To determine whether general practitioners (GPs) should have direct access to physical therapy, either through open-access or on-site therapy. Secondary aim is to determine whether earlier referral results in shorter courses of treatment.

HealthPLAN was searched from 1981 to December 1995, and MEDLINE from 1989 to January 1996; the search strategy is provided. References given in retrieved articles were assessed for inclusion.

Study designs of evaluations included in the review

The study designs included were randomised controlled trial (RCT), open prospective case series, and retrospective case note review.

Specific interventions included in the review

Studies comparing two or more models of providing physical therapy services where physical therapy is defined as the treatment of disorders with physical agents and methods to assist in rehabilitating patients and restoring normal functioning after illness or injury. Interventions of physiotherapy studied.

Participants included in the review

Patients referred for physiotherapy by the GP or hospital consultant. Therapy provide by NHS and private sector. Therapy provided in hospital, primary care or domiciliary setting. Patients reported as having back, neck, shoulder pain, soft tissue injury, knee problems, respiratory disorders, osteoarthritis, rheumatoid arthritis.

Outcomes assessed in the review

Referral rates, delay in treatment, treatment outcome (patient and physiotherapist assessment), time off work, patient costs, pressure on out-patient clinics, use of physiotherapy services, cost of providing open access.

How were decisions on the relevance of primary studies made?

The studies were reviewed by one of the authors.

The included studies were ranked to give a hierarchy of evidence according to study design. The authors do not state how the papers were assessed for validity, or how many of the authors performed the validity assessment.

The authors do not state how the data were extracted for the review, or how many of the authors performed the data extraction.

How were the studies combined?

Results from the individual studies were reported for the hypothesis being considered.

How were differences between studies investigated?

The authors do not state how differences between the studies were investigated.

Reduced number of treatment sessions required: assessed by 1 RCT (N=230), 3 prospective case series studies (N=991), and 1 retrospective case note review (N=319).

Delay in treatment: assessed by 1 RCT (N=230), 3 prospective case series studies (N=991), and 2 retrospective case note reviews (N=1,124).

Prompt treatment: assessed by 1 RCT (N=230), 3 prospective case series studies (N=991), and 2 retrospective case note reviews (N=1,124).

Reduced pressure on out-patient clinics: assessed by 1 RCT (N=230) and 2 prospective case series studies (N=1,861).

Recovery and recovery time: assessed by 1 RCT (N=230) and 2 prospective case series studies (N=791).

Higher patient assessment of progress: assessed by 1 RCT (N=230) and 2 prospective case series studies (N=991).

Lower financial cost to patient: assessed by 1 prospective case series study (N=401).

Health service costs: assessed by 1 prospective case series study (N=390).

There is little evidence to suggest that the number of sessions required for patients referred by direct access is reduced. Direct access significantly reduces the waiting times for treatment compared to referral via a consultant. Consultant referral seems to be reduced where direct access is available. Variable results between studies were found regarding patients own assessment of treatment, and recovery time. The financial cost to patients was lowest where a physiotherapist was provided by the GP.

Additional (marginal) cost to the physiotherapy department of providing open-access was approximately £3,300 per annum.

For a full discussion of the economic aspects of this study see NHS EED record 21997008145.

The main advantages for patients who are referred directly for physical therapy are convenience, a significant reduction in waiting times, and reduced costs to the patient and the health authority in terms of cost per treated patient. There is some evidence that the recovery time may be slightly better where patients receive direct access physiotherapy. There is a need to provide good quality evidence of cost-effectiveness of different models of physical therapy services.

A more extensive literature search may have produced more than the one RCT included in the review, and may have produced studies on forms of physical therapy other than physiotherapy. There was minimal evaluation of the quality of the primary studies and no investigation of the differing results reported between studies for some of the outcomes. In view of the lack of detail of the methodology, and lack of critical evaluation of the included studies, it is difficult to assess the evidence offered.

There is a need to evaluate the cost-effectiveness of different models of physical therapy services.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.