SCREENING FOR MEDICAL REFERRAL: DETERMINING VARIABLES THAT INFLUENCE ACCURACY HEATHER E. MOUNT

Transcription

1 SCREENING FOR MEDICAL REFERRAL: DETERMINING VARIABLES THAT INFLUENCE ACCURACY by HEATHER E. MOUNT CECILIA GRAHAM, COMMITTEE CHAIR DAVID M. MORRIS DIANE CLARK DIANE U. JETTE KATHLEEN T. FOLEY A DISSERTATION Submitted to the graduate faculty of The University of Alabama at Birmingham in partial fulfillment of the requirements for the degree of Doctor of Science BIRMINGHAM, ALABAMA 2012

2 SCREENING FOR MEDICAL REFERRAL: DETERMINING VARIABLES THAT INFLUENCE ACCURACY HEATHER E. MOUNT DOCTOR OF SCIENCE IN PHYSICAL THERAPY ABSTRACT Background: Screening for medical referral is essential to autonomous practice; however, no studies have examined the medical screening abilities of physical therapists in various settings. Objective: The purpose of this study was to determine if physical therapists in various practice settings could appropriately screen for medical referral, given brief clinical vignettes. Methods: A Delphi study was performed to enhance the content validity of the vignettes. After reviewing the vignettes, survey participants determined if they would provide intervention, provide intervention and refer, or refer before intervention. For each category of cases, the percentage of participants who made correct decisions for 100% of cases and the mean score was calculated. To determine which variables were associated with correct decisions in each category, 4 sets of logistic regressions were performed. ii

3 Results: A random sample of APTA members (n=214) completed the survey. Participants were able to make correct management decisions greater than 90% of the time in traditional and non-critical medical cases. Participants in outpatient settings were 2 times as likely to make correct decisions in critical medical and traditional cases. Participants with more than 30 years experience were 6 times as likely to make correct decisions in non-critical medical cases. Limitations: Generalizability of the results may be limited by the brief nature of the vignettes, lack of 100% consensus in the Delphi study, and the relatively low sample size. Conclusions: Despite the variety of cases presented spanning different settings, participants made correct management decisions for 84% of the cases. Screening for medical referral is vital in all practice settings and further research is needed to investigate knowledge and practice patterns related to medical screening. Keywords: physical therapy, medical screening, decision making iii

4 DEDICATION This dissertation is dedicated to my family, both my parents for their love and encouragement and my wonderful husband for his unwavering support and personal sacrifices made during my journey. I also dedicate this work to my two sons, who have brought more joy and love to my life than I ever thought possible. I hope that this accomplishment serves as inspiration to them that with hard work and perseverance anything is possible. I know the price of success: dedication, hard work, and an unremitting devotion to the things you want to see happen. Frank Lloyd Wright iv

5 ACKNOWLEDGEMENTS I would like to acknowledge the people who have been integral to the completion of my life long dream. I would like to thank the members of my dissertation committee, who have generously given their time and expertise to better my work. I am forever indebted to Dr. Cecilia Graham, the chair of my dissertation committee, for her patience, guidance and commitment to the success of this project. I am also grateful to those who have provided me with their expert opinions and advice, including the members of the Delphi panel, Scott Bickel and Sharon Rhodes, who has served as a mentor and friend throughout my career. I am grateful for the technical support provided by Amanda Sherman. She preserved my sanity when I needed it the most. Without each of you, this endeavor would not have been possible. v

6 TABLE OF CONTENTS ABSTRACT... ii DEDICATION... iv ACKNOWLEDGEMENTS...v LIST OF TABLES... vii INTRODUCTION...1 METHODS...4 Survey Development...4 Delphi Study...5 Sampling...6 Data Analysis...7 RESULTS...9 Total Score...11 Critical Medical Cases...12 Non- Critical Medical Cases...12 Traditional Cases...13 DISCUSSION...14 CONCLUSION...20 LIST OF REFERENCES...21 APPENDIX...24 A INSTITUTIONAL REVIEW BOARD APPROVAL FORM...24 B CASE DESCRIPTIONS...26 vi

7 LIST OF TABLES Table Page 1 Characteristics of Sample Percentage of Participants Making Correct Management Decisions Summary of Management Decisions of Category of Cases Results of Logistic Regression...12 vii

8 INTRODUCTION The ability to determine whether a client presents with a condition that is within the scope of physical therapist practice is essential to the autonomous practitioner. The vast majority of states allow some form of direct access and an increasing number of physical therapists are practicing in primary care environments. 1 When physical therapists act as the first point of contact, they must not only determine whether physical therapy is appropriate, but whether there are signs and symptoms or red flags that warrant a referral to another health care professional. Serious medical pathology can not only mimic common conditions that physical therapists treat but can progress quickly. Early detection of these conditions is important to prevent or minimize complications and comorbidities. 2 Several studies have demonstrated physical therapists ability to accurately screen for medical referral. Childs et al, 3 found that experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns, residents and all physician specialists except orthopedists. Moore et al 4 performed a study to determine the diagnostic accuracy between physical therapists, orthopedic surgeons and non-orthopedic providers. The authors found that the physical therapists outperformed the non-orthopedic providers and there was no significant difference between orthopedic surgeons and physical therapists. These studies were 1

9 performed in military facilities where physical therapists have additional training in primary care. Other studies have indicated areas in which physical therapists skills in screening for medical referral could be improved. In 2004, Riddle et al 5 examined the ability of physical therapists to identify patients who are considered at high risk for deep vein thrombosis (DVT). Each participant was asked to determine the probability of a DVT given 6 clinical vignettes using the Wells Clinical Prediction Rule 5 and decide if they would contact a physician. Due to the potential for mortality and morbidity, the vignettes that were considered moderate and high probability for DVT warranted a physician referral. For the 2 vignettes that were deemed moderate probability for DVT, 15% and 30% of participants would not have contacted the physician. Given the 2 vignettes that presented with a high probability of DVT, 32% and 27% of participants would not have contacted the physician. The participants underestimated the probability of DVT in the high probability cases by more than 60%. Board certification, practice setting or region of the country did not impact the results. Jette et al 6 examined physical therapists ability to accurately screen for medical referral utilizing a series of 12 case scenarios. The survey was distributed to a random sample of members of the American Physical Therapy Association (APTA) private practice section. For each case, respondents were asked to determine whether they would proceed with the intervention, provide the intervention and also consult or refer with another medical professional, or refer to another medical professional prior to providing intervention. The percentage of correct decisions made was calculated for each case. Approximately 50% of the participants responded correctly to all case scenarios. 2

10 Participants made a correct decision for 87.3% of the cases when intervention was appropriate, 87.8% of the cases when providing intervention and then consulting or referring was indicated and 79.0% of the cases when the correct decision was to refer. The researchers examined years of experience, degree obtained, and specialist certification. The only significant finding was that physical therapists with an orthopedic specialist certification were almost twice as likely to make correct decisions in critical medical and musculoskeletal conditions. There have not been any studies that have examined the medical screening ability of physical therapists in settings outside of outpatient or private practice. However, the APTA Board of Directors has clearly stated that autonomous practice applies to all therapists regardless of setting. 7 Therefore, the purpose of this study was to analyze the decision-making abilities of physical therapists related to medical screening. Specifically, the goal of the study was to determine if physical therapists, regardless of practice setting, could recognize situations in which a referral to a medical professional would be indicated. The study also examined the relationship between physical therapists accuracy in screening for medical referral and years of experience, entry-level degree, highest degree obtained, and specialist certification. 3

11 METHODS Survey Development Institutional Review Board approval for the study was obtained from the University of Alabama at Birmingham (Appendix A). The questionnaire contained 2 parts. The first part was the demographic component, which was adapted from the APTA demographic survey. 8 The second component consisted of 12 case studies, which were developed from a variety of resources. With permission, 3 of the cases were adapted from the study by Jette et al An additional 4 cases were adapted from a graduate level course series in medical screening in the Doctor of Science program at the University of Alabama Birmingham with permission from the instructor. I developed the remainder of the cases utilizing physical therapy literature, textbooks and clinical experience. 1,2,9,10 The cases were designed to represent realistic patient scenarios that therapists might encounter in different settings. Each case contained a brief medical history and description of signs and symptoms. Participants were asked to make a management decision based only on the information provided. Conditions that required a referral to another health care professional were considered critical or non-critical based on the urgency with which a referral was indicated. 4

12 Delphi Study A Delphi Study was performed to enhance the content validity of the cases. The panel consisted of 3 physical therapists considered experts in their field with at least 10 years of experience and continuing education in screening for medical referral, 3 physicians who also previously or currently practice as physical therapists, and 3 physical therapists that teach screening for medical referral in the academic setting. Doctoral degrees, including PhD, MD, or advanced doctorate, were held by 8 of the 9 members of the panel. The panel averaged 20 years of clinical experience, with one member having more than 35 years of experience. Certifications held by the panel included certified Athletic Trainer, Neurology Certified Specialist, Geriatric Certified Specialist, certification in Mechanical Diagnosis and Therapy and Vestibular Rehabilitation. In the first round, 12 case studies were presented. Panel members responded to a series of open and closed ended questions and were able to make comments. They were also asked to make a management decision. Three choices were given: (1) Proceed with physical therapy intervention without medical referral (treat) (2) Provide physical therapy intervention and then consult with or refer to a medical professional (treat/consult) or (3) Refer the patient to a medical professional before any physical therapy intervention (refer). One of the members of the panel dropped out of the study after round one. In the second round, the panel was able to make additional comments and suggestions as well as select the correct management decision. In the third round the panel was asked to select the correct management decision. After each round the management responses were totaled and comments reviewed. Appropriate revisions were made to the cases based on comments from the 5

13 panel while keeping the cases brief. If a case achieved 100% consensus, the case was eliminated from further rounds. One case was eliminated during each of the first two rounds. All cases were included in the study that reached a consensus of greater than 50% after round 3. Only 1 case was eliminated from the study because it did not reach this threshold. See Appendix B for the final cases that resulted from the Delphi process. Sampling To achieve an alpha level of 0.05 with a power of 80%, given a standard deviation of 1, the target sample size was 220 respondents. 14 Estimating a 30% response rate and 10% contact error, 1,100 physical therapists were initially contacted. I obtained a random sample from the membership directory of the APTA website 11 and 122 members addresses were chosen from each of the following sections: orthopedic, sports, private practice, acute care, cardiovascular and pulmonary, oncology, geriatric, neurology and home health. The target practice settings were acute care, outpatient/private practice, home health and rehabilitation. The frequency of sampling in each section was determined using the membership statistics. The method for random sampling was altered slightly for the orthopedic and sports section due to changes in the format of the membership directory. The goal of 55 respondents in each of the 4 practice settings was not reached after the first round. A second random sample was obtained utilizing the same method from the following sections: home health, acute care, oncology, geriatric and neurology. If an address was not provided in the directory, or the participant was already chosen from a different section, the subsequent name in the directory was chosen. This process continued until a participant with an address was obtained. 6

14 Physical therapists were contacted via . The explained that the purpose of the study was to examine the ability of physical therapists to screen for medical referral and included a link to the survey on QuestionPro. 12 Physical therapists currently practicing at least 20 hours per week were included in the study. Participants were informed that the cases were intentionally brief in order to avoid being a burden to busy clinicians. The survey instructions acknowledged that in a clinical situation additional tests would likely be carried out prior to a final decision being made. Respondents were provided with 3 possible management decisions for each case. The participants were given the same choices as in the study by Jette et al 6 which were also given to the panel. Data Analysis Data analysis was performed using IBM SPSS version 19, New York. 13 Descriptive statistics were used to describe the characteristics of the participants as well as percentages of participants who made correct management decisions in each case. The management decision chosen by the expert panel was utilized to divide the cases into 3 categories. If the management decision was to provide intervention without a referral, the case was considered a traditional case. If the decision was to proceed with the intervention then consult or refer, the case was a non-critical medical case. If the decision was to refer to another health care professional, the case was deemed a critical medical case. Correct management decisions for traditional cases were to treat or to treat/consult. An incorrect response was to refer. Non-critical medical cases were considered correct if the participant chose to treat/consult or refer. An incorrect response was to treat. Critical medical cases were considered correct if the participant chose to refer. 7

15 For each category of case scenarios a mean percentage of correct decisions was calculated. For each category of cases, participants were further classified based on whether they scored 100% on all cases or less than 100%. To be considered for this analysis, a participant had to respond to all cases in that category. I chose to perform a series of logistic regressions to determine which variables were associated with correct management decisions in each of the categories. 14 The original independent variables included practice setting (acute, rehabilitation, outpatient, home health), years of experience (<= 5 years, 6 to 29 years, >= 30 years), certification (yes or no), entry-level degree (baccalaureate, masters, doctorate) and highest earned degree (baccalaureate, masters, entry level doctorate, transitional doctorate, PhD). Based on multicollinearity statistics and a Pearson bivariate correlation of 0.76 between years of experience and entry level degree, entry-level degree was eliminated from the regression analysis. Due to the small sample sizes, 2 variables were collapsed. Practice setting (inpatient/outpatient) and highest earned degree (baccalaureate, masters, doctorate (all), PhD (all), were changed while certification and years of experience remained the same. The outpatient category consisted of participants in home health, outpatient, private practice, and health and wellness. The inpatient category included participants in acute care, inpatient rehabilitation, and long-term care facilities. I performed 4 sets of logistic regressions in a stepwise, forward, conditional manner. 14 Odds ratios and the 95% confidence intervals were determined for each level of the independent variables in those models that were significant. 8

16 RESULTS Survey requests were sent to 1378 physical therapists but 16 requests were returned due to invalid addresses. The survey was accessed by 391 (29%) of 1378 physical therapists contacted. Of the 391 that responded, 214 (62%) met the inclusion criteria and completed the survey and 77 (20%) exited the survey prior to completion. The 100 respondents (26%) that did not meet the inclusion criteria were redirected to the exit page of the survey. The demographic characteristics of the participants are found in Table 1. The characteristics of the participants in this study were fairly consistent with the characteristics of the APTA membership. The mean age of the participants was 43.81years, SD= The range was 25 to 69 years. For each case scenario, the percentage of participants who chose the correct management response is found in Table 2. 9

17 Table 1 Characteristics of Sample Characteristic Study Sample APTA Membership b % n a % Gender Male Female Region Midwest Northeast Northwest Southwest Southeast Years Experience <= 5 yrs yrs >= 30 yrs Entry level Degree Baccalaureate Masters/Post Doctorate Other Highest Degree Baccalaureate Masters Entry Level Doctorate Transitional Doctorate PhD Specialist Certification No Yes > 0.00 Practice Setting Home Health Rehab Hospital Outpatient/Private Practice Acute Care SNF/ECF/ICF School Academia Health and Wellness Other a The numbers of participants represented by each variable may be different because of missing data. b Membership Statistics

18 Table 2 Percentage of Participants Making Correct Management Decisions Case % of Participants Making Correct n Management Decisions Total Score The mean score for participants who completed all 11 cases was 9.28/11, SD= 1.29 (84.3%), with 18.9% of participants answering all 11 cases correctly. See Table 3. The logistic regression model was not significant and no independent variables were retained in the equation. Table 3 Summary of Management Decisions by Category of Cases Traditional Cases Non Critical Medical Critical Medical Mean Score 2.75/3 3.61/4 2.93/4 SD= 0.47 SD= 0.67 SD=0.87 Total Score 9.28/11 SD= 1.29 Mean Score 91.7% 90.25% 73.2% 84.3% % Participants that Made Correct Decisions for 100% of Cases 76.9% 69.9% 28.1% 18.9% 11

19 Critical Medical Cases There were 4 critical medical cases (1, 4, 6, 7). The mean score for participants completing all 4 cases was 2.93/4, SD= 0.87 (73.2%) and 28.1% of participants answered all 4 correctly. See Table 3. The stepwise logistic regression model containing the independent variable setting was statistically significant, X 2 = 4.4, (4, N= 182) P= The likelihood of making correct decisions in 100% of cases was approximately 2 times higher for participants practicing in the outpatient setting as compared to the inpatient setting (OR= 2.17, 95% CI= ). The model explained between 2.4% (Cox and Snell R square) and 3.4% (Nagelkerke R squared) of the variance and correctly classified 72.0% of cases. See Table 4. Table 4 Results of Logistic Regression 95% CI for EXP (B) Category/Variable B S.E. Wald df Sig. Exp Lower Upper (B) Critical Medical Outpatient setting Non-Critical Medical Yrs exp- 30+ yrs Traditional Outpatient setting Non-Critical Medical Cases There were 4 non-critical medical cases (2, 9, 10, 11). The mean score for participants completing all 4 cases was 3.61/4, SD= 0.67 (90.25%) and 69.9% of participants responded to all 4 cases correctly. See Table 3. The stepwise logistic regression model containing the variable years of experience was statistically 12

20 significant, X 2 =11.7 P= The likelihood of making correct decisions in 100% of cases was almost 2 times higher for participants with at least 30 years of experience as compared to those with 5 or less years of experience (OR= 6.26, CI= ). The model explained between 6.3% (Cox and Snell R square) and 8.9%(Nagelkerke R squared) of the variance and correctly classified 69.3% of cases. See Table 4. Traditional Cases There were 3 traditional cases (3, 5, 8). The mean score for participants completing all 3 cases was 2.75/3, SD= 0.47 (91.7%) and 76.9% of participants correctly answered all 3 cases. See Table 3. The stepwise logistic regression model containing the independent variable setting was statistically significant, X 2 = 4.9, P= The likelihood of making correct decisions in 100% of cases was 2 times higher for participants practicing in outpatient settings as compared to those practicing in inpatient settings (OR=2.22, CI= ). The model explained between 2.6% (Cox and Snell R square) and 3.9% (Nagelkerke R squared) of the variance and correctly classified 76.8% of cases. See Table 4. 13

21 DISCUSSION This is the first study to compare the ability of physical therapists in various settings to screen for medical referral. Practicing in outpatient settings was predictive of the ability to make correct management decisions in critical medical and traditional cases. In hypothetical cases, covering a variety of conditions in different settings, participants were able to make correct management decisions for 84% of cases. Participants were able to make correct management decisions for more than 90% of the traditional and noncritical medical cases and more than 70% of the critical medical cases. Practicing more than 30 years was predictive of correct management decisions in non-critical medical cases. Certification and highest earned degree did not affect accuracy of the management decisions. While more experienced therapists may not have been formally instructed in techniques such as screening for medical referral in their entry-level physical therapy programs, they were 6 times as likely as participants with less than 6 years of experience to make correct management decisions in non critical cases in this study. Clark 15 found that older, more experienced physical therapists not only had positive attitudes and beliefs toward screening for medical referral but felt it was important to patient/client management and outcomes. Almost all of the respondents in that study reported making a referral to another health care provider in the last 60 days. Although not specifically addressed in this study, it is possible that many of the participants with more experience 14

22 have taken additional coursework or have been involved in other educational opportunities to enhance their knowledge of screening for medical referral. Donato et al 16 found that physical therapists who have received additional training in screening for medical referral and practice in primary practice settings not only rated the importance of screening procedures more highly but utilized those behaviors more often than those therapists who did not. These types of educational programs should be recommended to provide additional instruction to therapists who have not had formal exposure to screening or do not feel confident in their abilities to screen for medical referral. Participants were less often correct in critical medical cases. Cases 1 and 4, both critical medical cases, had the lowest percentage of correct responses in the study. Case 1 described red flag symptoms including bilateral join pain, fever, chills, stiff neck and a rash. Goodman and Synder 2 stated that a physician referral is indicated when these symptoms are present to prevent joint destruction. In this case, 9 out of 210 of participants (4%) would not have referred at all. In case 4, a patient presented with several red flags including a new onset of severe shoulder pain that was unaffected by movement and demonstrated no loss of active or passive motion. These symptoms as well as the recent left sided trauma suggest possible visceral involvement, which would require an immediate referral or consultation. Just over 14% of participants chose not to refer at all. There have been other studies that have found inconsistencies in recognizing red flags. 6,22,23 In a study by Leerar et al 22 the researchers retrospectively examined documentation of red flags by physical therapists who evaluated patients with low back pain. The researchers found that 7 of the 11 red flags were documented 98% of the time 15

23 and that 96% of the charts had at least 64% of the red flags documented. However, Henschke et al, 24 demonstrated the importance of recognizing clusters of symptoms that would suggest a referral rather than focusing on the presence of one red flag alone. It is unclear whether participants in this study did not recognize the red flags or if they were unable to identify the significance of the symptoms when presented together. A better understanding of how physical therapists gather and interpret relevant information in their initial evaluations to make appropriate medical screening decisions is needed. Donato et al 16 reported that in examinations, physical therapists not practicing in a primary care setting less often included the identification of signs and symptoms potentially arising from visceral structures of the chest, abdomen and pelvis and their associated tests. In that study, physical therapists rated the importance of knowledge related to the gastrointestinal, endocrine and genitourinary systems as less important than knowledge associated with the musculoskeletal, nervous, integumentary, cardiovascular and pulmonary systems. Clark 15, in a study examining attitudes, beliefs, and frequency of behaviors related to screening for medical referral, found similar results. It is possible the participants in this study had similar beliefs and practice patterns and therefore had difficulty with cases 1 and 4. However, participants were able to recognize signs and symptoms from the genitourinary system found in case 10. Further study to determine the level of knowledge in both new graduates and clinicians as well as the frequency of medical screening of these systems in practice is needed. The participants in this study were better able to recognize signs and symptoms that suggest DVT than those who participated in a study by Riddle et al in In case 6 of the current study, 88.2% of participants chose to refer and an additional 9.3% chose 16

24 treat/consult. Only 2.5% (n= 5) chose not to refer. Riddle et al 5 found that for high-risk patients, 25% of the participants in that study would not have referred at all. This finding may be a result of enhanced awareness and educational efforts in recognition of signs of DVT, particularly in the DPT curricula. It is not surprising that participants practicing in outpatient settings were more likely to make correct management decisions than participants in inpatient settings for traditional and critical medical cases. Much of the educational focus and research has centered on outpatient musculoskeletal practice settings. Previous studies demonstrated the capability of physical therapists to screen in outpatient settings. 3,4,6 Physical therapists may be the first point of contact if the client arrives through direct access or is referred without being seen by the physician. 2 However, there is a vital need for screening for referral in inpatient settings as well. Clients in these settings are often medically unstable and present with multiple co-morbidities. Due to the close proximity of other health care professionals in these settings, who are often trusted to identify and monitor serious medical problems, physical therapists may not have as much experience in screening for medical referral. Both critical medical cases 1 and 4 were based in an acute care setting. There have been several studies that have discussed clinical decisionmaking and the importance of medical screening in acute care and other inpatient settings, 17,18,19 however, there have been no studies performed to determine the frequency and accuracy of this process in practice. Targeted educational programs focusing on screening for referral in inpatient settings may be needed. The literature supports the need for further research to examine practice patterns specifically related to medical screening in all settings. Frese et al 20 reported that only 6% 17

25 of clinical instructors measured heart rate and only 4.4% measured blood pressure when evaluating new patients. The majority of participants were in outpatient practice (43.4%) however other practice settings sampled in the study included acute care, long-term care facilities, home health, and inpatient rehabilitation. The reasons that were given by the participants included not important for my patient population, nurses measure vital signs, and only performed when necessary. Scherer et al 21 discovered in a survey of physical therapists, less than 50% monitored heart rate and blood pressure when initiating an aerobic conditioning program in outpatient settings. Participants in this study, as in the Jette et al 6 study were not as accurate in making clinical decisions in critical medical cases. In both studies, participants made correct decisions more often in cases that did not require immediate referral or those that are adequately managed by physical therapy. The mean score for traditional cases and non-critical medical cases parallel the musculoskeletal and non-critical medical cases in the Jette et al 6 study. Clinical certification was not found to be a significant factor in this study as it was in Jette et al, 6 despite the fact that the percentage of participants that were certified in each study was approximately the same. Previous studies have shown that orthopedic certification or specific continuing education courses such as those provided by the military improve accuracy in medical screening in musculoskeletal conditions. 3,4,6 It is possible this effect was not seen in this study because the vignettes were not specific to musculoskeletal conditions as in the Jette et al 6 study. While the percentage of participants holding certification was similar, not all participants in this study held orthopedic certification. Future research should investigate the relationship between the 18

26 types of courses taken and/or certification obtained and knowledge related to medical screening. There were several limiting factors in this study. Vignettes precluded clinicians from performing a thorough history and examination. However, there are several studies that demonstrate that vignettes can be used for diverse clinical settings, diseases and situations to isolate decision-making abilities of physicians. 25,26,27 The case scenarios were brief, making an accurate decision more difficult. However, if the cases were longer, it is probable that the number of participants exiting the survey prior to completion would have been even higher than 20%. The Delphi Study was implemented to improve content validity, although only 2 cases reached 100% consensus by the expert panel. The sample was taken from members of the APTA and can only be generalized for that population. The response rate was relatively low, so the sample size was smaller than anticipated. Due to low participant numbers, 2 variable categories, setting and highest earned degree, were collapsed in order to meet statistical assumptions. A different method of sampling might have resulted in a more even distribution among settings. A larger study that encompasses all practice settings would be beneficial to compare these results. For traditional and non-critical medical cases, more than 1 answer was categorized as correct. The decision to accept more than 1 correct management decision for these cases was based on methodology in previous studies. 6 Conservative management was not considered an incorrect response. However, in critical medical cases, only 1 response could be accepted due to the potential serious consequences of a lack of a referral. 19

27 CONCLUSION Despite the wide variety of cases presented spanning different settings, participants in this study were able to make correct management decisions for 84% of the cases. Participants were able to make correct management decisions greater than 90% of the time in traditional and non-critical medical cases. Participants practicing in outpatient settings were 2 times as likely to make correct decisions in critical medical and traditional cases. Participants practicing more than 30 years were 6 times as likely to make correct management decisions in non critical medical cases. Screening for medical referral is vital in all practice settings. A better understanding of knowledge and practice patterns specifically related to screening for medical referral in all settings is needed. 20

28 REFERENCES 1. Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St Louis, MI: Elsevier Inc; Goodman CC and Snyder TEK. Differential Diagnosis in Physical Therapy, 4 th edition. Philadelphia, PA, Saunders; Childs JD, Whitman JM, Sizer PS et al. A description of physical therapists knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord : Moore JH, Goss DL, Baxter RE, DeBerardino TM et al. Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopedic surgeons and nonorthopedic providers. J Orthop Sports Phys Ther.2005; 35: Riddle DL, Hillner BE, Wells PS et al. Diagnosis of lower extremity deep vein thrombosis in outpatients with musculoskeletal disorders: A national survey study of physical therapists. Phys Ther. 2004; 84: Jette DU, Ardleigh K, Chandler K, McShea L. Decision making ability of physical therapists: physical therapy intervention and medical referral. Phys Ther Dec; 86: American Physical Therapy Association. PT Bulletin: Autonomous Practice Spans All Settings, Says APTA. Available at: Accessed November 20, American Physical Therapy Association. Demographic Survey Questions. Available at: Accessed November 15, Mechelli F, Preboski Z, Boissonnault WG. Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm. J Orthop Sports Phys Ther. 2008; 38:

29 10. Walsh RM, Sadowski GE. Systemic disease mimicking musculoskeletal dysfunction: a case report involving referred shoulder pain. J Orthop Sports Phys Ther. 2001;31: American Physical Therapy Association. Membership Directory. Available at: d July 19, QuestionPro: Online Research Made Easy. Accessed at: QuestionPro.com. September 9, SPSS. Version 19. Somers, NY: IBM; Portney LB, Watkins MP. Foundations of Clinical Research: Applications to Practice. Upper Saddle River, NJ: Prentice Hall Health; Clark DE. Screening for medical referral: Attitudes, beliefs, and behaviors of physical therapists with greater than 10 years experience. (dissertation). Birmingham: University of Alabama; Donato, EB, DuVall RE, Godges JJ, et al. Practice Analysis: Defining the clinical Practice of Primary Contact Physical Therapy. J Orthop Sports Phys Ther. 2004;34: Masley PM, Havrilko CL, Mahnensmith MR et al. Physical therapist practice in the acute care setting: A Qualitative Study. Phys Ther. 2011;91: Smith M, Higgs J, Ellis E. Characteristics and processes of physiotherapy clinical decision-making: a study of acute care cardiorespiratory physiotherapy. Physiother Res Int. 2008;13: Wainwright SF, McGinnis PQ. Factors that influence the clinical decision-making of rehabilitation professionals in long-term care settings. J Allied Health. 2009;38: Frese EM, Richter RR, Burlis TV. Self-Reported Measurement of Heart Rate and Blood Pressure in Patients by Physical Therapy Clinical Instructors. Phys Ther. 2002;82: Scherer SA, Notebook JT, Flynn TW. Cardiovascular Assessment in the Orthopedic Practice Setting. J Orthop Sports Phys Ther. 2005;35: Leerar PJ, Boissonnault W, Domholdt E, Roddey T. Documentation of red flags by physical therapists for patients with low back pain. J Man Manip Ther. 2007; 15:

30 23. Haggman S, Maher Cg, Refshauge KM. Screening for symptoms of depression by physical therapists managing low back pain. Phys Ther. 2004:84: Henschke N, Maher CG, Refshauge KM, et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60: Peabody JW, Luck J, Glassman P et al. Comparison of Vignettes, standardized patients, and chart abstraction. A prospective validation study of 3 methods for measuring quality. JAMA. 2000: 283; Peabody JW, Luck J, Glassman P et al. Measuring the Quality of physician practice by using clinical vignettes: A prospective validation study. Ann Intern Med. 2004: 141: Veloski J, Tai S, Evans AS, Nash DB. Clinical vignette based surveys: A tool for assessing physician practice variation. Am J Med Qual. 2005;20:

31 APPENDIX A INSTITUTIONAL REVIEW BOARD APPROVAL FORM 24

32 25

33 APPENDIX B CASE DESCRIPTIONS 26

34 Type Case Description Traditional 3 A 60-year-old male is admitted to a skilled nursing facility following a cerebrovascular accident with right-sided hemiplegia five days earlier. His past medical history is significant for hypertension, type two diabetes mellitus, and gallbladder surgery. He is having difficulty performing transfers and maintaining his sitting balance. He complains of dizziness with transfers but it dissipates quickly. He is lethargic and fatigues quickly. 5 A 79-year-old male with a history of coronary artery disease, chronic obstructive pulmonary disease, chronic renal insufficiency and a right transfemoral amputation is seen in physical therapy with balance and ambulation difficulty. He has been ambulating with a rolling walker and a prosthesis for several years but his wife reports that his activity level has declined significantly over the past six months. He has had frequent falls and complains of mild shortness of breath with activity. 8 A 53-year-old woman with a fairly sedentary lifestyle complains of a recent onset of deep, dull, aching pain in the posterior cervical and interscapular region of her upper back. The pain began after she slipped off a curb and nearly fell. She has tenderness in her upper trapezius muscle and she states she has pain when raising her arm and turning her head. Pain is intermittent and is relieved when she lies down. She demonstrates no motor or sensory loss. Non critical 2 A 40-year-old female with a history of spina bifida who lives alone is referred to home health physical therapy for treatment of a sacral wound following an acute care stay. The physician has continued the intravenous antibiotics. She reports severe pain with sitting and is having difficulty with transfers. Her wound has moderate serosanguinous drainage, a strong odor and yellow exudate. 9 A 43-year-old female is seeking physical therapy for non-operative treatment of a right shoulder rotator cuff tear that occurred after a recent fall. She complains of pain during right shoulder elevation and an inability to lift her arm over her head. While reviewing her medical history, she mentions the development of a cough over the past few days along with a low-grade fever. She is being treated for melanoma that was diagnosed 4 months ago in the right cervical lymph nodes and has been receiving biochemotherapy for the past 3 months. 10 A 46 year old female with a history of irritable bowel syndrome and ovarian cysts complains of low back pain. It has bothered her on and off for about one year for no apparent reason. The low back pain varies and worsens with lifting and prolonged standing. It is intermittent, does not radiate and is relieved with rest. She mentions that she has had pain, occasional bloating and a sense of heaviness in the pelvic/ abdominal region for the past few months. 11 A 75-year-old female was referred to home health physical therapy following an open reduction internal fixation of the left ankle from a fall five days ago. She is non-weight bearing but is able to transfer in and out of a wheelchair independently and propel it short distances. She complains of a chronic non-productive cough over the past several years that seems to be worsening and a recent onset of increased shortness of breath since her injury. She notes that she has taken several types of medications during the past year due to repeated respiratory tract infections. 27

35 Critical Medical 1 A 65-year-old obese male is admitted to the hospital with pneumonia. Physical therapy is consulted to assist with ambulation. He reports having fever and chills for several weeks along with muscle and joint pain, especially his knees. During your examination he complains of a stiff neck and difficulty concentrating. He reports he is not sleeping well which he attributes to his muscle and neck pain. You also notice a rash on the back of his leg. 4 A 42-year-old male was involved in a motor vehicle accident last night when he was hit in the driver s side of his vehicle. He suffered a nondisplaced left tibia/fibula fracture and was casted. Physical therapy was consulted to assist with non- weight bearing ambulation but he is apprehensive because he reports constant severe left shoulder pain. It started this morning when he awoke. He describes the pain as a sharp, deep ache over the upper trapezius and shoulder. He demonstrates no loss of passive motion and is able to tolerate active and resisted motions without any change in pain. 6 An 18-year-old male suffered an incomplete C6 spinal cord injury due to MVA. The patient was treated in the hospital for 2 months and once stabilized was transferred to a rehabilitation facility. He has been in the facility for several weeks. During his am therapy session, you notice unilateral swelling (1 inch greater than right) and warmth of his left lower extremity. The swelling did not improve with elevation. 7 An 80- year- old active but frail woman fell on a rug in her apartment and landed on her outstretched hands. She complains of tenderness over the lateral aspect of the right wrist and distal forearm, and a bony deformity is palpable. Her wrist is swollen and painful, with decreased range of motion. 28