Date of Award
Spring 2024
Document Type
Open Access Dissertation
Department
Health Services and Policy Management
First Advisor
Brian Chen
Second Advisor
John Brooks
Abstract
Background
Physical therapy (PT) has been recommended as the first-line treatment for patients with incident musculoskeletal conditions without severe trauma. Initial or early use of PT may help address some of the nation’s most pressing health policy challenges, including escalating healthcare spending and an ongoing opioid epidemic, by encouraging the use of physical therapy as a substitute for expensive surgeries and the use of opioids. Yet, state scope of practice laws have historically restricted the diagnosis and treatment of medical conditions to physicians. Traditionally, patients seeking care from a physical therapist had to obtain a referral from a physician first. Over the years, however, states have increasingly liberalized their scope of practice laws through state direct access laws to permit patients to seek physical therapy directly without requiring a physician referral. As of 2017, states still vary in the extent to which direct access to physical therapy is permitted. However, the association between state direct access laws and physical therapy-seeking behavior and the subsequent effects on opioid use, healthcare utilization, and spending remain largely unknown. In light of these gaps in knowledge, I propose 3 objectives for this study. First, whether Medicare patients with an atraumatic rotator cuff tear seek care from a physical therapist first or early in the treatment process in states with laws permitting more direct access to physical therapy. Second, whether greater initial or early use of physical therapy in states permitting more direct access was associated with reductions in subsequent opioid use. Third, whether early use of physical therapy in states permitting more direct access was associated with reductions in subsequent healthcare utilization and spending.
Methods
Using Medicare claims data from 2016 to 2018, we identified beneficiaries diagnosed with atraumatic rotator cuff tear in 2017 and determined whether they sought care from a physical therapist first or within 30 days of the index visit. For the first aim, we conducted a multivariable logistic regression analysis to assess the association between initial or early use of physical therapists and state laws permitting more direct access to PT, controlling for patient clinical and demographic characteristics. For the second and third aims, we conducted an instrumental variable analysis of the effect of seeing a physical therapist first or early on subsequent healthcare utilization, spending, and opioid use, using the permissiveness of state direct access laws as instrumental variables. We used the American Physical Therapy Association’s classification to determine the permissiveness of state direct access laws, categorized as limited, provisional, or unrestricted direct access.
Results
For the first aim, our results show that relative to patients in states with limited access, patients in unrestricted and provisional access had, respectively, a 1.85, 95% confidence interval (CI) [1.56 – 2.19] and 1.85, 95% CI [1.54, 2.23] higher odds of seeing a physical therapist first. Similarly, relative to patients in states with limited access, patients in unrestricted and provisional access had, respectively, a 1.12, 95% CI [1.06, 1.19] and 1.22, 95% CI [1.16, 1.28] higher odds of seeing a physical therapist early. For our second aim, we found that patients whose choice to visit a physical as their first provider or early provider was sensitive to state direct access laws had lower MME, a decrease in total number of days of opioid supply and a lower rate of long-term opioid use, all p-value
Conclusion
My results show that Medicare patients with ARCT in states permitting more direct access to physical therapy had higher odds of seeing a physical therapist first or early. In turn, initial or early use of physical therapy was associated with lower opioid use, lower inpatient admissions, and reduced use of surgical repair. These findings are important for policymakers assessing the level of permissiveness of physical therapy in their state. Future studies should expand the study of state physical therapy direct access laws on other orthopedic conditions.
Rights
© 2024, Dakshu Jindal
Recommended Citation
Jindal, D.(2024). Association Between Direct Access Laws and Physical Therapy Use and the Effect of Change in Physical Therapy Use On Subsequent Healthcare Spending, Utilization, and Opioid Use. (Doctoral dissertation). Retrieved from https://scholarcommons.sc.edu/etd/7882