  Agree                          13.8            15.0        14.2
  Neutral                        23.6            24.3        23.8
  Disagree                       62.6            60.7        62.0
Direct access enhances
 patient care(a)
  Agree                          38.2            38.3        38.2
  Neutral                        41.6            45.8        43.2
  Disagree                       20.2            15.9        18.6

(a) No significant difference between states (chi-square analysis, P [is less than] .05, df=4).

Direct Access Stipulations

Respondents were asked about seven stipulations regarding direct access (Fig. 1). Therapists in Massachusetts and Connecticut differed in their opinions on three of the stipulations (Fig. 1). Therapists in Connecticut expressed the belief that when treating patients with direct access, treatment plans must be periodically reviewed by a physician, therapists must have a minimum of 1 year of postgraduate experience, and therapists should be required to attend a standard number of continuing education courses in order to practice in a direct-access mode. The majority of therapists in both states (84%) believed that having a statement of competency from a physician to practice in a direct-access mode should not be a requirement for physical therapists practicing in states with direct access.

[Figure 1 ILLUSTRATION OMITTED]

Therapists' Clinical Experiences

Therapists in Connecticut and Massachusetts did not differ in their views about clinical experiences concerning initial assessment, treatment payments, and referral to and from health care practitioners. We therefore pooled the data from both states. Therapists reported that they made a physical therapy assessment or diagnosis an average of 76.6% of the time during an initial evaluation. Therapists stated that an average of 15.3% of interventions that they provided were not paid for by insurance carriers. The reported percentage of patients referred for physical therapy "evaluation and treatment" was 66.3%. The reported percentage of patients referred for physical therapy with a generalized medical diagnosis was 55.6%. Therapists stated they referred 14.9% of patients with already existing physician orders to other health care practitioners for further evaluation and treatment.

Direct Access Practices

Thirty-four percent of therapists surveyed in Massachusetts stated that they saw patients under direct-access conditions. These therapists indicated that 34.9% of their patients were seen without a physician's referral. The entire sample of therapists surveyed in Massachusetts stated that 8.8% of their patients were treated without a physician's referral. Of these patients seen without a referral, 12.4% were referred by the therapists to another health care practitioner. The therapists indicated that they practiced limited direct access for a variety of reasons. The two most frequent responses were employer policies (43%) and lack of reimbursement (30%) (Fig. 2).

[Figure 2 ILLUSTRATION OMITTED]

Discussion

Few differences were found when comparing demographic, educational, and employment data between therapists practicing in Massachusetts and Connecticut. A difference was noted in the entry-level degrees held by therapists in Massachusetts and Connecticut. This difference may have existed because, at the time of the study, there were more entry-level physical therapy master's degree programs in Massachusetts (n=4) than there were in Connecticut (n=0).

Contrary to our hypotheses, therapists practicing in Massachusetts did not appear to be more satisfied or more challenged by their careers than therapists practicing in Connecticut. In view of the low percentage of patients in Massachusetts being seen through direct access (estimated to be 8.8%), we believe that an effect on therapist satisfaction would be unlikely. In addition, the majority of therapists surveyed in both states reported being highly satisfied and challenged by their careers. Thus, finding a difference between the therapists in Massachusetts and the therapists in Connecticut may have been difficult because the high degree of satisfaction of the sample as a whole and the limited number of therapists who experienced practicing in a direct-access mode.

Although we hypothesized that the opinions concerning direct access of therapists in Massachusetts would be more positive than those of therapists in Connecticut, this was not the case. Therapists in both states were highly supportive of direct access. Likewise, the majority of the therapists surveyed (73.6%) agreed that direct access is important to the development of the profession. This percentage is higher than the percentage of therapists surveyed by Domholdt and Durchholz[5] in 1989 who believed that direct access benefited the profession (43.4%).

Although a majority of the physical therapists thought that direct access is important to the development of the profession, the majority indicated that the status of direct-access legislation did not influence their decision to practice in their respective states. The therapists surveyed also believed that entry-level education does not adequately prepare students to practice under direct access. The therapists identified deficiencies in educational curricula and lack of clinical education experiences as reasons why they believed new graduates are unprepared to practice in a direct-access mode. Therapists in both states stated that their knowledge as a new graduate was less than that of current graduates, making it difficult for them to assess whether new graduates are prepared to practice under direct access.

The results supported our hypothesis that therapists in Massachusetts would feel the need for fewer stipulations regarding direct access than therapists in Connecticut would. More therapists in Connecticut agreed that when treating patients through the use of direct access, treatment plans should be reviewed by physicians, therapists must have a minimum of I year of postgraduate experience, and therapists should attend a minimum number of continuing education courses each year to be eligible to practice under direct access.

More than one third (34.1%) of the physical therapists who were surveyed in Massachusetts indicated that they evaluated and treated patients through direct access. These therapists indicated that 34.9% of their caseload were treated without physicians' referrals. Domholdt and Durchholz[5] conducted a similar study in 1989 in which they surveyed therapists in North Carolina, Indiana, and Utah regarding direct access practices. Our data are in contrast to the findings of Domholdt and Durchholz,[5] who reported that 44.5% of their respondents practiced direct access, which accounted for 10.3% of their caseload. The entire sample of therapists in Massachusetts who we surveyed reported that 8.8% of their patients were treated through direct access, whereas 4.6% of the patients were seen in this manner in the study by Domholdt and Durchholz. Therefore, it appears that a smaller proportion of therapists in Massachusetts are practicing in a direct-access mode than those in the study by Domholdt and Durchholz. The percentage of patients treated by these therapists in Massachusetts without a referral is higher than the percentage found by Domholdt and Durchholz (8.8% versus 4.6%). We calculated this percentage from one item in the questionnaire, which is different from the derived mathematical estimate that Domholdt and Durchholz used to estimate their value (personal communication, 1997). Had we used their method to arrive at the percentage of patients seen under direct access, it would have been 11.9%. Both of our estimates (8.8% and 11.9%) are higher than the estimate of 4.6% reported by Domholdt and Durchholz and may be an preliminary indication that the percentage of patients seen under direct access had increased since the time of data collection in 1989. Therefore, our hypothesis that trends toward managed care would decrease the number of patients seen through a direct-access mode of practice was not supported.

When comparing our respondents' reasons for not practicing in a direct-access mode with those of the respondents in the study by Domholdt and Durchholz,5 several differences exist. The reasons for limited direct access as reported by Domholdt and Durchholz's respondents (lack of insurance reimbursement, no patients, and personal preference) were indicated less frequently by the respondents in our study. The therapists in our study indicated that they practiced limited direct access more frequently because of employer policies. Other reasons our respondents gave for not practicing in a direct-access mode included fear of malpractice, fear of alienating physicians, lack of diagnostic technology, and Medicare regulations.

Generalization of our results is limited because it appears that only one third of the therapists in Massachusetts who we surveyed were actually practicing under direct access. Therefore, our study was not a clear comparison between therapists practicing under direct access and those not practicing under direct access. Rather than using Connecticut (a state that permits evaluation but not treatment without referral), a better comparison between a direct-access state and a nondirect-access state could have been made using a state that does not permit either evaluation or treatment without a referral. Another limitation was that only APTA members were surveyed. Differences concerning direct-access issues may exist between therapists who are APTA members and therapists who are not APTA members because APTA is supportive of direct access. In addition, we made no efforts to obtain data from those therapists who did not respond initially. The respondents, therefore, may have been therapists with stronger feelings about direct access. We surveyed only therapists in two states in the Northeast, and their opinions concerning direct access may not represent the opinions of therapists throughout the nation. The final limitation of our study is that we did not inquire about the basis for the respondents' perceptions about new graduates' competence to practice in a direct-access mode. We therefore do not know whether the respondents were in touch with entry-level standards and practices.

Recommendations for Further Study

Further investigation is needed to examine whether new graduates feel the same as the respondents of this study (who had practiced an average of 13.1 years) regarding their lack of preparation to practice in a direct access mode immediately after graduation. In addition, further investigation might explore why the therapists in Connecticut who we surveyed more strongly favored stipulations limiting direct access. Opinions of therapists who are not APTA members concerning direct-access issues also should to be examined to determine whether this group is similar to the sample we surveyed. Reasons stated by respondents in this study for limiting directaccess practice need to be further investigated. Employer policies should to be scrutinized to determine the rationale for restricting direct-access practice. Reimbursement policies of insurance carriers need to be examined to determine whether direct-access physical therapy services are being paid for, and if not, why not. Assessment of direct-access practices in other states is needed to determine whether they are comparable to t the practices in Massachusetts described in this report. Finally, further research is needed to determine which, if any, physical therapy specialty areas are differentially utilizing direct access.

Conclusion

A random sample of APTA members in Massachusetts and Connecticut were surveyed, and 75% of the respondents supported direct access. Therapists in Connecticut (a state without full direct access) were more likely than therapists in Massachusetts (a direct-access state) to believe that stipulations were necessary to regulate direct access practice. Thirty-four percent of the respondents in Massachusetts reported that they practice in a direct-access mode. Only 8.8% of the patients seen by the therapists in Massachusetts who we surveyed were self-referrals. Therapists practicing in Massachusetts indicated that employer policies and lack of insurance reimbursement were the primary limits to the directaccess mode of care.

Acknowledgments

We express our gratitude to Frederick Markland and Linda Tsoumas for their assistance in this study. We also thank the therapists in Maine and Virginia who completed our pilot study and the APTA members in Massachusetts and Connecticut who responded to the survey.

(*) Course Technology Inc, One Main St, Cambridge, MA 02142.

References

[1.] Taylor T, Domholdt E. Legislative change to permit direct access to physical therapy services: a study of process and content issues. Phys Ther. 1991;71:382-389.

[2.] Direct Access to Physical Therapy. Alexandria, Va: American Physical Therapy Association, Division of Professional Relations; 1987. N

[3.] Rose SJ. Physical therapy diagnosis: role and function. Phys Ther. 1989;69:535-537.

[4.] Mitchell J, de Lissovoy G. A comparison of resource use and cost of direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10-18.

[5.] Domholdt E, Qurchholz AG. Direct access use by experienced therapists in states with direct access. Phys Ther. 1992;72:569-574.

[6.] State Licensure Reference Guide, 1997. Alexandria, Va: American Physical Therapy Association, Department of Practice; 1997.

[7.] Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1988.

KL Crout, PT, is Coordinator of Clinical Care, HealthAlliance-Fairlawn Nursing Center, 370 West St, Leominster, MA 01453 (USA) ([e-mail]). Address all correspondence to Ms Crout.

J Hodgkins Tweedie, PT, is Physical Therapist, Rehabilitation Services Department, St Mary's Regional Medical Center, Lewiston, Me.

DJ Miller, PhD, PT, is Associate Professor, Department of Physical Therapy, Springfield College, Springfield, Mass.

This study was approved by the Springfield College Institutional Review Board.

This project was funded in part by the Graduate School Research Fund, Springfield College.

This research was present in poster format at the Annual Meeting of the Massachusetts Chapter of the American Physical Therapy Association, October 14-19, 1994, Sturbridge, Mass, and at the 12th International Congress of the World Confederation for Physical Therapy, June 25-30, 1995, Washington, DC.

This article was submitted June 12, 1996, and was accepted July 30, 1997.