title: The effect of patient, provider and financing regulations on the intensity of ambulatory physical therapy episodes: a multilevel analysis based on routinely available data.
abstract: BACKGROUND
  Many studies have found considerable variations in the resource intensity of physical therapy episodes. Although they have identified several patient- and provider-related factors, few studies have examined their relative explanatory power. We sought to quantify the contribution of patients and providers to these differences and examine how effective Swiss regulations are (nine-session ceiling per prescription and bonus for first treatments).
  
  
  METHODS
  Our sample consisted of 87,866 first physical therapy episodes performed by 3,365 physiotherapists based on referrals by 6,131 physicians. We modeled the number of visits per episode using a multilevel log linear regression with crossed random effects for physiotherapists and physicians and with fixed effects for cantons. The three-level explanatory variables were patient, physiotherapist and physician characteristics.
  
  
  RESULTS
  The median number of sessions was nine (interquartile range 6-13). Physical therapy use increased with age, women, higher health care costs, lower deductibles, surgery and specific conditions. Use rose with the share of nine-session episodes among physiotherapists or physicians, but fell with the share of new treatments. Geographical area had no influence. Most of the variance was explained at the patient level, but the available factors explained only 4% thereof. Physiotherapists and physicians explained only 6% and 5% respectively of the variance, although the available factors explained most of this variance. Regulations were the most powerful factors.
  
  
  CONCLUSIONS
  Against the backdrop of abundant physical therapy supply, Swiss financial regulations did not restrict utilization. Given that patient-related factors explained most of the variance, this group should be subject to closer scrutiny. Moreover, further research is needed on the determinants of patient demand.
authors.affiliation: Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and Faculty of Biology and Medicine, Biopole 2, Route de la Corniche 10, 1010, Lausanne, Switzerland. patricia.halfon@chuv.ch.
authors.forename: Patricia
authors.initials: P
authors.lastname: Halfon
authors.affiliation: Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and Faculty of Biology and Medicine, Biopole 2, Route de la Corniche 10, 1010, Lausanne, Switzerland. yves.eggli@bluewin.ch.
authors.forename: Yves
authors.initials: Y
authors.lastname: Eggli
authors.affiliation: Institute of Health Economics and Management, University Hospital Center and University of Lausanne, Route de Chavannes 31, 1015, Lausanne, Switzerland. yves.morel@fully.ch.
authors.forename: Yves
authors.initials: Y
authors.lastname: Morel
authors.affiliation: Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and Faculty of Biology and Medicine, Biopole 2, Route de la Corniche 10, 1010, Lausanne, Switzerland. patrick.taffe@chuv.ch.
authors.forename: Patrick
authors.initials: P
authors.lastname: Taffé
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D016208:Databases, Factual; D017050:Episode of Care; D005260:Female; D033161:Government Regulation; D017048:Health Care Costs; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D010361:Patients; D059825:Physical Therapists; D026741:Physical Therapy Modalities; D012017:Referral and Consultation; D013557:Switzerland