Cost-Effectiveness and Outcomes of Direct Access to Physical Therapy for Musculoskeletal Disorders Compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis

Hon S, Ritter RG, Allen DD. Cost-Effectiveness and outcomes of direct access to physical therapy for musculoskeletal disorders compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis. Physical Therapy. 2020;101(1). doi:10.1093/ptj/pzaa201

Link to Original Article: https://academic.oup.com/ptj/article/101/1/pzaa201/5999910

Key Points

- Direct access to physical therapy is a cost-effective alternative to physician-first access for patients with musculoskeletal disorders in the United States.

- Direct access reduces physical therapy costs, total health care costs, and the number of physical therapy visits compared to physician-first systems.

- Disability decreases in both direct access and physician-first groups, but functional outcomes improve significantly more with direct access.

- Direct access provides improved functional outcomes, increased patient satisfaction, and reduced health care utilization.

- Direct access allows physical therapists to provide evidence-based care and reduces the need for outdated interventions.

- Direct access to physical therapy is a viable and cost-effective option for spine-related musculoskeletal disorders in the US civilian health care system.

Introduction

Musculoskeletal disorders (MSDs) are prevalent in the United States, affecting 1 in 2 adults and driving a significant portion of healthcare visits. The direct and indirect costs of MSDs in 2012 were estimated to be $213 billion, or 1.4% of GDP. Traditionally, physicians have been the first point of contact for patients with MSDs. However, research suggests that patients who access physical therapy directly may achieve equal or better outcomes at a similar or lower cost.

Direct access to physical therapy has been successful in both domestic and international settings. In the US military, physical therapists have provided evidence-based care for MSDs with positive outcomes. The Wisconsin Physical Therapy Association found that physicians approved physical therapists' decision-making to begin physical therapy or refer to other professionals. In the United Kingdom, patients who visit physical therapists first have experienced reduced costs, improved outcomes, and patient-centered care.

Currently, all 50 states in the US have some form of direct access to physical therapy. Evidence suggests that earlier access to physical therapy is more cost-effective and reduces the burden of pain for patients. Other countries, such as Canada, England, the Netherlands, and Wales, also report improved patient function and reduced disability with direct access.

While critics raise concerns about overutilization and increased costs, evidence from non-military settings in the UK shows that effective evidence-based practice can reduce costs, improve outcomes, and decrease the use of prescription medication, MRI, and injections.

Systematic reviews have evaluated the cost-effectiveness and clinical outcomes of direct access to physical therapy in other countries but not in the US civilian healthcare system. The research hypothesis of the current study is that the costs of care, number of visits, and clinical improvements will not differ when patients have direct access to physical therapy compared to physician-first access.

Overall, evidence from other countries and the US military suggests that direct access to physical therapy can lead to lower costs, fewer visits, and greater clinical improvement in the management of MSDs in US non-military healthcare services.

Methods

Data Sources and Searches

The researchers conducted a systematic search of the current literature in multiple databases, including PubMed, CINAHL, Cochrane, and PEDro. They used a combination of terms such as direct access, self-referral, primary care, physical therapy, cost-effectiveness, outcomes, and prognosis to retrieve relevant articles. One researcher performed the initial searches, while another independently searched PubMed, the most productive database. The researchers screened the retrieved articles for irrelevance and duplication and then examined them based on predefined eligibility criteria. They also performed recursive searches by going through the references of the relevant articles. This comprehensive search strategy allowed the researchers to gather a wide range of information from various sources, ensuring a comprehensive view of the effects of direct access to physical therapy compared to physician-first access on healthcare costs and clinical outcomes in the US healthcare system for patients with musculoskeletal disorders.

Study Selection

The Study Selection section of the research paper outlines the criteria used to select relevant studies for analysis. The titles or abstracts of the articles needed to indicate referral sources for physical therapy in order to be considered. The inclusion criteria consisted of studies that reported extractable data on physical therapy for musculoskeletal disorders (MSDs) in US nonmilitary healthcare services. These studies needed to clearly specify whether they were examining direct access or physician-first access. The data reported in these studies needed to focus on visits, costs, or functional outcomes related to physical therapy.

The inclusion criteria also required that the studies compared "open referral" (physical therapist-directed treatment) to physician-prescribed physical therapy treatment. It is important to note that physical therapist-directed treatment is a critical component of direct access, but the presence of physician-first referral in both conditions may have diluted the effects. On the other hand, studies that only considered early or delayed access compared to physician-first access were excluded from the analysis.

In summary, the study selection process aimed to identify studies that focused on physical therapy for MSDs in US nonmilitary healthcare services. The studies needed to clearly indicate whether they examined direct access or physician-first access and report data on visits, costs, or functional outcomes related to physical therapy. Studies comparing open referral to physician-prescribed treatment were included, while those examining only early or delayed access were excluded.

Data Synthesis and Analysis

The Data Synthesis and Analysis section of the research paper involved extracting means and standard deviations from individual articles. Between-group effect sizes, variances, and 95% confidence intervals were calculated for each variable. This allowed for the combination of functional outcomes reported in different units and ensured consistent weighting of individual studies. Effect sizes and variances were also calculated for costs and visits to enable easier comparison.

Within-group effect sizes were calculated for functional outcomes when direct between-group comparisons were not available within studies. Fixed-effect models were used to combine data for each variable if the Q heterogeneity statistic had a p-value greater than 0.05. Random-effects models were used when the p-value was less than 0.05.

After the meta-analysis, the combined effect sizes were converted back to the natural units of the representative outcome measures for better interpretability.

In summary, this section details the methods used to analyze the data by calculating effect sizes, variances, and confidence intervals for each variable. It explains the use of fixed- and random-effects models depending on the heterogeneity of the data. The section also discusses the conversion of effect sizes to natural units for easier interpretation of the results.

Results

Study Selection

The study conducted a systematic review and meta-analysis of studies on the effects of direct access to physical therapy compared to physician-first access on healthcare costs and clinical outcomes in patients with musculoskeletal disorders (MSDs) in the US. The preliminary search yielded 32 studies in PubMed, 7 studies in CINAHL, 11 studies in the Cochrane database, and 2 studies in PEDro. After removing irrelevant and duplicate articles, recursive searching identified additional studies to review. Four relevant systematic reviews were excluded due to lack of US data or mixed data from other countries. Ultimately, 5 studies met the eligibility criteria and were included in the review. All 5 studies were retrospective cohort studies with level 2b evidence. One study compared open-referral to physician-prescriptive referral to physical therapy, while three studies compared direct access or open-referral physical therapy to physician-first access. One study only examined physician-first access, and another study only examined direct access. Functional outcome measures, cost information, and the number of physical therapy visits were reported in varying degrees across the studies. The Oswestry Disability Index and Neck Disability Index (ODI/NDI), Roland-Morris Disability Questionnaire (RMQ), and Overall Health Status (OHS) were used as functional outcome measures, with lower scores indicating improvement. OHS effect sizes were converted to negative numbers for consistency. The RMQ was selected as the representative outcome measure for converting effect sizes back to natural units after meta-analysis.

Outcome Effect Size (95% CI)

The research paper evaluated the effects of direct access to physical therapy compared to physician-first access on healthcare costs and clinical outcomes for patients with musculoskeletal disorders (MSDs) in the US healthcare system. The study included data from other countries and the US military, and it examined the expectations of lower costs, fewer visits, and greater clinical improvement with direct access in non-military US healthcare services.

The study found that within the direct access group, there was a larger effect size for function improvement from baseline to discharge compared to the physician-first access group (-1.78 vs. -0.89). However, when comparing the two groups, there was no significant difference in function at discharge (-0.14).

In terms of healthcare costs, the study found that total cost and physical therapy cost were lower in the direct access group compared to the physician-first access group (-0.19 and -0.23, respectively). Additionally, the number of physical therapy visits was also lower in the direct access group (-0.17).

The study included referral sources such as primary care, specialist, and occupational medicine physicians. The functional status of patients was assessed using OHS scores at the initial and final physical therapy visits. The authors reported an average of 7.4 physical therapy visits with physician-first access.

It is important to note that the study did not directly compare physical therapy direct access with physician-first access. Two other studies by Denninger et al. and Green et al. were referenced, but their findings did not contribute to the direct comparison between the two access models.

Summarizing Across Studies

The researchers calculated effect sizes for each variable in individual studies comparing direct access to physical therapy with physician-first access. A small effect size was found for reduction of disability, with no significant difference between the two approaches. However, when looking at functional improvements, a large effect size was found for direct access, indicating significant improvement in patients' functional outcomes. On the other hand, using physician-first access also showed a large effect size for functional improvement but to a lesser extent than direct access. The difference in functional improvements between the two groups was found to be significant. The researchers utilized the available data from different studies to calculate these effect sizes and compared them indirectly using a z test. The results suggest that direct access to physical therapy can lead to greater functional improvements in patients compared to physician-first access. However, there was no significant difference in reducing disability between the two approaches. These findings support the expectation of greater clinical improvement with direct access in non-military healthcare services in the US and align with the evidence from other countries and the US military, which also showed positive outcomes with direct access. These results have implications for healthcare costs and suggest that direct access may lead to fewer visits and lower healthcare costs for patients with musculoskeletal disorders.

Physical Therapy Cost

Two studies comparing physical therapy cost data found that direct access to physical therapy resulted in lower costs compared to physician-first access. The meta-analysis showed a significant, small effect size favoring direct access, with an average cost reduction of $242.63 per patient. In terms of total health care costs, data from two studies also showed that direct access was associated with lower costs compared to physician-first access. The grand effect size for total health care costs was small but significant, with an average cost reduction of $1828.03 per patient. These findings suggest that direct access to physical therapy can lead to cost savings in both physical therapy and total health care costs.

Number of Physical Therapy Visits

The research paper examined the effects of direct access to physical therapy compared to physician-first access on healthcare costs and clinical outcomes for patients with musculoskeletal disorders (MSDs). In terms of the number of physical therapy visits, three studies were included in a meta-analysis. The outcomes reported were homogeneous, indicating that a fixed-effect model was appropriate. The meta-analysis found a statistically significant, small grand effect size for the number of visits, favoring direct access. In clinical terms, direct access reduced the number of physical therapy visits by 1.01 visits per patient, compared to physician-first access. The range of reduction in visits per patient ranged from 0.30 to 1.72. This suggests that direct access to physical therapy leads to a decrease in the number of visits required for patients with MSDs.

Harm or Risk

In the research paper, the authors examined the potential harm or risk associated with direct access to physical therapy compared to physician-first access for patients with musculoskeletal disorders (MSDs) in the US healthcare system. Only one study specifically addressed this topic. The study by Denninger et al. reviewed post-discharge medical chart entries and identified any claims review, emergency visits, or ICD-9 codes indicating traumatic injury.

The findings of the study showed that there were 4 referrals made to orthopedic surgeons for hip osteoarthritis or other non-spine-related findings, and 1 referral to primary care for an ultimate oncologic diagnosis. However, no incidents of missed diagnoses or delays in care were attributed to physical therapist clinical decision making or direct access.

It is worth noting that the other studies included in the research paper did not mention any adverse events or harm associated with direct access to physical therapy. This suggests that there is a lack of evidence indicating significant harm or risk with this approach.

Overall, the available evidence from the included study and other studies suggests that direct access to physical therapy does not lead to increased harm or risk for patients with MSDs. However, it is important to note the limitations of the research, as the evidence base on this specific topic is limited. Further research is needed to fully understand the potential harm or risk associated with direct access to physical therapy in the US healthcare system.

Discussion

This systematic review and meta-analysis examined the effects of direct access to physical therapy compared to physician-first access on functional outcomes, physical therapy costs, total healthcare costs, and the number of physical therapy visits for patients with musculoskeletal disorders (MSDs). Five studies were included, and the quality of evidence was rated moderate to good. The pooled data showed statistically significant between-group effects favoring direct access for physical therapy costs, total healthcare costs, and the number of physical therapy visits. Within-group analysis revealed significant reductions in disability for both direct access and physician-first groups, with greater reductions for the direct access groups. Functional outcome data analysis showed better functional improvement for people in direct access groups compared to physician-first groups. The findings also suggest that direct access is more cost-effective at the clinical and healthcare level, with significant cost savings in physical therapy costs and total healthcare costs per patient. These findings are consistent with previous literature from other countries and the US military. One mechanism for cost savings is the reduction in the number of physical therapy visits, which counters the argument that physical therapists may take longer to assess patients via direct access. Another proposed mechanism is the autonomy of physical therapists to implement evidence-based interventions. The functional improvements observed in both access models exceeded the minimum clinically important difference (MCID). Overall, direct access to physical therapy may have important economic effects on US healthcare services. Further research is needed to explore the specific mechanisms underlying these findings and to investigate the MCID values for costs and number of visits.

Implications for Clinical Practice

The research paper suggests that direct access to physical therapy may lead to cost savings in physical therapy and overall healthcare costs, while also improving functional outcomes for patients with musculoskeletal disorders (MSDs). The findings support the idea that direct access is a more efficient and cost-effective approach for patients with spine-related MSDs. This could lead to increased awareness and acceptance of direct access in both institutions and among patients, ultimately benefiting the US economy.

Although direct access has benefits, there is a concern about potential misdiagnosis by physical therapists, which could harm patients. However, no study in the research reported any harm related to receiving care through direct access. Physical therapists are trained to perform differential diagnosis, identify red flags, and refer patients to physicians when necessary, whether in military or nonmilitary settings. Current doctoral-level education requirements for physical therapists include courses that integrate differential diagnosis and clinical decision-making. The integration of in-depth courses on primary care provision in the current curriculum could further enhance the ability of physical therapists to confidently refer and treat patients.

In summary, the research supports the use of direct access to physical therapy for patients with MSDs. It suggests that this approach can lead to cost savings, improved functional outcomes, and greater understanding and acceptance of direct access in healthcare. While there is a concern about potential misdiagnosis, physical therapists are equipped with the necessary training to identify and refer patients when needed. Further incorporating primary care provision courses in the curriculum can enhance the abilities of physical therapists in this regard.

Limitations

The limitations of this systematic review and meta-analysis are as follows. Firstly, only five studies were eligible for inclusion in the meta-analyses, spanning from 1997 to 2019. These studies utilized patient registry and claims-based data to analyze functional outcomes, costs, and number of visits. Two of the studies had overlapping samples drawn from the same database, and only one study was used for any separate meta-analysis. The inclusion of open-referral data had limitations and benefits. It could have contaminated the direct access effects with physician-first influences, but it also facilitated the observation of similar effects from physical therapist-directed treatment. However, the inclusion of this study did not appreciably change the effect sizes and confidence intervals.

There were several factors that were not adequately addressed in the studies. Nonphysician or DO referral to physical therapy, physical therapist practice ownership, and potential effects of an evolving policy environment on cost or function were not discussed. Additionally, the primary diagnoses in the included studies were limited to spine-related musculoskeletal disorders, and future studies should examine the effects of direct access for other conditions. One study did not provide enough data to calculate effect sizes directly, so estimations were made based on reported p-values.

In conclusion, although this study has limitations such as the limited number of articles, variable definitions, and limited information on relevant factors, the meta-analyses still yielded homogeneous effects and significant effect sizes. However, these findings should be interpreted considering the limitations and the need for further research in other areas.

Directions for Future Research

The research paper suggests that direct access to physical therapy can be a cost-efficient and effective alternative to physician-first access for patients with musculoskeletal disorders (MSDs) in the United States. While direct access is still met with resistance, future research should conduct randomized controlled trials (RCTs) in the US to determine the causal relationship between direct access and improved clinical outcomes and cost-efficiency.

The paper also suggests that future research should investigate possible differences in functional outcomes, costs, and number of physical therapy visits for different body regions of MSDs, including extremities. Additionally, including nonspinal MSDs along with spine-related MSDs could provide a more comprehensive understanding of how direct access to physical therapy impacts the US healthcare system and economy.

The meta-analysis of data from five studies shows that direct access to physical therapy leads to improved functional outcomes, lower healthcare costs, and fewer physical therapy visits for patients with spine-related MSDs. No adverse effects were reported. These findings support the idea that direct access to physical therapy is a cost-effective alternative for patients with spine-related MSDs, offering greater improvement compared to accessing physical therapy services after a physician referral.

In summary, the research paper highlights the benefits of direct access to physical therapy for patients with MSDs in the United States. It suggests that future research should further investigate the causal relationship between direct access and improved clinical outcomes and cost-efficiency. The findings indicate that direct access results in improved functional outcomes, lower costs, and fewer visits for spine-related MSDs, supporting its viability as a cost-effective healthcare access alternative.