Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review

Abstract: Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability\r\nto self-refer to physical therapy without a physician referral. This model of care in musculoskeletal\r\ndiseases (MSDs) has shown better outcomes than the traditional-based medical model of care that\r\nrequires physician referral to access physiotherapist services. This traditional physician referral\r\noften results in a delay in care. Unfortunately, DAPT is still not permitted in many countries.\r\nObjectives. The primary objective of this systematic review was to compare the effectiveness, safety,\r\nand accuracy of DAPT compared to the physician-led model of care for the management of\r\npatients with musculoskeletal disorders. The secondary objective of the present study is to define\r\nthe physiotherapists’ characteristics or qualifications involved in DAPT. Materials and methods.\r\nDatabases searched included: Medline, Scopus, and Web of Science. Databases were searched from\r\ntheir inception to July 2022. Research strings were developed according to the PICO model of clinical\r\nquestions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical\r\ntherapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when\r\npossible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators\r\n(AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-\r\nbias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS)\r\nfor observational studies. The authors qualitatively analyzed the results through narrative\r\nanalysis and narrative synthesis. The narrative analysis was provided for an extraction of the key\r\nconcepts and common meanings of the different studies, while the summary narrative provided\r\na textual combination of data. In addition, a quantitative analysis was conducted comparing the\r\nanalysis of the mean and differences between the means. Results. Twenty-eight articles met the\r\ninclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and\r\na reduction in the rate of return visits. The medical model had a higher use of imaging, drugs,\r\nand referral to another specialist. DAPT was found to be more cost-effective than the medical\r\nmodel. DAPT resulted in better work-related outcomes and was superior when considering patient\r\nsatisfaction. There were no adverse events noted in any of the studies. Regarding health outcomes,\r\nthere was no difference between the models. ROB-2 shows an intermediate risk of bias risk for the RCTs\r\nwith an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a\r\nsafe, less expensive, reliable triage and management model of care that results in higher levels of\r\nsatisfaction for patients compared to the traditional medical model. Prospero Registration Number:\r\nCRD42022349261.