Abstract
Background Direct access to physical therapist services is available in all 50 states, with reported benefits including reduced health care costs, enhanced patient satisfaction, and no apparent compromised patient safety. Despite the benefits and legality of direct access, few data exist regarding the degree of model adoption, implementation, and utilization.
Objectives The purposes of the study were: (1) to investigate the extent of implementation and utilization of direct access to outpatient physical therapist services in Wisconsin hospitals and medical centers, (2) to identify barriers to and facilitators for the provisioning of such services, and (3) to identify potential differences between facilities that do and do not provide direct access services.
Design A descriptive survey was conducted.
Methods Eighty-nine survey questionnaires were distributed via email to the directors of rehabilitation services at Wisconsin hospitals and medical centers. The survey investigated facility adoption of the direct access model, challenges to and resources utilized during model implementation, and current barriers affecting model utilization.
Results Forty-seven (52.8%) of the 89 survey questionnaires were completed and returned. Forty-two percent of the survey respondents (20 of 47) reported that their facility offered direct access to physical therapist services, but fewer than 10% of patients were seen via direct access at 95% of the facilities offering such services. The most frequently reported obstacles to model implementation and utilization were lack of health care provider, administrator, and patient knowledge of direct access; its legality in Wisconsin; and physical therapists' differential diagnosis and medical screening abilities.
Limitations Potential respondent bias and limited generalizability of the results are limitations of the study. These findings apply to hospitals and medical centers located in Wisconsin, not to facilities located in other geographic regions.
Conclusions Respondents representing direct access organizations reported more timely access to physical therapist services, enhanced patient satisfaction, decreased organizational health care costs, and improved efficiency of resource utilization as benefits of model implementation. For organizations without direct access, not being an organizational priority, concerns from referral sources, and concerns that the physician-patient relationship would be negatively affected were noted as obstacles to model adoption.
Direct access (the legal right to seek and receive the examination, evaluation, and intervention by physical therapists without the requirement of physician referral) is now available for many patients in all 50 states, with Nebraska being the first state to adopt such practice privileges in 1957 and Michigan being the most recent state to add the treatment component (2014).1 In addition, US military physical therapists have provided direct access services since the early 1970s.2 Numerous studies published since 1975 have reported the benefits of this health care delivery model, including reduced health care costs, enhanced patient satisfaction, and no apparent compromised patient safety.2–7
Besides these publications, recent studies have described the impact of early utilization of physical therapist services for patients with common musculoskeletal conditions. Fritz et al8 reported that patients with low back pain who received physical therapist services within 14 days of the primary care physician consultation had episodes of care associated with lower costs by an average of $2,736.23. Lower costs were coupled with decreased ordering of advanced imaging, additional physician visits, surgery, injections, and opioid medications.8 Gellhorn et al9 reported decreases in likelihood of subsequent lumbar surgery, lumbosacral injections, and back pain–related physician visits for patients with low back pain receiving physical therapist services within 4 weeks of the initial physician visit. Although early access to physical therapist services is not synonymous with direct access, this model provides the most direct route for patients seeking care from a physical therapist.
Despite availability by law and the apparent benefits of direct patient access to physical therapist services, few data are available regarding the degree of model adoption in the public sector (nonmilitary institutions). The data that do exist suggest underutilization, provide little information regarding obstacles to model implementation, and appear limited to surveys of clinicians rather than of administrators. In 1992, Domholdt and Durchholz10 surveyed physical therapists practicing in North Carolina, Nevada, and Utah, providing the first description of direct access service delivery in the United States. Twenty-five percent of the respondents reported not seeing any patients without a physician referral, and overall it was estimated that only 4.6% of all patients seen accessed the therapists' services within the direct access model.10 In 1998, Crout et al11 surveyed physical therapists in Massachusetts and Connecticut regarding opinions and practice associated with the direct access model and reported an estimate of only 8.8% of patients seen without physician referral. In 2012, McCallum and DiAngelis12 provided the most recent description of physical therapist opinions and utilization of direct access practice, reporting that therapists working in Ohio estimated that 1% to 10% of their caseload included patients seen without a physician referral. In all 3 studies, physical therapists reported that employers not permitting direct access practice and a lack of insurance reimbursement were the primary barriers to implementation of the direct access model.10–12 Although prior research noted institutional resistance to model implementation, there is inherent bias in survey-based studies limited to clinician viewpoints. We are not aware of published data that represent administrators' opinions regarding the delivery of direct access physical therapist services.
An additional barrier exists in many states for delivery of direct access services in hospital settings: state government administrative codes that supersede physical therapist practice act language.13 For example, the state of Wisconsin Administrative Code for Wisconsin hospitals contains language reflecting Centers of Medicare and Medicaid Services guidelines. The Wisconsin Physical Therapy Association (WPTA) received an opinion from the State Department of Health and Family Services stating that hospitals could implement a direct access policy, authorized by their medical staff, designating physical therapists as “allied health personnel” who could order outpatient physical therapy for patients not receiving Medicare or Medicaid.14 In response to this opinion, the WPTA created an Autonomous Practice Task Force in 2007 charged with creating resources to assist Wisconsin hospitals and medical centers in implementing a direct access practice model. Since then, 32 facilities have adopted the direct access model, but to what degree this model has been integrated into practice is unknown (WPTA, Autonomous Practice Task Force; personal communications; May 6, 2016). In addition, it is not known what specific obstacles to model implementation the remaining 75 hospitals in the state are facing, nor are we aware of studies that have surveyed hospitals and medical centers regarding implementation (ie, initial model development and administration approval) and utilization (ie, incorporation of the direct access model into daily clinical practice) of direct access services. The purposes of our study were: (1) to investigate the extent of implementation and utilization of direct access to outpatient physical therapist services in Wisconsin-based hospitals and medical centers, (2) to identify barriers to and facilitators for the provision of such services, and (3) to identify potential differences between facilities that do and do not provide direct access services. The survey results may provide a benchmark for future comparisons of the degree of delivery of direct access services and potentially identify inadequacies in currently available direct access resources.
Method
Survey Instrument Development
The framework for our survey was based on direct access surveys utilized in previous studies (American Physical Therapy Association [APTA], Public Policy, Practice, and Professional Affairs Unit; personal communications; May 11, 2015)11,12 and descriptions of challenges associated with the implementation and utilization of direct access practice models.9,10,14–16 The data collection categories included institution/facility and director of rehabilitation services (survey respondent) demographics. Additional survey categories for hospitals and medical centers that had implemented a direct access model included: (1) degree of model integration into the delivery of rehabilitation services; (2) challenges encountered during the implementation process; (3) marketing strategies and resources utilized related to the direct access initiative; (4) required credentials for physical therapist participation in the direct access program; (5) description of staff training program, if required; (6) current barriers affecting further utilization of the direct access model; and (7) perceived outcomes associated with the direct access model. For those hospitals and medical centers not having adopted the direct access model, additional survey categories included: (1) obstacles to implementation of the model and (2) desired resources to facilitate such implementation.
To establish the content validity of the survey and address clarity of questions and survey organization, 4 physical therapists with expertise and experience with implementation and promotion of the direct access model provided an initial review of the survey. Three of the 4 physical therapists were APTA staff members involved in practice, policy, and professional affairs (these experts also had experience in direct access survey development and implementation), and the fourth physical therapist chairs the WPTA's hospital direct access initiative. The survey was revised to reflect the feedback provided and sent to a panel of 6 rehabilitation administrators for pilot testing and further feedback regarding the clarity of questions and survey organization. The 6 administrators worked for Wisconsin-based hospitals and medical centers, with 4 of the 6 administrators representing facilities that had adopted the direct access model and 2 administrators representing facilities that had not. Based on their feedback, the survey was finalized (eAppendix).
Participants
A complete list of Wisconsin hospitals and medical centers (N=107) was obtained from the Wisconsin Hospital Association.17 Of the 107 identified hospitals and medical centers, 32 were known by the WPTA to offer direct access services to outpatient physical therapy (WPTA, Autonomous Practice Task Force; personal communications; May 6, 2016), 1 was currently implementing a direct access model, and 74 did not offer direct access to outpatient physical therapist services. Eighty-nine survey questionnaires were distributed to the directors of rehabilitation services at the 107 hospitals and medical centers; the majority of survey respondents represented a single hospital or medical center, but several umbrella organizations completed a single survey that represented 2 to 5 of the hospitals and medical centers identified on the Wisconsin Hospital Association list. The directors were identified via hospital or medical center website review, the primary author's (W.G.B.'s) list of known director contacts, and for the remaining facilities, physical therapist staff known to the primary author were contacted for names of their directors. Forty-seven (52.8%) of the 89 survey questionnaires were returned, representing 62 (57.9%) of the 107 hospitals and medical centers.
Study Variables
Data from the 47 survey questionnaires included in this study represent health care organizations that are defined by Blue Cross Blue Shield as facilities (ie, “A medical care center that provides a wide range of health care services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility, also known as a medical clinic or medical center”18). These facilities are characterized as: (1) nationwide (organizations with facilities located in more than one state), (2) statewide (organizations with multiple facilities located in more than one region within Wisconsin), (3) local (organizations with multiple facilities located within one region in Wisconsin), or (4) independent (organizations with one facility location). Survey respondents further characterized their organization as metropolitan if the facility was located in a city with a population of >50,000 people or within a county with a city of >50,000 people and a total population of >100,000 people. Organizations were characterized as rural if they did not meet the criteria for being within a metropolitan region.
Respondents also characterized their organization as: (1) acute care hospitals (ie, short-term hospitals with the facilities, personnel, and medical staff necessary to provide diagnosis and treatment for acute medical conditions)19; (2) larger health systems (ie, organizations with a multi-specialty medical group practice and associated hospitals, laboratories, pharmacies, and other medical facilities)20; (3) academic medical centers (ie, combination of allopathic or osteopathic medical schools, at least one other health professions school or program, and at least one affiliated teaching hospital)21; or (4) “other,” which included critical access hospitals, defined as hospitals with fewer than 25 inpatient beds, an average length of stay less than 96 hours, services that include 24-hour emergency care, and a location that is at least 35 miles from any other hospital.22
Administration of the Survey
The University of Wisconsin–Madison School of Education Human Subjects Committee reviewed the study protocol and deemed that this project did not meet the definition of human subjects research as defined under 45 CFR 46.102 (d) and 45 CFR 46.102 (f). The survey questionnaire was emailed as an attachment to directors of rehabilitation services of Wisconsin-based hospitals in March 2015. The survey's introduction described the study's purpose, emphasized results being reported in the aggregate, promised anonymity of individual responses, and stated that participation was voluntary. The survey questionnaires were coded by number to track respondent and nonrespondents and to facilitate follow-up communication. Two to 3 weeks after the initial survey distribution, a follow-up email, with survey questionnaire attached, was sent to the nonrespondent organizations. The final participation request was sent via email approximately 2 to 3 weeks following the second request.
Data Analysis
The data were hand entered by the second author (K.L.) into a Microsoft Excel (Microsoft Corp, Redmond, Washington) spreadsheet. To promote data entry accuracy, we met weekly to clarify interpretation of survey responses. The primary author (W.G.B.) compared survey responses with previously entered data sets for 30% of the survey questionnaires and found no inconsistencies. Descriptive statistics were calculated to determine the demographics of the hospitals and of the directors of rehabilitation services, the prevalence of direct access model implementation at Wisconsin hospitals and medical centers, and the characteristics of facilities with and without an implemented direct access program.
Descriptive statistics also were calculated to summarize administrator-identified reasons for implementing a direct access model (eg, decreased costs of facility-provided health care services) and obstacles to model implementation and utilization (eg, lack of health care provider and public knowledge of outpatient direct access and its legality in Wisconsin, concerns from referral sources, or concerns regarding decreased reimbursements or denied payments for patients receiving outpatient direct access services). Several survey questions were answered on a 5-point Likert scale, with a score of 3 indicating a neutral response. Descriptive statistics were calculated by determining the number and percentage of survey respondents scoring each question as <3 or as >3. Analysis of the remaining survey questions, which were not answered on a Likert scale, were calculated as percentage agreements. The association between hospital or medical center demographics and provision of direct access services was assessed using the Fisher exact test, with alpha set at .05.
Results
Twenty (42.6%) of the 47 survey respondents represented 25 hospitals or medical centers offering direct access, 26 respondents (55.3%) represented 36 hospitals or medical centers without direct access services, and 1 respondent (2.1%) represented a hospital or medical center in the implementation process. Of the hospitals or medical centers that are known by the WPTA to offer direct access services, 78.1% (25 of 32 facilities) responded. Forty-eight percent of the hospitals or medical centers in Wisconsin that do not offer direct access services (36 of 74 facilities) responded. For consistency, the results discussed below refer to survey respondents (n=47) rather than to hospital or medical center facility counts. Numbers of less than 47 represent missing data (survey items left blank by the respondent).
Organization Demographics
Table 1 provides a summary of hospital or medical center demographic information, revealing a range of business models, including nationally based, statewide, local, and independent organizations or facilities distributed across rural and metropolitan regions. The percentage of respondents offering direct access services varied considerably, from 70% of the statewide organizations (7 of 10 respondents) to just 11.1% of the independent facilities (1 of 9 respondents) (Tab. 1). There was not a statistically significant association between organization demographics and provision of direct access services by hospital or medical center organization type (eg, larger health system, acute care hospital, academic medical center; P=.06), business model (eg, nationally based, local, statewide, or independent organization or facility; P=.14), or geographic location (eg, rural, both metropolitan and rural, and metropolitan; P=.86). A wide range of staffing models also was noted among the respondents: 7 (15.2%) of 46 respondents employed 1 to 5 physical therapists, 15 (32.6%) employed 6 to 15 physical therapists, 10 (21.7%) employed 16 to 25 physical therapists, 11 (23.9%) employed 26 to 50 physical therapists, and 3 (6.5%) employed >50 physical therapists. Three respondent organizations did not employ any physical therapists with doctor of physical therapy degrees, and none of these hospitals or medical centers offered direct access services.
Hospital and Medical Center Demographics (n=47)
The majority of survey respondents held the title of Director of Rehabilitation Services and had served in their current position for a mean of 9.3 years (range=1–40). Forty-one of the respondents were physical therapists by training, 5 were occupational therapists, and 1 was a certified athletic trainer. Of the 41 physical therapists, 36 indicated that they were members of APTA. Of the 10 survey respondents who were not APTA members, either by choice or because they were not a licensed physical therapist, 50% worked at facilities offering direct access services. The respondents ranged in age from 30 to 62 years (X̅=44.5) and received their entry-level professional degree 4.5 to 40 years (X̅=20.6) previously.
Implementation of Direct Access Services
On a 5-point Likert scale, survey respondents representing hospitals or medical centers with and without direct access services reported obstacles to implementation of the direct access model (Tab. 2). Of the 47 survey respondents, 1 facility with direct access and 1 facility without direct access did not provide answers to the questions regarding obstacles to model implementation; therefore, the noted obstacles are representative of data from 45 respondents. Factors noted as obstacles by 33% or more of all respondents included a lack of health care provider or administrator knowledge of direct access and its legality in Wisconsin (23 of 45 respondents scoring >3, 51.1%), concerns about direct access expressed by physician referral sources (n=20, 44.4%), and concerns regarding physical therapist competence with medical screening and differential diagnosis (n=17, 37.8%). More than one-third of the 25 respondents from facilities without direct access noted additional obstacles, including direct access not being an administrative priority (n=12, 48.0%), concerns regarding staff requirements and training prior to offering direct access services (n=12, 48.0%), concerns that the physician-physical therapist relationship would be negatively affected (n=10, 40.0%), and concerns from the facility's or organization's fiscal, legal, or risk management department (n=9, 37.5%).
Reported Obstacles to Direct Access Implementation
Table 3 summarizes the value of (respondents representing organizations that have adopted the direct access model) and perceived value of (respondents representing organizations that have not adopted the direct access model) resources related to the implementation process. The items deemed most useful by all respondents on a 5-point Likert scale were information detailing the Wisconsin Physical Therapy Practice Act (40 of 44 respondents scoring >3, 90.9%) and relevant literature describing the results of direct access services in other clinics (40 of 44, 90.9%). More than 75% of respondents representing organizations that have adopted the direct access model indicated that consultation with a professional colleague (18 of 21 respondents), published evidence of direct access safety (17 of 20 respondents), and published evidence of direct access cost-effectiveness (17 of 21 respondents) also were useful. More respondents from organizations without direct access than organizations with direct access perceived that the following factors would be useful: (1) names of other medical facilities utilizing outpatient direct access, (2) WPTA website materials, (3) publications and information on long-standing direct access models, (4) APTA website materials, and (5) attending a conference or workshop on direct access. These respondents also wrote in that an additional resource of value would be a list of third-party payers that reimburse direct access services.
Resources Utilized During Direct Access Implementation and Perceived Usefulness of the Resources During Future Direct Access Implementation
Twenty (95.2%) of 21 respondents from hospitals or medical centers that have or were in the process of implementing a direct access model reported that more timely and efficient access to outpatient physical therapist services and enhanced patient satisfaction (n=19, 90.5%) were primary reasons for model implementation (Tab. 4). Increased therapist job satisfaction, increased competitiveness in the marketplace, and attracting additional patients were additionally noted factors driving implementation. Respondents revealed that the implementation of direct access services took an average of 9.81 months (range=2–26). Physical therapists were directly involved in the process at 19 of 20 facilities, administrators at 12 of 20 facilities, and physicians at 2 of 20 facilities. Respondents also indicated that legal and risk management services, marketing, compliance, and billing departments were participants in the process.
Reasons for Implementing a Direct Access Model (n=21)a
Hospital or Medical Center Utilization of Direct Access
Respondents representing hospitals or medical centers offering direct access services (n=20) were asked what percentage of their outpatient population were receiving direct access services. Thirteen respondents (65.0%) indicated that <5% were seen via the direct access model, 6 (30.0%) indicated 5% to 10%, and 1 (5.0%) indicated 26% to 50%. Regarding types of services offered, sports medicine and orthopedic rehabilitation (20 of 20 respondents) and spine physical therapy (18 of 20 respondents) were the most frequently noted service lines, but Table 5 reveals that direct access services are offered to a wide range of patients and clients.
Physical Therapist Services Offered via the Direct Access Model (n=20)
The following were most often cited as facility strategies to publicize and market the direct access model: 10 of 20 facilities sent informational letters or written communications to local health care providers, 8 of 20 scheduled meetings with facility clinical managers, and 7 of 20 published information via facility newsletters or websites and printed brochures. Respondents also commented that verbal communication with current patients was a primary marketing tool. Three of the respondents reported that no marketing strategies were implemented related to the direct access program.
Nineteen of the 20 respondents representing facilities with direct access responded to survey questions regarding perceived barriers to model utilization. On a 5-point Likert scale, the primary perceived barriers limiting the utilization of direct access services were identified as: (1) a lack of patient and public knowledge of the direct access model (18 of 19 respondents scoring >3, 94.7%); (2) a lack of physician, other health care provider, or administrator knowledge of the model (n=13, 68.4%); and (3) a lack of patient and public knowledge of physical therapist education on differential diagnosis and “red flag” (examination findings that may warrant a patient referral to a physician) identification (10 of 15 respondents, 66.7%) (Tab. 6). Despite the low utilization of direct access services, respondents indicated on a 5-point Likert scale that the implementation of a direct access model resulted in increased patient satisfaction (12 of 17 respondents scoring >3, 70.6%), more timely access to physical therapist services (n=11, 64.7%), and decreased costs of facility- or organization-provided health care services (n=10, 58.8%). Several respondents noted difficulty assessing the impact of model implementation because utilization remains low, and none of the respondents reported discontinuation of the direct access model.
Reported Obstacles to Direct Access Utilization (n=19)a
Physical therapist participation in the direct access model per organization varied, with 100% of the employed therapists participating at 9 of 20 organizations, 75% to 99% participating at 6 organizations, 51% to 75% participating at 1 organization, 26% to 50% participating at 2 organizations, and 11% to 25% participating at 2 organizations. Reasons for staff not participating in the model included staff unwilling to or not interested in participating (7 of 20 respondents) or staff not meeting established facility or organization qualifications (6 of 20 respondents). Eleven of the 20 respondents representing hospitals or medical centers offering direct access services required credentials above and beyond physical therapist licensure for staff to participate in the model. Six facilities required that staff have at least 1 to 2 years of clinical experience, and 3 facilities required that staff have a doctor of physical therapy degree, postprofessional academic degree (eg, MS, DSc, PhD), American Board of Physical Therapy Specialties certification, or completion of an APTA-accredited residency or fellowship program.
Thirteen of the respondents required a staff training program prior to therapists participating in the model. Training program content included medical screening or differential diagnosis (13 of 13 programs), diagnostic imaging (8 of 13 programs), and pharmacology (5 of 13 programs). The training was provided by external physical therapists (9 programs), internal physical therapists (6 programs), internal physicians (1 program), internal pharmacists (1 program), and internal physical therapist assistants (1 program). Training programs ranged from 7 to 64 hours in length (X̅=13.9 hours), with 0 to 14 hours of training occurring during clinic hours (X̅=6.6 hours). Nine organizations required staff to do work outside of clinic hours. Ten facilities utilized an in-service format for >50% of the training program, 8 facilities utilized required reading materials for 10% to 50% of the training, and 3 facilities utilized a seminar format for 60% to 90% of the training program. Seven of the organizations included a competency component as part of the training program, requiring a written examination, patient case presentation, or live patient examination, with 95% to 100% of therapists successfully completing the competency component on their first attempt. One respondent reported that the training program is offered annually, 7 reported that the training is offered as needed, 4 reported that the training was offered on a one-time basis, and 1 respondent did not answer this question.
Discussion
To our knowledge, this is the first survey of hospital or medical center administrators related to the implementation and utilization of patient direct access to outpatient physical therapist services. As found by McCallum and DiAngelis,12 patients with musculoskeletal conditions represented the largest patient population seen within our respondents' organizations; general orthopedics, sports medicine, and spine physical therapy were clinical settings consistently noted as offering direct access services. Our study also provided data suggesting that provision of direct access services is extending beyond the realm of outpatient musculoskeletal populations and including services that range from vestibular and geriatric rehabilitation to women's health and wound care. Despite the wide range of direct access services reportedly offered, our respondents reported very low overall patient utilization of direct access services. One explanation for the low utilization may be that many of the reporting organizations had recently adopted the direct access model, as the Wisconsin Department of Health and Family Services' opinion regarding hospital provisioning of direct access services was rendered in 2006.12 Despite this potential factor, the low percentage is consistent with findings reported in previous studies,10–12 suggesting that passage of direct access legislation and implementation of the model does not necessarily result in utilization.
The primary barrier to utilization reported by our respondents was lack of knowledge and awareness of the direct access practice model from patients or public, physicians, and organizational administrators. Another frequently stated barrier was a lack of patient or public knowledge of physical therapists' differential diagnosis and red-flag screening abilities. As also noted by McCallum and DiAngelis,12 these findings suggest the need for intensive marketing efforts aimed at multiple audiences (both within and external to the physical therapy profession), ideally a collaborative effort among APTA, components, and industry representatives intended to promote a clear and consistent message.
Another reported factor potentially connected with low utilization of the direct access model was lack of participation by physical therapists. Reasons provided included staff being unwilling to provide or not interested in providing such services and staff not meeting the adopted organizational qualifications to participate. Staff reluctance to participate may be tied to level of professional education. McCallum and DiAngelis12 noted greater willingness to partake in the direct access model by physical therapists who had obtained clinical board certification or post–entry-level degrees. Although the Wisconsin Physical Therapist Practice Act does not require additional credentials beyond licensure for the provision of direct access services, 11 of 20 respondents reported requiring such credentialing, and 13 of 20 respondents required staff to complete a training program. Reasons for the additional required credentials and training may be traced to facilities replicating the successful long-standing military model,2 administrative confusion associated with the variety of entry-level degrees currently held by physical therapists,14 or to the perception by some that physical therapists may lack necessary competence to safely practice in this model. Almost 40% of our respondents stated that concerns regarding physical therapist competence on medical screening and differential diagnosis were an obstacle to direct access implementation. This finding speaks to the need to educate others regarding the current level of physical therapist training in these areas.
Respondents also reported on obstacles to adoption and implementation of the direct access model. Although there was some overlap with factors impeding utilization of direct access services (eg, lack of awareness by health care providers and administrators, the need for developing a staff training program), other factors were noted, including: (1) direct access not being an organizational priority, (2) concerns or opposition raised by referral sources (physicians), and (3) concerns that the physician-patient relationship would be negatively affected. Concerns about reimbursement for provided direct services were noted by only 20% of our respondents. This finding differed from those of McCallum and DiAngelis,12 who reported reimbursement being the most commonly cited concern. Domholdt and Durchholz10 reported reimbursement being the second most frequently cited reason for not practicing in the direct access model. This difference may be explained, in part, by our sample including only hospitals or medical centers with their associated reimbursement models compared with studies that surveyed practitioners working in a variety of settings that function under different reimbursement regulations and guidelines. Last, hospitals or medical centers that self-identified as “statewide organizations” were more likely to offer direct access to physical therapist services than hospitals or medical centers with facilities in more than one state. Implementing a direct access model within a nationally based organization may have increased complexity due to the variations in state legislation.
Although this survey had a response rate of 52.8%, falling within the 30% to 60% level considered to be standard for email questionnaires, it did not fall into the 60% to 80% response rate considered excellent for survey research.23 Formal cognitive testing of the survey was not done, which may have resulted in questions not being clearly understood. To minimize this possibility, the content experts and administrators involved in the survey development and pilot testing were asked to provide feedback regarding question clarity and survey organization. In addition, survey respondents were instructed to contact the primary author (W.G.B.) if there were any questions regarding the survey itself; no respondents made contact. Respondent bias must be considered from various perspectives: (1) 78% of the facilities in Wisconsin known to offer direct access responded to the survey, whereas only 48% of the facilities without direct access responded; and (2) respondents represented hospitals or medical centers located only in Wisconsin, so our results would not be generalizable to hospitals or medical centers located in other states. In addition, although respondents were asked if reimbursement for direct access services was an obstacle to implementation or utilization, the specific payer mix for the facilities was not investigated. We also did not investigate the entry-level education or the postprofessional credentials for each physical therapist employed by our respondents' organizations. This information would have allowed for a better comparison with the results provided by McCallum and DiAngelis12 regarding the impact of levels of education. Future hypothesis-driven research can begin to investigate causation of such factors influencing implementation or utilization of direct access services, and similar studies of hospitals or medical centers located in other geographic areas are needed. Despite the limitations, to our knowledge, this study provides the first description of the primary obstacles to the implementation and utilization of a direct access model from the perspective of hospital or medical center administrators.
In conclusion, although it is encouraging that 32 Wisconsin hospitals or medical centers adopted the direct access model between 2006 and March 2015, significant work remains for the model to be implemented at the remaining 74 hospitals or medical centers and to increase the provision of services at current direct access sites. The reported perceived obstacles, although wide-ranging in nature, appear to be centered on a lack of awareness and understanding of direct access to physical therapist services model.
Footnotes
Both authors provided concept/idea/research design, writing, and data collection data analysis. Dr Boissonnault provided project management and facilities/equipment.
Dr Boissonnault is a Fellow of the American Academy of Orthopaedic Manual Physical Therapists.
The authors acknowledge the participation of Anita Bemis-Dougherty, Sarah Miller, Elise Latawiec, Megan Warren, and Dennis Kaster, all of whom provided valuable input regarding survey development.
- Received September 19, 2015.
- Accepted May 30, 2016.
- © 2016 American Physical Therapy Association
References
Issue highlights
