Policy versus practice: comparison of prescribing therapy and durable medical equipment in medical and educational settings
OBJECTIVE: The American Academy of Pediatrics (AAP) has promoted pediatrician involvement in the care of children with special health care needs (CSHCN), including the prescription and/or supervision of therapies and durable medical equipment (DME) for children in both medical and educational settings, such as schools and early intervention programs. Through this survey, we attempted to quantify objectively how pediatricians direct and coordinate therapy and DME for CSHCN and how these efforts correlate with AAP recommendations.
METHODS: A survey was mailed to a random sample of 500 physicians listed in the AAP directory, resulting in a final sample of 217 responding physicians who indicated that they provide services to CSHCN. Results of the survey were reported as proportions, means with standard deviations, or medians with interquartile range. Comparisons of proportions among certain subgroups of interest were made using Fisher exact tests.
RESULTS: The most recent AAP policy revision addressing the role of physicians in prescribing therapy services for children with motor disabilities appeared in Pediatrics 1996. It listed 6 key items that should be part of a therapy prescription: diagnosis, precautions, type, frequency, anticipated goals (educators may prefer the term "objectives"), and duration. The policy addressed and emphasized the need for what may be additional objectives, namely regular communication between all parties involved, ongoing supervision and reevaluation of the program and problem, and awareness of other community resources for possible referrals. Except for providing a diagnosis, the majority of surveyed pediatricians do not regularly comply with AAP policy recommendations on prescribing therapies and DME in medical and educational settings. Physicians who were trained before 1980 tend to follow AAP recommendations more closely than later graduates. Decreasing involvement of private outpatient pediatricians in coordinating and supervising CSHCN's care was noted. Furthermore, the majority is willing to defer decisions about treatment and goals to nonphysician health care providers (NPHCPs) and, in some cases, even equipment vendors. More than two thirds of the respondents indicated that they would sign a prescription for therapy without their previous initiation if it had been initiated by a therapist. Likewise, most respondents said that they would sign a wheelchair prescription sent to them by a therapist. Few expressed confidence in determining the appropriateness of leg brace (orthosis) prescriptions and arm/hand brace prescriptions. The majority of survey participants said that they give open-ended length of time (no limits under 1 year) on prescriptions for therapy services as part of school-based programs. However, patients' conditions and their therapeutic or equipment needs may change during the school year. Because open-ended prescriptions do not require periodic renewal, they do not provide opportunities for periodic feedback that helps to ensure that the pediatrician is kept abreast of the patient's status and progress. The majority of respondents indicated that they would see a patient before signing either a therapy or DME prescription if they had not seen that patient in the past year. A little more than half of survey respondents said that they would participate initially in recommending which professional services or therapies should be performed as part of early intervention programs most of the time, but one third said that they participated less than half the time and approximately 14% said that they never participated. A majority would require being involved before authorizing therapy services as part of a school-based program, but a substantial minority would provide retroactive authorization for services that they did not initiate themselves. More than three quarters of respondents would prefer to let the therapist or educator set the goals. Only 58% of pediatricians reported receiving a detailed progress report once or twice a year, and approximately one fifth received no reports on patients in school-based programs. A literature review suggested that there are different perceptions among physicians and educationally based service providers regarding the physician's role in initiating and supervising educationally based services and equipment, which may influence the extent of physician involvement. AAP and other professional organizations, such as the American Medical Association and the American Academy of Physical Medicine and Rehabilitation, as well as federal guidelines and third-party payers emphasize the important role of physicians in initiating, determining the medical necessity, and ordering of services as well as in ongoing patient treatment. If therapists through their states' scope of practice guidelines have autonomy of practice or if the school self-funds educationally based services, then there may be no issues regarding physician authorization. However, if a physician's authorization is required for reimbursement, then the physician's professional, legal, and practice guidelines come into play. Physicians should be conscientious about fulfilling their responsibilities in serving as the medical home and supervising and monitoring medical services for their patients in both community and educational settings. Failure to properly fulfill the responsibilities inherent in signing a prescription may bring adverse consequences for the patient as well subject the physician to legal liability if adverse events occur.
CONCLUSIONS: Ideally, there should be a seamless continuity and cooperation among the environments of medicine, home, community, and education rather than separate and perhaps conflicting domains. All health care professionals and other service providers involved should be acknowledged as collaborative team members. Except for provision of the diagnosis, the majority of surveyed pediatricians do not comply with AAP policy recommendations on prescribing community/medical-based and educationally based services for CSHCN. Furthermore, the majority are willing to defer these decisions to other NPHCP. This raises issues regarding overall continuity of care versus care of the child in a variety of environments, the concept of the medical home, and legal risk as a result of failure to follow federal and state practice guidelines. Also, there seem to be different cultural perceptions among physicians and educationally based service providers regarding the physician's role in educationally based services. These cultural differences should be explored further to promote a greater collegial cooperation and understanding. Decreasing involvement of private outpatient pediatricians in coordinating and supervising CSHCN care and a trend toward greater deference to NPHCP since 1979 were noted. If the numerous policies and guidelines previously promoted by AAP have not had a significant impact on pediatrician practices in these fields, then other, more effective alternatives should be explored.