Effectiveness of Physical Therapists Serving as Primary Care Musculoskeletal Providers as Compared to Family Practice Providers in a Deployed Combat Location: A Retrospective Medical Chart Review [Military Medicine]
By McGill, Troy | |
Proquest LLC |
ABSTRACT Objectives: A medical records review to compare efficiency and effectiveness of a physical therapist (PT) functioning as a musculoskeletal primary care provider (PCP) compared to family practice (FP) physicians functioning as musculoskeletal PCP. Hypothesis: (1) Use of medication/imaging studies will be significantly less with a PT as PCP compared to FP as PCP. (2) Return-to-duty (RTD) rate will show significant increases when patients with musculoskeletal conditions are seen by PT as compared to FP. Methods: One PT practicing in a deployed combat location collected data on patients that presented directly to the PT clinic or FP clinic for care of musculoskeletal complaints. Treatment patterns of two
INTRODUCTION Physical therapists (PTs) that practice in the
-- Provide patient evaluation and treatment,
-- Provide consultation and discharge for patients with neuro- musculoskeletal symptoms referred by physicians, indepen- dent nurse practitioners, dentists, and physician assistants.
-- Make referral to other clinics on or off the federal med- ical facility.
-- Initiate duty limiting restrictions.
-- Direct access without referral.
-- Order diagnostic laboratory and radiographic/MRI studies (to be interpreted by a radiologist, physician, or orthopedist).
-- Prescribe medications limited to NSAIDS, inflamma- tories, and muscle relaxants.
-- Perform and interpret electromyographic/nerve conduction diagnostic studies.
-- Admit and discharge patients to/from quarters.
PTs deployed in support of operations occurring in remote or hazardous locations practice with the full complement of DoD-granted credentials.
Army PTs are considered musculoskeletal gatekeepers2 and see the majority of patients with musculoskeletal complaints. When a patient evaluated by an Army PT through direct access is considered to have a condition that is beyond the scope of care for PT, then a referral comes directly from the PT to the patient's primary care provider (PCP) or another appropriate health care provider, based on the clinical judg- ment of the PT. Approximately 35 years ago, the first study3 outlining how military PTs were used as frontline screeners for patients with low back pain was published. The study noted that "The quality of care rendered in this screening clinic was assessed through patient interviews, physician interviews, and record reviews. This concept and the quality of care rendered were found to be acceptable to the patient, the physician, and the physical therapist."
The purpose of this study was to evaluate a PT functioning as the PCP for patients with musculoskeletal complaints. The outpatient family practice (FP) clinic patient load at
METHODS
The study setting was
Data from 150 patients were randomly selected from the electronic database (AHLTA) over the period of
Total sample size was 149. After data collection, it was discovered that the actual numbers collected were 54 patients for PT and 95 patients for both the FP providers. This was noted once outside the deployed location. It was surmised that this difference was minor and would have minimal effect on the final data analysis.
Subject inclusion:
* Active-duty or civilian contract personnel > 18 years of age with a musculoskeletal complaint
Subject exclusion:
* Fractures, dislocations, or trauma where deformity is present
* Fevers or pain of a nonmechanical, nonmusculoskeletal origin were referred to the emergency department.
Subject inclusion/exclusion criteria were the same for PT and FP data collection. Patients presented with a variety of musculoskeletal complaints (Fig. 1).
DATA ANALYSIS
Age, gender, and demographic data were collected for all patients who met the inclusion criteria. Categorical data were gathered for use of medication and radiology. A Fisher's exact test was performed to assess the significance for all variables of interest.
Return to duty, defined as, the patient was able to return to all duties that were involved with completing their deployed physical requirements to include all physical training times 7 days. Individuals who were required to wear body armor had to be able to complete 3 full days of armor wear without complaint of symptom recurrence.
RESULTS
Of the study sample, 95 patients belonged to FP acting as PCP group (N=95), 54 to PT as PCP (N=54), the number of males was 126, number of females was 23 (or 84% male). Age range was 19--54 years and the median age was 29. The FP as PCP group had 82.11% compared with only 11.11% radiology utilization in the PT as PCP group, which is signif- icantly different ( p <0.0001; see Fig. 2). FP as PCP group had 90.53% medication use compared with only 24.07% in the PT as PCP group, which is significantly different ( p < 0.0001; see Fig. 3). There was no significant difference between groups for number of visits, but a statistically signif- icant difference was noted with RTD rate between groups ( p < 0.0001).
DISCUSSION
In all but two states, patients can see a PT without a physi- cian's referral, and direct access to PT is being considered by
A
In the Guide to Physical Therapy Practice,8 diagnosis is stated as an integral part of the physical therapy evaluation and is not limited to functional impairments but encompasses differential diagnosis and screening for various medical dis- eases. Proper diagnosis is vital in screening for potential problems that would require referral. This screening practice pattern is no different than that of an FP provider who screens a patient for issues that are out of their scope of practice and then refers onto the appropriate providers. PTs have more hours of training and practice in musculoskeletal management than FP providers, physician assistants, and nurse practi- tioners.10,11 In a recent study, it was reported that 79% of practicing physicians, residents, and recent medical school graduates failed a basic musculoskeletal cognitive examina- tion.12 PTs use their knowledge of disease and injury, signs and symptoms, mechanism of injury, outcome and prognosis, treatment response, and the relevant individual and environ- mental factors to arrive at a medical diagnosis.13
Patient safety should be the number one concern for any health care provider. Are PTs safe to function as a portal or gatekeeper for patients with musculoskeletal conditions? In a recent retrospective analysis of 472,013 patient visits at 25 military health care sites, 45.1% of the visits were patients seen through direct access, without physician referral. The study identified no adverse events from either physical therapy management or diagnosis. In a similar study that examined 560 patients, clinical diagnostic accuracy by PT and orthope- dic surgeons regarding musculoskeletal injuries was signifi- cantly greater than that for nonorthopedic providers, with no difference observed between PTs and orthopedic surgeons.9,17
Health Providers Service Organization15 (HPSO), the leading liability insurer of PTs in
Are PTs able to fill a niche in the delivery of health care for patients with musculoskeletal complaints, or would the PT profession be creating a new provider in an already satu- rated market of health care providers who act as PCP for patients with musculoskeletal complaints? A recent study reports a drastic decrease in the last two decades of PCPs.19 General internists in
Military PTs practicing as the musculoskeletal PCP would in theory decrease the need for additional FP providers in military treatment facilities and in deployed locations. This practice model would allow patients to see the correct pro- vider at the correct time. Evaluation of this practice model comparing PTs as PCPs for musculoskeletal complaints with traditional PCPs such as FP physicians, physician assistants, and nurse practitioners has not been fully evaluated in the literature. PT as PCP demonstrated significantly better RTD rates while at the same time drastically decreasing the use of medication and imaging studies. This is the first time that medication usage and imaging study use has been examined comparing FP physicians with a PT. This fact is not surpris- ing since most PTs are not credentialed to order medication and imaging studies; however, with APTA's Vision 2020 this practice model will hopefully become the standard for outpatient orthopedic PTs.21
CRITICAL APPRAISAL
Cost of care was not evaluated because of the use of multiple prescription medication and varied imaging study options. A generalized practice pattern was examined instead, one that should mirror practice patterns as PT are used as inde- pendent musculoskeletal gatekeepers. The results of this study cannot necessarily be generalized to PTs with direct access privileges in the private sector because of the lack of credentialing to order medications and imaging, as well as the typical makeup of patients would not be so skewed toward males with approximately 85% males supplying data for this article. The greater than 50% difference for the RTD rates when comparing PT with FP physicians could be con- sidered an important finding. As health care costs are highly scrutinized, the ability of a particular provider to offer care that will allow patients a 50% greater RTD rate is very attrac- tive to payers and employers alike.
This was a highly pragmatic study because of the opera- tional environment and as a result mitigation to alleviate potential sources of bias was limited. I served as author, data collector, and processor of that data. My retrospective analy- sis may have been strengthened by independent analysis.
Confounding variable could have accounted for differences in medication and radiology usage; however, this patient pop- ulation was considered to be homogenous and as such signifi- cant positive outcomes regarding medication and radiology utilization were less when patients used PT as PCP. RTD rates for PT as PCP demonstrated significant results. Safety was not an issue with PT used as the PCP. Power was not calculated a priori , as this was the first study of its kind to examine PT compared with FP acting as the musculoskeletal PCP.
The institutional review boards at Walter Reed Army Med- ical
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Lt ColTroy McGill, USAF BSC
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doi: 10.7205/MILMED-D-13-00066
Copyright: | (c) 2013 Association of Military Surgeons of the United States |
Wordcount: | 3537 |
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