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, Stevens A. Kelly An official website of the United States government. We used the Oxford 2011 Centre of Evidence-Based Medicine (CEBM) recommendations to rate each article's level of evidence16 and the Downs and Black checklist17 to assign a methodological quality score to each article because all of our included studies were nonrandomized. Moore and colleagues10 retrospectively compared harm between direct access and physician referral groups. We can refer to specialists, insurance is the only problem but if they came to you and required a referral for specialists they would need a PCP appt to see you. The term direct access, in this report, will be defined as patients seeking physical therapy care directly without first seeing a physician or physician assistant to receive a script or referral for physical therapy services. Conclusion: Epub 2005 Jun 1. The following review of the literature presents the current arguments over direct access to physical therapy including (1) the current usage and reimbursement of services, (2) legislative actions relating to Medicare and direct patient access to physical therapy, and (3) the efforts 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. 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). Findings include the influence of direct access on the health care system: cost-benefit analysis, advantages and challenges, as well as the perspective of main stakeholders: physicians, physical therapists and patient-clients. We have attached a chart it prepared on the topic (Attachment 1). Furthermore, physical therapists may require referrals from medical providers due to legal constraints, third-party payer requirements for reimbursement, and hospital bylaws. Now that Direct Access is a reality it will be up to all of us to make the public aware of the change in the law. , Bruinvels DJ, Elbers NA, et al. L If this happens . 2. 2022 Mar 17;23(1):260. doi: 10.1186/s12891-022-05201-3. A point was awarded if the study specifically stated that those assessing the outcome measures were unaware of (or would have no way of knowing) whether the patients were in the direct access or physician referral group. If the authors in prospective studies reported nonadherence to physical therapy intervention or adherence could not be determined, the study was not awarded a point. government site. Pts with msk injuries from 26 general practices, Fewer GP contacts 3 mo after physical therapy, VAS score decreased from 5.7 (SD=2.3) to 2.7 (SD=1.7), More GP contacts 3 mo after physical therapy, VAS score decreased from 5.7 (SD=2.2) to 3.2 (SD=1.6), Pts with msk injuries from 26 general practices throughout Scotland, Average cost per episode of care 66.31 (136.02), Average cost per episode of care 88.99 (138.26), Pts with msk injuries from 26 general practices, Acute/sporadic msk- related disorders, adults aged <65 y and their children, BCBS, PTs at private practices listed in a database: specialist, Adults (1864 y) treated in outpatient clinics (private or hospital based) on private, Mean allowable amounts: PT=$503.12 (SD=$478.18), non-PT=$526.26 (SD=$1,448.95), Mean allowable amounts: PT=$605.49 (SD=$549.61), non-PT=$678.64 (SD=$1,744.11), One level 3 study and 2 level 4 studies showed significantly decreased cost in the direct access group vs the physician referral group; 1 study (level 3) did not report significance, but reported means show a large effect size, 3 level 4 studies and 1 level 3 study showed significantly decreased visits in the direct access group vs the physician referral group; 2 studies (levels 2 and 3) showed no significant differences between groups, 3 studies (2 level 3 studies, 1 level 4 study) showed significantly more use of pharmacological interventions in the physician referral group vs the direct access group, All 3 studies (2 level 3 studies, 1 level 4 study) showed significantly increased imaging ordered in the physician referral group vs the direct access group, General practitioner, consultation services, or hospital admits, 2 studies (1 level 3 study, 1 level 4 study) showed significantly fewer GP visits after physical therapy discharge and significantly fewer hospital admissions during physical therapy care; 2 studies (both level 3) showed no difference between groups, 2 studies (level 3) reported significantly greater satisfaction in the direct access group vs the physician referral group, Discharge outcomes (function/ goals) and harm. Ovid MEDLINE, CINAHL (EBSCO), Web of Science, and PEDro were searched using terms related to physical therapy and direct access. A point was awarded if inclusion or exclusion criteria, or both, were indicated. 09/04/97 Nancy Brinly, PT Deborah Tharp, PT Executive Secretary Chairman . , Hendershot GE, Marano MA. The focus of this paper was to investigate direct access to physical therapy which includes both evaluation and . However, in this report, the terms direct access and open access seem to have been defined as expeditious physical therapy referrals from generalist physicians, such as on-demand physical therapy clinics, which reflects a gatekeeping model, with the GP initiating the physical therapy referral. The allowable amount, also known as the allowable fee, the maximum allowable fee, or the usual, customary, and reasonable fee (Blue Cross Blue Shield 2011) is a proxy for health care cost and is defined as the total amount of physical therapy benefit for the physical therapist services and procedures billed regardless of member responsibility or the contractual relationship between the payer and the provider of physical therapist services. 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. Although all 50 states, D.C., and the U.S. Virgin Islands all enjoy a form of direct access to physical therapist services, provisions and limitations vary among jurisdictions. A point was not awarded it the main outcome to be measured was first mentioned in the "Results" section. Opioid side effects include depression, overdose, addiction, and withdrawal symptoms. There is no evidence that self-referral to physical therapy puts patients at increased risk. September 21, 2022 by Alexander Johnson. Webster et al14 showed 5% more of the participants in the direct access group were satisfied or very satisfied (P<.001). Please enable it to take advantage of the complete set of features! The validity of studies using a between-group comparison was evaluated by 2 authors not blinded to authors or journals. Identify physical therapist services/procedures through billing codes for services (ie, CPT codes 9700197999 and revenue code Y42xx) and provider specialty type for physical therapist. CA Study Characteristics and Results of Included Studiesa. Abstracts of initially identified articles (n=1,501) were screened for eligibility. Publication types English Abstract MeSH terms Cost-Benefit Analysis Delivery of Health Care / economics In this study, significantly less average pain was reported at discharge (the direct access group decreased 3 points on the visual analog scale and the physician referral group decreased 2.5 points on the visual analog scale) (P=.011), although we question whether this is a clinically meaningful finding. Despite . We developed guidelines, specific to our study type, to improve agreement between raters (Appendix 1). Would Moving Forward Mean Going Back? 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. It is found that with direct access, patients who are self-referred have fewer physical therapy visits decreased allowable amounts. SRK When defining whether the physical therapy episode of care could reasonably be considered initiated by a physician or not in the 30-day window prior to the first physical therapist evaluation visit, disregard diagnoses reported on the physician claims because a patient might see a physician for one problem and request a physical therapy referral at that time for an unrelated medical issue. G Hackett et al15 reported a mean difference of approximately 38 ($59) less cost* per patient among those who incurred costs from physical therapy (P<.01; 95% confidence interval=12.41, 63.65); however, this finding was largely because the referral practice had a high percentage of patients who received private physical therapy treatments (description of private physical therapy not fully explained in the article). File activity specifies percent of actual records which proceed in a single run. Physical Therapy has been a top chosen profession since . Data Synthesis. It represents a new model of care, which might lead to improve patients' health status and decrease cost services for healthcare compared with a secondary care referral pathway. The requirement that a physical therapist have a practitioner of record review and sign a plan of treatment does not apply when a patient has been physically examined by a physician licensed in another state, the patient has been diagnosed by the physician as having a condition for which the physical therapy is required, and the physical Was an attempt made to blind study participants to the intervention they received? EW The advantages and disadvantages of using technology in hand injury evaluation. All studies were independently scored using a modification of the Downs and Black tool17 by 2 reviewers (H.A.O. 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. Finishing treatment in fewer visits results in less therapy copays and more savings in your pocket. 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. Texas Direct Access Law Loopholes What new medical bill would be complete without a few stipulations and loopholes? Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Was an attempt made to blind those measuring the main outcomes of the intervention? Your doctor, after a lengthy period of time, may even end up referring you to . J MeSH Finally, although Holdsworth et al13 did not run statistical analyses, patients in the direct access group had approximately 22 ($34) less cost (not including cost to patients), which we extrapolated would amount to an average cost benefit to the National Health Service of Scotland of approximately 2 million per year ($3,107,400). The purpose of this study was to establish the effects of direct access and physician-referred episodes of care in individuals receiving physical therapy based on a systematic review of peer-reviewed literature. In contrast, in our review, we investigated a group of physical therapists, the majority of whom were not practicing in advanced practice roles (7 out of 8 studies exclusively focused on physical therapists without any special training reported who largely held master's or bachelor's degrees), and still found advantages in terms of treatment effectiveness, use of resources, economic costs, and patient satisfaction over initial physician care. May 3, 2020 / Article. Direct selection. In fact, with direct access PT, studies support fewer number of PT visits and quicker recovery. 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). Cost Savings - Direct access eliminates unnecessary physician visits and copays. E Downs Mitchell and de Lissovoy9 reported the largest mean difference, with the direct access group using 20.2 visits compared with the physician referral group using 33.6 (P<.0001); however, this study was conducted in 1997, so it might not reflect more recent practice patterns. Grooving evidence suggests that patients could have Direct Access (DA) to physiotherapy. Pendergast Background Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system . These observations are consistent with prior individual studies that collectively support improved outcomes for patients and decreased costs associated with earlier initiation of physical therapy clinical management.2326 Between-cohort differences in each study were generally small in magnitude; however, they could result in meaningful optimization of patient outcomes and decreases in costs when distributed over the large US health care environment. Harm was not reported in the majority of the studies; however, one large-scale study examining military physical therapists showed no harm when individuals received direct access physical therapy. Methods: Furthermore, health care costs vary substantially across countries, thus cost savings and expenditure cannot be generalized. Functional evaluation, diagnosis, impairment calculations and data storage are easy to perform. A point was not awarded if at least one of the primary outcome measures in the study was not valid or reliable or if this information was not reported or could not be determined (ie, a questionnaire without reported validity or reliability). Patients were determined to be representative if they comprised the entire source population, an unselected sample of consecutive patients, or a random sample (only feasible where a list of all members of the relevant population exists). For the purposes of this review, this question was omitted due to reasons previously stated. Home safety. Primary limitations were lack of group randomization, potential for selection bias, and limited generalizability. JH The https:// ensures that you are connecting to the For studies where the effect of any nonadherence was likely to bias any association to the null, the study received a point. The mean NOS score for study quality was 6.4 1.4 out of a possible total score of nine points. A point was awarded if quantitative data were reported for all of the main outcome measures indicated in the introduction or "Method" section. Please check for further notifications by email. Direct Access to Physical Therapy 5 . The relevance of a systematic review at this time is that additional scientific weight can be provided to guide the physical therapist's role in health care reform and serve as a concise report to improve the ability of consumers, legislators, hospital administrators, and third-party payers to synthesize the existing literature and make conclusions regarding the quality and cost-effectiveness of primary access physical therapy. Conclusions Physical therapy by way of direct access may contain health care costs and promote high-quality health care. Click here to see where your state stands on Direct Access according to the APTA, or call your nearest Phoenix Physical Therapy clinic and ask. Direct access is the removal of the physician referral. Dependent variable measurements and data reporting were so heterogeneous that data could not be pooled through meta-analytic procedures. The consistent results identified across the several moderate-quality studies included in this systematic review may form a solid basis for policy and payment decisions that would facilitate delivery of physical therapist services through direct access.8,9,1115,28 Some form of direct access to physical therapist services is currently available by statute in 47 out of 50 states (United States),29 as well as internationally.8,15 However, self-referral accounts have been estimated to account for as little as 6% to 10% of referral volume30 in some direct access states. #3: Patient satisfaction scores are higher. . A point was awarded when participants from both direct access and physician referral groups were recruited from the same population. 2010 Dec;8(4):256-8. doi: 10.1111/j.1744-1609.2010.00177.x. Included studies compared data from physical therapy by direct access with physical therapy by physician referral, studying cost, outcomes, or harm. , Childs JD, Wainner RS, Flynn TW. We decided that criterion 17 (In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients, or, in case-control studies, is the time period between the intervention and outcome the same for cases and controls?) was not a good evaluation of quality because the follow-up period in many studies was initial evaluation to discharge, which was influenced by one of our primary outcome measures (number of physical therapy visits). Where a study red not report the proportion of the source population horn which the patients are derived, the question was answered as unable to determine. Health care use can be measured by the number of physical therapy visits per episode of care and the total allowable amounts per visit and for the episode extracted from the claims data. Are the main outcomes to be measured clearly described in the introduction or "Method" section? There was no evidence for harm. Mitchell and de Lissovoy9 found that paid claims per episode of care were $1,232 less in the direct access group for all services and drugs per episode of physical therapy care (P<.001). To contact our billing office call (888)644-7747. DA showed less number of physiotherapy treatments, visits to physician, imaging performed and required fewer non-steroidal anti-inflammatory drugs and secondary care. Some injuries are, after all, more severe than others; a broken leg, for instance, requires more than just physical therapy. 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. Any differences in rating were resolved through consensus. Old tape drives use sequential access while hard drives use direct access to read and write to files. All 3 studies 9,13,15 investigating imaging showed significant differences between groups. Direct Access to Physical Therapy In order to provide physical therapy without a prior referral, a physical therapist must meet the requirements of Tenn. Code Ann. Aggressive Vertebral Hemangioma and Spinal Cord Compression: A Particular Direct Access Case of Low Back Pain to Be Managed-A Case Report. , Webster V. Holdsworth 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. Opioid's side effects include depression, overdose, addiction, and withdrawal symptoms. , Black N. Chudyk 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. Achieving direct access has been a major initiative for APTA and its chapters. Verify that all physical therapy visits occurred in a physical therapy office or in a hospital-based outpatient facility setting. , Nilsson B, Moller M, Gunnarsson R. Desmeules One of the main beefs surgeons and physicians have with patients skipping a doctor's referral and heading straight to a physical therapist is the risk of injury or an overlooked diagnosis. Identify the ending date as the last physical therapy claim before a 60-day window with no further physical therapy claims (any second initial evaluation within that episode was considered a re-evaluation rather than the start of a new episode). No point was awarded if the study did not report the number of patients lost to follow-up or this information could not be obtained from the tables, figures, or text of the study. Criterion 27 (Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance is less than 5%?) also was not scored because we consulted a statistician who believed that significance found should not be influenced by post hoc power analyses and a difference between groups is either significant or not at study end, regardless of how much power was assumed a priori.21 The maximum score on the scale was 26, as one item had a potential of 2 points and we omitted 2 criteria (Tab. Careers. Currently 30 states (see Table 1) permit both physical therapy evaluation and treatment through direct access (APTA, Govt Affairs Dept, 1992). There is evidence across level 3 and 4 studies (grade B to C CEBM level of recommendation) that physical therapy by direct access compared Avoiding trips to multiple doctor's offices can save you, your insurance company, and the health system money. It saves time and can be repeated. Unable to load your collection due to an error, Unable to load your delegates due to an error. . Hackett et al15 showed 9% more of the participants in the direct access group evaluated management of their condition as average or above average, although it was difficult to conclude whether the level of significance (P<.01) would have been the same if only direct access and physician referral groups were compared because the study ran these tests among 3 groups (including one group for which data was not extracted). was kappa=.931 (P<.001; Cohen kappa.025 standard error). All the three methods have their own advantages and disadvantages as discussed below: 1. The direct access, as opposed to the indirect access which requires a referral from a general physician, has several merits including better quality, timeliness, cost effectiveness of treatment and better probability of preventing acute conditions from turning into chronic ailments. 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. The studies were appraised using the Centre for Evidence-Based Medicine (CEBM) levels of evidence criteria and assigned a methodological score. 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. and R.S.S.) Accessibility FOIA More health care providers are offering to "see" patients by computer and smartphone. Were the staff, places, and faculties where the patients were treated representative of the treatment the majority of patients receive? HHS Vulnerability Disclosure, Help A systematic review was carried out through MEDLINE, CINAHL, and EMBASE databases from their inceptions until March 2018 using keywords related with DA. , Goss DL, Baxter RE, et al. The chart indicates that 33 states allow direct access to physical therapists for both evaluation and treatment. 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. Physical therapy visits per episode of care (mean across all patients). Titles and abstracts were screened by the authors (H.A.O. The potential benefit of direct access to physical therapy in other practice settings should be further explored, as well as alternate pathways for providing health services that take advantage of the safety, efficacy, and cost-effectiveness of direct access physical therapy. None of the studies which met our criteria were randomized; 4 were nonrandomized prospective cohort studies, and 4 were nonrandomized retrospective cohort studies. For the purposes of this evidence-based review, this question was omitted. Epub 2022 Sep 2. All searches were restricted to 1990 to present because we wanted to specifically focus on more recently published literature to improve generalizability of results, reflecting changes in modern practice patterns and updated interpretations of the search terms direct access and open access. We searched the databases using combinations of the key words direct access, primary care, physical therapy, physiotherapy, and open access. In addition to these key words, we searched Ovid MEDLINE (1990 and later) using a comprehensive list of Medical Subject Headings (MeSH) terms related to our topic. Patients who want insurance to help pay for their . In the United States, the Commission on Accreditation in Physical Therapy Education (CAPTE) criteria support the ability of all physical therapists to engage in the delivery of physical therapy through direct access. was not awarded if a study made no mention of the presence or absence of adverse events (eg, loss of license of a therapist, minor or serious side effects of intervention) in the direct access or physician referral groups. PF The site is secure. Please check with your insurance company to determine if you can use your benefits to cover direct access for physical therapy care. Copyright 2023 American Physical Therapy Association. 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. Direct access means the removal of the physician referral mandated by state law to access physical therapists' services for evaluation and treatment. If an individual had multiple physical therapy episodes of care in the identified time frame, randomly select an episode for inclusion in the analysis. Request an initial evaluation appointment by filling out the form below or calling (713) 521-0020 or (888) 301-8477.