Physician referrals to physical therapy for the treatment of musculoskeletal conditions

doi:10.1016/S0003-9993(03)00375-7

Archives of Physical Medicine and Rehabilitation

Volume 84, Issue 12, December 2003, Pages 1839-1849

Presented in part at the Academy for Health Services Research and Health Policy’s Annual Meeting, June 2002, Washington, DC

https://doi.org/10.1016/S0003-9993(03)00375-7 Get rights and content

Abstract

Freburger JK, Holmes GM, Carey TS. Physician referrals to physical therapy for the treatment of musculoskeletal conditions. Arch Phys Med Rehabil 2003;84:1839–49.

Objectives

To identify factors associated with orthopedic surgeons’ and primary care physicians’ referrals to physical therapy (PT) for musculoskeletal conditions.

Design

Cross-sectional analysis of National Ambulatory Medical Care Survey data.

Setting

US office-based physician practices.

Participants

Visits to primary care physicians (N=4911) or orthopedic surgeons (N=4201) for musculoskeletal conditions.

Interventions

Not applicable.

Main outcome measure

Whether a PT referral was made.

Results

After controlling for diagnosis, illness severity, and PT supply, insurance status and physician characteristics remained strong predictors of PT referral. Primary care visits covered by Medicaid or a managed care plan were less likely to result in PT referral than were visits covered by private insurance or a nonmanaged care plan. Orthopedic surgeon visits covered by workers’ compensation or managed care were more likely to result in PT referral than were visits not covered by workers’ compensation or not covered by managed care. Osteopathic primary care visits were more likely than allopathic primary care visits to result in PT referral. Given identical visit characteristics, orthopedic surgeon visits were more likely than primary care visits to result in PT referral.

Conclusions

Significant differences exist in orthopedic surgeons’ and primary care physicians’ referrals to PT, both within and across specialties. Variation in PT referral may be indicative of problems with access and/or inappropriate referral.

Section snippets

Methods

This observational study was conducted using data from the 1995–1999 NAMCS. The NAMCS is an ongoing, annual survey of US office-based physicians conducted by the National Center for Health Statistics.33 The survey uses a multistage sampling design that consists of sampling geographic areas of the United States (referred to as primary sampling units [PSUs]), physician practices within PSUs, and patient visits within practices. Physicians are randomly selected from the American Medical

Determinants of PT referral for orthopedic surgeon visits

The results of the probit analysis for orthopedic surgeon visits are presented in table 2. To make the results more interpretable, the marginal effects (defined as the change in the probability of an outcome due to a change in the independent variable) are presented. After controlling for illness severity, diagnosis, and PT supply, 2 of the insurance status variables were significantly associated (P<.05) with the probability of PT referral. The marginal effect of managed care visits was .05 or

Discussion

After controlling for diagnosis, illness severity, and PT supply, insurance status had a moderate effect on PT referral and varied by specialty. Workers’ compensation visits to orthopedic surgeons were 37% more likely to result in PT referral than were other types of insurance visits. Others have reported similar findings for patients with LBP (ie, patients with LBP who are on workers’ compensation are more likely to be referred to PT.)10, 52 Managed care visits to orthopedic surgeons were also

Conclusions

Our results indicate that there is significant variation in physicians’ referral to PT for musculoskeletal conditions, even after controlling for diagnosis, illness severity, and PT supply. Specific physician characteristics and the insurance status of the patient appear to influence whether visits to orthopedic surgeons and/or primary care physicians result in PT referral. Variation in PT referral may be indicative of problems with access and/or inappropriate referral and may ultimately affect

References (55)

N.E. Lane et al.
Musculoskeletal medicine. Introduction
Rheum Dis Clin North Am
(1996)
P. Holmich et al.
Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletesrandomised trial
Lancet
(1999)
M. Nordin et al.
Physical therapyexercises and the modalities: when, what, and why?
Neurol Clin
(1999)
F.J. Ritchey et al.
Perceptual correlates of physician referral to physical therapistsimplications for role expansion
Soc Sci Med
(1989)
E. Yelin et al.
A national study of medical care expenditures for musculoskeletal conditions
Arthritis Rheum
(2001)
P.F. Adams et al.
Current estimates from the National Health Interview Survey, 1996
Vital Health Stat
(1999)
D.A. Woodwell
National ambulatory medical care survey1998 summary
Vital Health Stat
(2000)
S.M. Schappert
Office visits to orthopedic surgeonsUnited States, 1995– 96
Vital Health Stat
(1998)
R.S. Stafford et al.
Trends in adult visits to primary care physicians in the United States
Arch Fam Med
(1999)
A.M. Jette et al.
A comparison of hospital-based and private outpatient physical therapy practices
Phys Ther
(1991)

C. Nelson

Physiotherapy office visits: National Ambulatory Medical Care Survey: United States, 1980–81

Vital Health Stat

(1986)

L.G. Hart et al.

Physician office visits for low back pain

Spine

(1995)

T.J. Mielenz et al.

Physical therapy utilization by patients with acute low back pain

Phys Ther

(1997)

Disparities in health care

AHRQ Focus on Research

(2002)

M. van Ryn

Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care

Med Care

(2002)

R.D. Herbert et al.

Effective physiotherapy

BMJ

(2001)

M.D. Bang et al.

Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome

J Orthop Sports Phys Ther

(2000)

M.J. Bell et al.

A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis

J Rheumatol

(1998)

M. Fransen et al.

Physical therapy is effective for patients with osteoarthritis of the kneea randomized controlled clinical trial

J Rheumatol

(2001)

K.A. Ginn et al.

A randomized, controlled clinical trial of a treatment for shoulder pain

Phys Ther

(1997)

S.M. Griggs et al.

Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment

J Bone Joint Surg Am

(2000)

A.R. Gross et al.

Conservative management of mechanical neck disorders. A systematic overview and meta-analysis

Online J Curr Clin Trials

(1996)

G.V. Kjellman et al.

A critical analysis of randomised clinical trials on neck pain and treatment efficacya review of the literature

Scand J Rehabil Med

(1999)

P. O’Sullivan et al.

Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylosis or spondylolisthesis

Spine

(1997)

G.G. Peeters et al.

The efficacy of conservative treatment in patients with whiplash injurya systematic review of clinical trials

Spine

(2001)

M.S. Templeton et al.

Effects of aquatic therapy on joint flexibility and functional ability in subjects with rheumatic disease

J Orthop Sports Phys Ther

(1996)

A.A. Vendrig et al.

Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck

Spine

(2000)

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^☆: Supported by the Agency for Healthcare Research and Quality (National Research Service Award Postdoctoral Traineeship) and the Cecil G. Sheps Center for Health Services Research (grant no. T32-HS00032).

¹: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

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ArticlePhysician referrals to physical therapy for the treatment of musculoskeletal conditions1☆,

Abstract

Objectives

Design

Setting

Participants

Interventions

Main outcome measure

Results

Conclusions

Section snippets

Methods

Determinants of PT referral for orthopedic surgeon visits

Discussion

Conclusions

Rheum Dis Clin North Am

Lancet

Neurol Clin

Soc Sci Med

A national study of medical care expenditures for musculoskeletal conditions

Arthritis Rheum

Current estimates from the National Health Interview Survey, 1996

Vital Health Stat

National ambulatory medical care survey1998 summary

Vital Health Stat

Office visits to orthopedic surgeonsUnited States, 1995– 96

Vital Health Stat

Trends in adult visits to primary care physicians in the United States

Arch Fam Med

A comparison of hospital-based and private outpatient physical therapy practices

Phys Ther

Physiotherapy office visits: National Ambulatory Medical Care Survey: United States, 1980–81

Vital Health Stat

Physician office visits for low back pain

Spine

Physical therapy utilization by patients with acute low back pain

Phys Ther

Disparities in health care

AHRQ Focus on Research

Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care

Med Care

Effective physiotherapy

BMJ

Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome

J Orthop Sports Phys Ther

A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis

J Rheumatol

Physical therapy is effective for patients with osteoarthritis of the kneea randomized controlled clinical trial

J Rheumatol

A randomized, controlled clinical trial of a treatment for shoulder pain

Phys Ther

Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment

J Bone Joint Surg Am

Conservative management of mechanical neck disorders. A systematic overview and meta-analysis

Online J Curr Clin Trials

A critical analysis of randomised clinical trials on neck pain and treatment efficacya review of the literature

Scand J Rehabil Med

Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylosis or spondylolisthesis

Spine

The efficacy of conservative treatment in patients with whiplash injurya systematic review of clinical trials

Spine

Effects of aquatic therapy on joint flexibility and functional ability in subjects with rheumatic disease

J Orthop Sports Phys Ther

Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck

Spine

Article
Physician referrals to physical therapy for the treatment of musculoskeletal conditions¹☆,