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Screening for medical referral: Attitudes, beliefs, and behaviors of physical therapists with greater than 10 years experience

Dissertation
Author: Diane E. Clark
Abstract:
Background and Purpose. Changing practice environments and the health status of the American population highlight the need for physical therapists to screen for medical referral (SMR). Current research suggests that opportunities exist for physical therapists to improve SMR skills related to non-musculoskeletal systems. The purpose of this study was to describe and explore older, more experienced physical therapists' attitudes, beliefs and behaviors to SMR and to describe perceived barriers. Methods. A web-based survey measured participants' agreement with statements related to attitudes and beliefs, the frequency of use of behaviors associated with SMR, confidence in utilizing SMR and identified barriers. Descriptive statistics were calculated and analyzed for each section. Results. Of a random sample of 1,108 APTA physical therapist members, 268 participated. Physical therapists reported overall positive attitudes and beliefs related to SMR (P<.001). Less positive beliefs were reported regarding academic preparation for SMR and its importance and relevance in outpatient and direct access settings. Physical therapists reported frequent use of the cardiopulmonary, integumentary, nervous and psychological systems and their related signs and symptoms, selected tests and measures, diagnostic imaging results and patient medication data during initial patient examinations ( P <.001). The gastrointestinal, genitoreproductive, urinary and endocrine systems were less frequently reported as screened. Barriers included lack of access to patient information and equipment, a lack of confidence and insufficient time to perform SMR. Discussion and conclusions. Physical therapists described a strong framework for SMR utilizing body systems considered to form the basis for physical therapy practice. Opportunities exist to standardize approaches to SMR and further define physical therapists' responsibilities related to SMR. More extensive continuing education and a mentorship program may increase physical therapists' skills and confidence related to SMR.

TABLE OF CONTENTS

Page

ABSTRACT....................................................................................................................ii

DEDICATION...............................................................................................................iv

ACKNOWLEDGMENTS...............................................................................................v

LIST OF TABLES.......................................................................................................viii

LIST OF FIGURES........................................................................................................ix

INTRODUCTION...........................................................................................................1

METHODS.....................................................................................................................8

SURVEY DEVELOPMENT....................................................................................8 SURVEY STRUCTURE..........................................................................................9 CONTENT VALIDITY..........................................................................................10 SAMPLING AND SURVEY ADMINISTRATION................................................10 DATA ANALYSIS.................................................................................................11 ATTITUDES AND BELIEFS............................................................................12 BEHAVIORS....................................................................................................12 BARRIERS........................................................................................................12 RELIABILITY..................................................................................................13

RESULTS....................................................................................................................14

DEMOGRAPHIC PROFILE ...................................................................................14 RELIABILITY.........................................................................................................16 ATTITUDES AND BELIEFS...................................................................................16 IMPORTANCE TO PATIENT MANAGEMENT AND OUTCOMES.……….18 BENEFITS/VALUES/BARRIERS....................................................................18 APPROPRIATENESS AND RELEVANCE TO PRACTICE SETTINGS AND DIRECT ACCESS.............................................................................................19 BEHAVIORS...........................................................................................................19

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KNOWLEDGE.........................................................................................................23 BARRIERS..............................................................................................................24

DISCUSSION..............................................................................................................25 LIMITATIONS..................................................................................................31

CONCLUSION............................................................................................................32

LIST OF REFERENCES..............................................................................................33

APPENDICES A SCREENING FOR MEDICAL REFERRAL SURVEY..............................38 B IRB APPROVAL........................................................................................48 C ADVANCED NOTIFICATION POSTCARD.............................................50 D EMAIL INVITATION................................................................................52

viii

LIST OF TABLES

Tables Page

1 DEMOGRAPHIC CHARACTERISTICS OF PHYSICAL THERAPISTS.........15

2 ATTITUDES AND BELIEFS OF PHYSICAL THERAPISTS..........................17

3 COMPARISON OF MEAN RESPONSES.........................................................18 4 SOURCES OF INFORMATION FOR INITIAL EXAMINATION....................20 5 FREQUENCY OF PHYSICAL THERAPISTS’ EXPLORATION OF SIGNS AND SYMPTOMS RELATED TO MEDICAL PROBLEMS................21 6 FREQUENCY OF PHYSICAL THERAPISTS’ PERFORMANCE OF TESTS AND MEASURES.............................................................................................21 7 FREQUENCY OF PHYSICAL THERAPISTS’ UTILIZATION OF LAB VALUES...........................................................................................................22 8 FREQUENCY OF PHYSICAL THERAPISTS’ UTILIZATION OF DIAGNOSTIC IMAGING RESULTS...............................................................22 9 PHYSICAL THERAPISTS’ KNOWLEDGE AND CONFIDENCE IN UNDERSTANDING RELEVANCE AND IMPORTANCE OF MEDICATIONS................................................................................................23 10 BARRIERS TO PHYSICAL THERAPISTS’ PERFORMANCE OF SCREENING FOR MEDICAL REFERRAL IN PHYSICAL THERAPY PRACTICE… .....………………………………………………………….……..24

ix

LIST OF FIGURES

Figure Page

1 SCREENING FOR MEDICAL REFERRAL SCHEMES.....................................3

1

INTRODUCTION

Screening for medical referral (SMR) is a process intended to facilitate physical therapists’ determination of the appropriateness of a patient or client for physical therapy. 1,2,3 The purpose of SMR is not to make a medical diagnosis but rather to recognize signs and symptoms that suggest an underlying medical disease or condition outside the scope of physical therapy practice that requires consultation or referral of the patient to a physician or other health care professional. 1,2,3 Changing practice environments and the health status of the American population highlight the need for physical therapists to screen for medical referral. 4,5,6 Direct access is now a legislative reality in most states. 5 With the privileges associated with professional autonomy, physical therapists assume greater responsibility for ensuring the safety and best interests of patients/clients. 4,7 Consideration of the changing demographic profile of the American population reinforces the need for physical therapists to be vigilant regarding the need for medical referral. 7 Patients/clients seeking physical therapy services are expected to be older, more racially diverse and to present with a high prevalence of medical and surgical comorbidities and medication usage. 8 Given these circumstances, physical therapists can expect increasing numbers of patients/clients to present with “red flags” or signs and symptoms of underlying systemic disease that warrant consultation or referral to other health care professionals.

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The process of SMR begins during the initial examination and continues throughout the episode of care. 1,2,3,9 SMR is based on the systematic collection and analysis of subjective data from the patient interview (e.g. risk factors, demographics, social and health habits, family history, medical/surgical history, medications, signs and symptoms identified through a review of systems), and objective data from the systems review, and selected tests and measures. 1,9 The Guide to Physical Therapist Practice directs clinicians to consult with other health care professionals as necessary to interpret examination findings and to incorporate outside sources of information such as lab values and diagnostic imaging results into decision making. 9 Throughout the examination process, physical therapists seek information that is suggestive of “red” flags that may either be extinguished through further examination or lead the physical therapists to conclude that referral of the patient to a physician or other health care professional for further investigation is warranted. Varying approaches to SMR have been described in the physical therapy literature. Boissonnault and Goodman and Snyder have described methodologies for SMR that are primarily centered on a body systems approach and are congruent with the systems framework described in the Guide to Physical Therapist Practice. 1,2 Physical therapists in the Uniformed Health Services are able to order diagnostic tests, laboratory work and prescribe certain medications. 10,11 While the approaches are similar, differences exist between the methods with respect to terminology, system classifications, signs and symptoms addressed, professional responsibilities and emphasis placed on sources of information outside of the physical examination (see Figure 1). No professional consensus has been reached as to which approach(es) is/are most comprehensive and

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effective in SMR. Consequently, confusion and uncertainty may exist among physical therapists as to what skills are needed and how best to incorporate SMR into practice.

SMR Characteristics Boissonnault, 1995 Goodman & Snyder 2000 Boissonnault 2005 Goodman & Snyder 2007 Systems Addressed

Systems screening based on body region

Use of Physical Examination

Medication interaction and adverse effects

Use of Lab Values

Use of Diagnostic Imaging Results Cardiovascular Pulmonary Gastro-intestinal Endocrine Musculoskeletal Nervous Rheumatologic Skin Urogenital Psychological Head and facial

No

Yes

Yes

Limited

Yes Cardiovascular Pulmonary Hematological Gastrointestinal Renal and urologic Hepatic and biliary Endocrine/metabolic Oncology Immunological Musculoskeletal

Yes

Limited

Limited * Cardiovascular lab values and medications only

Limited

Limited Cardiovascular Pulmonary Gastro-intestinal Endocrine Musculoskeletal Integument Urinary Reproductive

Yes

Yes

Yes

Yes

Yes Viscerogenic pain patterns: Hematologic Cardiovascular Pulmonary Gastrointestinal Hepatic and biliary Musculoskeletal Urogenital Endocrine/metabolic Immunologic Psychogenic

Yes

Limited

Yes

Limited (Cardiovascular/Cancer)

Limited

Figure 1. Screening for Medical Referral Schemes

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Numerous studies have examined physical therapy practice under direct access conditions and demonstrated effectiveness and safety. 12,13,14 Recent research suggests that physical therapists utilize SMR practices “relatively well”. 15 Studies to assess physical therapists’ abilities to identify red flags and make appropriate referral decisions demonstrated that the majority of physical therapists correctly made decisions for medical referral in the management of patients who presented with serious medical conditions. However, Riddle et al reported that 25% of physical therapists would not have referred patients to physicians when presented with high probability scenarios of deep vein thrombosis. 16 Jette et al found that 21% of physical therapists made incorrect decisions with respect to referral in patients who presented with serious medical conditions. 17 Given the potential consequences associated with the lack of referral in critical situations, physical therapists’ opportunities to improve the skills needed to screen for medical referral may benefit some patients. 16,17,18,19,20 One possible cause for physical therapists’ inaccurate decisions related to serious pathology is that physical therapists may not consistently and comprehensively screen for or identify relevant signs and symptoms related to these medical conditions. 16,17,18,19,20

Studies have demonstrated that physical therapists do not measure vital signs during initial examinations or aerobic conditioning programs as frequently as recommended by professional guidelines. 18,19 In a practice analysis of primary contact physical therapy, Donato et al demonstrated that physical therapists did not rate as importantly knowledge related to integumentary, cardiovascular, pulmonary, gastrointestinal, urogenital or endocrine system as knowledge related to the musculoskeletal and nervous system. 11

Additionally, physical therapists in nonprimary care practice were less likely to perform

5

procedures and identify abnormalities and signs potentially arising from visceral structures of the head, neck, chest, abdomen and pelvis while performing a musculoskeletal exam. As a result of these practices, physical therapists may overlook signs and symptoms related to prevalent conditions such as diabetes, hypertension or of the gastrointestinal system related to the use of non-steroidal anti-inflammatory drug (NSAID) and make less appropriate decisions regarding patient medical referral or consultation. 18,21,22

Healthcare professionals’ attitudes and beliefs related to a behavior or practice has been recognized as important determinants of that behavior, with less positive attitudes and beliefs resulting in less frequent performance of the behavior. 23,24 The Theory of Planned Behavior has proposed that behavior is predicated on behavioral intention that is in turn, formed as a result of the interaction among individuals’ personal attitude and beliefs (the degree to which the person has a favorable or unfavorable evaluation of the behavior in question), referent attitudes and beliefs (the degree to which important “others” would approve of the behavior), and the importance of the individual’s perception of confidence in performing the behavior (the degree to which the person feels that the performance or nonperformance of the behavior is under his/her volitional control). 25 Jette et al investigated the attitudes and beliefs of physical therapists related to evidence-based practice (EBP) and demonstrated that older, more experienced clinicians did not exhibit the same level of interest or positive attitude toward skills and knowledge related to EBP as did younger clinicians with more advanced degrees. 23 Younger physical therapists may have reported more positive attitudes and beliefs toward EBP as a

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result of skills, knowledge and competencies gained from formal exposure to curricula reflective of advanced competencies required by autonomous practice. Physical therapists’ without more advanced professional degrees may have gained SMR expertise from continuing education opportunities, reviews of the literature and / or from less evidence-based sources of information such as anecdotal evidence arising from experience or consultation with colleagues. Case reports and other evidence in the literature are limited to physical therapist practice in an outpatient setting with adult patients/clients. Application of SMR to other populations and settings is minimal. Screening for medical referral as performed by physical therapists is essential to current practice given physical therapists’ increasingly autonomous practice and progressively more complex patient populations. Given the limited body of knowledge available regarding SMR practice outside of the outpatient setting, physical therapists have few guidelines to follow. Physical therapists’ behavior related to SMR may also be influenced by the presence of barriers that extend beyond skill and knowledge (cognitive and technical) to include those that may be attitudinal and perceptual in dimension. 25

Implications of the EBP study conducted by Jette et al suggest that the attitudes, beliefs and education of older, more experienced clinicians may influence the extent to which and frequency with which SMR processes are incorporated into practice. 23

The development of a quantitative method to measure and describe these attributes related to SMR is essential to understanding current SMR practices performed by physical therapists. The purpose of this study is to describe and explore these factors of older, more experienced physical therapists’: 1) practice/behaviors related to screening for medical referral; 2) attitudes and beliefs related to SMR; 3) and barriers related to

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SMR behaviors as practiced by physical therapists. Three research questions were addressed: 1) Do physical therapists report a frequency of use of screening for medical referral behaviors that are consistent with SMR practice? 2) Do physical therapists demonstrate overall positive attitudes and beliefs towards screening for medical referral? 3) Do physical therapists perceive barriers to the performance of screening for medical referral?

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METHODS Survey Development The survey intentionally focused on body systems that were least recognized in the literature as being important and used by physical therapists to SMR. 11 Survey items were developed based upon a number of sources. Survey items related to “attitudes and beliefs” were based on the Theory of Planned Behavior and addressed physical therapists’ perception of their qualifications to perform screening procedures, whether SMR improved patient care and outcomes, the potential benefits of SMR and its appropriateness and relevance to different practice settings. 25 Items related to “behavior and practice” were based on several references. The proposed SMR schemes presented in Figure 1 served as the basis for the selection of systems in the “review of systems” section. 1,2 The American Physical Therapy Association (APTA) document Minimum Required Skills of Physical Therapist Graduates at Entry-Level served as a resource for the ‘selection of signs and symptoms” and “tests and measures utilized by physical therapists” in the performance of screening for medical referral. 26 The laboratory values category reflected the diseases and comorbidities most prevalent in patient populations who seek or are referred to physical therapy across practice settings. 1,2,8 The dimension of behavior addressing “diagnostic imaging results most relevant and available to physical therapists in practice” was developed based on a review of the literature. 1,11,27,28

“Selected medications” reflected those most frequently prescribed to patients referred to

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physical therapy and included in physical therapy program curricula. 8,29 Potential barriers were identified as they related to behavioral intention and based upon those cited by physical therapists in evidence-based practice literature. 23,24

Survey Structure The SMR Survey is a self-report measure that contains 54 items organized into 5 sections (see Appendix A). Section one contained demographic and practice data (13 items). Section two items explored respondents’ attitudes and beliefs towards medical screening (21 items). Participants were asked to rate their level of agreement or disagreement to a given statement using a 10-point Likert scale that was anchored by Strongly Disagree and Strongly Agree. Numbered intervals from 1-10 were denoted on the line. A 10-point Likert scale was selected to minimize respondents’ avoidance of extreme responses. 30 Negative statements minimized the tendency of respondents to reply in an automatic manner using only part of the rating scale. 30 In section three (16 items), participants were asked to use a 5-point Likert scale anchored by “Never” and “Always” to rate the frequency of use of behaviors associated with SMR. A 5-point Likert scale was selected so that specific adjectives describing frequency could be assigned to each value on the scale. While subjective, this methodology provided some standardization of frequency. These behaviors included the frequency of use of: (1) specific body systems used when performing a review of systems, (2) signs and symptoms related to general health and specific organ systems, (3) tests and measures, (4) laboratory, and (5) diagnostic imaging results. Section four (3 items) explored “confidence in performance of procedures” relating SMR to the participant’s role as a mentor to physical therapy

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students. Participants were then asked to rate their level of confidence in understanding the relevance and importance of medications frequently prescribed to patients using a 5- point Likert scale anchored by “not confident at all” and “very confident”. In section five (1 item), participants were asked to identify from a list all “barriers to their performance of screening for medical referral” that they encountered in their practice setting. They were given the opportunity to add additional barriers.

Content Validity Four University of Alabama at Birmingham (UAB) DPT faculty members and nine experienced physical therapists practicing in pediatrics (n = 2), acute care (n = 2), outpatient (n = 2), inpatient rehabilitation (n = 1), home health (n = 1) and skilled nursing/subacute rehab (n = 1) were presented with a draft of the survey to assess content validity. Each physical therapist was asked to review the survey for appropriateness, comprehensiveness and clarity. Agreement among the reviewers about the instrument indicated good content validity. The survey was modified based on reviewers’ suggestions.

Sampling and Survey Administration This research study received approval from the UAB Investigational Review Board (see Appendix B). A random sample of 2,000 physical therapists with current membership was obtained from the APTA. From this list, 1304 physical therapists had registered email and street addresses and were contacted to participate. Fifteen percent of

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the email addresses were invalid and therefore the final sample size was 1108 physical therapists. Survey administration followed principles developed by Dillman for mail and internet surveys. 31 All participants received advance notification via a mailed postcard informing them that they would be receiving an email invitation to participate in a survey about physical therapists’ perceptions and currents practices related to SMR (see Appendix C). Approximately one week later, invitations were emailed to participants and included information regarding the study’s purpose, confidentiality, informed consent, IRB approval and link to the website where the survey could be found (see Appendix D). Participants were informed that completion of the survey indicated informed consent. QuestionPro’s online survey software was utilized to administer the survey. 32 Upon completion of the survey, respondents received an email thanking them for their participation. Nonrespondents were sent email reminders every 2-4 weeks over a period of 12 weeks for a total of 4 reminders. Data collection occurred from October 2006 through January 2007. To determine the reliability of the survey items, a small subgroup of participants (n=24) completed the survey a second time two to four weeks after completion of the initial survey. 33

Data Analysis Data analysis was performed with SAS Version 9.0 (SAS Institute Inc.; Cary, NC). Data from the 10-point and 5-point Likert scales were considered interval data. 30

Descriptive statistics were generated for each item and table or section. For ordinal and

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categorical level data, frequency and percentage for each item were determined. An alpha level of 0.05 was selected for all statistical tests.

Attitudes and Beliefs (Question 1) Negative statements from Section 2 were recoded for analysis such that strongly agree = 1 and strongly disagree = 10. Positive attitudes and beliefs were defined as responses greater than 5.0 and negative responses as less than or equal to 5.0. Post-hoc analysis was conducted to determine whether characteristics of physical therapists with strongly positive beliefs of having the skills and knowledge to perform SMR (defined as responses > 7) were statistically significantly different from those with less positive or negative attitudes and beliefs. 33 Chi square analysis was used to determine the association between strong attitudes and beliefs of having the skills and knowledge and perceived confidence in performing SMR behaviors. 33

Behaviors (Question 2) A behavior was considered to be part of physical therapy SMR practice if the frequency of use was statistically significantly equal to or greater than 3.0 indicating that the behavior was sometimes, almost always or always performed.

Barriers (Question 3) Barriers were tabulated and percentages calculated for each response.

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Reliability Intrarater reliability was analyzed utilizing an intraclass correlation coefficient (ICC [3,1]) for ordinal/interval items (Sections 2-4 only). 33 The standard error of measurement (SEM) was calculated to estimate absolute reliability. 34 Unlike the ICC that is reflective of the ability of a test to differentiate between different individuals, the SEM provided an absolute index of reliability that assesses the within subject variance. 34 Internal consistency was measured using Cronbach’s α with a 95% confidence interval. 33

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RESULTS While the list of potential participants was randomly generated by the APTA, it was confirmed that the random sample actually did not include representation of physical therapist members who were aged 20-29 years or with five or fewer years of experience. Of the 1108 participants who were sent emails, thirty-five percent (387) viewed or started the survey. A total of 280 participants submitted their responses to the survey. Six submitted surveys were eliminated from the final analysis as they were not complete and six were eliminated as the physical therapists had ten or less years of experience. The final number of completed surveys submitted was 268 resulting in a response rate of 24.2%. The average time to complete the survey was 14 minutes.

Demographic Profile Overall, the participant demographic profile (Table 1) mirrored that of the APTA membership profile except for age and experience. 35 Respondents were primarily between the ages of 30 – 49 and had greater than 10 years of experience. Ninety percent of our participants practiced in states with direct access.

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Table 1. Demographic Characteristics of Physical Therapists α

Characteristics Physical Therapists

n % APTA Membership

% Gender, n (%)

Males 93 34 32 Females 178 66 68 Age Group, n (%)

20 – 29 yr 0 0 15 30 – 39 yr 104 39 32 40 – 49 yr 112 41 27 50+ yr 54 20 26 Experience practicing Physical Therapy, n (%)

≤ 5 yr 0 0 21 6 – 10 yr 6 2 19 11 – 15 yr 144 54 13 16+ yr 115 44 47 Entry Level Degree,

Baccalaureate 157 58 49 Certificate 9 4 5 Masters 97 36 38 Doctorate 4 1 7 Others 4 1 1 Highest Earned Degree

Baccalaureate 80 30 31 Masters (MSPT) 110 41 46 Doctorate in Physical Therapy 41 16 15 Other Doctorate 20 7 8 Facilities, Patient Care Performed

Acute care hospital Inpatient / Subacute Rehab 36 14 10 4 12 3 Skilled Nursing Facility 8 3 5 Privately Owned Outpatient Clinic 116 44 32 Hospital/Health system Outpatient Home care 19 7 25 9 19 7 School System 8 3 4 University Other 17 6 26 10 10 8 Certified Specialist

Yes 66 25 No 201 75 Clinical Instructor, n (%)

Yes 146 55 No 120 45 α The number of participants for each variable may vary because of missing data

16

Reliability Intrarater reliability for Section 2 attitude and belief items, as measured by ICC (3,1) was 0.71 (95% CI=0.58-0.93) with 2 SEM of 2.4. ICCs for sections 3 and 4 ranged from 0.75 – 0.88 with 2 SEM ranging from 0.5-1.0. The survey demonstrated strong internal consistency as demonstrated by Cronbach alpha values ranging between 0.83- 0.94. 33

Attitudes and Beliefs Overall, respondents reported having positive attitudes and beliefs about SMR that were significantly greater than 5.0 on a 10-point Likert scale with a mean response of 7.5 (P < .001). Table 2 contains descriptive data for Section 2 responses. The results regarding physical therapist qualifications indicated that respondents “strongly believed” that they possessed the skills and knowledge needed for SMR, that they were well qualified to accept the responsibility and accountability for performing SMR and that their general experience with patients enabled them to know when to refer the patient or consult with another healthcare professional. In general, respondents had mixed responses as to whether their academic preparation contributed to their skills and knowledge and whether physical therapists, rather than physicians, should be responsible for SMR. Physical therapists who strongly agreed to the statement “I have the skills and knowledge necessary to perform SMR” (response > 7) had significantly stronger positive attitudes and beliefs (P < 0.005) than those who had less positive perceptions related to their skills and knowledge (Table 3). These respondents also reported more frequent use

17

of behaviors related to signs and symptoms (P<.007) and lab results (P<.001) and had greater confidence in their knowledge related to medications (P<.002). A statistically significant, positive association was shown to exist between responses to the statement “I have the necessary skills and knowledge to perform SMR” and confidence related to the ability to perform SMR procedures ( (.05) χ 2 (16)

= 148.5, P=.001).

Table 2. Attitudes and Beliefs of Physical Therapists (Likert Response scale Range: 1= Strongly disagree – 10 = Strongly Agree)

Attitudes and Beliefs Mean Standard Deviation 95% CI Qualifications

General experience Skills and knowledge Well-qualified to accept responsibility & liability PTs responsible for SMR not MD Academic preparation adequate

9.0 8.6 8.1 6.7 4.9

1.4 1.7 2.1 2.7 2.9

8.8–9.1 8.4–8.8 7.8-8.3 6.3-7.0 4.6-5.3

Improves patient management and Outcomes

Helps me make better decisions about patient care Improves patient/client management and outcomes Patient care improved by knowing medications Having diagnostic imaging results improves care Important component of patient/client management Having lab results improves decisions about care

9.0 8.8 8.5 8.5 8.4 7.2

1.6 1.5 1.9 1.9 2.0 2.6

8.8-9.2 8.7-9.0 8.3-8.8 8.3-8.8 8.2-8.7 6.9-7.5

Benefits/Values

Not too time consuming Administration support Patients more satisfied when I use SMR Valued by other member of team for SMR skills Peers perform SMR I receive more referrals because of SMR practices

8.5 8.0 7.5 7.3 6.6 5.2

2.2 2.2 2.2 2.3 2.7 2.8

8.2-8.7 7.7-8.2 7.2-7.8 7.0-7.6 6.3-7.0 4.9-5.5 Practice Settings

Sure of application in practice setting SMR is essential in all practice settings Most appropriately used in outpatient setting Most relevant for physical therapists with direct access

8.8 8.4 5.5 5.4

2.0 2.2 3.0 3.5

8.5-9.0 8.1-8.6 5.1-5.8 5.0-5.8

Overall 7.6 2.1 7.4-7.7

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Table 3. Comparison of Mean Responses Physical Therapists score of > 7 vs. score of ≤ 7 to statement: “I have the skills and knowledge to perform SMR processes related to physical therapy.”

Sections & Tables Score > 7 Score of ≤ 7 P - value Section 2: Attitudes and Beliefs 7.7 6.4 0.005 Section 3: Review of Systems Signs and symptoms Diagnostic Imaging Results Tests & Measures Lab results 3.7 3.6 3.4 2.8 2.3

3.2 2.9 3.1 2.3 1.8 0.183 0.007 0.332 0.174 0.000

Section 4: Medications 3.7 2.8 0.002

Importance to patient management and outcomes SMR was strongly perceived as being important to patient/client management, decision-making and improving patient outcomes and care with mean responses of 8.4 (SD =2.0), 9.0 (SD =1.7) and 8.8 (SD=1.6) respectively (Table 2). Respondents believed that having diagnostic imaging results and knowledge of patient medications (mean = 8.5, [SD =1.8]) more strongly contributed to improved patient/client management and outcomes than did laboratory values (mean = 7.2 [SD = 2.6]).

Benefits/Values/Barriers Physical therapists were positive in the belief that screening for medical referral was not too time-consuming to perform (mean = 8.5 [SD = 2.2]; Table 2). They believed that patients/clients and other health care professionals valued their screening skills in determining the appropriateness of a patient/client for physical therapy services (mean = 7.3 [SD = 2.3]). While respondents reported a small positive response to whether their peers incorporated screening for medical into their patient/client management (mean = 6.6 [SD=2.7]), they believed that administration was supportive of their practice (mean =

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8.0 [SD=2.2]). Respondents indicated that they were unsure whether SMR increased their patient referrals (mean=5.2 [SD =2.8]).

Appropriateness and relevance to practice settings and direct access Respondents strongly believed that SMR was essential in all practice settings (mean = 8.4, [SD = 2.2]) (Table 2) and that they were certain of how SMR applied to their practice setting (mean = 8.8, [SD = 2.0]). Physical therapists had mixed responses related to statements that SMR was most appropriate in outpatient settings (mean = 5.4 [SD =3.0]) and most relevant in direct access conditions (mean = 5.4, [SD 3.5]). The standard deviations for each statement were large suggesting significant response variability.

Behaviors Behaviors were found to be significantly positive (P<.001), with the exception of those related to tests and measures (Table 6) and laboratory results (Table 7). Ninety-nine percent of respondents indicated that they had made at least one referral to another health care professional as a result of information identified during screening practices for medical referral. During a patient’s initial examination, physical therapists’ responses indicated that they “sometimes” or “almost always” performed a review of systems and general health as well as utilized information related to patients’ current medications (mean = 3.6 [SD-0.7, P <0.001; Table 4). Systems most frequently screened were the nervous, cardiovascular and pulmonary, integumentary and psychological systems. Those systems less frequently reviewed, as indicated by those with mean responses less than the

20

overall mean of 3.6, were the gastrointestinal, urinary, endocrine, and genito-reproductive systems. Physical therapists reported that they “rarely to sometimes” reviewed patient lab results during an initial examination (mean = 2.8 [SD=1.2]; Table 4). This finding was corroborated by an overall mean response of 2.2 (SD=1.1) or “rarely” for the frequency of use of specific lab values (Table 7).

Table 4. Sources of Information for Initial Examination (Likert Response Scale: 1 = Never – 5 = Always)

Questions Relating to Initial Examination Mean Response SD 95% CI Medications 4.6 0.7 4.5-4.6 General health 4.6 0.7 4.5-4.6 Nervous 4.4 0.7 4.4-4.5 Cardiovascular/Pulmonary 4.1 0.9 4.0-4.2 Psychological 3.7 1.0 3.6-3.8 Urinary 3.3 1.1 3.2-3.4 Gastrointestinal 3.2 1.1 3.0-3.3 Endocrine 3.0 1.2 2.9-3.2 Lab results 2.8 1.2 2.6-2.9 Genito-reproductive 2.5 1.2 2.3-2.6 Overall 3.6 0.7 3.5-3.7

Full document contains 63 pages
Abstract: Background and Purpose. Changing practice environments and the health status of the American population highlight the need for physical therapists to screen for medical referral (SMR). Current research suggests that opportunities exist for physical therapists to improve SMR skills related to non-musculoskeletal systems. The purpose of this study was to describe and explore older, more experienced physical therapists' attitudes, beliefs and behaviors to SMR and to describe perceived barriers. Methods. A web-based survey measured participants' agreement with statements related to attitudes and beliefs, the frequency of use of behaviors associated with SMR, confidence in utilizing SMR and identified barriers. Descriptive statistics were calculated and analyzed for each section. Results. Of a random sample of 1,108 APTA physical therapist members, 268 participated. Physical therapists reported overall positive attitudes and beliefs related to SMR (P<.001). Less positive beliefs were reported regarding academic preparation for SMR and its importance and relevance in outpatient and direct access settings. Physical therapists reported frequent use of the cardiopulmonary, integumentary, nervous and psychological systems and their related signs and symptoms, selected tests and measures, diagnostic imaging results and patient medication data during initial patient examinations ( P <.001). The gastrointestinal, genitoreproductive, urinary and endocrine systems were less frequently reported as screened. Barriers included lack of access to patient information and equipment, a lack of confidence and insufficient time to perform SMR. Discussion and conclusions. Physical therapists described a strong framework for SMR utilizing body systems considered to form the basis for physical therapy practice. Opportunities exist to standardize approaches to SMR and further define physical therapists' responsibilities related to SMR. More extensive continuing education and a mentorship program may increase physical therapists' skills and confidence related to SMR.