Patient attitudes and beliefs associated with self-referral to physical therapy for musculoskeletal complaints: a qualitative study

Non-pharmacologic treatments such as physical therapy are advocated for musculoskeletal pain to decrease opioid use [1]. Early access to physical therapy via self-referral has been shown to decrease health care costs and improve patient outcomes [2‐5]. Self-referral (direct access) refers to a treatment pathway in which patients are evaluated and treated by a physical therapist without receiving a prior physician consultation [6]. Self-referral is safe, efficient, and cost-effective; however, utilization remains low and is estimated at around 6% in privately insured populations [7‐9].

Within the United States (U.S.), many factors may influence a patient’s decision to access physical therapy via self-referral. Once a patient identifies a need for physical therapy, the choice of treatment pathway (self-referral or provider referral) may be constrained by state-level legislation, institutional-level policies, or individual-level characteristics. Self-referral laws and regulations about access to physical therapy services for treatment and evaluation vary across states. Some states allow for unrestricted self-referral, others allow for self-referral with provisions; yet others limit patient self-referral [10]. Even if a patient resides in a state that offers some form of self-referral, the choice of self-referral to physical therapy might be restricted because of institutional-level policies developed by insurance providers, and/or healthcare organizations’ management policies [7, 11, 12].

Independent of state and organizational barriers, self-referral to physical therapy may also be influenced by patient-level determinants. Research has identified multiple patient-specific determinants that influence how a patient accesses physical therapy, including condition-related characteristics [2, 3, 13, 14], past physical therapy treatment experiences [13, 14], sociodemographic characteristics [2, 11, 13‐15], knowledge of the ability to self-refer [7, 16], attitudes to and beliefs about access [15, 16], and the geographical location of the physical therapy practice [3].

Evidence on the clinical and cost-effectiveness of “self-Webster VS, ferral” to physical therapy in the literature is substantial. Self-referral has been shown to extend healthcare users’ choice of providers [17], reduce treatment delay [18], enhance patient satisfaction, and improve resources utilization efficiency [7]. Several studies have also reported that self-referral is associated with lower costs to patients, insurance providers, and healthcare organizations [8, 9, 19‐21]. Although this evidence supports that self-referral is safe, efficient, and cost-effective - which indicates that it is the superior pathway- studies have reported that patients utilization of self-referral remains low [7, 8, 11].

The limited evidence surrounding self-referral service users’ actual perspectives/views for such a pathway emphasizes the need to understand how patients with musculoskeletal complaints choose a treatment pathway when seeking medical care. Our main research question was “What influences healthcare workers’ choice of treatment pathway (provider referral or self-referral) when seeking treatment for musculoskeletal complaints?”. We studied patients with musculoskeletal complaints who worked for a large, self-funded employer that reduced the cost of physical therapy services to financially promote ‘early physical therapy’ utilization in South Carolina, a state which has legislation supporting patients self-referral. By understanding the factors that influence a healthcare worker’s decision on how to access physical therapy services using qualitative research contextual evidence for the designing and re-evaluation of clinical practices may be provided.

This was a qualitative research study involving semi-structured interviews of healthcare workers of a large self-funded employer (> 14,000 employees) in South Carolina. In 2012, the musculoskeletal program (MSK program) - a partnership between a private physical therapy organization Prisma Health [employer], Steadman Hawkins Clinics of the Carolinas, and Blue Cross Blue Shield [insurance provider for all Prisma Health employees] - encouraged its employees to choose initiating physical therapy through self-referral with a reduced patient liability ($20 copay) or the traditional provider referral pathway ($60 copay for consulting a primary care physician or $80 copay for a consulting a specialist). The program’s goal was to remove institutional barriers and give employees lower co-payments for physical therapy visits if they chose to participate. The program was marketed via department meetings, emails, and fliers.

Our study design complied with the Standards for Reporting Qualitative Research (SRQR) checklist. Purposive criterion-based sampling technique was used; the selection of participants was based on eligibility criteria that are of importance to this study [22]. Individuals were eligible to participate if they were current employees of the health system; were experiencing a spine, shoulder, knee or hip-related complaint; were participating in the MSK program; and were over the age of 18 years. Sampling was continued until saturation was reached, that is when additional interviews reveal no new information, further coding was no longer possible [23], and enough information was available to duplicate the study [24]. Patients were recruited through flyers placed in seven physical therapy clinics across a 3-county region in the southeastern metropolitan area of Greenville, South Carolina. Interested participants contacted the author by phone and were screened for eligibility before interviews were scheduled. All interviews took place in a private office between August 2017 and March 2018 and were audio-recorded. Each interview lasted approximately 40 minutes. Written informed consent was obtained, and the rights of subjects were protected. The study received ethical approval from the Prisma Health Upstate Institutional Review Board.

A sociodemographic questionnaire was administered at the end of the interview to collect information about educational attainment, ethnicity, and income. Patients’ ages and gender were abstracted from electronic health records. The Mann-Whitney U test was used to analyze continuous variables and the Fisher exact test to analyze categorical variables.

To ensure credible findings, a number of steps were taken. Two additional coders were involved to improve the credibility of the findings. Both coders understood the practice of coding and analyzed data independently to dispel any misinterpretations. The researcher along with the two additional coders met on a regular basis to discuss the codes. Each coder was allowed to create emergent codes if they saw fit. This approach ensured reliability, as well as improved the trustworthiness of the analysis. In addition, coding and preliminary findings were continually shared with two co-authors (MC and MM) as an additional check on validity.

Thirty-two interviewees (17 interviewees were provider referred and 15 were self-referred) were enrolled in the study. A total of 20 interviewees were health care practitioners (e.g., nurses, surgical technologists, pharmacists, and respiratory therapists); the remaining 12 were administrative workers (clinical supervisors, medical transcriptions, unit secretaries, and front desk specialists). The number of healthcare practitioners and administrative workers in the two groups is presented in Fig. 1. Most participants in both groups complained of chronic musculoskeletal complaints. Neck, shoulder, back, and knee complaints were prevalent in both groups. Table 1 details the sociodemographic characteristics of interviewees, which did not differ between groups.

This study has provided insights into the underlying factors that affect the choice of treatment pathway (usual care vs. self-referral) for physical therapy among healthcare workers. Based on the major themes observed, a conceptual framework showing the major factors influencing patients selecting self-referral and provider referral is shown in Fig. 2.

In this study, although self-referral to physical therapy was supported through a reduction in co-payments, its effects appear limited given the 10–15% participation rate [8]. we have found that patients’ decisions to self-refer rather than consult a medical provider were driven by an interplay between knowledge of the self-referral program, resonant prior experience with physical therapy, and patients’ attitudes and beliefs toward treatment. Knowledge of the program, especially knowledge of the ability to self-refer, was a major factor for why patients stated they did so. Consistent with previous research, in our study knowledge was a fundamental factor influencing contact initiation; lack of knowledge hinders autonomous behavior [13, 28, 29]. For instance, misconceptions surrounding the administration of the program and insurance coverage resulted in some patients seeking the provider referral pathway despite knowledge of the program. Moreover, some patients who had previously participated in the program did not consider self-referring to physical therapy initially and took the provider referral pathway for their new complaint. When questioned, patients reported a lack of knowledge of the ability to self-refer. This suggests that patients knowledge of the existence of the program does not necessarily translate into their understanding that the program allows self-referral to physical therapy. If patients’ uptake of the self-referral pathway is to be encouraged, developing effective communication strategies about patients’ ability to self-refer and how access can be achieved is of paramount.

Another strong determinant of the choice of the self-referral pathway was patients experience with physical therapy, in line with previous studies [13, 14]. Interestingly, however, our study revealed that some provider-referred patients had experience with physical therapy yet still sought physician care first. It could be, as proposed by other authors, that participants were not exposed to all physical therapy aspects resulting in insufficient overall knowledge [16]. A further reason for this finding could be that these patients past physical therapy experience was not relevant enough to encourage them to think about physical therapy for their current musculoskeletal complaint. It should be noted that provider-referred patients only talked about their previous physical therapy experience when they were specifically asked about it, unlike the self-referred patients who spoke about it spontaneously in the interviews.

Another factor influencing the selection of self-referral or provider-referral to physical therapy was attitudes toward and beliefs about treatment, in line with previous work [16]. Self-referral patients held beliefs that physical therapy and other active treatments could help in relieving their pain. While it is known that self-referred patients tend to display autonomous and proactive behavior [15, 16], we have found that this is likely related to their self-expressed aversion toward medications and the desire to treat the root cause of the problem rather than the symptoms.

However, it should be pointed out that some self-referred patients had previously received assurances from a physician that physical therapy could assist with their pain, so their behavior to access physical therapy at a later point in time was not completely autonomous. In contrast, those selecting the provider referral pathway showed a preference for physician-focused diagnosis and treatment. Specifically, they had a desire for pharmacological treatments because these treatments offered a spontaneous solution to their pain. Although prescribed medications have potential benefits in managing musculoskeletal complaints, it has been shown they may be associated with a broad spectrum of adverse effects on the gastrointestinal, cardiovascular, cerebrovascular, and renal systems [30‐32].

The provider-referred patients in this study knew about the role of physical therapy in pain management yet they still chose to see a physician first. This is because they believed that physicians were more qualified to make medical judgments than physical therapists. While this finding is perhaps understandable it shows that patients acceptance of physical therapist appropriateness to make medical decisions presents a unique challenge that needs to be addressed. Given the provider referral treatment pathway implications on costs and healthcare utilization [33], strategies aimed at reshaping beliefs about the role of physical therapy, raising awareness of PT,and increasing confidence in its effectiveness both directly to the public and through partnerships with physicians, will be vital.

This study should be interpreted within the limitations of the design. First, South Carolina does allow direct access to physical therapy (with some provisions); and the results may not apply to states with more restrictions on direct access. Recruitment involved self-selection, so patients who chose not to participate might have different reasons underlying their choice of pathway than the interviewed population. While the large female bias of the sample represented the demographics of the employer with an incentivized self-referral; a study of a more general population might generate different results. Finally, the interviews reflect the perspectives of healthcare workers of one health system in one metropolitan area within the southeastern U.S., which may limit generalizability to other settings.

Healthcare workers with musculoskeletal complaints interviewed in this study based their choice of self- or provider referral pathway on their knowledge of the program, most importantly ability to self-refer, prior experiences with physical therapy, and their attitudes toward and beliefs about musculoskeletal medical treatment. Knowledge alone about physical therapy as a musculoskeletal complaint treatment option did not appear to influence healthcare workers’ choice of treatment pathway. Self-referred patients made conscious choices, attaching greater importance to their previous experience with physical therapy, while provider-referred patients’ choices were mainly determined by their attitudes and beliefs toward treatment and illness. The results of this study can be utilized to inform and guide policy makers efforts aimed at changing patients’ behaviors toward using physical therapy as a first-line approach for treating and managing their pain. It also provides physical therapists and health plan administrators with an understanding of how to empower patients to adopt autonomous health-seeking behaviors.