Referral for Imaging in Physical Therapist Practice: Key Recommendations for Successful Implementation

Reliability of a Musculoskeletal Imaging Competency Examination for Physical Therapists

INTRODUCTION

The Burley Readiness Examination (BRE) for Musculoskeletal (MSK) Imaging Competency assesses physical therapists' baseline MSK imaging competency. Establishing its reliability is essential to its value in determining MSK imaging competency. The purpose of this study was to test the reliability of the BRE for MSK Imaging Competency among physical therapists (PTs) with varying levels of training and education.

REVIEW OF LITERATURE

Previous literature supports PTs' utility concerning diagnostic imaging; however, no studies directly measure their competency. With PTs expanding their practice scope and professional PT education programs, increasing their MSK imaging instruction, assessing competency becomes strategic in determining the future of MSK education and training.

SUBJECTS

One hundred twenty-three United States licensed PTs completed the BRE.

METHODS

Physical therapists completed the BRE through an online survey platform. Point biserial correlation (rpb) was calculated for each examination question. Final analyses were based on 140 examination questions. Examination scores were compared using independent sample t-test and one-way analysis of variance. Chi-square tests and odds ratios (ORs) assessed the relationship of a passing examination score (≥75%) and the type of training. Reliability of the BRE was assessed using Cronbach's alpha (α).

RESULTS

Mean overall examination score was 75.89 ± 8.56%. Seventy PTs (56.9%) obtained a passing score. Physical therapists with additional MSK imaging training, board certification, and residency or fellowship training scored significantly higher (P < .001) compared with those with only entry-level PT program education. Physical therapists with additional MSK imaging training scored significantly higher (x̄ = 81.07% ± 8.93%) and were almost 5 times (OR = 4.74, 95% CI [1.95-11.50]) as likely to achieve a passing score than those without. The BRE demonstrated strong internal consistency (Cronbach's α = 0.874).

DISCUSSION AND CONCLUSIONS

The BRE was reliable, consistently identifying higher examination scores among those with increased MSK imaging training. Training in MSK imaging influenced competency more than other factors. The BRE may be of analytical value to PT professional and postprofessional programs.

Determining the Optimal Length of Clinical Education Experiences: Surveying Doctor of Physical Therapy Academic and Clinical Faculty

INTRODUCTION/REVIEW OF LITERATURE

There is wide variability in the length of full-time clinical education experiences (CEEs) among Doctor of Physical Therapy (DPT) programs. We investigated academic and clinical faculty perspectives on the optimal length and level of agreement on the length, timing, and offering of full-time CEEs.

SUBJECTS

A survey assessing perspectives on the optimal length and level of agreement for the length, timing, and offering of full-time CEEs was completed by 100 academic and 240 clinical faculty.

METHODS

Differences between academic and clinical faculty responses on the optimal length and level of agreement were assessed with a 2-sample test of proportions and 2-sample t-test.

RESULTS

Participants believed that the length of full-time CEEs (in weeks) should be single CEE 10.6 (SD 2.3); first CEE 7.8 (SD 2.1); terminal CEE 12.5 (SD 5.4); integrated CEE 9.6 (SD 1.9); and total CEEs 37.2 (SD 6.9). There were significant differences (MD = -3.0; 95% confidence interval [CI] -4.6 to -1.6) between academic and clinical faculty perspectives for the total length of CEEs. No significant differences between academic and clinical faculty perspectives for the length of single, first, terminal, or integrated CEEs. There were significant differences between academic and clinical faculty perspectives for the optimal length of inpatient (MD = 1.1; 95% CI 0.6-1.6) and specialty (MD = 0.8; 95% CI 0.2-1.3) settings. There were significant differences between academic and clinical faculty level of agreement for 8 of 15 items.

DISCUSSION AND CONCLUSION

There was consistency between academic and clinical faculty regarding the perceived optimal length of full-time CEEs. Academic and clinical faculty perspectives for the optimal length of terminal full-time CEEs (12.5 weeks) were different than those for the national average (21.8 weeks) length of terminal full-time CEEs. Our study provides evidence to support DPT programs' clinical education curriculum decisions regarding the length of full-time CEEs to optimize students learning and maturation.

Physical therapist awareness of diagnostic imaging referral jurisdictional scope of practice: an observational study

OBJECTIVES

To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency.

METHODS

This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency.

RESULTS

Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01).

DISCUSSION/CONCLUSION

There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Private physical therapy practice implementation of direct referral for radiograph imaging: an administrative case report

BACKGROUND

Prior research indicates physical therapists make appropriate, judicious diagnostic imaging referrals, but have not described how to implement imaging referral processes in organizations without an imaging department.

OBJECTIVE

This administrative case report describes the implementation of a direct referral process for radiographic imaging in a private physical therapy practice.

CASE DESCRIPTION

Guided by the Interactive Systems Framework, a collaborative business agreement between a physical therapist-owned practice, musculoskeletal urgent care clinic, and radiology practice provided a clinical process for physical therapists to directly refer patients for radiographic imaging.

OUTCOMES

When clinically appropriate, physical therapists signed referrals for radiographic imaging that was acquired by qualified urgent care clinic staff, interpreted by a radiologist, and reported to the physical therapist. The physical therapist, urgent care clinic, and radiologist bill for the physical therapy evaluation, technical component, and professional component, respectively. In the 5 months following implementation, 5 referrals were acquired within 15 minutes, the interpretation was returned within 30 minutes, and all entities received insurance reimbursement.

CONCLUSION

This clinical process allows the physical therapist to execute clinical decision making within the scope of physical therapist practice, yet expeditiously acquire imaging studies to facilitate appropriate patient care. Formal collaboration between discrete organizations provided a system to deliver the necessary imaging services.

Physical therapy students' application of an imaging decision rule for acute knee pain

BACKGROUND

Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students.

OBJECTIVE

The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy.

METHODS

An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool.

RESULTS

Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.

Physical Therapists Are Routinely Performing the Requisite Skills to Directly Refer for Musculoskeletal Imaging: An Observational Study

OBJECTIVES

To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging.

METHODS

An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists.

RESULTS

4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001).

CONCLUSION

Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging.

Extended roles in primary care when physiotherapist-initiated referral to X-ray can save time and reduce costs

OBJECTIVE

The objective of this study was to evaluate an extended role for the physiotherapist in primary care in referring patients to plain X-ray.

METHODS

This prospective cohort study was set in a single region in Sweden. It included 20 physiotherapists who were educated in a 1-day training in performing referral to X-ray, along with 107 patients with musculoskeletal disorders who were referred to X-ray. We evaluated referral quality and patient and physiotherapist satisfaction and calculated healthcare and patient costs.

RESULTS

All referrals fulfilled the basic requirements of quality, and 78% were classified as good, fulfilling all criteria. Both patients and physiotherapists were satisfied with the extended role for the physiotherapist that decreased the waiting time to diagnosis and to adequate treatment. Costs were reduced for patients (by €53/patient) and healthcare (by €6286.2/107 patients). The cost to visit a physician was twice that of a physiotherapist visit.

CONCLUSIONS

An extended role for physiotherapists in primary care in referring patients to X-ray was effective and safe for patients and reduced costs for patients and for healthcare. Physiotherapists in primary care were able to refer patients to X-ray after a 1 day of training, and the extended role freed up 45 min of physician time for each patient with a musculoskeletal disorder in need of an X-ray.