Date of Award


Document Type

Open Access Dissertation


Health Services and Policy Management


The Norman J. Arnold School of Public Health

First Advisor

Melanie Cozad


Purpose: Non-pharmacologic treatment such as physical therapy (PT) are advocated for musculoskeletal pain for decreasing opioid use. Early access to PT has been shown to decrease costs and improve outcomes through direct access via self-referral. Although self-referral to PT is permitted in the majority of U.S states, health insurance coverage has been identified as a barrier preventing some patients with musculoskeletal complaints from using it. There are few studies examining patient factors related to early access to physical therapy via self-referral. The purpose of this study was to identify the factors outside of insurance that influence the choice to access physical therapy care through the self-referral or usual care pathway.

Methods: A program removing these barriers was administered in partnership with a self-funded employer where a physician referral was not required with lower copayments for each visit. After program implementation, the majority of patients still selected to access PT by seeking a referral from a physician (usual care pathway). Thirty-two in-depth semi-structured interviews were conducted after patients with this benefit accessed physical therapy for non-operative musculoskeletal complaints. Interviews lasted approximately 35 minutes. Each interview was audio recorded and transcribed for qualitative analysis. Concurrent patient data was pulled from the ATI Patient Outcomes Registry including comorbidities, patient reported disability, duration of pain , and baseline level of pain. A grounded theory approach using open, axial, and selective coding techniques thematically identified major factors contributing to the choice of the self-referral or the usual care pathway when accessing PT. Mann-Whitney U and Fisher’s exact tests were used to compare baseline patient differences between groups. (α<=0.05).

Results: There were no significant association in clinical or socio-economic variables and patient choice of care (usual care vs self-referral pathway). However, thematic differences included: 1,) patients’ knowledge of the program, 2.) attitudes/preferences toward treatment, and 3.) resonant prior experiences with PT. Patients selecting the usual care pathway lacked program knowledge, preferred pharmacological treatments, and desired physician reassurance. Patients selecting self-referral knew about the program, were open to a wide array of treatment options which were associated with existing beliefs about pharmacological treatments and surgery. Patients using direct access also had positive prior experiences with PT or members of their network did.

Conclusion: This study provides evidence that knowledge, attitudes and beliefs about treatment, and resonant prior experience with PT influence patient choice of self-referral to PT. The sample is limited to employees of one health system in one metropolitan area within the southeastern U.S and is generalizable only to this demographic. Programs aimed at improving patient knowledge and changing patient attitudes appear warranted to increase utilization of self-referral to PT for musculoskeletal complaints


© 2018, Noor Alshareef