A Deeper Look: Why Referred Patients Fail to Start Physical Therapy

Physical therapy (PT) plays a pivotal role in managing a diverse range of health conditions. However, a significant number of patients who are prescribed this form of treatment often fail to initiate their PT journey.

Shockingly, 76% of patients referred to PT for musculoskeletal problems do not initiate treatment (NIH Study, 2021). Unfortunately, patients that defer or avoid PT realize material downstream health impacts and quality of life issues, and generate significant cost consequences for their affiliated health plans and providers.

Scheduling and Accessibility Issues

For many patients considering PT, inconvenient appointment times and locations present significant barriers. Many individuals with busy schedules due to work, family responsibilities, or school often find the time commitment challenging. This difficulty is exacerbated when traditional PT operating hours align with typical working hours, as noted by Jack et al. (2010).

Physical location also plays a critical role in accessibility. Long travel times or distances to clinics are particularly problematic in rural areas, where services may be spread out and public transportation options limited. The strain of the commute increases the likelihood of patients missing appointments or discontinuing care altogether.

Adding to these challenges are the often lengthy waitlists at clinics. As demand for services has grown, the capacity of clinics to meet these demands hasn't always kept pace, leading to significant wait times (Pienta, McDonald, & Ketcham, 2018).

These combined time, location, and availability constraints often result in patients abandoning the idea of starting PT before they've even begun.

Financial Concerns

Out-of-pocket costs, high deductibles, or limited insurance coverage can make PT treatments seem unaffordable (Resnik et al., 2020). High co-pays are a notable factor leading to decreased utilization of outpatient services. Additionally, patients with public insurances (Medicaid in particular) were less likely to pursue PT services (NIH Study, 2021).

Communication, Motivation, and Expectations

Poor communication between healthcare providers and patients can result in the patient not fully understanding the necessity of therapy, leading to abandonment (Daker-White et al., 1999). Moreover, unmet patient expectations about the recovery process may also discourage therapy initiation (Hush et al., 2011). On the other hand, educating patients about the benefits of postoperative PT can increase adherence (Rondon et al., 2018).

Patients who do not perceive their health conditions as severe are less likely to adhere to PT (Pienta, McDonald, and Ketcham, 2018). That being said, patients with a diagnosis of knee, ankle, thoracic or hip conditions (orthopedic referrals) were more likely to use PT compared with patients with lower back pain diagnoses (typically associated with primary care or urgent care referrals) (NIH Study, 2021).

Altogether, PT requires active participation from the patient. If a patient is not motivated or does not believe in the benefits of PT, they may not initiate and adhere to the treatment plan.

Physical and Psychological Barriers

Pinto et al. (2012) revealed that fear of pain and exacerbation of existing discomfort are significant psychological barriers that prevent patients from seeking therapy. Furthermore, the absence of immediate results can lead to disillusionment and early discontinuation.

Mental health issues, such as depression and anxiety, can further complicate the situation, dissuading patients from starting therapy (Slade, Molloy, and Keating, 2009). The fear of movement or potential harm can also deter patients from initiating therapy, particularly in cases of chronic low back pain (Caiata-Zufferey et al., 2012).

Sociocultural Factors, Health Literacy, and Support

Cultural, ethnic, and social beliefs about health and healing can influence patients' decisions to initiate PT. Lower health literacy, as discussed by Berkman et al. (2011), is another significant barrier to starting PT.

Furthermore, patients with low social support are less likely to start PT (Friedrich, Cermak, and Maderbacher, 1996). Conversely, patients who perceive significant benefits from PT are more motivated to initiate it (Holden, Nicholls, Young, Haywood, and Foster, 2009).

Impacts on Health Plans and Providers:

Failure to start or adhere to PT can lead to a number of downstream cost consequences for health plans and providers, including:

• Increased healthcare costs: Non-adherence to PT often leads to prolonged illness or injury and a slower recovery process. These complications result in more frequent doctor visits, additional medical tests, and even hospitalizations, all of which increase healthcare costs.
• Surgery and interventional procedures: PT often prevents the need for surgery or other invasive procedures by helping patients manage their conditions non-surgically.
• Increased medication costs: Patients may need to rely more on medications for pain management or to improve their condition.
• Increased disability costs: Failure to adhere to PT can result in long-term disability, leading to increased costs related to disability payments, home health care, and adaptive equipment.

Impacts on Patients’ Quality of Life 

Deferring or avoiding PT can lead to a number of downstream health impacts for patients, including:

• Poor health outcomes: Patients recovering from surgery or stroke may see slower progress in their mobility, strength, and general function. For chronic conditions like arthritis or back pain, non-adherence can lead to increased pain, stiffness, and decreased function. Over time, these conditions can deteriorate and lead to permanent damage or disability.
• Decreased quality of life: As a result of these poorer health outcomes, patients might also experience a decreased quality of life. They may not be able to participate in activities they enjoy, whether that's playing a sport, gardening, or playing with their children or grandchildren - and can lead to depression and anxiety.
• Increased pain and discomfort: Without the relief provided by PT, patients may experience prolonged or increased pain and discomfort. This can affect their daily life, including their ability to work, socialize, and perform basic tasks.
• Poorer long-term prognosis: Patients may be more likely to suffer from long-term disability, require more invasive treatments or surgeries, or even have a shortened lifespan, particularly if the PT is meant to manage a serious condition like heart disease or stroke.

Where Luna Can Help

At-home physical therapy can help overcome several of these barriers by providing convenient, personalized, and flexible services. By improving accessibility, affordability, and comfort, we can encourage more patients to embark on their PT journey, leading to superior healthcare efficiencies and enhanced patient outcomes.

References

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8679185/ - 2021, NIH Study about “Identifying patients who access musculoskeletal physical therapy: a retrospective cohort analysis”
• Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of Internal Medicine, 155(2), 97-107.
• Caiata-Zufferey, M., Schulz, P. J., Buchi, S., & Nakamoto, K. (2012). The Influence of Kinesiophobia (Fear of Movement) on Patients' Recovery After Cardiac Surgery: A Structural Equation Model. Psychology & Health, 27(7), 813-829.
• Daker-White, G., Carr, A. J., Harvey, I., Woolhead, G., Bannister, G., Nelson, I., & Kammerling, M. (1999). A randomized controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology & Community Health, 53(10), 643–650.
• Friedrich, M., Cermak, T., & Maderbacher, P. (1996). The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Physical Therapy, 76(10), 1082–1088.
• Holden, M. A., Nicholls, E. E., Young, J., Hay, E. M., & Foster, N. E. (2009). UK-based physical therapists' attitudes and beliefs regarding exercise and knee osteoarthritis: findings from a mixed-methods study. Arthritis & Rheumatism, 61(11), 1511–1521.
• Hush, J. M., Cameron, K., & Mackey, M. (2011). Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Physical Therapy, 91(1), 25–36.
• Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy, 15(3), 220–228.
• Larsson, M. E., Nordholm, L. A., & Ohrn, I. (2016). Patients’ views on responsibility for the management of musculoskeletal disorders—a qualitative study. BMC Musculoskeletal Disorders, 10(1), 110.
• Pienta, A. M., McDonald, N., & Ketcham, J. (2018). Active Patients following Treatment: The Impact of Copayments. Health Services Research, 53(2), 853–873.
• Pinto, R. Z., Maher, C. G., Ferreira, M. L., Ferreira, P. H., Hancock, M., Oliveira, V. C., McLachlan, A. J., & Koes, B. (2012). Patient-centered communication is associated with positive therapeutic alliance: a systematic review. Journal of Physiotherapy, 58(2), 77–87.
• Resnik, L., Hart, D. L. (2020). Using clinical outcomes to identify expert physical therapists. Physical Therapy, 83(11), 990–1002.
• Rondon, A. J., Tanaka, M. J., Martin, S. D., & Berkson, E. M. (2018). A multimedia patient education program on the management of knee osteoarthritis can save healthcare resources without compromising quality of care. American Journal of Orthopedics, 47(8).
• Slade, S. C., Molloy, E., & Keating, J. L. (2009). Stigma experienced by people with nonspecific chronic low back pain: a qualitative study. Pain Medicine, 10(1), 143–154