State regulation and the delivery of physical therapy services

The study purpose was to examine the relationship between state regulations of physical therapists (PT) and three dependent variables: physical therapist assistant (PTA) utilization more than 50 percent of the time during the treatment episode (high PTA utilization), number of visits, and patient self-reported functional health status (FHS) at discharge. We evaluated regulations governing licensure of PTAs, PT/PTA ratio, frequency of PT re-evaluation, and PTA supervision.

The analytic sample included 63,900 patients from 38 states drawn from 395 clinics who participated in the Focus on Therapeutic Outcomes Inc. (Knoxville, TN) database in 2000 and 2001.

Using a Bayesian modeling approach with the Markov Chain Monte Carlo estimation method, we fitted separate multilevel multivariate regression models predicting high PTA utilization, number of visits, and discharge FHS.

Patients completed FHS surveys at intake and discharge. Clinicians recorded the number of visits and percentage of time a patient spent with each provider.

After controlling for patient, therapist, and clinic characteristics, the presence of state regulations regarding PTA supervision was not associated with the likelihood of high PTA utilization. High PTA utilization and regulations requiring full-time onsite supervision were associated with more visits, whereas regulation of PT/PTA ratio was associated with fewer visits. Supervisory regulations were associated with better discharge FHS. High PTA utilization and use of therapy aides were associated with more visits per episode and lower discharge FHS.

The use of care extenders in place of PTs is likely to result in less efficient and lower quality care in outpatient rehabilitation.