Johny 1 George Johny 3/15/14 Lesile Wilcott Spring.

2014 This document has been written to provide an overview on a problem of direct access in the practice of physical therapy. The term direct access, in this annotated bibliography 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. The problem is that the practice of physical therapy is contingent upon the prescription or referral of a physician. This requirement does not recognize the professional training and expertise of the licensed physical therapist nor does it serve the needs of those patients who require physical therapy but must first be seen by a physician. Two primary professions seem to clash in this document, general practitioners and physical therapists, where PTs like Jonathon Kruger, the manager of the APA's policy and professional standards divisions say, "we felt we had the skills to become primary contact professionals". The evidence over the course of 35 years, in terms of efficacy, patient satisfaction and cost has proven confidence to be fully justified. The problem of reimbursement now emerges from this problem, and that puts a clear constraint upon the direct access policy; physical therapist by law, now decline to serve their clients until they go to a physician who would then determine if they need physical therapist assistance. The goal of the document is to introduce the topic as well as engage the public to self motivate them to act upon the call to implement direct access in the health care model. This information presented here is gathered from peer-reviewed academic journals and articles that deal with direct access benefits and limitations. The primary authors of those journals and articles were higher educated physical

Johny 2 therapists who have gained either a Doctorate or Masters in the field who were also a part of a physical therapy organization such as APA, or APTA. The presidents of those organizations hold the authoritative power in the discourse in which they manage problem needs their undivided attention like direct access and the remainder of the organization would figure out ways in solving the issue. The studies below will show the progress of direct access, over comings and limitations and how it benefited the setting, in which it was adopted. McCallum, Christine, A., and Tom DiAngelis. "Direct Access: Factors That Affect Physical Therapist Practice In The State Of Ohio."Physical Therapy 92.5 (2012): 688706. CINAHL Plus with Full Text. Web. 9 Mar. 2014. A sign of relief has appeared when the APTA released a statement saying that in 2020 physical therapists who are recognized as doctors of physical therapy will have the direct of access. One of the reasons the author thinks why access is being impeded is the fear of associated patient risks and inadequate knowledge about the current view of the professional practice. The purpose of the study was to describe physical therapy and its environment that may impede or facilitated change in direct access policy. This study does not seem to be bona fide because the respondents of the questionnaire might enter in inaccuracies that might hinder what the study want to examine. From the study they found that 31% of respondents of the survey used direct access primarily in private setting, 80% that are left reported that they want to if presented with the opportunity . Reimbursement and organizational polices appear to impede the process of direct access in state of Ohio.

Johny 3 Shoemaker, Michael, J. "Direct Consumer Access To Physical Therapy In Michigan: Challenges To Policy Adoption... [Corrected] [Published Erratum Appears In PHYS THER 2012 Mar;92(3):471]." Physical Therapy 92.2 (2012): 236-250. CINAHL Plus with Full Text. Web. 9 Mar. 2014. Due to the Affordable Care Act, the U.S requires to examine the deployment of nation's health care providers. The act will improve access and reduce cost by eliminating unnecessary provider visits. In Michigan though, the state will still require physician prescription or referral rather than directing the patient to a PT without referring. The study was made to figure out why the most recent attempts to passing a direct access legislature in Michigan has failed. Walt and Gilson developed a policy triangle that will aim to figure out why the bills failed to pass, the analysis contained not only content, but actor, context and process. The author tells that their analysis is retrospective in which it can provide insight on why the policy was or was not adopted, and if it is how effectively, the policy was implemented. The results revealed that direct access does not pose risk to public safety and may result in better outcomes with regard to quality and cost. The failure of the bill in 2006 was due to the scope of practice conflicts. Michigan's legislature should reconsider the health policy to alleviate the primary care provider for those with musculoskeletal disorders. "Direct Access To Physical Therapy For Patients With Low Back Pain In The Netherlands: Prevalence And Predictors." Physical Therapy 94.3 (2014): 363-370. CINAHL Plus with Full Text. Web. 10 Mar. 2014.

Johny 4 In this article, it talks about how the new health care system in the Netherlands has changed in a way that aims to control health care costs and reduce waiting lists thus giving freedom to the patients. The purposes of this study were to investigate the prevalence of direct access to physical therapy for patients with low back pain in the Netherlands from 2006 to 2009,examine associations between mode of access (direct versus referral) and describe the severity of the back complaints at the beginning and end of treatment for direct access and referral-based physical therapy. The study was a crosssectional study was conducted using registration data of physical therapists obtained from a longitudinal study; Data were collected from the National Information Service for Allied Health Care, a registration network of Dutch physical therapists. Mode of access (direct or referral) registered for each episode of physical therapy care due to back pain from 2006 to 2009. Logistic regression analysis was then used to explore associations between mode of access and patient/clinical characteristics. Direct access was used for an increasing percentage of episodes of physical therapy care in the years 2006 to 2009. Patient/clinical characteristics associated with the mode of access were education level, recurrent back pain, previous physical therapy sessions, and age. The study could not compare outcomes of physical therapy care by mode of access because this information was not registered from the beginning of data collection and, therefore, was missing for too many cases. Green, Mary, et al. "Physical Therapist Professional Autonomy, Malpractice, And Adverse Professional License Action: Results From A Twenty-Year Review Of The National Practitioner Data Bank." HPA Resource 13.3 (2013): J1-j10. CINAHL Plus with Full Text. Web. 10 Mar. 2014.

Johny 5

This study has been made to determine the incidence of and reasons for physical therapist malpractice and adverse professional license action, and their relationship to state adoption of direct access. The study used Primary data sources from the National Practitioner Data Bank (NPDB) Public and the US Bureau of Labor Statistics. Analyses included descriptive statistics and comparison of malpractice and adverse professional license action incidence before and after state adoption of direct access in a subgroup of 14 states. The study found that there was more adverse professional action than malpractice; the annual incidence of physical therapist following the adoption of direct access was significantly lower as well as the adverse professional action. The study demonstrated no increase in malpractice or adverse professional license following the adoption of direct access. Boissonnault, WG, MB Badke, and JM Powers. "Pursuit And Implementation Of Hospital-Based Outpatient Direct Access To Physical Therapy Services: An Administrative Case Report." Physical Therapy 90.1 (2010): 100-109. CINAHL Plus with Full Text. Web. 11 Mar. 2014. The authors of the study are both physical therapists and both are well known in this discourse. This study talks about how even though direct access was approved by legislation in 48 states other regulatory barriers and internal institutional policies have been set. The case report describes steps and strategies associated with successful execution of a direct access physical therapy model at a large academic medical center. The process of obtaining institutional medical board and implementing a pilot program is

Johny 6 examined. Program details, like therapist qualifications and scope of practice, the required internal training program, and program outcome assessment are provided. Early pilot program findings, including challenges faced and subsequent actions are described. The pilot program success led to the institutional adoption of the direct access model in all physical therapy outpatient clinics. This case report describes the interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice. Ries, Eric. "Direct Results Around The World... ...Think Direct Access And Advancing Scope Of Practice Are Essentially American Issues? Think Again." PT In Motion 3.5 (2011): 20. CINAHL Plus with Full Text. Web. 11 Mar. 2014. This Academic article looks to be different than any of the other annotated bibliographies, it looks more like a textbook text. It counter contradicts what seems to be the format of an academic journal thus giving an assumption of it being legitimate or not. This academic journal talks about the increase of direct access not only in America but also around the globe. Jonathon Kruger, the manager of the APA's policy and professional standards divisions says, "we felt we had the skills to become primary contact professionals". The evidence over the course of 35 years, in terms of efficacy, patient satisfaction and cost has proven confidence to be fully justified. Authors talk about the limitations of direct access due to reimbursement; how money follows the access. US and International PTs agree on this wide body of research that patients benefit from self-referral and direct access. One issue the article stresses on is that demand for physical therapy is on the rise and there has never been a better time to push for

Johny 7 expanding the role of physical therapy thus putting pressure on lawmakers and health officials to provide those policies. It talks about a model in Australia in which pts, and Opts work in hospital emergency room in which if a patient is present with straightforward musculoskeletal problem, doctor wont see you if a PT is there, they even have the ability to refer or discharge the patient. This model shows an effective way of reducing waiting lists and costs. Ludvigsson, Maria, Landn, and Paul Enthoven. "Evaluation Of Physiotherapists As Primary Assessors Of Patients With Musculoskeletal Disorders Seeking Primary Health Care." Physiotherapy 98.2 (2012): 131-137. CINAHL Plus with Full Text. Web. 12 Mar. 2014. The validity of this study seem to be concurrent in that Paul Einthoven, a professor in the Department of Medical and Health Sciences, Division of Physiotherapy, Linkoping University has joined to be a corresponding author. This study starts with statistics of Musculoskeletal pain accounts around the nation and it seem to increase. This study acknowledges other studies results in a way that demonstrates to the audience the competence of physiotherapists to assess musculoskeletal disorder. Both General practitioners and physiotherapists have reported high levels of comfort with and confidence in physiotherapist to be first contact practitioners. It then lists out the pros, which include cost effectiveness, decreasing waiting times, and the satisfaction of the patients with their care. The study aims to evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a GP. The study was held in a healthcare centre, where they focused on patients with

Johny 8 musculoskeletal disorder. The method of the study was an observational, retrospective cohort study reviewing medical records and a separate consecutive patient satisfaction questionnaire. The study included Four hundred and thirty-two patients who were assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP. Eighty-five percent of the patients did not need to see a GP, and were satisfied with assessment by a physiotherapist. Crout, KL, JH Tweedie, and DJ Miller. "Physical Therapists' Opinions And Practices Regarding Direct Access... This Research Was Presented In Poster Format At The Annual Meeting Of The Massachusetts Chapter Of The American Physical Therapy Association, October 14-19, 1994, Sturbridge, Mass, And At The 12Th International Congress Of The World Confederation For Physical Therapy, June 25-30, 1995, Washington, DC." Physical Therapy 78.1 (1998): 52-61. CINAHL Plus with Full Text. Web. 12 Mar. 2014. This academic journal looks significantly different from any of the others I have examined. The format of this journal looks more as a data based text. I had hard time looking up the authors, thus the validity of the article seems to me to be shaken. This study examines whether differences exist about physical therapists' opinions and practices regarding the use of direct access between therapists practicing in MA, a direct access state, and therapists practicing in CT, a state that allows only evaluation without referral. The study had a sample of 329 therapists in MA, and 179 in CT who were surveyed; they were sent a cover letter, questionnaire and a return-reply envelope. Therapists in both states found to be equally supportive of direct access. Limitation of direct access was a result of employer policies and lack of insurance reimbursement. Even though therapists in both states were supportive of direct access, therapists in ma found it to be useless since the number of patients is limited because of practice and financial restraints.

Johny 9 Muir, J. "Direct Access In (Private) Practice." PT: Magazine Of Physical Therapy 12.6 (2004): 56. CINAHL Plus with Full Text. Web. 14 Mar. 2014. This article talks about the progress and future progressions in place to better direct access. In 1970s, physical therapists envisioned a future where the public had the right to directly access PT services for evaluation, examination and intervention. 25 years later, 39 out of 50 states are have now some form of direct access. The intervening years have witnessed dozens of state-level legislative victories and remarkable progress at the federal level toward achieving Medicare direct access. It also talks about consistency in each state, saying that in Georgia, evaluation is accepted by but law-suggesting treatment is prohibited, in Carolina most insurance companies require physician referral mean while in Alabama is highly regulated. The article talks about how clients and PTs are frustrated about the process of referrals and why PTs should be allowed the first access to a patient. The article is written for educating the payers, the consumer and the medical establishment. A major hurdle that needs to be overcome is pushing congress into passing Medicare Direct Access which in return will ease the problem of insurance companies and third party payers. Even though this article is a Magazine, which loses some creditability to its reader, but the author Muir, J has published over 53 academic journals. Turner, D. "An Exploratory Study Of Physiotherapy Telephone Assessment... Including Commentary By Foster NE." International Journal Of Therapy & Rehabilitation 16.2 (2009): 97-105. CINAHL Plus with Full Text. Web. 15 Mar. 2014. The study aims that the popular adoption of self referral to physiotherapy across the United Kingdom through the use of the telephone as a means of accessing the service. This relies on the physiotherapist's ability to make an accurate diagnosis, leading to an appropriate management decision and thus facilitating the best possible outcome for the patient. This study examined the agreement between telephone and face-to-face management of musculoskeletal conditions and assessed the accuracy of diagnosis over the telephone. Fifty-five patients with musculoskeletal conditions were assessed over the telephone and then face to face. Patients were assigned to two physical therapist, one with two years of experience and one with 4 years of experience. The physiotherapist on the telephone and the physiotherapist in the department made independent diagnoses clinical impression and management decisions. The study measured the agreement between the provisional telephone diagnosis and the final department diagnosis. They found that diagnosis over the telephone appears to be comparable with face-to-face diagnosis. However, the management of conditions was more difficult or less sufficient than faceto-face management. The study offers an alternative solution to direct access but it also has its down falls and that may hinder direct access as a whole since the findings will

Johny 10 show ineffective treatments. The author seems to be credible by the fact that he wrote over a 100 academic article and a dissertation. Moore, J. "Government Affairs. Direct Access Under Medicare Part B: The Time Is Now! We All Must Work To Ensure That The Medicare Patient Access To Physical Therapists Act Becomes Law." PT: Magazine Of Physical Therapy 10.2 (2002): 30-32. CINAHL Plus with Full Text. Web. 15 Mar. 2014. This article talks about the bill that the APTA strongly supports, the Medicare Patient Access to Physical Therapist Act, and the reasons why the legislation should pass it. The Author directs his talk to Physical therapists for a chance of having them advocate the process of passing the bill. The bill contained three things, the elimination of physician referral, defining a qualified PT, and the division of different scopes of therapy so that they would not be all be called physical therapy. The article says lists the benefits of direct access while saying" Direct access does not designate PTs as primary care providers. It does not restrict patient/client access to other health care providers, but encourages collaborative relationships among PTs and Physicians to assist the patient in meeting their goals, needs and expectations." The article solidifies its credibility by naming 3 major organizations of state legislators that endorse direct access: The NCSL, NBSCL, and the ALEC. The Author is credible because he has published over 250 academic journals and he is a part of the discourse community. Massey, BF, Jr. "2002 APTA Presidential Address. What's All The Fuss About Direct Access?." Physical Therapy 82.11 (2002): 1120-1123. CINAHL Plus with Full Text. Web. 15 Mar. 2014. This Speech talks about the History and the progress that PT organizations had on pushing direct access in each state. It also talks about the victories and bills that were passed such as the Medicare act, which by the author deemed to be the most important. Also talks about a goal that needs to be done before 2020. In order for that to happen, direct access must be recognized within each state act, and third party payers must recognize it. The speech also talks about the accomplishments of PTs overall and how they shown that they worth to calm autonomy in their occupation. The speech is a motivational element in which it relies on aspiring other PTs and their organization to finish off the goal they started out with two decades ago. A power statement saying, "We are so close to seeing our dreams for this profession become a reality, concludes the speech. Each of you here today--and the thousands more back in your clinics, and classrooms, and offices, and labs--must believe in our ability to make a difference." The speech is an instant credibility because it was the APTA presidential address to its members.

Johny 11 Ojha H, Snyder R, Davenport T. Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review.Physical Therapy [serial online]. 2014;94(1):1430. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed February 28, 2014. The authors stat that restrictions have been set due to therapists' qualifications, third party payer requirements, and the lack of public awareness. The authors are the primary source since they are specialized physical therapists who also are members of OCS, and FAAOMPT. The article talks about the estimated number of people in the U.S that suffer from musculoskeletal injuries that seek physical theory for their treatment. Studies have showed that with the availability of direct access, physical therapy can reduce waiting time, improve convenience, reduce costs to both the patient and the health care system and most importantly improve recovery time. The purpose of the article was to conduct a review of the literature of patients with the musculoskeletal injuries and compare heath care costs, and patient's outcomes by direct access compared with referred physical therapy, to ensure that changes did happen. The study gathered the articles from Ovid MEDLINE, CINAHL, Web of Science and PEDro, the articles were appraised using CEBM levels of evidence criteria and assigned methodological score. Out of 1501 articles, eight studies were chosen. The outcome of the study showed that there were lower health care costs and improved health care, and stating that there was no harm done. By looking at the results, legislators and health care providers will able to decide wither or not to support, direct access. Bury T, Stokes E. A Global View of Direct Access and Patient Self-Referral to Physical Therapy: Implications for the Profession.Physical Therapy [serial online]. April 2013;93(4):449-459. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed February 28, 2014. Both authors are involved with the work of WCPT. Ms Bury is an employed member of staff, and Dr Stokes is currently Vice President and sits on the Executive Committee; at the time of the study, she was the European regional representative on the Committee. This article is a survey-based study, in which the world confederation for physical therapy (WCPT) is trying to map out the presence of direct access services in the member organizations of the World Confederation for physical therapy (WCPT) in the context of physical therapist practice around the globe. WCPT says that attaining professional autonomy is a high priority for physical therapists thus this study was formed to plan where it needs to dedicate its time on. An online survey was sent to all WCPT member organizations internationally. Little under 60% of the respondents reported direct access to physical therapy with greater prevalence in private institutions. In the majority of the countries, organizations seems to equip its entry-level therapist with direct of access. The National physical therapy associations and the public seem to be in support of direct access, while less support is shown from policy makers and physicians. Professional

Johny 12 legislation, the medical profession, politicians, and policy makers are perceived to act as both barriers to and facilitators of direct access. Clinical effectiveness and costeffectiveness with good practice will be an important role in facilitating change and advocacy for direct access. Research Roundup. Direct Access Associated With Lower Costs, Fewer Visits, New Study Says. PT In Motion [serial online]. November 2011;3(10):13. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed March 15, 2014. This article talks about a previous study and the results it will have in the future for U.S health care system. The study was printed from the Health Services Research, and it reviewed over 60 thousand episodes of physical therapy using non-Medicare claims data from an insurer over a 5-year period. The study showed that patients who visited a physical therapist (PT) directly for outpatient care (27%) experienced fewer visits and lower overall costs on average than those who were referred by a medical doctor. The article talks about direct access benefits and how it does not hinder continuity of care or the contact of physician. It also adds that the researchers found that Concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer might be overstated. This study is important because it is the most comprehensive to date. It looked at far more extensive number of episodes than previous studies. I find this article to be less credible than any of the ones I have read because it doesnt include the authors name but gives the source of where it came from. .