Should Physical Therapists Delegate Care to Physical Therapist Assistants?

In keeping with the theme for today, labor... who should do the labor?

Linda Resnik, PT, PhD has delved into the physical therapy world a little deeper to answer the question of what clinic qualities can potentially determine best overall performance in the treatment of patients with low back pain syndromes.

Data from her and her colleagues' current work came from Focus on Therapeutic Outcomes, Inc (FOTO) from 2000 to 2001.  The majority of the clinics included in the study were hospital settings.  The reason for mainly hospital settings was probably due to FOTO clientele.  I am quite confused at the comparison of included versus excluded clinics because mathematically the numbers aren't adding up.  Inclusion criteria was applied to 487 clinics.  114 clinics were included; 373 were excluded (but the comparison table data only analyzed 291 excluded clinics instead of 373 clinics).  There was also a comment that 36% of the clinic sample had no patient with higher physical therapist assistant utilization and those clinics were removed.  Almost 60% of the clinics excluded were something other than a hospital setting.  When looking at the tables, it seems to me that this study mainly captured clinic performance in a hospital setting.  Determination of utilization of physical therapist assistants was based solely on memory.  There might have been a better way to more accurately capture physical therapist assistant utilization because we all know that memory is not accurate.

At a time when reimbursement continues to dwindle, professionally we desire clinical autonomy with fewer rules and regulations.  The results of this study (specific to low back pain syndromes) paint a bleak picture in implementing a solution that combines utilizing supportive staff efficiently with a focus on effectiveness of treatment with lower utilization of services.  The results indicate clinics that utilize a PTA less frequently than 50% of the time during an episode of care are 6.6 times more likely to be a highly effective clinic; clinics that use a PTA less frequently than 50% of the time during an episode of care are 6.7 times more likely to have less treatment visits per episode of care; clinics that utilize a PTA less frequently than 50% of the time are 12.4 times more likely to be rated as a best overall performance clinic.

Do we take this information at face value and consider eliminating the use of physical therapist assistants?  Combined with Resnik's previous work on expert physical therapists and their lower utilization of physical therapist assistants, this current work seems to indicate that the higher the frequency that physical therapist assistants are utilized within an episode of care, the worst the actual outcomes.

Do we take this information and polarize ourselves in our discussions?  Do we now start describing ourselves as "evidence based" and describe care provided as one-on-one AND only by a physical therapist 100% of the time? 

OR can we take this information and maybe do deeper thinking?  Was the plan of care for each patient predominantly rooted in evidence?  Was there variation of practice in treating low back pain syndromes within the clinic itself?  Were those patients with low back pain syndromes classified as our literature suggests into a treatment based classification system?  Were appropriate interventions provided to the patient at the appropriate time?  Were physical therapist assistants following the plan of care?  How did the physical therapist determine when to delegate patients?  (Did the physical therapist really delegate patients to physical therapist assistants or did front office staff do this automatically during scheduling?)  Is there a delegation process?  What is communication like between front office staff, physical therapists and physical therapist assistants?  What is the physical layout of the staff documentation area?  Do physical therapists have their documentation space very near physical therapist assistants?  Do physical therapists work in an actual team, for example, with maybe one or two physical therapist assistants? 

At face value it certainly appears that care provided by a physical therapist assistant at a high frequency during the episode of care for patients with low back syndrome is more financially costly to the patient and also tends to be less effective than care provided by a physical therapist.

What can we do with this type of information?  How will this information alter our choices in service delivery?

Selena Horner