Accessibility of Medical Diagnostic Equipment for Patients with Disability: Observations from Physicians

Abstract

Objective:

To explore attitudes and practices of physicians relating to accessible medical diagnostic equipment in serving patients with mobility disability.

Design:

Open-ended individual telephone interviews, which reached data saturation. Interview recordings were transcribed verbatim for qualitative conventional content analysis.

Setting:

Massachusetts, U.S, October 2017 – January 2018.

Participants:

20 practicing physicians from five clinical specialties.

Interventions:

Not applicable.

Main Outcome Measures:

Common themes concerning physical accessibility.

Results:

Mean (S.D.) time in practice was 27.5 (12.5) years; 14 practices had height-adjustable exam tables; and 7 had wheelchair accessible weight scales. The analysis identified 6 broad themes: height-adjustable exam tables have advantages; height-adjustable exam tables have drawbacks; transferring patients onto exam tables is challenging; rationale for examining patients in their wheelchairs; perceptions of wheelchair-accessible weight scales; and barriers and facilitators to improving physical accessibility. Major barriers identified by participants included costs of equipment, limited space, and inadequate payment for extra time required to care for persons with disability. Even physicians with accessible exam tables sometimes examined patients seated in their wheelchairs.

Conclusions:

Even if physicians have accessible equipment, they do not always use it in examining patients with disability. Future efforts will need to consider ways to eliminate these access barriers in clinical practice. Given small sample size, results are not generalizable to physicians nationwide and globally.

Introduction

Nearing 30 years since the 1990 passage of the Americans with Disabilities Act (ADA), health care services often remain inaccessible to persons with disability.¹ Access to buildings and internal spaces (e.g., restrooms) has improved, with ramped or barrier-free entrances and other structural changes. However, medical diagnostic equipment, such as examination tables, weight scales, and diagnostic imaging equipment, is often inaccessible.

These barriers persist despite powerful demographic forces for change. In 2013, 13% of adult Americans reported difficulties with mobility, including walking and climbing stairs.² The number of persons with disability will rise substantially with aging of the 54 million “baby boomers”³ and increasing prevalence of chronic conditions.⁴ Virtually every U.S. health care setting will serve growing numbers of persons with disability.

An expanding literature documents the extent and implications of inaccessible medical care, primarily drawing from surveys of persons with disability.^5–9 Individuals with mobility disability describe difficulties transferring onto fixed-height examination tables and the absence of accessible weight scales. They recount providers examining them in their wheelchair, raising questions about care quality, such as the ability to conduct comprehensive physical exams.^7,10–12 One study used “secret shopper” methods and telephoned subspecialty practices to schedule an appointment for a fictional patient with disability unable to transfer independently.¹³ Of 256 contacted practices, 22% said they could not accommodate the patient; only 9% of practices had an automatic, height-adjustable exam tables or assistive lift.¹³ Few studies, however, have directly sought physicians’ views about accessibility of care for patients with physical disability.^14,15 Given that physicians’ attitudes toward caring for persons with mobility disability can affect their use of accessible equipment,¹⁶ seeking physicians’ perspectives on physical access can inform efforts to improve care for this population.

The purpose of this study was to use in-depth interviews with a sample of practicing physicians in Massachusetts, U.S., to explore physicians’ perceptions of accessibility within their own practice and potential barriers to improving access for patients with disability.

Methods

The Partners HealthCare System – Massachusetts General Hospital Institutional Review Board approved this research. We framed our study around universal design concepts, an approach that aims to create products, policies, and built environments accessible to all users. In health care, universal design principles encompass patients, families, health care professionals, and other persons using the space or equipment.¹⁷

Participant Recruitment

Given our qualitative methods, we aimed to recruit 25 practicing physicians in specialties where patients might frequently need accommodations: primary care, neurology, obstetrics/gynecology (OB/GYN, e.g., women in late pregnancy), orthopedics, and rheumatology. Using a commercial source (SK&A Healthcare Databases, Irvine, CA), we obtained contact information for a random sample of Massachusetts physicians within these specialties (total n = 520). We excluded fellows, residents, and trainees and physicians associated with Partners HealthCare because of concerns about response bias and logistical considerations (remaining n = 365). We randomly selected physicians to contact via email, with telephone follow-up, aiming for 5 interviews within each specialty. We stopped recruitment after 20 total interviews because we reached data saturation (i.e., new interviews elicited little additional information). Participants came from different practices, eliminating potential concerns about over-reporting or clustered responses at the practice level.

Interview Protocol and Procedures

Drawing upon literature reviews and our prior research,^6,7,16,18,19 we designed an open-ended interview protocol (supplemental material) in modules addressing factors that might affect physicians’ care of persons with disability. Two modules were relevant for this report: physical environments of participants’ practices (e.g., built structures and diagnostic equipment); and recommendations for improving care of persons with disability. We treated the first three interviews as pilot tests, afterward making only small changes to the interview protocol. We included results from these three interviews in the final data because changes made to the interview protocol were minor. Interviews occurred between October 2017 and January 2018.

L.I.I. conducted all interviews, which averaged 41 minutes. Willingness to participate after being informed of interview procedures represented implied informed consent. We offered participants $100 for participation, but 4 refused, viewing the interview as their contribution to research.

All interviews were audio recorded, and a professional transcription service transcribed the audio files verbatim. N.D.A. compared all audio recordings to the transcripts and made minor corrections.

Analysis

After reviewing transcripts, we generated coding categories using the conventional content analysis method,²⁰ a qualitative descriptive analysis approach,^21,22 which draws explicitly from the data without overinterpretation of reported experiences. The research team reached consensus about coded themes and identified patterns. Although this research is qualitative, below we sometimes indicate numbers of interviewees reporting specific themes to avoid vague language such as “some,” “several,” or “many.” Given our small sample size and sampling procedures, we do not present percentages to avoid implying that results are statistically rigorous or represent all physicians in our sampling frame.

Results

Table 1 describes the 20 participants and their practices. Their mean (S.D.) time in practice was 27.5 (12.5) years. Sixteen practices were hospital-based, and four were private, non-hospital practices. Fourteen physicians reported having height adjustable exam tables, 7 had wheelchair accessible weight scales, and most had accessible structural features (entrances and restrooms, Table 1).

Table 1.

Characteristics of Interviewees and Their Practices N = 20

Characteristic
Age: mean (S.D.) years	53.5 (11.7)
Age range: years	38–76
Gender: n
Male	10
Female	10
Race:n
White	18
Nonwhite	2
Hispanic ethnicity: n	1
Specialty: n
Internal medicine	7
Family practice	1
Rheumatology	2
Neurology	6
Obstetrics/gynecology	2
Orthopedics	2
Time in practice: mean (S.D.) years	27.5 (12.5)
Completed medical school before 1990 passage of Americans with Disabilities Act: n	11
Type of practice: n
Hospital-based	16
Private, not hospital-based	4
Accessibility of practice: n
Has at least one outside entrance with automatic door opener	13
Has at least one wheelchair accessible restroom facility	17
Has at least one automatic, height-adjustable exam table	14
Has transfer equipment, such as Hoyer lift	3
Has at least one wheelchair accessible weight scale	7

Results presented here concentrate on medical diagnostic equipment access, identifying 6 major themes elucidated below with representative quotations. Tables 2 and 3 contain selected additional quotations supporting these themes. Seven participants reported structural barriers to their practices (e.g., lack of automatic doors into offices), while the major barriers involved medical diagnostic equipment.

Table 2.

Advantages and Drawbacks of Height-Adjustable Exam Tables

Specialty	Practice years*	Practice type†	Has HA table‡	Selected Quotations
Benefits of height-adjustable exam tables
Rheumatology	14	HB	no	… I think you mentioned adjustable exam tables. That would be very, very nice, because we do have some patients, when they have weakness from their muscle inflammation, then they have trouble to go onto that bed. And that would be very, very helpful.
Neurology	43	HB	yes	… They just don’t have to climb up on the step to get up onto the exam table … The transfer can be made to be exactly level with their wheelchair or if they’re ataxic but don’t need a wheelchair, even so getting up on the narrow step is a problem.
OB/GYN	29	HB	yes	They will go all the way pretty much down to wheelchair height. So it can easily transfer folks.
Orthopedics	48	HB	yes	… It’s much more user-friendly. I think it’s good for a clinic who have a number of those tables that go up and down … and we do.
Drawbacks of height-adjustable exam tables
Internal medicine	21	PP	yes	I’m always sure I’m going to start moving the thing and they’re going to pitch off the table. So I’m always holding onto people while I – no one’s ever even come close, but … I forget that I’ve left it up. Or I’m afraid I’m going to forget, and they don’t realize that they’re up in the air.
Internal medicine	34	HB	yes	… The controls are kind of awkward. So they’re just not that userfriendly.
Rheumatology	35	HB	yes	Well, they’re kind of big and clunky, and the part that pulls out so the legs can be supported are often sticky.
Neurology	11	HB	yes	They don’t have any safety support on the side, though. So for people that can’t, who don’t have truncal stability, I can’t trust to put them on it alone.
Neurology	43	HB	yes	The problem with those exam tables is that they don’t permit storage under the exam table because the table lowers. … You have to have storage for your gowns, the paper for the exam table has to be elsewhere, and some rooms don’t have the capacity for that kind of storage.
Neurology	12	HB	yes	I would say the tables themselves are not very movable to move it around the room.
OB/GYN	17	HB	yes	It’s we can never find the pedal. It feels like we’re constantly chasing after the pedal – “Can you move the pedal? Can you hit the pedal?”… It’s just the pedal that drives everybody crazy. If they had another way to do it, then we wouldn’t get annoyed.

^*Years in practice

^†Hospital-based (HB) or private practice (PP)

^‡Has automatic, height-adjustable exam table in practice

Table 3.

Experiences Transferring Patients onto Exam Tables and Rationale for Examining Patients in Their Wheelchairs

Specialty	Practice years*	Practice type†	Has TD‡	Selected Quotations
Experiences transferring patients onto exam tables
Internal medicine	25	HB	no	… The patients with limited mobility, especially large patients with limited mobility, they’re tough – patients who have difficulty transferring, and they’re heavy, and so you don’t feel very safe trying to help them, and you need to get them, for example, on an exam table
Internal medicine	40	HB	no	… I’ve had sore backs and stuff like that … If I were really candid, I’d say we live in a world where you just do what you’ve got to do, and you don’t really pay much attention … And that certainly is a recipe sometimes for injury … I think we probably are a little bit naively ignoring that. So we usually, if somebody comes in with a wheelchair, I’ll usually just get one of our volunteers or myself to help them get in. But as I get older, I’m starting to realize that’s a formula for disaster.
Neurology	11	HB	yes	I will say that we could definitely do a better job of having more transfer devices and ambulatory assistance devices in our clinics, because I do have patients sometimes that come in on stretchers or that come in with wheelchairs, and we frankly just don’t have the manpower to help do the two-person assistance, if the patient can even do that… And I personally think that examining someone in a wheelchair is not as optimal.
Neurology	12	HB	NK§	I’ve seen a bazillion MAs [medical assistants] that have been injured transferring patients, but not ours.
Orthopedics	31	HB	no	So we don’t have a Hoyer lift. We have enough people to help them.
Rationale for examining patients in their wheelchairs
Internal medicine	34	HB	no	But I have other patients in wheelchairs who we’ll sometimes just examine them in the chair unless there’s a specific reason to get them supine or examine their skin.
Rheumatology	14	HB	no	Our exam table is super old, and it’s just a fixed height … So sometimes we will try to finish the exam when they are in the wheelchair, so it would be difficult to go to the bed.
Neurology	41	HB	NK§	… So I examine some of the patients either in the wheelchair or in a stretcher because that’s the easiest way to manage it …
Neurology	51	PP	NK§	… Realizing we don’t have to lie patients down to supine, we can examine people in a wheelchair just as well as getting them onto the exam table.
Orthopedics	31	HB	no	A lot of my patients, I don’t have to actually get them on the table because I have a lot of upper extremity injuries, and a lot of my visits are actually in the chair.

^*Years in practice

^†Hospital-based (HB) or private practice (PP)

^‡Has assistive transfer device (TD), such as Hoyer lift

^§NK = not known, unclear

Automatic, Height-adjustable Exam Tables Have Advantages

Participants reported two major advantages to height-adjustable tables: making patients’ transfers easier and safer compared with fixed-height tables; and benefitting physicians in addition to patients using wheelchairs (Table 2). “For the people who do have difficulty transferring to the table, it is so much better than the old table,” an internist observed. “I don’t even remember how we did that.” Similarly, an OB/GYN physician recalled lifting patients onto exam tables, saying “that was much worse for everybody involved but specifically much worse for the patient because it’s just demeaning.” One neurologist reported, “I’m using them more for my own needs, rather than the patient’s needs. … When I’m doing procedures, I have to position the patients so that they’re at the correct level for me …”

Height-adjustable Exam Tables Have Drawbacks

Physicians reported both mechanical and personal factors as disadvantages with height-adjustable tables (Table 2). Mechanical factors included the absence of safety supports on the sides of tables and mechanical failures: “The problem is they’re expensive, and every once in a while they fail mechanically.” Personal factors included feeling awkward using the table, frustrations finding the pedal to raise or lower the table, annoyance with the slowness of adjusting table height, lack of storage space under the table, and difficulty moving the heavy table around the exam room. “I hate them,” said an internist in private practice, “the raising and lowering is so slow.” Another internist from a hospital-based practice also described the tables as frustratingly “slow and somewhat ungainly.” A neurologist said the tables are “annoying” because “I can’t always find the darn control.”

Transferring Patients onto Exam Tables Is Challenging

Only 3 participants reported assistive lifts or transfer devices in their practice. Nonetheless, 6 participants expressed fear of staff injuries during patient transfers, 8 admitted that transferring patients without equipment is difficult, and only 2 participants felt their staff was handling transfers safely (Table 3). Four participants described an office staff member being injured while transferring a patient without an assistive device. Clinical staff have had their “back thrown out by trying to lift people,” said one OB/GYN physician. “That happens a lot, actually including to me.” Another physician concurred that transferring patients is “something we struggle with all the time. And I’m not an ergonomic engineer, but I think there’s got to be a better way.” One orthopedist described his approach when seeing a patient who needs transfer assistance: “We’ll make sure the appointment is … up in the physiotherapy department where they have a lot of special equipment. And sometimes I’ll do my evaluations up there directly …”

Rationale for Examining Patients in Their Wheelchairs

Participants offered two primary reasons for this choice: avoiding difficult transfers is easier; and assessment on the examination table is clinically unnecessary (Table 3). Eight physicians often examined patients in their wheelchairs, despite having accessible equipment. A neurologist who had a height-adjustable table reported, “I examine some of the patients either in the wheelchair or in a stretcher because that’s the easiest way to manage it.” Another neurologist admitted that even with a height-adjustable table:

… If a patient isn’t on the table, …it’s not for lack of the table being moved down. It’s due to your laziness. I will fully admit if I’ve had a patient in a wheelchair, and they’re a true quad or true paraplegic, … I do my exam in their chair. … I could go get help, and we can transfer them to the table. But most times it’s my laziness. It’s not the table.

For participants without accessible equipment, the ease of examining patients seated in their wheelchairs sometimes superseded concerns about missing clinical findings. One internist described the challenges of getting a patient onto a fixed-height table with the usual step-stool and admitted that for “the old ladies who can’t make it, I just examine in the chair or even in their wheelchair, which is not optimal at all.” When asked about risks of missing a pressure injury without a full physical examination, the internist conceded, “If they don’t complain about it, I don’t suspect it, they don’t have a history of it, I could miss it.”

Perceptions of Wheelchair-Accessible Weight Scales

Participants generally acknowledge the importance of accurately measuring patient weight, but without having readily-available wheelchair accessible weight scales, they described other approaches to obtain weight, such as asking patients their weight, looking for previous measures in medical records, and visual estimation of patients’ weight. One internist indicated, “They can be weighed in the hospital. … If they’re going to the hospital for other testing, we try to get the weight there…No, it’s not optimal.” An OB/GYN physician, who provides prenatal care but does not have a wheelchair-accessible weight scale, often relies upon self-reported weight: “We usually just either ask them or go to their primary care doc and ask them what their most recent weight was.”

Barriers to Improving Physical Accessibility

Participants without accessible equipment in their practices recommended adding such equipment when asked for recommendations to improve care for their patients with disability. Two physicians suggested adding assistive transfer devices, although one acknowledged, “I don’t even know how to use the Hoyer lift, but let’s just pretend I did. It would be nice to have those in the majority of rooms.” However, 11 participants identified cost barriers to improving accessibility of their practice, and 14 raised concerns about lack of space. One participant observed, “It’s physical space issues that I think hold me back,” while another concurred: “If we had more space, you could have an idealized room… with a lift in it that made it easier to get a handicapped patient off and on the table and always had a widened door.”

Seven participants raised concerns about inadequate financial compensation for extra time that they must spend to see patients with disability. “We have a very mixed population,” stated one internist, “and we try everything to help everybody. But it’s just not implemented because of money.” A rheumatologist observed, “If the practice is spending a lot of resources on accommodations, … there ought to be a system to reimburse them for that.” A neurologist raised concerns about compromising patient care without financial incentives to spend extra time in a busy practice:

I can imagine for the people that do have 20 to 30 patients in a morning session, if you are confronted with a patient that you might have every good intention of wanting to help – but to get them that help, it’s going to take another 20 minutes of your time and that person was only scheduled for 10 minutes – I can imagine that that’s frustrating for everyone involved. … [Patients] probably get substandard care for that reason. So if there was some sort of financial incentive or way to block out longer time periods for these patients … I don’t know that they get compensated for the fact that their visits are longer.

Discussion

Most physicians interviewed here agreed that complete physical examinations, including accurate weight measurement, are essential for routine care of their patients with disability. Most recognized benefits from using accessible medical equipment to facilitate this care and – consistent with principles of universal design²³ – to improve ergonomics and safety for them and their clinical staff. Nonetheless, most reported not using accessible equipment consistently. They frequently relied upon self-reported information from patients, such as weights, or examined patients seated in their wheelchairs, which could yield inaccurate or incomplete information.

Our results are consistent with other studies that have found potentially substandard care for persons with disability related specifically to inaccessible equipment.²⁴ One study investigating accessibility of primary care and specialty care clinics reported that 70%−87% of patients using wheelchairs were examined seated in their wheelchairs.²⁵ In another study, women with physical disability who had early-stage breast cancer were often examined in their wheelchairs, even by their oncologists and surgeons.^6,18 Other studies found that clinicians frequently ask patients with mobility disability to report their own weights, with patients’ estimates used to determine medication dosages^6,8 or inform prenatal care assessments.⁷ Inaccurate weight measures lead to errors in medication dosage with adverse outcomes.²⁶

Most research has examined these issues from patients’ perspectives. With few exceptions,^14,15 we are unaware of other studies that consider views of physicians, who described various concerns. Some concerns may be outside the daily knowledge of most providers; nonetheless, solutions do exist. For example, federal standards for height-adjustable exam tables, promulgated by the U.S. Access Board (known formerly as the Architectural and Transportation Barriers Compliance Board), in consultation with the Food and Drug Administration and effective February 8, 2017, included structural supports for examination tables.²⁷ In acquiring height-adjustable exam tables, practices should seek equipment that meets U.S. Access Board standards. If physicians feel it is clinically appropriate to examine patients without disability on an exam table, the ADA requires that persons with disability receive equivalent care.

Fourteen of our 20 participants reported that their practices had height-adjustable exam tables. This high prevalence of accessible equipment among our participants diverges sharply from other research findings that relatively few practices currently have accessible exam tables.^13,25,28 It is important to note that not all physicians who had at least one height-adjustable table reported frequently using it. However, our finding that few practices had assistive transfer devices, such as patient lifts, is consistent with other studies.^7,13,25,29 One participant suggested accommodating patient in the physical therapy department, which had assistive transfer devices, but this was the only such suggestion among the interviewees. Although using a transfer device can pose risks for certain patients or untrained clinical staff, transferring a patient without an assistive device also raises substantial safety concerns for both patients and clinical staff.²⁴ Patients report being afraid of injury from transfers without assistive equipment.⁶ One study found that installing assistive lift devices in health care facilities significantly reduced lower-back injuries among nursing staff, decreased numbers of work days lost to back injuries from transferring patients, and cut average yearly costs associated with staff back injuries more than 50%, from $201,100 to $91,800.³⁰

Although participants reported wanting more accessible medical equipment, they described 3 major barriers to acquiring and using this equipment – inadequate space, high perceived equipment costs, and lack of financial compensation for extra time spent accommodating patients with disability. Space constraints can be difficult to address, especially in older facilities with structural barriers such as small exam rooms. When seeking or renovating space, practice managers and physician leadership should consider the extra room required for accessibility. Height-adjustable tables can cost more than twice the price for fixed-height tables. Fixed-height tables can cost between $500 and $850, while height-adjustable tables may cost from $1,800 to $2,100.^13,31 Under the ADA, patients cannot be charged for accommodation costs. Private practices may be eligible for tax credits to offset expenditures on accessible equipment.³² Having more accessible equipment can potentially decrease turnover due to staff injuries and workers’ compensation claims, as well as lower insurance premiums, thus reducing overall practice costs.

Participants also expressed concern about inadequate compensation for extra time needed to care for persons with disability. In 2017, the Centers for Medicare & Medicaid Services (CMS) introduced two new billing codes – HCPCS Codes G0513 and G0514.³³ These codes apply only to Medicare-covered preventive services and are intended to compensate for additional time required to serve certain patients. Code G0513 represents the first 30 minutes beyond that for usual patients, while Code G0514 indicates each additional 30-minute increment. In the Federal Register notice announcing these codes, CMS’s comments suggest that these codes are one strategy to “improve access for people with disability,”³³ despite applying only to specific Medicare-covered services.

Furthermore, we speculate that obtaining recommendations from physical medicine and rehabilitation physicians could potentially offer insights into mitigating physical access barriers, given their extensive experience in accommodating patients with diverse needs. Physiatrists could possibly teach physicians in other specialties about safe and efficient methods for improving physical accessibility. In addition to this technical and clinical education, physiatrists could also potentially educate other physicians about the legal, moral, and ethical imperatives for improving physical access to care.

Study Limitations

Our study has important limitations, notably concerns about generalizability of our findings. Our findings are limited by the small sample of participants and do not generalize to all Massachusetts physicians or health care providers nationwide or globally. We did not design our study to compare findings across specialties or care settings. Although we sometimes presented numbers of participants reporting specific situations or views, we did so for clarity, recognizing these numbers do not represent generalizable values. Our interview protocol did not inquire about participants’ perceptions of the incremental benefit of accessible equipment to improving quality of patient care. Nonetheless, our findings have face validity (e.g., concerns about costs, space, time) and are consistent with reports from patients about inaccessible services.

Conclusions

We found that physicians perceive barriers to caring for patients with disability in the absence of accessible diagnostic equipment, but even if physicians have accessible equipment (e.g., exam tables), they do not always use them. Our findings were limited by the small sample of participants. Nonetheless, our results are consistent with reports from patients with disability. Further investigation regarding the perceptions of practice staff, who are often the personnel assisting patients in their transfers, could inform other ways of improving clinical accessibility. Future efforts will need to consider ways to eliminate access barriers in clinical practices, including potential roles for physical medicine and rehabilitation physicians, and to develop approaches to make care accessible to growing populations of patients with mobility disability.