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]

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 Air Force physicians were accessed regarding patients with musculoskeletal conditions. Fifty-four patients were randomly selected for the PT group and 95 patients for FP group. AHLTA was searched for cases reported from June 2009 to January 2010. Data regarding age, gender, medication, imaging use, and return to duty (RTD) rate were collected. Results: Of the study population, 126 (84%) were males, 23 (16%) were females (age range: 19--54, mean 29). RTD rate was 50% greater for PT. Rate of medication and imaging use for PT was 24% and 11%, whereas FP was 90% and 82%, respectively ( p <0.01). Conclusion: Using PT as the musculo- skeletal PCP was shown to be an effective and efficient practice model to assess and treat patients with musculoskel- etal complaints.

INTRODUCTION Physical therapists (PTs) that practice in the Department of Defense (DoD) health care system are granted privileges that differ from those practicing outside it. PTs within the DoD are credentialed1 to:

-- 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 Institute of Medicine4 has defined primary care as "the provision of integrated, accessible health care services by cli- nicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partner- ship with patients, and practicing with the context of family and community." PTs fit into this category of PCPs when dealing with musculoskeletal conditions.

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 Craig Joint Base Theater (CJBT) Hospital comprises approximately 35% patients with musculoskeletal complaints. The FP clinic is composed of a mixture of family practice providers to include physician assistants, nurse practitioners, and physi- cians. Approximately 75% of the musculoskeletal patients seen by FP providers are referred to physical therapy after the initial FP visit for more definitive care. It is not known if PTs functioning as PCPs for musculoskeletal injuries will increase the return-to-duty (RTD) rate and decrease costs rela- tive to medication and imaging use. It is postulated that DoD PTs functioning as musculoskeletal PCPs may save cost by decreasing the number of FP providers required in theater or freeing up physician time for other cases.

METHODS

The study setting was CJBT Hospital, Bagram Airfield, Afghanistan. A retrospective chart review was conducted, which examined only active-duty or contract personnel. The CJBT Hospital is responsible for providing care to active duty, contract, and local national population. I gathered data myself, practicing as the sole PT in this deployed location. I have 16 years outpatient orthopedic PT experience, am credentialed by the DoD to practice autonomously, and have completed advanced training offered by the U.S. Air Force, which allows credentialing to order medications and imaging studies. I am a diplomat with the McKenzie Institute International. Two board-certified FP active-duty U.S. Air Force physicians with a combined 20 years experience as physicians agreed to have their management of musculoskeletal conditions accessed.

Data from 150 patients were randomly selected from the electronic database (AHLTA) over the period of June 2009 to January 2010. Only the patients who had been seen in physical therapy without a referral from an FP provider were included. Patients were not randomized to FP or PT because of the nature of the clinical setting. The PT and FP clinics operated 7 days per week, with very high patient volume. Patients were seen on a first-come, first-served basis; typically the clinic with the least wait time would see the patient with musculoskeletal complaints first. Fifty patients for the PT and 50 patients for each PCP were assessed. One patient had incomplete data, so the patient was excluded from the analysis. This was a sample of convenience, with sam- pling conducted in the following manner: simple randomiza- tion was performed where a number between 1 and 100 was randomly selected out of a hat.5 The number selected was 12. So every twelfth patient chart that was seen in either FP or PT clinical setting was selected. If the criteria for inclusion were met, then the case was included in the data collection. If the chart had criteria that would exclude the patient from the study, then the patient was excluded and the next twelfth chart was examined for study appropriateness. This process continued until 54 patients were evaluated for PT and 95 patients for the FP providers. As mentioned, the opera- tional pace in the theater was very brisk, so a random sample of 50 patients for each provider was decided upon based purely on time constraints. Power was not calculated before study. Data were assessable only in theater. No data was allowed out of theater, so patient charts had to be evaluated at CJBT Hospital. The PT clinic saw 3,897 patients and the two FP physicians saw 4,779 musculoskeletal patients total in a 6-month period.

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 Congress for Medicare patients.6

A Seattle Medical Center hospital,7 in cooperation with some of the state's major employers and Aetna insurance company as the payer, investigated the cost of care for patients with back pain. The goal of the investigation was to cut cost, streamline care, and improve outcomes. It was dis- covered that most patients were going through a lengthy wait period between test and a reexamination by the physician prior to initiation of physical therapy services. Most patients with musculoskeletal injuries were eventually referred to PT, however, in most cases, it was not until physical therapy was initiated that improvements were realized.7 The new stream- lined process enables patients to see a physician, and if cleared by the physician, a PT evaluates and treats the patient, typically the same day. The more efficient process now means wait times have been reduced to 1 day. Within the first year of program implementation, the number of MRIs dropped approximately 40%, and lost time from work dropped a staggering 94%. The only criticism to the stream- lined process was from the hospital, due to lost revenue in the radiology department. The article goes on to state that "although the initial push for the change was cost savings, patients have benefited overall by receiving effective care earlier, which in the end has shown decreased cost, by decreasing complications of untreated conditions."7

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 the United States, indicated in a March 22, 2001 letter to the American Physical Therapy Association (APTA) that "PT direct access is not a risk factor that we specifically screen for in our program because it has not negatively impacted our claims experience in any way." In addition, HPSO noted that they do not have a premium differential for PT in states that allow direct access, nor do their competitors-a strong testament to the fact that direct access to physical therapy services has not increased risk exposure.15 In another study, which examined the effective- ness of PTs as a musculoskeletal gatekeeper during the 1998--99 Western Pacific Naval deployment, PT had 3,373 patient visits onboard.16 It was noted that "having PT professionals onboard resulted in fewer patient visits to sick call for musculoskeletal problems and fewer evacuations compared with other similar carrier deployments where PT was not part of the clinical treatment team."16 Using PTs as the musculoskeletal gatekeeper was described as an effective, beneficial, and cost-saving landmark improvement in provid- ing quality medical care to the fleet. In a study conducted in a deployed noncombat zone, it was found that approximately 17% of all soldiers reporting to the 21st Combat Support Hospital were evaluated and treated by PTs without refer- ral.18 In addition, the author notes "Physical therapy services provided musculoskeletal evaluations, developed field-expedient rehabilitative programs for the deployed soldiers, and pro- vided injury prevention programs for the peace implemen- tation and sustainment forces; physical therapy helped to provide a high return to duty status and a low rate of air evacuation for deployed troops."

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 the United States are "a shrinking force," said study author Dr. Mark D. Schwartz, an internist himself. "There really is a pending crisis in primary care in this country, particularly as [many older Americans] are retiring. The shrinking primary-care workforce becomes a bottleneck to health care reform."19 The report goes on to note that since 2007 the number of medical students choosing internal medicine residencies has fallen from 9% to only 2%. FP providers are experiencing the same decline in number of physicians choosing FP residencies. According to a recent article in the Herald Times less than 7% of physicians are choosing to go into FP.20 This shortage will leave a wide gap that must be filled for patients to have quality health care, which includes access for musculoskeletal complaints. PT direct access will help fill this void and give patients the safe care they need in a reasonable time.

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 Center, Washington, DC; Madigan Army Medical Center, Tacoma, Washington, DC; and the University of California, San Francisco, San Francisco, CA, approved this study.

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Lt ColTroy McGill, USAF BSC

96 Medical Group, 307 Boatner Road, STE 114, Eglin AFB, FL 32542.

doi: 10.7205/MILMED-D-13-00066