Implementation of Direct Access Physical Therapy Within the Military Medical System

Racialized Inequities in Knee Arthroplasty Receipt After Osteoarthritis Diagnosis in the US Military Health System

OBJECTIVE

The goal was to evaluate institutional inequities in the US Military Health System in knee arthroplasty receipt within three years of knee osteoarthritis diagnosis when accounting for other treatments received (eg, physical therapy, medications).

METHODS

In this retrospective observational cohort study, medical record data of patients (n = 29,734) who received a primary osteoarthritis diagnosis in the US Military Health System between January 2016 and January 2020 were analyzed. Data included receipt of physical therapy one year before diagnosis and up to three years after diagnosis, prediagnosis opioid and nonopioid prescription receipt, health-related factors associated with levels of racism, and the primary outcome, knee arthroplasty receipt within three years after diagnosis.

RESULTS

In a generalized additive model with time-varying covariates, Asian and Pacific Islander (incidence rate ratio [IRR] 0.58, 95% confidence interval [CI] 0.45-0.74), Black (IRR 0.52, 95%CI 0.46-0.59), and Latine (IRR 0.66, 95%CI 0.52-0.85) patients experienced racialized inequities in knee arthroplasty receipt, relative to white patients (all P < 0.001).

CONCLUSIONS

In the present sample, Asian and Pacific Islander, Black, and Latine patients were significantly less likely to receive a knee arthroplasty, relative to white patients. Taken together, system-level resources are needed to identify and address mechanisms underlying institutional inequities in knee arthroplasty receipt, such as factors related to systemic and structural, institutional, and personally mediated racism.

Diagnostic and decision-making abilities of Swiss physiotherapists in a simulated direct access setting

BACKGROUND

Direct access to physiotherapy requires physiotherapists to recognize red flags and determine adequate management plans.

PURPOSE

Investigate Swiss physiotherapists' ability to diagnose and triage patients in a simulated direct access setting and whether their characteristics were associated with correct diagnoses and decision-making.

METHODS

We conducted a national online survey using a questionnaire containing 12 first-contact case scenarios. A linear mixed model estimated scores for correct diagnoses and management decisions, differences between musculoskeletal (MSK), non-critical medical (non-CrM), and critical medical (CrM) case scenarios, and the estimated effects of physiotherapists' characteristics.

RESULTS

The linear mixed model of data from 1492 participants estimated 55.0% correct diagnoses (62.7% for non-CrM, 61.7% for MSK, and 40.5% for CrM scenarios) and 71.2% correct management decisions (78.1% for non-CrM, 73.0% for MSK, and 62.3% for CrM scenarios). For correct diagnoses, the 'academic education/continuing education' variable showed significant estimated effects for the MSK and CrM scenarios, as did 'professional experience' for the non-CrM scenarios, and the '≥ 50% musculoskeletal patients in consultations' variable for all scenario groups. For correct management decisions, 'academic education/continuing education' variable showed significant estimated effects in CrM scenarios, as did 'professional experience' in non-CrM and CrM scenarios, and the '≥ 50% musculoskeletal patients in consultations' variable in MSK scenarios.

CONCLUSION

The estimated effects of physiotherapists' characteristics on correct diagnoses and management decisions showed substantial heterogeneity. Improving Swiss physiotherapists' screening abilities remains important. Further research is required to develop innovative educational concepts and improve training for screening for red flags.

Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review

Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.