Referral Source and Outcomes of Physical Therapy Care in Patients With Low Back Pain - Journal of Orthopaedic & Sports Physical Therapy - Vol. 42, No

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RESEARCH REPORT
GARY BROOKS, PT, DrPH, CCS1 MICHELLE DOLPHIN, PT, DPT, OCS2 PATRICK VANBEVEREN, PT, DPT, OCS, GCS3 DENNIS L. HART, PT, PhD4
Referral Source and Outcomes of Physical Therapy Care in Patients With Low Back Pain
Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 24, 2013. For personal use only. No other uses without permission. Copyright 2012 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
T STUDY DESIGN: Retrospective longitudinal

cohort.
T OBJECTIVES: To describe the clinical charac-
individual clinicians, and clinicians working within individual clinics.
teristics of patients with low back pain according to physician referral source, and to identify associations between referral source and discharge functional status, as well as number of physical therapy visits.
T RESULTS: Bivariate and multilevel analyses
T BACKGROUND: Little is known about as-
sociations between physician referral source and outcomes of physical therapy care for patients with low back pain. Exploring these associations can contribute to better understanding of physician physical therapist relationships and may lead to improved referral patterns.
T METHODS: Data from a proprietary clinical
revealed signicant associations between referral source and discharge overall health status, as well as number of visits. After multilevel adjustment for covariate and clustering effects, primary care and occupational medicine referrals were associated, on average, with point increases of 1.6 (95% CI: 0.7, 2.6) and 4.8 (95% CI: 2.7, 6.9) in discharge overall health status scores, respectively, compared to specialist referral. Similarly, primary care and occupational medicine referrals were associated, on average, with 0.44 (95% CI: 0.27, 0.61) and 0.83 (95% CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral.
ow back pain (LBP) is among the most prevalent and costly musculoskeletal disorders in the United States.1,27,28 There is considerable variation in how LBP is managed within the current healthcare
environment. 36,43 Primary care physicians (PCPs) are the most commonly utilized provider for individuals with LBP, 34 and 2 of the most common providers to which PCPs refer patients with LBP are orthopaedic surgeons and physical therapists.9,34,36 Patients with spine dysfunction comprise a substantial portion of outpatient physical therapy caseloads.11 Overall, however, PCPs manage the majority of LBP cases without referral to other healthcare providers.9 Primary care practice guidelines for LBPabsent red ags, such as systemic or radicular signsrecommend an initial trial of self-care and appropriate pharmaceutical agents before a referral is made for nonpharmacological management.5
database were examined retrospectively. Physician referral source was classied as primary care, specialist, or occupational medicine. Outcomes were overall health status at discharge and number of physical therapy visits. Descriptive statistics and bivariate associations between referral source and each outcome were assessed by calculating differences and 95% condence intervals (CIs) in means and proportions. To account for potential confounding, multilevel linear regression was used to adjust for baseline clinical covariates, effects related to clustering of patients treated by
T CONCLUSION: After accounting for clinical
covariates and clustering, patients with low back pain who were referred by occupational medicine and primary care physicians tended to have better functional outcomes and required fewer physical therapy visits per episode of care.
T LEVEL OF EVIDENCE: Prognosis, level 2c.
J Orthop Sports Phys Ther 2012;42(8):705-715, Epub 8 March 2012. doi:10.2519/jospt.2012.3957 practice-based evidence
T KEY WORDS: lumbar spine, physician referral,
Associate Professor, Department of Physical Therapy Education, College of Health Professions, SUNY Upstate Medical University, Syracuse, NY. 2Assistant Professor, Department of Physical Therapy Education, College of Health Professions, SUNY Upstate Medical University, Syracuse, NY. 3Supervisor of Physical Therapy, St Camillus Health and Rehabilitation Center, Syracuse, NY. 4(Deceased) Director of Consulting and Research, Focus On Therapeutic Outcomes, Inc, Knoxville, TN. This research was supported by a grant from the Section on Health Policy & Administration of the American Physical Therapy Association. This study was determined to be exempt from review by the Institutional Review Board for the Protection of Human Subjects of SUNY Upstate Medical University, Syracuse, NY. Drs Brooks, VanBeveren, and Dolphin affirm that they have no nancial affiliation, including research funding, or involvement with any commercial organization that has a direct nancial interest in any matter included in this manuscript. Dr Hart was an employee of, and investor in, Focus On Therapeutic Outcomes, Inc (FOTO), the database management company that managed the data analyzed in the manuscript. Analyses of data like the analyses presented in this article were part of Dr Harts daily work activities. Address correspondence to Dr Gary Brooks, SUNY Upstate Medical University, 250 East Adams Street, Room 2231, Silverman Hall, Syracuse, NY 13210. E-mail: brooksg@upstate.edu t Copyright 2012 Journal of Orthopaedic & Sports Physical Therapy
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journal of orthopaedic & sports physical therapy | volume 42 | number 8 | august 2012 | 705
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Little is known about the patterns and sources of referral to physical therapy for LBP in the United States. Freburger and colleagues11 found that physical therapy referral for patients with spine disorders was associated with factors such as medical diagnosis and physician decision to order more diagnostic tests or to consult another physician, in addition to other patient-level variables. An investigation of individuals receiving workers compensation found that referral to physical therapy was associated with greater baseline disability, as measured by the Roland-Morris questionnaire and the Short-Form 12-Item Health Survey.6 For patients with chronic LBP, physical therapy referral was positively associated with specialist physician providers and workers compensation insurance, and negatively associated with having no insurance.10 With regard to referral source, referrals from PCPs and orthopaedists were associated with better discharge functional status outcomes in patients with lumbar or cervical involvement. 33 Another investigation noted that referral source was not associated with functional outcome; however, there was a trend toward an association between specialist physician and lower number of visits. 3 Patients referred from specialist physicians may have clinical characteristics different from those of patients referred by PCPs; for example, they may be more likely to have chronic LBP or more complicated clinical presentations, or to have failed to respond to treatment by a PCP. By the time a patient with LBP is referred to a physical therapist, she/ he might have been seen by a PCP and perhaps additional specialist physicians, and might also have undergone diagnostic procedures, such as imaging studies. During this process, patients may experience delays in receiving physical therapy care, thus increasing their symptom duration at initiation of physical therapy treatment and inuencing outcomes of care.7,33 Identifying associations between physician referral source and physical
RESEARCH REPORT
therapy outcomes can inform policy and practice regarding physician-physical therapist referral trends, and may inuence communication between the physical therapist and referring physicians. These associations can provide insights into the nature of the physicianphysical therapist relationship and suggest further exploration of the optimal referral pathway among PCPs, specialist physicians, and physical therapists for patients with LBP. The purpose of this investigation was to describe the characteristics of patients with LBP according to physician referral source, including specialist, primary care, and occupational medicine physicians. An additional purpose was to identify associations between referral source and functional status at discharge from physical therapy, as well as utilization of physical therapy, as indicated by number of physical therapy visits. In identifying associations, we sought to adjust for potential confounding by patient characteristics such as age, sex, symptom duration, medication use, payer source, and baseline functional status, and also to adjust for clustering of patients within clinicians and clinics.
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cluded all records in the database of patients who were treated for nonspecic LBP syndromes between the years 2003 and 2005. From this initial data set, we derived an analysis data set, as described subsequently.
Subjects
Selection of observations to be used in the study analyses was based on nonmissing values for several inclusion and exclusion criteria. FIGURE 1 illustrates the selection of observations from the initial, full data set to the nal sample used in the analysis data set. Observations were included in analyses if they were classied as having orthopaedic and lumbar impairment, treated by a physical therapist or physical therapist assistant, and referred by a physician. Observations were excluded from analyses if they had surgery for the current condition or had missing values for both dependent variables. To maintain Health Insurance Portability and Accountability Act compliance, observations of those aged 90 years or older were also excluded.
Variables
The primary independent variable, referral source, was physician status, categorized as primary care, specialist, or occupational medicine. Physicians listed as internal medicine, obstetrician/gynecologist, pediatrician, or family practice were coded as PCPs. Orthopaedic surgeons, neurologists, neurosurgeons, rheumatologists, physiatrists, and plastic surgeons were coded as specialist physicians. Occupational medicine physician status was retained and coded as a third referral-source category. Discharge overall health status (OHS) and number of visits were the 2 dependent variables. The OHS is a patient selfreport measure of physical function that adapts to different patient conditions, the development of which has been described in detail elsewhere.15-17,20 Briey, the OHS was developed from health-related quality-of-life measures in the widely used Medical Outcomes Study 36-Item Short-
METHODS
Data Source
ata were extracted from the Focus On Therapeutic Outcomes, Inc (FOTO, Knoxville, TN) clinical database. The FOTO database has been used for outcomes research in a number of clinical populations, including patients with musculoskeletal impairments,7,22 spine pathology, 24,25 knee pathology,23 and upper extremity impairments.19,26 In addition, researchers have used the FOTO database to examine clinical expertise in physical therapy,31 orthopaedic clinical specialization in physical therapy,18 and physical therapy clinic performance.33 The FOTO database has also been useful in comparative-effectiveness research7 and pay-for-performance methodology.17 We acquired a data set from FOTO that in-
706 | august 2012 | volume 42 | number 8 | journal of orthopaedic & sports physical therapy
Form Health Survey and Short-Form 12Item Health Survey.39,42 These measures establish 8 constructs within the OHS, including general health, physical functioning, emotional and physical roles, bodily pain, mental health, vitality, and social functioning. Three items assessing upper extremity function not measured by the Medical Outcomes Study 36-Item Short-Form Health Survey or ShortForm 12-Item Health Survey were added to the physical functioning component of the instrument.15,16 The OHS is scored according to published algorithms,40,41 resulting in a total, summary score ranging from 0 to 100, with higher values representing higherlevel functioning. Internal consistency reliability coefficients (Cronbach alpha) for OHS constructs represented by 2 or more questions within the instrument varied between 0.57 and 0.89, with the highest coefficient for physical function in a sample of adults in industrial rehabilitation.15 Test-retest reliability (intraclass correlation coefficient [ICC2,1]) for the OHS was 0.90 in a sample of adults in outpatient musculoskeletal rehabilitation, and 0.92 for outpatients with chronic symptoms.16 The instrument has also demonstrated strong sensitivity to change, with a standardized response mean of 0.87 and effect size of 0.83, in a sample of patients with lumbar spine dysfunction.31 Number of visits was tallied and recorded for each episode of care. To eliminate implausible values for analyses involving number of visits, observations were also excluded if the number of visits exceeded the duration of care, as measured in days. Patient-level variables recorded on initial visit included age, sex, baseline OHS score, whether the patient was taking prescription medications, exercise status, and symptom duration. Symptom duration was based on the number of days between the onset of LBP symptoms and initial physical therapy examination. This item was coded such that the patient was considered acute if duration of symptoms
66 524 observations (initial dataset)
64 814 observations were classified as having orthopaedic and lumbar impairment.
47 126 observations were treated by a physical therapist or physical therapist assistant. 10 017 observations were referred by a physician and had nonmissing values for referral source.
7971 observations (analysis dataset)
2046 observations excluded: Had surgery for the primary condition, n = 1505 Had missing values for discharge OHS and number of visits, n = 592 Age 90 or older, n = 22
FIGURE 1. Data selection procedure. Abbreviation: OHS, overall health status.
was 21 days or fewer, subacute if between 22 and 90 days, and chronic if greater than 90 days. This methodology, which classies patients into 3 clinically useful categories, has been utilized in previous studies that employed the FOTO database to investigate outcomes in patients with LBP.7,17,33,44 Exercise status on initial visit was classied into 1 of 3 categories: at least 20 minutes 3 or more times per week, 1 to 2 times per week, or seldom or never. Payer source was classied in 8 categories, representing fee-for-service, health maintenance organization or preferred provider organization, litigation, Medicaid, Medicare, self-pay, workers compensation, and other. Also included in the analyses was duration of the episode of care, measured in calendar days between the date of initial evaluation and discharge.
Data Analysis
To assess potential bias that might have been introduced during the data-selection process, variables in the analysis data set were compared to those of ob-
servations excluded from the analyses (FIGURE 1). These comparisons used independent-samples t tests to calculate mean differences and 95% condence intervals (CIs) for numeric variables, and for categorical variables used contingency-table analyses to calculate risk differences and 95% CIs. Results of these analyses are displayed in TABLE 1. Prior to the study, physician referral source was classied as 2 levels, primary care and specialist, with occupational medicine classied within the specialist category. During preliminary analyses, however, it became apparent that additional stratication of referral source would better t the data. Accordingly, we elected to classify referrals from occupational medicine physicians as a third category. Using 1-way analyses of variance and contingency-table analyses to determine differences and 95% CIs in means and proportions, respectively, we compared baseline characteristics, as well as number of visits and discharge OHS, according to referral source. Associations between referral source
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TABLE 1
RESEARCH REPORT
Nonmissing Values of Patient Characteristics in Observations Excluded From, and Observations Included in, the Analysis Dataset
Excluded Observations (n = 58553) n Value 49.1 16.2 48.0 11.6 60.6 16.6 8.4 6.4 31.8 25.9 23140 (39.5) 12508 (21.4) 14241 (24.3) 31766 (54.3) 34589 11706 (33.8) 8624 (24.9) 14259 (41.2) 34622 8359 3737 (44.7) 3436 (41.1) 498 (6.0) 688 (8.2) 34661 2071 (6.0) 220 (0.6) 1867 (5.4) 7629 (19.4) 279 (0.8) 17422 (50.3) 4882 (14.1) 1191 (3.4) 7952 579 (7.3) 52 (0.6) 297 (3.7) 1289 (16.2) 81 (1.0) 3765 (47.4) 1589 (20.0) 300 (3.7) 1.3 (1.9, 0.7) 0.0 (0.1, 0.2) 1.7 (1.2, 2.1) 3.2 (2.3, 4.1) 0.2 (0.5, 0.0) 2.9 (1.7, 4.1) 5.9 (6.9, 4.9) 0.3 (0.8, 0.1) 24111 (69.6) 7783 7971 4515 (56.6) 2392 (30.0) 1064 (13.4) 0 (0.0) 11.9 (13.5, 10.4) 11.1 (9.6, 12.6) 7.4 (8.3, 6.5) 8.2 (7.6, 8.8) 7762 2634 (33.9) 2027 (26.1) 3101 (39.9) 5353 (68.8) 0.1 (1.3, 1.1) 1.2 (2.3, 0.1) 1.3 (0.1, 2.5) 0.8 (0.3, 2.0) Included Observations (n = 7971) n 7970 7971 5163 7943 7690 7969 7970 2182 (27.4) 2107 (26.4) 3681 (46.2) 6.0 (7.0, 5.0) 2.1 (3.1, 1.1) 8.1 (7.0, 9.3) Value 48.4 16.5 48.9 11.0 64.1 17.2 7.4 5.0 29.3 22.9 3158 (39.6) Difference* 0.7 (0.3, 1.1) 0.9 (1.2, 0.7) 3.5 (4.1, 3.1) 1.0 (0.8, 1.1) 2.5 (1.9, 3.1) 0.1 (1.2, 1.1)
Age, y Baseline OHS score Discharge OHS score Number of visits, n Duration of care, d
58541 58553 23234 32724 31987 58519 58515
Male Symptom duration Acute Subacute Chronic Exercise 3 or more times per wk 1 to 2 times per wk Seldom or never Took prescription medications on admission Referral source Primary care Specialist Occupational medicine Nonphysician Payer source Fee-for-service Litigation Medicaid Medicare Self-pay HMO or PPO Workers compensation Other
Abbreviations: CI, condence interval; HMO, health maintenance organization; OHS, overall health status; PPO, preferred provider organization. *Values are mean (95% CI) differences for numeric variables, or differences in proportions (95% CI) for categorical variables. Values are mean SD. Values are n (%).
and each outcome were assessed for confounding through a 2-step process using multilevel modeling. Multilevel modeling is appropriate for hierarchically structured data, in which individual observations are nested within larger units. In the current investigation, patients were nested within treating clinicians, who were nested within clinics where they were employed. Factors at each level may inuence outcomes and
should be controlled in analyses of hierarchical data.32 In step 1 of the analysis, separate linear regression models for each of the 2 outcomes were tted for individual-level variables. Variables entered at this stage included referral source (specialist physician was the reference value), baseline OHS score, age, sex, symptom duration (acute status was the reference value), taking medications on admission, exercise status (no exercise
was the reference value), payer source (fee-for-service was the reference value), and duration of care. For step 2, randomintercept models were tted for each outcome by entering the unique identiers for clinician and clinics, respectively, as random-effects variables. These models tested whether associations found in individual-level analyses persisted after adjustment for higher-level effects of clinician and clinic. All variables in the
individual-level models were retained in the multilevel models. All analyses were performed with SAS Version 9.1 (SAS Institute Inc, Cary, NC), using PROC MIXED for multilevel analysis with = .05.
75 70 65 60 55 50 45 40 Baseline OHS Discharge OHS
RESULTS
T
he acquired FOTO data set included 66524 observations, of which 7971 met inclusion criteria for analysis. TABLE 1 displays the descriptive variables in the excluded observations and those included for analyses. Two variables for which there was no signicant difference between observations included in and excluded from the analyses were sex and taking prescription medications on admission. For all other variables, the 95% CIs indicated that there were signicant differences in the characteristics for those included in and excluded from analyses. Due to the large sample size, some of these differences were small and of no practical importance. Potentially important differences were seen in discharge OHS (included observations had higher mean scores), symptom duration (included observations were more likely to be acute and less likely to be chronic), referral source (referrals from included observations were more likely to be from PCPs or occupational medicine physicians and less likely to be from specialist physicians), and workers compensation payer source (included observations were more likely to have workers compensation insurance). Baseline and discharge OHS scores, according to referral source, are illustrated in FIGURE 2. Results of bivariate analyses are presented in TABLES 2 and 3. The 95% CIs for the differences in means (TABLE 2) and in proportions (TABLE 3) of variables indicated that there were signicant differences according to referral source in all variables. Of the 2 primary outcomes, mean discharge OHS scores were lowest for referrals from specialist physicians and highest for referrals from occupational medicine physicians. Mean
Primary care Specialist Occ med
FIGURE 2. Unadjusted baseline and discharge OHS scores according to referral source. Abbreviations: Occ med, occupational medicine; OHS, overall health status.
pared to referral from specialist physicians, referrals from primary care and occupational medicine physicians were associated, on average, with 0.44 (95% CI: 0.27, 0.61) and 0.83 (95% CI: 0.44, 1.2) fewer visits, respectively. Other associations with a lower number of visits included higher admission OHS scores and Medicaid payment. Older age, longer duration of care, use of prescription medication on intake, and workers compensation payer source were all associated with a higher number of visits.
DISCUSSION
number of visits was lowest in referrals from occupational medicine physicians and highest in referrals from specialist physicians. TABLE 4 displays linear and multilevel analyses for discharge OHS score. After adjustment for individual-level covariates and for clustering of patients within clinician and clinic, referral source continued to be associated with discharge OHS score. Compared to referral from specialist physicians (reference category), referral from PCPs was associated, on average, with nearly a 1.7-point increase (95% CI: 0.73, 2.6) in discharge OHS, and referral from occupational medicine was associated, on average, with a 4.8-point increase (95% CI: 2.7, 6.9) in discharge OHS. Other variables were associated with discharge OHS score after multilevel analysis. Higher admission OHS scores, exercise 3 or more days per week, and payment by a health maintenance organization or preferred provider organization were all associated with higher discharge OHS scores. Older age, longer duration of care, chronic and subacute symptom duration, and Medicaid payment were all associated with lower discharge OHS scores. TABLE 5 presents linear and multilevel analyses for number of visits. After adjustment for individual-level covariates and for clustering of patients within clinician and clinic, referral source was also associated with number of visits. Com-
he current ndings indicate that physician referral status is associated with functional status on discharge and with number of visits. Compared to referrals from specialist physicians, referrals from both primary care and occupational medicine physicians were associated with higher discharge OHS scores, indicating better function, and fewer visits. Associations seen in bivariate analyses persisted after adjustment for important individual-, therapist-, and clinic-level variables, and were stronger for occupational medicine physicians than for PCPs relative to specialist physicians. Our results may be compared with previous investigations that included referral source in analyses of physical therapy outcomes using FOTO data. Deutscher and associates7 found that referral from general practitioners was associated with higher discharge functional status relative to other physicians in Israeli patients with lumbar spine impairment. Our results are consistent with this nding, despite the fact that Deutscher et al7 used a different referral-source classication. Our ndings are also in agreement with Resnik and colleagues,33 who also found that referral from PCPs was associated with better discharge function (higher OHS scores). In contrast to our study, Resnik and colleagues33 also found that referral from orthopaedists was associated with higher discharge OHS
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TABLE 2
RESEARCH REPORT
Baseline Characteristics and Outcomes and Differences by Referral Source: Numeric Variables
Total Nonmissing* Primary Care (n = 4515) Specialist (n = 2392) 2392, 51.7 16.4 2392, 48.6 11.0 1549, 60.6 16.5 2310, 8.4 5.4 2324, 33.2 23.5 Occ Med (n = 1064) 1064, 39.4 11.4 1064, 46.5 9.7 749, 68.9 19.6 974, 6.6 4.3 992, 19.9 19.7 Differences Among Referral Sources Primary Care, Specialist 2.9 (3.8, 1.9) 1.1 (0.5, 1.8) 4.2 (2.9, 5.4) 1.3 (1.6, 1.0) 3.8 (5.1, 2.4) Primary Care, Occ Med 9.4 (8.1, 10.7) 3.2 (2.3, 4.1) 4.1, (5.8, 2.5) 0.5 (0.1, 0.9) 9.5 (7.7, 11.4) Specialist, Occ Med 12.3 (10.9, 13.7) 2.1 (1.1, 3.0) 8.3 (10.1, 6.6) 1.8 (1.4, 2.2) 13.3 (11.3, 15.3)
Age, y Baseline OHS score Discharge OHS score Number of visits Duration of care, d
4514, 48.8 16.7 4515, 49.7 11.2 2865, 64.8 16.5 4365, 7.1 4.6 4374, 29.4 22.7
Abbreviations: Occ Med, occupational medicine; OHS, overall health status. *Values are n, mean SD. Values are mean (95% condence interval).
TABLE 3
Baseline Characteristics and Differences by Referral Source: Categorical Variables

Total Nonmissing* Primary Care (n = 4515) Specialist (n = 2392) 1482 (62.0) 300 (12.5) 638 (26.7) 1454 (60.8) 827 (35.5) 572 (24.6) 930 (39.9) 1589 (68.0) Occ Med (n = 1064) 441 (41.5) 773 (72.7) 202 (19.0) 89 (8.4) 278 (27.3) 282 (27.7) 459 (45.0) 885 (86.7) Primary Care, Specialist 2.0 (0.4, 4.4) 12.1 (10.2, 13.9) 1.4 (0.8, 3.6) 13.4 (15.9, 11.0) 0.9 (3.3, 1.5) 2.0 (0.2, 4.2) 1.1 (3.6, 1.3) 2.9 (5.2, 0.5) Differences Among Referral Sources Primary Care, Occ Med 22.5 (19.3, 25.8) 48.1 (51.0, 45.1) 9.1 (6.4, 11.8) 39.0 (36.8, 41.2) 7.4 (4.3, 10.4) 1.1 (4.1, 1.9) 6.3 (9.6, 2.9) 21.6 (24.1, 19.1) Specialist, Occ Med 20.5 (17.0, 24.1) 60.1 (63.1, 57.1) 7.7 (4.7, 10.6) 52.4 (49.9, 55.0) 8.2 (4.9, 11.6) 3.1 (6.4, 0.1) 5.1 (8.8, 1.5) 18.7 (21.5, 15.9)
Sex (female) Symptom duration Acute Subacute Chronic Exercise 3 or more times per wk 1 to 2 times per wk Seldom or never Took prescription medications on admission Payer source Fee-for-service Litigation Medicaid Medicare Self-pay HMO or PPO Workers compensation Other
2888 (64.0) 1109 (24.6) 1267 (28.1) 2138 (47.4) 1529 (34.6) 1173 (26.6) 1712 (38.8) 2879 (65.1)
398 (8.8) 43 (1.0) 236 (5.2) 764 (16.9) 52 (1.1) 2523 (56.0) 301 (6.7) 192 (4.3)
180 (7.6) 8 (0.3) 58 (2.4) 524 (22.0) 29 (1.2) 1221 (51.3) 252 (10.6) 108 (4.5)
1 (0.1) 1 (0.1) 3 (0.3) 1 (0.1) 0 (0.0) 21 (2.0) 1036 (97.5) 0 (0.0)
1.2 (0.1, 2.6) 0.6 (0.3, 1.0) 2.8 (1.9, 3.7) 5.1 (7.1, 3.1) 0.1 (0.6, 0.5) 4.7 (2.2, 7.1) 3.9 (5.3, 2.5) 0.2 (1.3, 0.7)
8.7 (7.9, 9.6) 0.9 (0.5, 1.2) 4.9 (4.2, 5.7) 16.8 (15.7, 18.0) 1.2 (0.8, 1.5) 54.0 (52.3, 55.7) 90.8 (92.0, 89.6) 4.3 (3.7, 4.8)
7.5 (6.4, 8.5) 0.2 (0.1, 0.5) 2.1 (1.5, 2.9) 21.9 (20.2, 23.6) 1.2 (0.8, 1.7) 49.3 (47.2, 51.5) 86.9 (88.4, 85.3) 4.5 (3.7, 5.4)
Abbreviations: HMO, health maintenance organization; Occ Med, occupational medicine; PPO, preferred provider organization. *Values are n (%). Values are percentages (95% condence interval).
scores, and that referral from occupational medicine physicians was not associated with discharge OHS scores. Regarding number of visits, only Resnik and associates33 modeled this variable, and they did
not nd an association between referral source and number of visits per treatment episode. These previous studies included referral source as explanatory variables; however, the meaning of re-
lationships between referral source and outcomes was not discussed. Variations between the current ndings and previous studies should be explored in future research.
TABLE 4
Individual-Level and Multilevel Models for Discharge OHS*

Individual-Level Linear Model Adjusted for Patient-Level Variables Multilevel Model Adjusted for Patient-Level Variables, Clinic, and Clinician P Value <.0001 <.0001 <.0001 <.0001 <.0001 .1041 <.0001 <.0001 .0001 .4797 .1625 .0004 .2331 .0239 .2983 .7812 .0723 .0751 .6370 Estimate 42.4519 1.6608 4.8271 0.6513 0.1622 0.7794 0.0678 5.9128 3.2908 0.6915 0.4101 1.9036 0.4902 3.2676 0.6320 1.1405 2.1347 1.5320 0.1592 SE 1.8299 0.4737 1.0827 0.0196 0.0161 0.4109 0.0090 0.5379 0.5611 0.4407 0.4891 0.4566 2.4207 1.5075 1.0624 2.1571 0.9201 1.1554 1.4574 P Value <.0001 .0005 <.0001 <.0001 <.0001 .0579 <.0001 <.0001 <.0001 .1167 .4018 <.0001 .8395 .0302 .5520 .5970 .0204 .1849 .9130
Variable Intercept Referral source Primary care Occupational medicine Admission OHS score
Estimate 42.3800 2.3003 6.8459 0.6232 0.1545 0.7213 0.0666 5.4592 2.3177 0.3365 0.7424 1.7554 3.0527 3.3827 1.0908 0.6322 1.5410 2.0647 0.6566
SE 1.8114 0.4858 1.0408 0.0210 0.0172 0.4437 0.0094 0.5777 0.6050 0.4761 0.5314 0.4945 2.5597 1.4968 1.0486 2.2758 0.8573 1.1597 1.3913
Age, y Sex (male), n Duration of care, d Symptom duration Chronic Subacute Took prescription medications on intake Exercise status 1 to 2 d per wk 3 or more d per wk Payer source Litigation Medicaid Medicare Self-pay HMO/PPO Workers compensation Other
Abbreviations: HMO, health maintenance organization; OHS, overall health status; PPO, preferred provider organization. *The individual-level model included the variables referral source, baseline OHS, age, sex, symptom duration, taking medications on admission, exercise status, payer source, and duration of care. The multilevel model also included clinician and clinic effects as random effect variables. Reference category is specialist physician. Reference category is acute duration of symptoms. Reference category is no exercise. Reference category is fee-for-service payer source.
The parameter estimates for discharge OHS and number of visits associated with referral source represent differences in outcomes that may appear small when viewed through the lens of clinical treatment effects for individual patients; however, from an epidemiologic perspective, these differences may reect important benets in function and resource utilization across a population. Furthermore, this investigation seeks to inform about the potential impact of an important element of the physical therapy referral process rather than treatment effectiveness. From this health services utilization
perspective, the magnitude of the associations disclosed by our ndings may be important, as little is currently known about the impact of referral source on physical therapy outcomes. Future studies may build on these ndings, further illuminating the referral pathway and factoring in current trends such as direct access to physical therapy. In the current study, differences in the distribution of symptom duration among the 3 physician referral sources are evident. Most referrals from occupational medicine physicians (72.7%) were in the acute phase of recovery and
thus more likely to make gains during treatment. Most referrals from specialist physicians (60.8%), however, were in the chronic phase of recovery and would not be expected to achieve similar functional gains.4,12,33 Referrals from PCPs occupied a middle ground in terms of the distribution of symptom duration as well as functional improvement. Symptom duration on admission is an important predictor of functional status outcomes in LBP.7,12,33 Delays in physical therapy referral may shift acute episodes of LBP to subacute or chronic episodes. Early referral to physical therapy, that is,
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TABLE 5
RESEARCH REPORT
Individual-Level and Multilevel Models for Number of Visits*

Individual-Level Linear Model Adjusted for Patient-Level Variables Multilevel Model Adjusted for Patient-Level Variables, Clinic, and Clinician P Value <.0001 <.0001 <.0001 <.0001 <.0001 .0107 <.0001 .8010 .1389 <.0001 .5293 .0170 .6148 .0347 <.0001 .2266 .4679 <.0001 <.0001 Estimate 3.7377 0.4419 0.8277 0.0265 0.0249 0.1200 0.1449 0.0602 0.1234 0.2215 0.0318 0.0418 0.6037 0.6454 0.1795 0.5294 0.0608 1.2143 0.0910 SE 0.3362 0.0859 0.1976 0.0035 0.0028 0.0744 0.0016 0.0979 0.1021 0.0802 0.0884 0.0827 0.4705 0.2469 0.1890 0.3776 0.1624 0.2033 0.2531 P Value <.0001 <.0001 <.0001 <.0001 <.0001 .1067 <.0001 .5387 .2266 .0058 .7189 .6129 .1995 .0090 .3422 .1610 .7079 <.0001 .7191
Variable Intercept Referral source Primary care Occupational medicine Admission OHS score
Estimate 3.3323 0.5003 1.1723 0.0320 0.0194 0.2081 0.1469 0.0269 0.1650 0.4373 0.0615 0.2172 0.2555 0.5247 0.7753 0.4896 0.1113 1.8068 1.1793
SE 0.3228 0.0890 0.1888 0.0038 0.0031 0.0815 0.0017 0.1065 0.1115 0.0880 0.0978 0.0910 0.5077 0.2484 0.1903 0.4049 0.1533 0.2057 0.2441
Age, y Sex (male), n Duration of care, d Symptom duration Chronic Subacute Took prescription medications on intake Exercise status 1 to 2 d per wk 3 or more d per wk Payer source Litigation Medicaid Medicare Self-pay HMO/PPO Workers compensation Other
Abbreviations: HMO, health maintenance organization; OHS, overall health status; PPO, preferred provider organization. *The individual-level model included the variables referral source, baseline OHS, age, sex, symptom duration, taking medications on admission, exercise status, payer source, and duration of care. The multilevel model also included clinician and clinic effects as random effect variables. Reference category is specialist physician. Reference category is acute duration of symptoms. Reference category is no exercise. Reference category is fee-for-service payer source.
when patients are in the acute phase of symptom duration, has been associated with improved outcomes in individuals with LBP2,8,13,29,30 and associated with decreased recurrence of LBP episodes.21 Symptom duration was also related to referral source in the current study, which suggests that the timing of physical therapy referral may vary according to referral source. Optimal referral pathways for patients with LBP have not been identied. PCPs manage the majority of their patients with LBP without referral,9 but they may also refer patients to other specialist physicians, rather than
to physical therapists.35,36 Whether a patient is referred to physical therapy for LBP may depend on factors such as sex, age, and patient expectations for physical therapy services.11 Future investigations should identify patients who may benet from early physical therapy referral from a PCP, and those who should see a specialist physician prior to physical therapy referral. Distinguishing patients who may directly access physical therapy from those who need prior physician consultation is also a topic that should be explored in future research. The current investigation is informa-
tive regarding the relationship between payer source and physician referral source. Over 97% of occupational medicine referrals were paid through workers compensation (TABLE 3). In multilevel analyses, occupational medicine physician status was associated with fewer visits, yet workers compensation payer source was associated with more visits (TABLE 5). This apparently paradoxical result was explored by examining the number of visits within the workers compensation stratum. This analysis revealed that referrals by occupational medicine physicians were treated, on average, in
6.5 visits, whereas referrals by PCPs and specialists were treated, on average, in 8.5 and 10.6 visits, respectively (analysis available on request). Thus, occupational medicine physicians, referring mostly through the workers compensation system, utilized fewer physical therapy visits when compared to PCPs and specialists. These ndings suggest that occupational medicine physicians may function under different reimbursement circumstances from those of primary care or specialist physicians, and that they may also have different clinical obligations, such as to minimize lost work time for injured workers. In contrast, reimbursement for primary care and specialist physician services was more broadly distributed among the various payer sources, though the majority of the reimbursements were through health maintenance organizations or preferred provider organizations. The extent to which bias might have been introduced during the selection of observations included in the analyses warrants discussion. Because of the large sample size, some differences in baseline characteristics or outcomes between included and excluded were statistically signicant but small and clinically unimportant. For other characteristics, differences in included and excluded data sets may be meaningful. Among the 2 outcome variables, the observations included in the analyses had mean OHS scores that were, on average, 3.5 points higher than those of observations excluded from the analyses. Because no minimal clinically important improvement has been established for the OHS, we are unable to use that as a benchmark to assess the importance of this difference. Furthermore, because minimal clinically important improvement for a given outcome may be sensitive to baseline value, as well as comorbidity status and demographic attributes,38 it is less likely to be informative as an index of clinical importance in a broad population. In addition, included observations had, on average, 1 fewer visit than excluded observations. It is possible that included observations had fewer vis-
its because they had shorter episodes of care, or were less likely to have chronic symptom duration. Differences in the distribution of referral source and other predictor variables, such as symptom duration and workers compensation payer source, were also seen in the included and excluded data sets. The degree to which these factors may be interrelated as potential confounders may be explored in future research. Another potential source of selection bias resulted from including only those observations with complete data at both admission and discharge. For example, it is possible that clinicians or clinics chose better-performing patients to complete the discharge assessment, resulting in selective inclusion of higher performers in analyses of OHS outcome. In our experience with the FOTO administration, however, it is more likely that noncompletion was a random rather than a systematic occurrence, which would neutralize any bias that might have been introduced by exclusion of noncompleters. In addition, selection bias that might have been introduced by characteristics of clinics or clinicians would have been mitigated by multilevel adjustment for clustering within clinicians and clinics in the analysis. The observed differences in distribution of predictor and outcome variables in the included and excluded data sets might also have affected external validity, limiting generalizability of the current ndings to, for example, those patients who completed a course of care for LBP. The explanatory power of the analyses is indicated by the coefficient of determination (R2) of the individual-level models tted for each outcome. For number of visits, R2 was 0.523, and for discharge OHS scores, R2 was 0.262, meaning that each model explained 52.3% and 26.2% of the variability in the respective outcomes. The strongest predictor of the number of visits was duration of the episode of care, based on the change in R2 (decreased to 0.073) when the variable for duration of care was removed from the model. Thus, referral source, though
it remained signicant in the individuallevel multivariate analysis for number of visits, was a relatively weak predictor. As a predictor, referral source was more robust in the model for discharge OHS score, as the value of R2 changed relatively little when other variables were removed from the model (analysis available upon request). We reported only the R2 values for the individual-level models because there is no comparable and readily interpretable analog to R2 in multilevel analyses.
Limitations
This study has several limitations. The current ndings reveal associations between referral source and important outcomes of physical therapy care but do not fully explain the reasons for these associations, nor do they establish cause and effect. Other factors not measured in the current study have been shown to contribute to variation in outcomefor example, patient expectation of improvement, and clinic and therapist characteristics.2,7,37 Data regarding the length of time from physician visit to initiation of physical therapy were not available, nor were we able to determine whether a patient saw more than 1 physician (eg, a PCP, then a specialist) prior to physical therapy referral. Knowing this would have permitted a better description of the physical therapy referral. Number of visits has been used as an indicator of resource utilization by previous investigators,2,17,33 but number of visits per episode of care is a crude measure of physical therapy resources and does not capture other aspects of patient/ client management, such as administrative time and expense or the length and cost of interventions or examination procedures. Also, patients who underwent surgery for the current episode of care were excluded from our analyses; therefore, our ndings cannot be generalized to patients who had surgery immediately prior to their current episode of care. We also did not know if observations represented patients who had undergone prior surgery, or if the current episode
[
was a rst or a recurrent episode of LBP syndrome. Another limitation pertains to potential confounders that were not included in the analyses. For example, number of comorbidities7 and fear-avoidance beliefs14 have been shown to be predictive of outcomes in LBP. These elds, although available in the FOTO data set, were not well populated and so were not included in the analyses. Another potential confounder, the presence and amount of copayments, was not available in the FOTO package. Finally, the generalizability of our ndings to current practice may be limited by the age of the data (20032005), as referral or reimbursement patterns might have evolved since the data were collected.
RESEARCH REPORT
and clinics. Compared to specialist physician referral, referral from occupational medicine physicians and PCPs was associated with higher discharge OHS scores and fewer visits. IMPLICATIONS: Patients/clients who are referred to physical therapy may have different clinical characteristics, depending on referral source. Timing of physical therapy referral may also vary according to referral source, and this may influence outcomes, depending on whether patients are seen earlier or later in the course of an episode of LBP. CAUTION: Other factors not measured in this investigation, including the number of physicians visited prior to physical therapy referral, the length of time between physician visit(s) and initiation of physical therapy, and comorbidities, may also determine referral pathways and influence outcomes of physical therapy care. In addition, patients who had surgery for the current episode of care were excluded from analyses.
ACKNOWLEDGEMENTS: The authors would like
]
and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491. Cote P, Baldwin ML, Johnson WG. Early patterns of care for occupational back pain. Spine (Phila Pa 1976). 2005;30:581-587. Deutscher D, Horn SD, Dickstein R, et al. Associa tions between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Arch Phys Med Rehabil. 2009;90:1349-1363. http://dx.doi.org/10.1016/j. apmr.2009.02.005 Ehrmann-Feldman D, Rossignol M, Abenhaim L, Gobeille D. Physician referral to physical therapy in a cohort of workers compensated for low back pain. Phys Ther. 1996;76:150-156; discussion 156-157. Forrest CB, Nutting PA, Stareld B, von Schrader S. Family physicians referral decisions: results from the ASPN referral study. J Fam Pract. 2002;51:215-222. Freburger JK, Carey TS, Holmes GM. Physical therapy for chronic low back pain in North Carolina: overuse, underuse, or misuse? Phys Ther. 2011;91:484-495. http://dx.doi.org/10.2522/ ptj.20100281 Freburger JK, Carey TS, Holmes GM. Physician referrals to physical therapists for the treatment of spine disorders. Spine J. 2005;5:530-541. http://dx.doi.org/10.1016/j.spinee.2005.03.008 Fritz JM, Hunter SJ, Tracy DM, Brennan GP. Utilization and clinical outcomes of outpatient physical therapy for Medicare beneciaries with musculoskeletal conditions. Phys Ther. 2011;91:330-345. http://dx.doi.org/10.2522/ ptj.20090290 Gellhorn AC, Chan L, Martin B, Friedly J. Man agement patterns in acute low back pain: the role of physical therapy. Spine (Phila Pa 1976). 2012;37:775-782. http://dx.doi.org/10.1097/ BRS.0b013e3181d79a09 Grotle M, Vollestad NK, Brox JI. Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II. Spine (Phila Pa 1976). 2006;31:1038-1046. http://dx.doi.org/10.1097/01. brs.0000214878.01709.0e Hart DL. The power of outcomes: FOTO Industrial Outcomes Tool -- initial assessment. Work. 2001;16:39-51. Hart DL. Test-retest reliability of an abbreviated self-report overall health status measure. J Orthop Sports Phys Ther. 2003;33:734-744. Hart DL, Connolly JB. Pay-for-Performance for Physical Therapy and Occupational Therapy: Medicare Part B Services. Knoxville, TN: Focus On Therapeutic Outcomes, Inc; June 1, 2006. Centers for Medicare & Medicaid Services grant #18-P-93066/9-01. Hart DL, Dobrzykowski EA. Inuence of or thopaedic clinical specialist certication on clinical outcomes. J Orthop Sports Phys Ther. 2000;30:183-193.
6.
7.
8.
9.
10.
CONCLUSION
he current study adds to the knowledge of physician referral patterns to physical therapy and outcomes for LBP management in non work-related settings. Referral source was associated with discharge function and number of physical therapy visits, after adjusting for important covariates such as baseline functional status, symptom duration, exercise habits, medication use, and payer source, as well as clinician- and clinic-level clustering. Compared to referrals from specialist physicians, referrals from occupational medicine physicians and PCPs were associated with higher discharge function and fewer visits. These ndings shed light on the physical therapy referral process for patients with LBP; however, elucidation of optimal physical therapy referral pathways and sequences needs to be explored in future research. t
11.
12.
to thank Paula Rosenbaum, PhD, for her assistance with data analysis and Janet Freburger, PT, PhD, for her manuscript review and advice.
13.
REFERENCES
1. A ndersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354:581-585. http://dx.doi.org/10.1016/ S0140-6736(99)01312-4 2. Badke MB, Boissonnault WG. Changes in disability following physical therapy intervention for patients with low back pain: dependence on symptom duration. Arch Phys Med Rehabil. 2006;87:749-756. http://dx.doi.org/10.1016/j. apmr.2006.02.033 3. Brooks G, Dripchak S, VanBeveren P, Allaben S. Is a prescriptive or an open referral related to physical therapy outcomes in patients with lumbar spine-related problems? J Orthop Sports Phys Ther. 2008;38:109-115. http://dx.doi. org/10.2519/jospt.2008.2591 4. Carey TS, Garrett JM, Jackman AM. Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain. Spine (Phila Pa 1976). 2000;25:115-120. 5. Chou R, Qaseem A, Snow V, et al. Diagnosis 14.
15.
16.
KEY POINTS
FINDINGS: Referral source was indepen-
17.
dently related to discharge functional status and number of visits after accounting for other important factors, such as age, symptom duration, and payer source, and after accounting for variation among individual clinicians
18.
19. H art DL, Tepper S, Lieberman D. Changes in health status for persons with wrist or hand impairments receiving occupational therapy or physical therapy. Am J Occup Ther. 2001;55:68-74. 20. Hart DL, Wright BD. Development of an index of physical functional health status in rehabilitation. Arch Phys Med Rehabil. 2002;83:655-665. 21. Hides JA, Jull GA, Richardson CA. Long-term effects of specic stabilizing exercises for rstepisode low back pain. Spine (Phila Pa 1976). 2001;26:E243-248. 22. Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997;77:145-154. 23. Jette DU, Jette AM. Physical therapy and health outcomes in patients with knee impairments. Phys Ther. 1996;76:1178-1187. 24. Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Phys Ther. 1996;76:930-941; discussion 942-945. 25. Jewell DV, Riddle DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005;85:1139-1150. 26. Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009;89:419-429. http://dx.doi.org/10.2522/ptj.20080250 27. Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976). 2004;29:79-86. http://dx.doi.org/10.1097/01. BRS.0000105527.13866.0F 28. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-664.
http://dx.doi.org/10.1001/jama.299.6.656 29. N ordeman L, Nilsson B, Moller M, Gunnarsson R. Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial. Clin J Pain. 2006;22:505-511. http://dx.doi.org/10.1097/01. ajp.0000210696.46250.0d 30. Pinnington MA, Miller J, Stanley I. An evaluation of prompt access to physiotherapy in the management of low back pain in primary care. Fam Pract. 2004;21:372-380. http://dx.doi. org/10.1093/fampra/cmh406 31. Resnik L, Hart DL. Using clinical outcomes to identify expert physical therapists. Phys Ther. 2003;83:990-1002. 32. Resnik L, Liu D, Hart DL, Mor V. Benchmarking physical therapy clinic performance: statistical methods to enhance internal validity when using observational data. Phys Ther. 2008;88:10781087. http://dx.doi.org/10.2522/ptj.20070327 33. Resnik L, Liu D, Mor V, Hart DL. Predictors of physical therapy clinic performance in the treatment of patients with low back pain syndromes. Phys Ther. 2008;88:989-1004. http://dx.doi. org/10.2522/ptj.20070110 34. Ritzwoller DP, Crounse L, Shetterly S, Rublee D. The association of comorbidities, utilization and costs for patients identied with low back pain. BMC Musculoskelet Disord. 2006;7:72. http:// dx.doi.org/10.1186/1471-2474-7-72 35. Robert G, Stevens A. Should general practitioners refer patients directly to physical therapists? Br J Gen Pract. 1997;47:314-318. 36. Stareld B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract. 2002;15:473-480. 37. Swinkels IC, Hart DL, Deutscher D, et al. Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the
38.
39.
40.
41.
42.
43.
44.
Netherlands: cross sectional analyses of data from three clinical databases. BMC Health Serv Res. 2008;8:163. http://dx.doi. org/10.1186/1472-6963-8-163 Wang YC, Hart DL, Stratford PW, Mioduski JE. Baseline dependency of minimal clinically important improvement. Phys Ther. 2011;91:675688. http://dx.doi.org/10.2522/ptj.20100229 Ware J, Jr., Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220-233. Ware JE, Kosinski M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. 2nd ed. Boston, MA: The Health Institute, New England Medical Center; 1995. Ware JE, Kosinski M, Keller SD. SF-36 Physical and Mental Health Summary Scales: A Users Manual. 5th ed. Boston, MA: The Health Institute, New England Medical Center; 1994. Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-483. Weiner DK, Kim YS, Bonino P, Wang T. Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med. 2006;7:143-150. http://dx.doi. org/10.1111/j.1526-4637.2006.00112.x Werneke MW, Hart DL, Cutrone G, et al. Associa tion between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther. 2011;41:22-31. http://dx.doi. org/10.2519/jospt.2011.3415
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Referral Source and Outcomes of Physical Therapy Care in Patients With Low Back Pain - Journal of Orthopaedic & Sports Physical Therapy - Vol. 42, No

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[

T STUDY DESIGN: Retrospective longitudinal

T OBJECTIVES: To describe the clinical charac-

individual clinicians, and clinicians working within individual clinics.

T RESULTS: Bivariate and multilevel analyses

T BACKGROUND: Little is known about as-

T METHODS: Data from a proprietary clinical

T CONCLUSION: After accounting for clinical

T LEVEL OF EVIDENCE: Prognosis, level 2c.

T KEY WORDS: lumbar spine, physician referral,

66 524 observations (initial dataset)

64 814 observations were classified as having orthopaedic and lumbar impairment.

7971 observations (analysis dataset)

FIGURE 1. Data selection procedure. Abbreviation: OHS, overall health status.

58541 58553 23234 32724 31987 58519 58515

75 70 65 60 55 50 45 40 Baseline OHS Discharge OHS

Primary care Specialist Occ med

Baseline Characteristics and Differences by Referral Source: Categorical Variables

1 (0.1) 1 (0.1) 3 (0.3) 1 (0.1) 0 (0.0) 21 (2.0) 1036 (97.5) 0 (0.0)

Individual-Level and Multilevel Models for Discharge OHS*

Individual-Level and Multilevel Models for Number of Visits*

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