Factors influencing referrals amongst allied health and medical practitioners managing people with musculoskeletal conditions in Australian primary care

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However, despite clinical recommendations, referral and collaboration between AHPs and medical practitioners (MPs) in primary care remains limited. Gaining insight into factors that influence referral decisions may improve collaboration and inform the design of more effective care pathways. Aims 1. Describe referral practices of Australian AHPs and MPs managing people with MSK conditions in primary care. 2. Explore practitioners’ perceptions of optimal referral pathways, and the barriers and facilitators to implementing a proposed clinical pathway of care (PACE-MSK). Methods Semi-structured interviews were conducted with 58 Australian AHPs (physiotherapists, exercise physiologists, psychologists) and MPs (orthopaedic and neurosurgeons, physicians, general practitioners (GPs)). Practitioners in primary care managing MSK conditions on at least two days per week were invited to participate. Participants discussed current referral practices and identified barriers and facilitators to involving specialist AHPs in a proposed care pathway. Data collection and analysis were iterative. Themes were generated using reflexive thematic analysis, refined through team discussion and consensus. Results Referral practices of both AHPs and MPs were prompted by the patient’s presentation and preferences, but the choice of whom to refer was shaped by trusted professional relationships. System-level constraints, such as service affordability and access for both practitioners and patients, determined whether referrals occurred and were identified as barriers to optimal and proposed care pathways. Conclusions Referral practices of Australian AHPs and MPs are influenced by patient, practitioner and system-level factors. Clarifying interprofessional roles, building trusted professional relationships and reforming funding models to improve affordability and access for patients and practitioners are likely to be key to improving referral pathways and patient outcomes in MSK primary care. Referral Musculoskeletal Interprofessional collaboration Trust Primary Care Pathways Introduction Musculoskeletal (MSK) conditions are a major global burden and a leading cause of non-fatal disease burden in Australia. [ 1 ] In Australia, 87% of MSK-related health expenditure (approximately $ 12.6 billion) is allocated to hospital care, pharmaceuticals and medical imaging, while only 1% is directed towards allied health services. [ 2 , 3 ] This imbalance in healthcare expenditure persists despite clinical guidelines recommending evidence-based, allied health-led care (e.g., education, exercise therapy, and psychosocial support) for most people with MSK conditions before resorting to costly medical interventions or imaging. [ 4 – 10 ] The current stepped care model is not only expensive, but also contributes to health system congestion, delays access to appropriate evidence-based care and leads to poorer patient outcomes. [ 11 , 12 ] Effective patient-centred care requires collaboration between healthcare practitioners, particularly for patients with complex MSK conditions or those at risk of poor outcome due to the presence of multiple impairments, comorbidities, or significant psychosocial factors. [ 8 , 9 ] Long-term lifestyle changes are often required which can be challenging for busy GPs to manage independently but are more achievable through collaborative models involving AHPs, such as physiotherapists, exercise physiologists and psychologists. [ 13 , 14 ] Despite these recognised benefits, research suggests that collaboration between MPs and AHPs within primary care remains limited. [ 15 – 17 ] Studies of GP referral rates to AHPs show that, despite the high prevalence of MSK presentations to GPs, only 7% of people are referred for physiotherapy and fewer than 1% are referred to exercise physiologists. [ 16 , 17 ] Moreover, one third of people with hip and knee arthritis are not offered AHP-led management before being placed on surgical waiting lists. [ 18 ] Several factors have been reported to contribute to the low referral rates from GPs to AHPs including restrictions on public subsidies for AHP services, limited consultation time and lack of confidence in managing MSK conditions. [ 18 , 19 ] In Australia, primary care services provided by AHPs are predominantly privately funded. Consequently, patients face substantial out-of-pocket expenses, contributing to GP’s reluctance to refer. [ 18 ] While subsided AHP services are available through Australia’s national public health [ 20 ] and/or third-party compensation schemes, access requires a GP referral. The additional administrative burden creates a referral ‘bottleneck’, adding delays, costs and workload pressure to an already overstretched GP workforce. Similar system and practitioner-related barriers have also been reported in France, [ 21 ] Denmark, [ 22 ] South Africa [ 23 ] and the UK. [ 24 ] In contrast to referral practices of GPs, little is known about the referral practices of AHPs and other MPs who manage people with MSK conditions in primary care. In Australia, physiotherapists, exercise physiologists, and psychologists act as first-contact practitioners and play an important role in referring patients to MPs and other AHPs. [ 25 ] One study found that physiotherapists’ referral practices were influenced by confidence and trust in professional relationships alongside patient and system-related factors such as specific diagnoses and financial impacts. [ 26 ] Factors shaping MSK referral practices of exercise physiologists and psychologists remain unknown. It is also unclear whether referral drivers differ between AHPs and MPs, or whether referral recipients consider the referrals they receive are clinically appropriate. Understanding bidirectional referral patterns amongst MPs and AHPs could inform more efficient and collaborative models of care. One proposed model to reduce health system congestion and improve access to evidenced-based care involves a stratified approach where treatment is tailored based on a patient’s risk of poor outcome. These stratified models recommend referring appropriate patients to specialist AHPs instead of specialist MPs. Appropriate patients may be those with comorbid biopsychosocial factors that place them at risk of poor outcome as identified via validated prognostic screening tools. [ 27 ] Such patients may benefit from expert allied health care (e.g., specialist MSK physiotherapists) who can address these factors efficiently, thereby reserving specialist medical practitioners to manage more urgent conditions. [ 28 – 30 ] Specialist AHP-led stratified models have reduced surgical waitlists and improved patient outcomes in tertiary care [ 31 – 33 ] and it is proposed that similar models could reduce GP workload and enhance referral efficiency in primary care. [ 34 ] Early clinical trials of stratified care in the United Kingdom have showed promise, [ 29 ] and our group is evaluating a comparable model - Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in Australian primary care (PACE-MSK; Australian New Zealand Clinical Trials Registry: ACTRN12619000871145, registration date: 19/06/2019; www.anzctr.org.au ). [ 35 ] However, more recent stratified care trials have reported mixed outcomes in the United Kingdom, [ 36 ] United States, [ 38 ] and the Netherlands [ 37 ] with the authors attributing these findings to significant implementation challenges. Such challenges included practitioners not complying with referral and collaboration guidelines, even when clear criteria were provided. These authors, along with others [ 39 , 40 ] suggest that the success of such models depends on a greater understanding of barriers and facilitators that influence effective referral pathways and interprofessional collaboration. Methods The aims of this study were to: 1. Describe referral practices of Australian AHPs and MPs managing people with MSK conditions in primary care. 2. Explore practitioners’ perceptions of optimal referral pathways, and the barriers and facilitators to implementing a proposed clinical pathway of care (PACE-MSK). Study Design This study adopted a qualitative descriptive approach utilising an interpretative framework. [ 41 – 43 ] The study was approved by the Human Research Ethics Committee at The University of Sydney (Project number: 2019 − 219). Participants Eligible participants were AHPs or MPs managing people with MSK conditions in primary care for at least two days per week. Email invitations were sent to (i) health care practitioners who had participated in prior clinical trials and consented to future contact, [ 28 ] and (ii) clinicians identified through publicly available contact details. Respondents received study information and provided informed consent before participation. Data Collection Semi-structured interviews were conducted via videoconferencing ( Zoom v5.16.2) by two female researchers (KE, SC), each with over 30 years of experience as MSK physiotherapists and educators, and training in qualitative interviewing. While some participants were known to the interviewers through previous trials [ 44 ] or professional networks, no direct working relationships existed. To mitigate any influence of prior familiarity, interviewers emphasised voluntary participation, confidentiality, and reflexive awareness of potential bias throughout data collection and analysis. Interviewers clarified study aims before commencing, obtained permission to record and assured de-identification of transcripts. The interview guide was co-developed by the research team and six key informants (two AHPs, two MPs and two consumers) to ensure clinical relevance. [ 45 ] The guide contained eight open-ended questions enabling participants to speak openly about their perspectives and experiences (Appendix 1). [ 41 , 46 ] Interviews were structured into four sections. First, participants provided demographic details (e.g., profession, years of experience) and information about their work setting (e.g., metropolitan or rural; solo or multidisciplinary clinic). Second, participants discussed current intra- and interprofessional referral practices (e.g., “Who do you refer to/get referrals from?” “Why?”). Third, they were asked to reflect on optimal care pathways (e.g., “ If you were designing a clinical pathway of care to optimise referrals and patient outcomes, what would that pathway look like ?”). Finally, participants shared their views on a proposed stratified pathway involving early referral to specialist AHPs for people at risk of a poor outcome. [ 35 ] The interview guide was refined after the 5th, 10th and 15th interview to improve clarity, flow and data richness. [ 47 – 49 ] Field notes were recorded during and after each interview. All interviews were transcribed verbatim and assigned a participant code to de-identify individuals. Participants were offered the opportunity to review and comment on their transcripts to confirm accuracy (member-checking). Data Analysis A reflexive thematic analysis [ 47 , 50 ] was conducted, following Braun and Clarke’s six phase process. [ 51 , 52 ] One researcher (SC) transcribed all interviews using manual and automated methods (Rev.com © https://www.rev.com ). Two researchers, KE and TR (specialist MSK physiotherapists and experienced qualitative researchers) reviewed a random sample of transcripts for accuracy and analytic rigour. Transcripts were coded using Excel and NVivo (QSR International v12), with Excel serving as the primary platform for logging coding frequencies and analytic decisions. In phase one and two, three researchers, SC, KE and TR, independently reviewed and coded 5 AHP and 5 MP transcripts. In phase three, the team consolidated codes and generated preliminary themes. Data collection and analysis proceeded concurrently, with fortnightly meetings to refine themes. Recruitment continued until no new themes were identified. In phase four, themes were refined and checked against the full dataset. [ 48 , 53 ] In phase five, final themes were demarcated through team consensus. The study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies (COREQ). [ 54 ] Results Fifty-eight interviews were conducted with 38 AHPs: 18 physiotherapists, 6 exercise physiologists, and 7 psychologists; and 20 MPs: 4 GPs, 10 medical specialists (sport and exercise medicine, rheumatology, pain, rehabilitation), and 6 surgical specialists (orthopaedics, neurosurgery). Participants worked in five different Australian states (Queensland, New South Wales, South Australia, Victoria, Western Australia ). The majority of AHPs (89%) and MPs (90%) worked in private practice in metropolitan areas, with 68% of AHPs and 32% of MPs working within multidisciplinary settings. Forty-five percent of AHPs and eighty percent of MPs were male. AHPs had been practising for an average of 11.5 years (SD = 10.7) and MPs for 17.3 years (SD = 10.6). Interviews ranged from 24 to 76 minutes (mean ± SD 43 ± 11 minutes). No repeat interviews were conducted, no participants withdrew from the study, and all provided consent for their data to be included in the analysis. [ 48 ] Factors influencing referral practices of Australian AHPs and MPs Our analysis identified three interconnected themes shaping referral practices: (i) clinical presentation and preferences (Table 1 ), (ii) trusted professional relationships (Table 2 ), and (iii) service accessibility and affordability (Table 3 ). Patient-related factors typically initiated the referral process, trusted relationships influenced to whom the referral was directed to, and system-related constraints often determined whether the referral ultimately occurred. Theme 1: Patient-related influences – Clinical presentation and patient preferences Clinical presentation was the most common trigger for referral. Suspected serious pathology (e.g., fracture, neuropathy) prompted urgent imaging or specialist medical review, while psychosocial factors (e.g., distress or sleep disturbance) often led to psychology referrals. Complex or non-resolving presentations highlighted differences in approaches: AHPs often sought advice from senior colleagues within their practice, whereas MPs, with direct referral access to imaging and specialist medical services, favoured further investigations or specialist medical opinion. Patient preferences were also drivers of referrals for both AHPs and MPs. Participants described feeling pressure to meet patient expectations for imaging or specialist review, even when such referrals were not clinically indicated: “Not everyone needs a scan…but they get referred to me with an expectation they're going to get a scan [Sport and Exercise Physician,15].” Table 1 Patient-related influences on the referral practices of AHPs and MPs managing people with MSK conditions in primary care Theme Subtheme Quotes Clinical presentation Red flags “They were reporting bladder and bowel problems, and they'd had bowel cancer before … the symptoms weren't lining up to back pain [Physiotherapist,38].” “So, if there's any of those red flags pop us then I'll either kindly ask the GP if they think it's warranted to investigate [Exercise Physiologist,30].” “As soon as there's a red flag. I don't hold back on that [referring for imaging] [GP,56] .” Psychosocial risk factors “It could be that they have unhelpful beliefs or understanding about their condition, and I believe having a psychologist with experience in communicating and reframing these unhelpful beliefs [Specialist MSK Physiotherapist,24].” “If there is distress, fear around movement that is usually where we see referrals” [Psychologist,53] “I’ll identify this person's level of depression is high enough [to refer] just by simple screening tools [Rheumatologist,7].” Complex or unresolving presentations “If it's a super complex case, I'm quite fortunate where I get to utilize our seniors… I'll refer on to them [Physiotherapist,6].” “If we are unsure of the cause of it, that's when we want to refer to [our senior] physio to, I guess, have that real initial assessment and that diagnosis [Exercise Physiologist, 19].” My referral [for imaging] would be based on lack of improvement or really, pain that's quite disabling [GP,16].” Patient preferences “It is good for the patient to feel that they are safe to move. … they take that information more readily from a doctor as they would from myself [Psychologist,53] “We're often under pressure from the patient [to refer for imaging] [GP,16] “….Mainly to get reassurance for the patient [Rheumatologist,7] Theme 2: Practitioner-related influences - Trusted professional relationships Once a referral was being considered, decisions about who to refer the patient to were influenced by the presence, or absence of trusted professional relationships. As one AHP noted: “ Why do I get referrals? Well, relationships would be number one. So just knowing other people and them having confidence and trust in your ability [Physiotherapist,7].” Trusted professional relationships were developed and sustained through three interrelated processes: (i) perceptions of practitioner competence, (ii) alignment in treatment philosophies and effective communication, and (iii) reliable and reciprocal referral behaviours. Trust began with perceptions of practitioner competence, typically embedded in traditional professional hierarchies and role expectations. AHPs described deferring to MPs when uncertain, reflecting perceptions of greater diagnostic authority: “… if they're not responding….and I just want a higher opinion …then I'll refer on to the [neurosurgeon] [Physiotherapist,39].” Similar dynamics were evident within professions, with AHPs tending to avoid intradisciplinary referrals unless the colleague was clearly more senior: “Well, it might even be pride... happy to take some sort of instruction from a medical specialist, but not from someone I see as a colleague [Physiotherapist,11].” Clear role expectations further contributed to perceptions of competence. AHPs understood MP roles and referred with specific expectations: “ I’ll generally get the opinion of the sports doctor if I feel like an injection may be warranted [Physiotherapist,7].” In contrast, MPs typically referred patients to AHPs for “ conservative management [Orthopaedic Surgeon,1]” but expressed uncertainty about the scope of AHP roles: “ I think that acute back pain will often be physio[therapist], maybe chiro[practor], maybe an exercise [physiologist], you know, probably physio[therapist] [Sport and Exercise Physician,18].” Beyond hierarchies and role expectations, alignment in treatment philosophies and effective communication fostered perceptions of competence and deepened trust: “I’ve seen this guy work and what he does… I feel very comfortable sending to that person [Sport and Exercise Physician,15].” Open communication and ongoing collaboration helped strengthen relationships over time. Participants described open dialogue and shared decision-making as central to building trusted relationships: “You're safe with each other….you can tell each other what you think? And it takes a little while to develop that [ Sport and Exercise Physician,13].” Conversely, negative patient feedback could quickly undermine trust and discourage future referrals: “Yeah, that does reflect on you…. I just won’t refer again [Sport and Exercise Physician,14].” Finally, trusted professional relationships were sustained by reliable and reciprocal referral behaviours. Practitioners valued colleagues who kept them informed and returned patients for ongoing care: “Being part of the whole system to do the right thing by the patient's best interest and making sure they send [the patient] back to that person [Physiotherapist,11].” Reciprocity was viewed as a marker of respect and reliability: “If you help someone [by referring], I guess you expect when you need help, they'll help you as well [by referring] [Exercise Physiologist,30].” Table 2 Practitioner-related influences on the referral practices of AHPs and MPs managing people with MSK conditions in primary care Theme Subtheme Quotes Trusted Professional Relationships Perceived Competence “I usually refer them to one of the physios here as well for that hands-on management…which is obviously something I can't provide [Exercise Physiologist,8].” “I'm not actually all that across what these different people exactly do. I just want patients to move [Neurosurgeon,11].” “I guess they're [GPs] at the top, above physios, because they're the ones, I guess, that we get the referrals from... the specialists and the GPs are at the top [Physiotherapist,46].” Effective communication and alignment in treatment philosophies “You feel confident that they will support the patient in the best way. You want them to be aligned with the treatment approach [Psychologist,25].” “And you sort of get a feel for them…it takes a while to build trust and rapport…you can tell someone knows what they're talking about and who should be referred [Orthopaedic Surgeon,47].” “It's really trial and error. And probably listening to patients as well, because if you get feedback, "Oh, he was arrogant and didn't listen", and then you get that several times you start to.[not refer] [GP,58].” “But we'd get feedback from the patients…you know, people can have a title, but still not do things the way that sits with our way of doing things [Psychologist,22].” Reciprocity of referral “it really comes down to how they turned up to a clinic and where it's come from, making sure that you don't [annoy] the people that feed it to you [Physiotherapist,33].” “very often I refer back to who they came from [Sport and Exercise Physician,54].” Theme 3: System-related Influences - Service accessibility and affordability System-related constraints played a decisive role in whether referrals were enacted. Practitioners consistently described geographical location, referral rights, and funding models as the key structural factors shaping their decisions. Geographical location often provided the most immediate opportunities for referral. Convenience and proximity to patients facilitated referrals, particularly for surgeons: “So mostly, it's geographic. … I say, look on Google, find someone close to you who's got free parking and hours that suit you [Orthopaedic Surgeon,2].” For AHPs and MPs in multidisciplinary clinics, co-location encouraged in-house referrals, offering convenience for patients and fostering interprofessional collaboration: “My biggest referrals are to other clinicians within our practice [Physiotherapist,13].” Referral access restrictions, however, frequently overshadowed location. AHPs expressed frustration at their lack of referral rights to medical specialists under Medicare, despite feeling confident in their expertise to recognise when specialist review was warranted: “We want direct access to specialists without having to use the GPs as the gatekeeper… it just hamstrings our profession [Physiotherapist,14].” Some MPs resisted expanded referral rights for AHPs, citing boundaries around professional roles: “I suppose it's a bit of a turf war, but I would feel uncomfortable with physios referring to orthopaedic surgeons [Sport and Exercise Physician,15].” Affordability was a strong theme. Referrals were more likely when services were subsidised by Medicare or insurance, but out-of-pocket costs deterred patients and practitioners: “ Probably the cost … quite sort of tight for some people [Exercise Physiologist,32].” Financial pressures on their own business were also reported by practitioners, especially AHPs who acknowledged the difficulty of referring clients elsewhere when their business survival relied on patient retention: “It can be really hard for people in private practice to refer on because... they rely on income to survive. [Psychologist,4].” Financial competition and lack of collaboration between AHPs in primary care was also observed by some MPs - “ I think physio is very cut-throat [Sport and Exercise Physician,15].” Table 3 System-related influences on the referral practices of AHPs and MPs managing people with MSK conditions in primary care Theme Subtheme Quotes Access to practitioners Geographical Location “I would also think very carefully about where people live [before referring][Psychologist,22].” “It'll be one of three or four that I use that are convenient. … because clearly people don't want to travel long distances [GP,16].” Preference for multi -disciplinary, co-located care “I think that multidisciplinary care is really important for patients, and it's better just have the one team working together in house I think [Physiotherapist,28].” “The advantage is having the multiple disciplines all kind of working together under the one roof at the one-time [Pain physician,50].” Direct referral pathways “I think sometimes going back through the surgeon or whatever is a bit convoluted. It would be nice to be accepted as the primary referrer [Physiotherapist,2].” “A lot of physios say [to patients], “can you ask your GP to write a letter to see XXX? I'm not saying we need to remove that but the ways that a physio can directly contact the rheumatologists becomes more important [Rheumatologist,9].” Affordability for patients and practitioners Negative impact on patients and practitioners “The negative of seeing the sports doctor is the net total cost of the journey. I just do that sum in my head and put it to the patient and they weigh it up [Physiotherapist,25].” “Nobody's got endless dollars so you can't give people 100 buck referrals [Sport and Exercise Physician,18].” “But that's hard because you're sending patients away from your business, which is, the right thing by the patient. Sometimes you just do it, but at the same time and you've got to be mindful of that [Physiotherapist,51].” Referrals facilitated when subsided “They get referred [to me] If it’s in a compensable setting - people who are struggling to return to work] [Psychologist, 25].” “If it's self-insured, or Workcover, they'll [caseworker] always just say “have you done a scan” [GP,56].” Practitioner perceptions of optimal and proposed pathways of care (PACE-MSK) After reflecting on their current referral practices, participants were invited to describe what they would consider an optimal model of care for people with MSK conditions. Most supported GPs as central co-ordinators of care but highlighted GPs’ limited time and insufficient MSK-specific training: “a lot of doctors are very poorly trained when it comes to musculoskeletal medicine... We just don't get a lot of training at university [GP,16].” AHPs advocated for direct referral rights to specialists to streamline care. Surgeons were generally receptive to AHP referrals provided that non-operative measures had been fully trialled: “ I just want them [AHPs and MPs] to explore all of the sensible, non-operative measures and exhaust those completely before getting referred [to me] [Orthopaedic Surgeon,9].” Participants also emphasised the need for greater education about interprofessional roles, particularly when managing complex patients, and resources to identify expert AHPs locally: “My knowledge of who to refer to is not great….. need better education [Exercise Physiologist,3].” Psychologists highlighted their underutilisation in MSK care and exclusion from referral networks: - “It's very clear, especially with a physio in a solo practice, they [physio] don't refer to us very often [Psychologist,5].” When introduced to the proposed PACE-MSK pathway [ 35 ], in which patients at risk of poor outcomes are first referred to a specialist MSK physiotherapist instead of to a medical or surgical specialist, both MPs and AHPs expressed broad support but also identified barriers. First, many reported that did know any specialist MSK physiotherapists, nor did they understand the scope of specialist MSK physiotherapist roles: “I couldn't clearly identify a specialist musculoskeletal practitioner at all [GP,16]; “…… I see.. physio as a physio [Orthopaedic surgeon,1]” and “[need a] better understanding of what that specialist [physiotherapist] does [Physiotherapist, 5].” Second, financial concerns were raised, both in terms of potential loss of income for referring practitioners and increased costs to patients. “As a private practitioner who makes money off bums on seats, if I'm referring, I'm losing clientele and money [Physiotherapist, 2].”; “The specialist [physiotherapist] taking work and income away … I’m not sure how that would work [Rehabilitation Physician,43].” However, all participants agreed that the model was warranted and acceptable if the barriers could be overcome. I don't have any issues with that. It's more the organisational infrastructure [Neurosurgeon,1]”; “seems needed I think, for the benefit of both the patient but also the practitioner [Physio,9]. Suggested enablers to support implementation of the pathway centred on trust-building mechanisms: clarity on roles, clear communication and shared care models, together with funding reforms to support collaboration (e.g., Medicare-subsidised telehealth consultations): “ perhaps there's a Zoom once a week/fortnight [GP,2].” Discussion This study examined referral practices of Australian AHPs and MPs managing people with MSK conditions in primary care, their perceptions of optimal referral pathways, and barriers and facilitators to implementing a proposed clinical pathway of care (PACE-MSK). Referrals were usually prompted by the patient’s presentation and preferences. However, practitioner factors, such as trust in professional relationships, influenced to whom the patient was referred. System factors, including perceived cost and access barriers, often determined whether the practitioner went ahead with the referral. Our findings reinforce previous evidence that clinical presentation remains the most consistent influence on referral practices in MSK primary care. [ 55 – 60 ] In particular, when presentations were suggestive of serious pathology or psychosocial distress, immediate referrals to specialist medical practitioners or psychologists were made. However, our study is the first to show differences in referral practices of AHPs and MPs when cases were complex or unresolving. MPs tended to favour further investigations or specialist medical review whereas AHPs, without direct access to these services, were more likely to seek help from senior colleagues within their practice. Also, aligning with previous research, patient preferences prompted consideration of a referral. [ 61 , 62 ] Both AHPs and MPs in this study acknowledged that they sometimes escalated referrals for medical opinion (and in the case of MPs, for imaging) primarily to meet patient expectations, even when not clinically indicated. Thus, patient-factors, such as clinical presentation and preferences, remain strong influences on referral practices in MSK primary care for both AHP and MPs. Whilst patient factors often prompted consideration of referral, decisions regarding whom to refer to were shaped by practitioner-related factors, particularly trust within professional networks. Trust has long been recognised as a cornerstone of interprofessional collaboration. [ 63 – 67 ] This study is the first to describe how trusted professional relationships develop and influence referral practices among AHPs and MPs managing MSK conditions in Australian primary care. These relationships were established and sustained through three interrelated processes: (i) perceptions of practitioner competence, (ii) effective communication and alignment in treatment philosophies, and (iii) reliable and reciprocal referral behaviours. Trust began with perceptions of practitioner competence, shaped by professional hierarchies and role expectations. Established professional hierarchies and clear role expectations shaped perceptions of competence and trust more strongly in favour of MPs than AHPs, regardless of discipline. For example, AHPs often viewed MPs as occupying higher status roles and referred patients to them with clearly defined expectations. In contrast, MPs lacked a clear understanding of AHPs’ skills and scope of practice, which shaped their perceptions of AHPs’ competence. Nevertheless, competence and trust in both groups could be cultivated over time through shared treatment philosophies and effective communication and collaboration. In contrast, poor communication or negative patient feedback quickly eroded trust and deterred future referrals. Finally, trusted professional relationships were consolidated and sustained when practitioners demonstrated reliable and reciprocal referral practices. Colleagues who referred patients back to their referrer for on-going care were highly valued, with reciprocity regarded as both a marker of professional respect and as a safeguard against reputational or financial risks associated with patient loss. For AHPs, the possibility of “losing patients” when referring away from their practice was a particular concern. Although one prior study has documented these financial considerations amongst physiotherapists, [ 26 ] we are not aware of comparable evidence for other AHPs, including exercise physiologists or psychologists. Together, these dynamics show how trust influences referral behaviour and how professional hierarchies, and role ambiguity can limit the optimal use of AHP expertise in primary care. Financial impacts on patients and practitioners, location, and direct referral access were key system-related determinants of whether referrals ultimately occurred. Consistent with international studies, [ 67 , 68 ] subsidised services or insurance coverage facilitated referral, whereas out-of-pocket costs deterred referral. Co-location within multidisciplinary clinics improved accessibility, supported collaboration, and reinforced referral relationships. [ 64 , 69 – 71 ] Surgeons were an exception, rarely working in multidisciplinary settings and, as the perceived “captain of the ship” [ 72 ] in the medical hierarchy, often adopting more authoritative decision-making approaches. Barriers to implementing the PACE-MSK pathway, where patients at risk of poor outcomes are referred first to a specialist AHP instead of a specialist MP, mirrored current referral challenges. Participants highlighted a lack of awareness of, and hence a lack of trusted relationships with, specialist MSK physiotherapists alongside concerns about the financial impact on both practitioners and patients. Studies exploring acceptance of referral to specialist MSK physiotherapists for the management of whiplash-associated disorders and other MSK conditions have also reported lack of trust between practitioners and financial issues as barriers. [ 73 , 74 ] Moreover, distrust amongst health professionals has been observed by patients recounting their experiences of referral practices for chronic low back pain. [ 75 ] Patients described their care as “fragmented” and particularly noted a lack of collaboration between AHPs. [ 75 ] Models of care that increase utilization of AHPs such as PACE-MSK [ 35 ] and others [ 28 , 36 – 38 ] are proposed as a solution to the increasing burden of MSK conditions amidst an overwhelmed medical workforce. Expert AHPs (e.g., specialist physiotherapists) are well-placed to manage complex MSK patients, where risk factors are often lifestyle or psychosocial-related and rarely require medical or surgical intervention. However, successful implementation of these newer pathways will require deliberate efforts to build interprofessional trust and reduce system-level barriers. Educational initiatives, both pre-service and continuing professional development, should prioritise interprofessional role clarity and collaboration. [ 76 , 77 ] Formal and informal opportunities for shared practice, particularly in co-located or networked models, may accelerate the trust-building needed for efficient and effective referral pathways. Equally, funding reform is key. Current payment structures may inadvertently discourage referrals that are in patients’ best interests. Incentives to support shared care and reduce out-of-pocket costs could promote appropriate utilisation of AHP expertise and to minimise unnecessary imaging and surgery. Conclusions While patient presentation and preferences remain central to MSK referral decisions, trusted professional relationships, service access and affordability play a significant role. For stratified care pathways such as PACE-MSK to succeed, implementation must directly address these relational and structural influences. Clarifying interprofessional roles, creating opportunities for collaboration to enable development of trusted professional relationships, and reforming funding models are likely to be key to improving referral efficiency and patient outcomes in MSK primary care. Abbreviations MSK Musculoskeletal AHP Allied Health Practitioner MP Medical Practitioner PACE-MSK PAthway of CarE- Musculoskeletal Clinical Trial Declarations Ethics approval and consent to participate All participants gave their informed consent prior to participating in this study. The study was approved by the Human Research Ethics Committee at The University of Sydney (Project number: 2019-219). Reporting was in accordance with COREQ guidelines. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This study was supported by a project grant from the National Health and Medical Research Council of Australia (GNT1141377). The funder had no role in the design of the study, collection, analysis, interpretation of data, or writing of the manuscript. Authors’ contributions SC: Conceptualisation, Methodology, Data curation, Formal analysis, Writing – original draft. KE: Conceptualisation, Methodology, Validation, Formal analysis, Writing – review and editing. TR: Conceptualisation, Methodology, Validation, Formal analysis, Writing – review and editing. All authors read and approved the final manuscript. Acknowledgements We would like to acknowledge all the health practitioners who volunteered their time to participate in this study. References Liu S, Wang B, Fan S, Wang Y, Zhan Y, Ye D. Global burden of musculoskeletal disorders and attributable factors in 204 countries and territories: a secondary analysis of the Global Burden of Disease 2019 study. BMJ Open. 2022;12:e062183. Australian Institute of Health and Welfare. Disease expenditure in Australia 2019–20 [Internet]. Canberra: Australian Institute of Health and Welfare, 2022 [cited 2024 Jan 10]. 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[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In Australia, 87% of MSK-related health expenditure (approximately \u003cspan\u003e$\u003c/span\u003e12.6\u0026nbsp;billion) is allocated to hospital care, pharmaceuticals and medical imaging, while only 1% is directed towards allied health services. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] This imbalance in healthcare expenditure persists despite clinical guidelines recommending evidence-based, allied health-led care (e.g., education, exercise therapy, and psychosocial support) for most people with MSK conditions before resorting to costly medical interventions or imaging. [\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The current stepped care model is not only expensive, but also contributes to health system congestion, delays access to appropriate evidence-based care and leads to poorer patient outcomes. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eEffective patient-centred care requires collaboration between healthcare practitioners, particularly for patients with complex MSK conditions or those at risk of poor outcome due to the presence of multiple impairments, comorbidities, or significant psychosocial factors. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Long-term lifestyle changes are often required which can be challenging for busy GPs to manage independently but are more achievable through collaborative models involving AHPs, such as physiotherapists, exercise physiologists and psychologists. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Despite these recognised benefits, research suggests that collaboration between MPs and AHPs within primary care remains limited. [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eStudies of GP referral rates to AHPs show that, despite the high prevalence of MSK presentations to GPs, only 7% of people are referred for physiotherapy and fewer than 1% are referred to exercise physiologists. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Moreover, one third of people with hip and knee arthritis are not offered AHP-led management before being placed on surgical waiting lists. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Several factors have been reported to contribute to the low referral rates from GPs to AHPs including restrictions on public subsidies for AHP services, limited consultation time and lack of confidence in managing MSK conditions. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] In Australia, primary care services provided by AHPs are predominantly privately funded. Consequently, patients face substantial out-of-pocket expenses, contributing to GP\u0026rsquo;s reluctance to refer. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] While subsided AHP services are available through Australia\u0026rsquo;s national public health [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and/or third-party compensation schemes, access requires a GP referral. The additional administrative burden creates a referral \u0026lsquo;bottleneck\u0026rsquo;, adding delays, costs and workload pressure to an already overstretched GP workforce. Similar system and practitioner-related barriers have also been reported in France, [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Denmark, [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] South Africa [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and the UK. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn contrast to referral practices of GPs, little is known about the referral practices of AHPs and other MPs who manage people with MSK conditions in primary care. In Australia, physiotherapists, exercise physiologists, and psychologists act as first-contact practitioners and play an important role in referring patients to MPs and other AHPs. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] One study found that physiotherapists\u0026rsquo; referral practices were influenced by confidence and trust in professional relationships alongside patient and system-related factors such as specific diagnoses and financial impacts. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Factors shaping MSK referral practices of exercise physiologists and psychologists remain unknown. It is also unclear whether referral drivers differ between AHPs and MPs, or whether referral recipients consider the referrals they receive are clinically appropriate. Understanding bidirectional referral patterns amongst MPs and AHPs could inform more efficient and collaborative models of care.\u003c/p\u003e\u003cp\u003eOne proposed model to reduce health system congestion and improve access to evidenced-based care involves a stratified approach where treatment is tailored based on a patient\u0026rsquo;s risk of poor outcome. These stratified models recommend referring appropriate patients to specialist AHPs instead of specialist MPs. Appropriate patients may be those with comorbid biopsychosocial factors that place them at risk of poor outcome as identified via validated prognostic screening tools. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Such patients may benefit from expert allied health care (e.g., specialist MSK physiotherapists) who can address these factors efficiently, thereby reserving specialist medical practitioners to manage more urgent conditions. [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eSpecialist AHP-led stratified models have reduced surgical waitlists and improved patient outcomes in tertiary care [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and it is proposed that similar models could reduce GP workload and enhance referral efficiency in primary care. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Early clinical trials of stratified care in the United Kingdom have showed promise, [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and our group is evaluating a comparable model - Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in Australian primary care (PACE-MSK; Australian New Zealand Clinical Trials Registry: ACTRN12619000871145, registration date: 19/06/2019; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.anzctr.org.au\u003c/span\u003e\u003cspan address=\"http://www.anzctr.org.au\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHowever, more recent stratified care trials have reported mixed outcomes in the United Kingdom, [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] United States, [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and the Netherlands [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] with the authors attributing these findings to significant implementation challenges. Such challenges included practitioners not complying with referral and collaboration guidelines, even when clear criteria were provided. These authors, along with others [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] suggest that the success of such models depends on a greater understanding of barriers and facilitators that influence effective referral pathways and interprofessional collaboration.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe aims of this study were to:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e1. Describe referral practices of Australian AHPs and MPs managing people with MSK conditions in primary care.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e2. Explore practitioners\u0026rsquo; perceptions of optimal referral pathways, and the barriers and facilitators to implementing a proposed clinical pathway of care (PACE-MSK).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study adopted a qualitative descriptive approach utilising an interpretative framework. [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] The study was approved by the Human Research Ethics Committee at The University of Sydney (Project number: 2019\u0026thinsp;\u0026minus;\u0026thinsp;219).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEligible participants were AHPs or MPs managing people with MSK conditions in primary care for at least two days per week. Email invitations were sent to (i) health care practitioners who had participated in prior clinical trials and consented to future contact, [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and (ii) clinicians identified through publicly available contact details. Respondents received study information and provided informed consent before participation.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted via videoconferencing (\u003cem\u003eZoom\u003c/em\u003e v5.16.2) by two female researchers (KE, SC), each with over 30 years of experience as MSK physiotherapists and educators, and training in qualitative interviewing. While some participants were known to the interviewers through previous trials [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] or professional networks, no direct working relationships existed. To mitigate any influence of prior familiarity, interviewers emphasised voluntary participation, confidentiality, and reflexive awareness of potential bias throughout data collection and analysis. Interviewers clarified study aims before commencing, obtained permission to record and assured de-identification of transcripts.\u003c/p\u003e\u003cp\u003eThe interview guide was co-developed by the research team and six key informants (two AHPs, two MPs and two consumers) to ensure clinical relevance. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] The guide contained eight open-ended questions enabling participants to speak openly about their perspectives and experiences (Appendix 1). [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] Interviews were structured into four sections. First, participants provided demographic details (e.g., profession, years of experience) and information about their work setting (e.g., metropolitan or rural; solo or multidisciplinary clinic). Second, participants discussed current intra- and interprofessional referral practices (e.g., \u003cem\u003e\u0026ldquo;Who do you refer to/get referrals from?\u0026rdquo; \u0026ldquo;Why?\u0026rdquo;).\u003c/em\u003e Third, they were asked to reflect on optimal care pathways (e.g., \u0026ldquo;\u003cem\u003eIf you were designing a clinical pathway of care to optimise referrals and patient outcomes, what would that pathway look like\u003c/em\u003e?\u0026rdquo;). Finally, participants shared their views on a proposed stratified pathway involving early referral to specialist AHPs for people at risk of a poor outcome. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe interview guide was refined after the 5th, 10th and 15th interview to improve clarity, flow and data richness. [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] Field notes were recorded during and after each interview. All interviews were transcribed verbatim and assigned a participant code to de-identify individuals. Participants were offered the opportunity to review and comment on their transcripts to confirm accuracy (member-checking).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eA reflexive thematic analysis [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] was conducted, following Braun and Clarke\u0026rsquo;s six phase process. [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] One researcher (SC) transcribed all interviews using manual and automated methods (Rev.com \u0026copy; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rev.com\u003c/span\u003e\u003cspan address=\"https://www.rev.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Two researchers, KE and TR (specialist MSK physiotherapists and experienced qualitative researchers) reviewed a random sample of transcripts for accuracy and analytic rigour. Transcripts were coded using Excel and NVivo (QSR International v12), with Excel serving as the primary platform for logging coding frequencies and analytic decisions.\u003c/p\u003e\u003cp\u003eIn phase one and two, three researchers, SC, KE and TR, independently reviewed and coded 5 AHP and 5 MP transcripts. In phase three, the team consolidated codes and generated preliminary themes. Data collection and analysis proceeded concurrently, with fortnightly meetings to refine themes. Recruitment continued until no new themes were identified. In phase four, themes were refined and checked against the full dataset. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] In phase five, final themes were demarcated through team consensus. The study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies (COREQ). [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFifty-eight interviews were conducted with 38 AHPs: 18 physiotherapists, 6 exercise physiologists, and 7 psychologists; and 20 MPs: 4 GPs, 10 medical specialists (sport and exercise medicine, rheumatology, pain, rehabilitation), and 6 surgical specialists (orthopaedics, neurosurgery). Participants worked in five different Australian states (Queensland, New South Wales, South Australia, Victoria, Western Australia ). The majority of AHPs (89%) and MPs (90%) worked in private practice in metropolitan areas, with 68% of AHPs and 32% of MPs working within multidisciplinary settings. Forty-five percent of AHPs and eighty percent of MPs were male. AHPs had been practising for an average of 11.5 years (SD\u0026thinsp;=\u0026thinsp;10.7) and MPs for 17.3 years (SD\u0026thinsp;=\u0026thinsp;10.6). Interviews ranged from 24 to 76 minutes (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD 43\u0026thinsp;\u0026plusmn;\u0026thinsp;11 minutes). No repeat interviews were conducted, no participants withdrew from the study, and all provided consent for their data to be included in the analysis. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eFactors influencing referral practices of Australian AHPs and MPs\u003c/h2\u003e\u003cp\u003eOur analysis identified three interconnected themes shaping referral practices: (i) clinical presentation and preferences (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), (ii) trusted professional relationships (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and (iii) service accessibility and affordability (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Patient-related factors typically initiated the referral process, trusted relationships influenced to whom the referral was directed to, and system-related constraints often determined whether the referral ultimately occurred.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTheme 1: Patient-related influences – Clinical presentation and patient preferences\u003c/h3\u003e\n\u003cp\u003eClinical presentation was the most common trigger for referral. Suspected serious pathology (e.g., fracture, neuropathy) prompted urgent imaging or specialist medical review, while psychosocial factors (e.g., distress or sleep disturbance) often led to psychology referrals. Complex or non-resolving presentations highlighted differences in approaches: AHPs often sought advice from senior colleagues within their practice, whereas MPs, with direct referral access to imaging and specialist medical services, favoured further investigations or specialist medical opinion.\u003c/p\u003e\u003cp\u003ePatient preferences were also drivers of referrals for both AHPs and MPs. Participants described feeling pressure to meet patient expectations for imaging or specialist review, even when such referrals were not clinically indicated: \u003cem\u003e\u0026ldquo;Not everyone needs a scan\u0026hellip;but they get referred to me with an expectation they're going to get a scan [Sport and Exercise Physician,15].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient-related influences on the referral practices of AHPs and MPs managing people with MSK conditions in primary care\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eClinical presentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRed flags\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They were reporting bladder and bowel problems, and they'd had bowel cancer before \u0026hellip; the symptoms weren't lining up to back pain [Physiotherapist,38].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, if there's any of those red flags pop us then I'll either kindly ask the GP if they think it's warranted to investigate [Exercise Physiologist,30].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;As soon as there's a red flag. I don't hold back on that [referring for imaging] [GP,56] .\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsychosocial risk factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It could be that they have unhelpful beliefs or understanding about their condition, and I believe having a psychologist with experience in communicating and reframing these unhelpful beliefs [Specialist MSK Physiotherapist,24].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If there is distress, fear around movement that is usually where we see referrals\u0026rdquo; [Psychologist,53]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ll identify this person's level of depression is high enough [to refer] just by simple screening tools [Rheumatologist,7].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplex or unresolving presentations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If it's a super complex case, I'm quite fortunate where I get to utilize our seniors\u0026hellip; I'll refer on to them [Physiotherapist,6].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If we are unsure of the cause of it, that's when we want to refer to [our senior] physio to, I guess, have that real initial assessment and that diagnosis [Exercise Physiologist, 19].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eMy referral [for imaging] would be based on lack of improvement or really, pain that's quite disabling [GP,16].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient preferences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is good for the patient to feel that they are safe to move. \u0026hellip; they take that information more readily from a doctor as they would from myself [Psychologist,53]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We're often under pressure from the patient [to refer for imaging] [GP,16]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;.Mainly to get reassurance for the patient [Rheumatologist,7]\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 2: Practitioner-related influences - Trusted professional relationships\u003c/h3\u003e\n\u003cp\u003eOnce a referral was being considered, decisions about who to refer the patient to were influenced by the presence, or absence of trusted professional relationships. As one AHP noted: \u0026ldquo;\u003cem\u003eWhy do I get referrals? Well, relationships would be number one. So just knowing other people and them having confidence and trust in your ability [Physiotherapist,7].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTrusted professional relationships were developed and sustained through three interrelated processes: (i) perceptions of practitioner competence, (ii) alignment in treatment philosophies and effective communication, and (iii) reliable and reciprocal referral behaviours.\u003c/p\u003e\u003cp\u003eTrust began with perceptions of practitioner competence, typically embedded in traditional professional hierarchies and role expectations. AHPs described deferring to MPs when uncertain, reflecting perceptions of greater diagnostic authority: \u0026ldquo;\u0026hellip;\u003cem\u003eif they're not responding\u0026hellip;.and I just want a higher opinion \u0026hellip;then I'll refer on to the [neurosurgeon] [Physiotherapist,39].\u0026rdquo;\u003c/em\u003e Similar dynamics were evident within professions, with AHPs tending to avoid intradisciplinary referrals unless the colleague was clearly more senior: \u003cem\u003e\u0026ldquo;Well, it might even be pride... happy to take some sort of instruction from a medical specialist, but not from someone I see as a colleague [Physiotherapist,11].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eClear role expectations further contributed to perceptions of competence. AHPs understood MP roles and referred with specific expectations: \u0026ldquo;\u003cem\u003eI\u0026rsquo;ll generally get the opinion of the sports doctor if I feel like an injection may be warranted [Physiotherapist,7].\u0026rdquo;\u003c/em\u003e In contrast, MPs typically referred patients to AHPs for \u0026ldquo;\u003cem\u003econservative management\u003c/em\u003e [Orthopaedic Surgeon,1]\u0026rdquo; but expressed uncertainty about the scope of AHP roles: \u0026ldquo;\u003cem\u003eI think that acute back pain will often be physio[therapist], maybe chiro[practor], maybe an exercise [physiologist], you know, probably physio[therapist] [Sport and Exercise Physician,18].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBeyond hierarchies and role expectations, alignment in treatment philosophies and effective communication fostered perceptions of competence and deepened trust: \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve seen this guy work and what he does\u0026hellip; I feel very comfortable sending to that person [Sport and Exercise Physician,15].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOpen communication and ongoing collaboration helped strengthen relationships over time. Participants described open dialogue and shared decision-making as central to building trusted relationships: \u003cem\u003e\u0026ldquo;You're safe with each other\u0026hellip;.you can tell each other what you think? And it takes a little while to develop that\u003c/em\u003e [\u003cem\u003eSport and Exercise Physician,13].\u0026rdquo;\u003c/em\u003e Conversely, negative patient feedback could quickly undermine trust and discourage future referrals: \u003cem\u003e\u0026ldquo;Yeah, that does reflect on you\u0026hellip;. I just won\u0026rsquo;t refer again [Sport and Exercise Physician,14].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFinally, trusted professional relationships were sustained by reliable and reciprocal referral behaviours. Practitioners valued colleagues who kept them informed and returned patients for ongoing care: \u003cem\u003e\u0026ldquo;Being part of the whole system to do the right thing by the patient's best interest and making sure they send [the patient] back to that person [Physiotherapist,11].\u0026rdquo;\u003c/em\u003e Reciprocity was viewed as a marker of respect and reliability: \u003cem\u003e\u0026ldquo;If you help someone [by referring], I guess you expect when you need help, they'll help you as well [by referring] [Exercise Physiologist,30].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePractitioner-related influences on the referral practices of AHPs and MPs managing people with MSK conditions in primary care\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eTrusted Professional Relationships\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerceived Competence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I usually refer them to one of the physios here as well for that hands-on management\u0026hellip;which is obviously something I can't provide [Exercise Physiologist,8].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I'm not actually all that across what these different people exactly do. I just want patients to move [Neurosurgeon,11].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I guess they're [GPs] at the top, above physios, because they're the ones, I guess, that we get the referrals from... the specialists and the GPs are at the top [Physiotherapist,46].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffective communication and alignment in treatment philosophies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You feel confident that they will support the patient in the best way. You want them to be aligned with the treatment approach [Psychologist,25].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And you sort of get a feel for them\u0026hellip;it takes a while to build trust and rapport\u0026hellip;you can tell someone knows what they're talking about and who should be referred [Orthopaedic Surgeon,47].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's really trial and error. And probably listening to patients as well, because if you get feedback, \"Oh, he was arrogant and didn't listen\", and then you get that several times you start to.[not refer] [GP,58].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But we'd get feedback from the patients\u0026hellip;you know, people can have a title, but still not do things the way that sits with our way of doing things [Psychologist,22].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReciprocity of referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it really comes down to how they turned up to a clinic and where it's come from, making sure that you don't [annoy] the people that feed it to you [Physiotherapist,33].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;very often I refer back to who they came from [Sport and Exercise Physician,54].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: System-related Influences - Service accessibility and affordability\u003c/h2\u003e\u003cp\u003eSystem-related constraints played a decisive role in whether referrals were enacted. Practitioners consistently described geographical location, referral rights, and funding models as the key structural factors shaping their decisions.\u003c/p\u003e\u003cp\u003eGeographical location often provided the most immediate opportunities for referral. Convenience and proximity to patients facilitated referrals, particularly for surgeons: \u003cem\u003e\u0026ldquo;So mostly, it's geographic. \u0026hellip; I say, look on Google, find someone close to you who's got free parking and hours that suit you [Orthopaedic Surgeon,2].\u0026rdquo;\u003c/em\u003e For AHPs and MPs in multidisciplinary clinics, co-location encouraged in-house referrals, offering convenience for patients and fostering interprofessional collaboration: \u003cem\u003e\u0026ldquo;My biggest referrals are to other clinicians within our practice [Physiotherapist,13].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eReferral access restrictions, however, frequently overshadowed location. AHPs expressed frustration at their lack of referral rights to medical specialists under Medicare, despite feeling confident in their expertise to recognise when specialist review was warranted: \u003cem\u003e\u0026ldquo;We want direct access to specialists without having to use the GPs as the gatekeeper\u0026hellip; it just hamstrings our profession [Physiotherapist,14].\u0026rdquo;\u003c/em\u003e Some MPs resisted expanded referral rights for AHPs, citing boundaries around professional roles: \u003cem\u003e\u0026ldquo;I suppose it's a bit of a turf war, but I would feel uncomfortable with physios referring to orthopaedic surgeons [Sport and Exercise Physician,15].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAffordability was a strong theme. Referrals were more likely when services were subsidised by Medicare or insurance, but out-of-pocket costs deterred patients and practitioners: \u0026ldquo;\u003cem\u003eProbably the cost \u0026hellip; quite sort of tight for some people [Exercise Physiologist,32].\u0026rdquo;\u003c/em\u003e Financial pressures on their own business were also reported by practitioners, especially AHPs who acknowledged the difficulty of referring clients elsewhere when their business survival relied on patient retention: \u003cem\u003e\u0026ldquo;It can be really hard for people in private practice to refer on because... they rely on income to survive. [Psychologist,4].\u0026rdquo;\u003c/em\u003e Financial competition and lack of collaboration between AHPs in primary care was also observed by some MPs - \u0026ldquo;\u003cem\u003eI think physio is very cut-throat [Sport and Exercise Physician,15].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSystem-related influences on the referral practices of AHPs and MPs managing people with MSK conditions in primary care\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAccess to practitioners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeographical Location\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would also think very carefully about where people live [before referring][Psychologist,22].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It'll be one of three or four that I use that are convenient. \u0026hellip; because clearly people don't want to travel long distances [GP,16].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreference for multi -disciplinary, co-located care\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that multidisciplinary care is really important for patients, and it's better just have the one team working together in house I think [Physiotherapist,28].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The advantage is having the multiple disciplines all kind of working together under the one roof at the one-time [Pain physician,50].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect referral pathways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think sometimes going back through the surgeon or whatever is a bit convoluted. It would be nice to be accepted as the primary referrer [Physiotherapist,2].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of physios say [to patients], \u0026ldquo;can you ask your GP to write a letter to see XXX? I'm not saying we need to remove that but the ways that a physio can directly contact the rheumatologists becomes more important [Rheumatologist,9].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAffordability for patients and practitioners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative impact on patients and practitioners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The negative of seeing the sports doctor is the net total cost of the journey. I just do that sum in my head and put it to the patient and they weigh it up [Physiotherapist,25].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Nobody's got endless dollars so you can't give people 100 buck referrals [Sport and Exercise Physician,18].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But that's hard because you're sending patients away from your business, which is, the right thing by the patient. Sometimes you just do it, but at the same time and you've got to be mindful of that [Physiotherapist,51].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReferrals facilitated when subsided\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They get referred [to me] If it\u0026rsquo;s in a compensable setting - people who are struggling to return to work] [Psychologist, 25].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If it's self-insured, or Workcover, they'll [caseworker] always just say \u0026ldquo;have you done a scan\u0026rdquo; [GP,56].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePractitioner perceptions of optimal and proposed pathways of care (PACE-MSK)\u003c/h2\u003e\u003cp\u003eAfter reflecting on their current referral practices, participants were invited to describe what they would consider an optimal model of care for people with MSK conditions. Most supported GPs as central co-ordinators of care but highlighted GPs\u0026rsquo; limited time and insufficient MSK-specific training: \u003cem\u003e\u0026ldquo;a lot of doctors are very poorly trained when it comes to musculoskeletal medicine... We just don't get a lot of training at university [GP,16].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAHPs advocated for direct referral rights to specialists to streamline care. Surgeons were generally receptive to AHP referrals provided that non-operative measures had been fully trialled: \u0026ldquo;\u003cem\u003eI just want them [AHPs and MPs] to explore all of the sensible, non-operative measures and exhaust those completely before getting referred [to me] [Orthopaedic Surgeon,9].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants also emphasised the need for greater education about interprofessional roles, particularly when managing complex patients, and resources to identify expert AHPs locally: \u003cem\u003e\u0026ldquo;My knowledge of who to refer to is not great\u0026hellip;.. need better education [Exercise Physiologist,3].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePsychologists highlighted their underutilisation in MSK care and exclusion from referral networks:\u003cem\u003e- \u0026ldquo;It's very clear, especially with a physio in a solo practice, they [physio] don't refer to us very often [Psychologist,5].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhen introduced to the proposed PACE-MSK pathway [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], in which patients at risk of poor outcomes are first referred to a specialist MSK physiotherapist instead of to a medical or surgical specialist, both MPs and AHPs expressed broad support but also identified barriers.\u003c/p\u003e\u003cp\u003eFirst, many reported that did know any specialist MSK physiotherapists, nor did they understand the scope of specialist MSK physiotherapist roles: \u003cem\u003e\u0026ldquo;I couldn't clearly identify a specialist musculoskeletal practitioner at all [GP,16]; \u0026ldquo;\u0026hellip;\u0026hellip; I see.. physio as a physio [Orthopaedic surgeon,1]\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;[need a] better understanding of what that specialist [physiotherapist] does [Physiotherapist, 5].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSecond, financial concerns were raised, both in terms of potential loss of income for referring practitioners and increased costs to patients. \u003cem\u003e\u0026ldquo;As a private practitioner who makes money off bums on seats, if I'm referring, I'm losing clientele and money [Physiotherapist, 2].\u0026rdquo;; \u0026ldquo;The specialist [physiotherapist] taking work and income away\u003c/em\u003e \u003cb\u003e\u0026hellip;\u003c/b\u003e\u003cem\u003eI\u0026rsquo;m not sure how that would work [Rehabilitation Physician,43].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, all participants agreed that the model was warranted and acceptable if the barriers could be overcome.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI don't have any issues with that. It's more the organisational infrastructure [Neurosurgeon,1]\u0026rdquo;; \u0026ldquo;seems needed I think, for the benefit of both the patient but also the practitioner [Physio,9].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSuggested enablers to support implementation of the pathway centred on trust-building mechanisms: clarity on roles, clear communication and shared care models, together with funding reforms to support collaboration (e.g., Medicare-subsidised telehealth consultations): \u0026ldquo;\u003cem\u003eperhaps there's a Zoom once a week/fortnight [GP,2].\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined referral practices of Australian AHPs and MPs managing people with MSK conditions in primary care, their perceptions of optimal referral pathways, and barriers and facilitators to implementing a proposed clinical pathway of care (PACE-MSK). Referrals were usually prompted by the patient\u0026rsquo;s presentation and preferences. However, practitioner factors, such as trust in professional relationships, influenced to whom the patient was referred. System factors, including perceived cost and access barriers, often determined whether the practitioner went ahead with the referral.\u003c/p\u003e\u003cp\u003eOur findings reinforce previous evidence that clinical presentation remains the most consistent influence on referral practices in MSK primary care. [\u003cspan additionalcitationids=\"CR56 CR57 CR58 CR59\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] In particular, when presentations were suggestive of serious pathology or psychosocial distress, immediate referrals to specialist medical practitioners or psychologists were made. However, our study is the first to show differences in referral practices of AHPs and MPs when cases were complex or unresolving. MPs tended to favour further investigations or specialist medical review whereas AHPs, without direct access to these services, were more likely to seek help from senior colleagues within their practice. Also, aligning with previous research, patient preferences prompted consideration of a referral. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] Both AHPs and MPs in this study acknowledged that they sometimes escalated referrals for medical opinion (and in the case of MPs, for imaging) primarily to meet patient expectations, even when not clinically indicated. Thus, patient-factors, such as clinical presentation and preferences, remain strong influences on referral practices in MSK primary care for both AHP and MPs.\u003c/p\u003e\u003cp\u003eWhilst patient factors often prompted consideration of referral, decisions regarding \u003cem\u003ewhom\u003c/em\u003e to refer to were shaped by practitioner-related factors, particularly trust within professional networks. Trust has long been recognised as a cornerstone of interprofessional collaboration. [\u003cspan additionalcitationids=\"CR64 CR65 CR66\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] This study is the first to describe how trusted professional relationships develop and influence referral practices among AHPs and MPs managing MSK conditions in Australian primary care. These relationships were established and sustained through three interrelated processes: (i) perceptions of practitioner competence, (ii) effective communication and alignment in treatment philosophies, and (iii) reliable and reciprocal referral behaviours.\u003c/p\u003e\u003cp\u003eTrust began with perceptions of practitioner competence, shaped by professional hierarchies and role expectations. Established professional hierarchies and clear role expectations shaped perceptions of competence and trust more strongly in favour of MPs than AHPs, regardless of discipline. For example, AHPs often viewed MPs as occupying higher status roles and referred patients to them with clearly defined expectations. In contrast, MPs lacked a clear understanding of AHPs\u0026rsquo; skills and scope of practice, which shaped their perceptions of AHPs\u0026rsquo; competence. Nevertheless, competence and trust in both groups could be cultivated over time through shared treatment philosophies and effective communication and collaboration. In contrast, poor communication or negative patient feedback quickly eroded trust and deterred future referrals.\u003c/p\u003e\u003cp\u003eFinally, trusted professional relationships were consolidated and sustained when practitioners demonstrated reliable and reciprocal referral practices. Colleagues who referred patients back to their referrer for on-going care were highly valued, with reciprocity regarded as both a marker of professional respect and as a safeguard against reputational or financial risks associated with patient loss. For AHPs, the possibility of \u0026ldquo;losing patients\u0026rdquo; when referring away from their practice was a particular concern. Although one prior study has documented these financial considerations amongst physiotherapists, [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] we are not aware of comparable evidence for other AHPs, including exercise physiologists or psychologists. Together, these dynamics show how trust influences referral behaviour and how professional hierarchies, and role ambiguity can limit the optimal use of AHP expertise in primary care.\u003c/p\u003e\u003cp\u003eFinancial impacts on patients and practitioners, location, and direct referral access were key system-related determinants of whether referrals ultimately occurred. Consistent with international studies, [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] subsidised services or insurance coverage facilitated referral, whereas out-of-pocket costs deterred referral. Co-location within multidisciplinary clinics improved accessibility, supported collaboration, and reinforced referral relationships. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan additionalcitationids=\"CR70\" citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] Surgeons were an exception, rarely working in multidisciplinary settings and, as the perceived \u0026ldquo;captain of the ship\u0026rdquo; [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e] in the medical hierarchy, often adopting more authoritative decision-making approaches.\u003c/p\u003e\u003cp\u003eBarriers to implementing the PACE-MSK pathway, where patients at risk of poor outcomes are referred first to a specialist AHP instead of a specialist MP, mirrored current referral challenges. Participants highlighted a lack of awareness of, and hence a lack of trusted relationships with, specialist MSK physiotherapists alongside concerns about the financial impact on both practitioners and patients. Studies exploring acceptance of referral to specialist MSK physiotherapists for the management of whiplash-associated disorders and other MSK conditions have also reported lack of trust between practitioners and financial issues as barriers. [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e] Moreover, distrust amongst health professionals has been observed by patients recounting their experiences of referral practices for chronic low back pain. [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] Patients described their care as \u0026ldquo;fragmented\u0026rdquo; and particularly noted a lack of collaboration between AHPs. [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eModels of care that increase utilization of AHPs such as PACE-MSK [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and others [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] are proposed as a solution to the increasing burden of MSK conditions amidst an overwhelmed medical workforce. Expert AHPs (e.g., specialist physiotherapists) are well-placed to manage complex MSK patients, where risk factors are often lifestyle or psychosocial-related and rarely require medical or surgical intervention. However, successful implementation of these newer pathways will require deliberate efforts to build interprofessional trust and reduce system-level barriers. Educational initiatives, both pre-service and continuing professional development, should prioritise interprofessional role clarity and collaboration. [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e] Formal and informal opportunities for shared practice, particularly in co-located or networked models, may accelerate the trust-building needed for efficient and effective referral pathways. Equally, funding reform is key. Current payment structures may inadvertently discourage referrals that are in patients\u0026rsquo; best interests. Incentives to support shared care and reduce out-of-pocket costs could promote appropriate utilisation of AHP expertise and to minimise unnecessary imaging and surgery.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWhile patient presentation and preferences remain central to MSK referral decisions, trusted professional relationships, service access and affordability play a significant role. For stratified care pathways such as PACE-MSK to succeed, implementation must directly address these relational and structural influences. Clarifying interprofessional roles, creating opportunities for collaboration to enable development of trusted professional relationships, and reforming funding models are likely to be key to improving referral efficiency and patient outcomes in MSK primary care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMSK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMusculoskeletal\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAHP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAllied Health Practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePACE-MSK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePAthway of CarE- Musculoskeletal Clinical Trial\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants gave their informed consent prior to participating in this study.\u0026nbsp;The study was approved by the Human Research Ethics Committee at The University of Sydney (Project number: 2019-219).\u0026nbsp;Reporting was in accordance with COREQ guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a project grant from the National Health and Medical Research Council of Australia (GNT1141377). The funder had no role in the design of the study, collection, analysis, interpretation of data, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSC: Conceptualisation, Methodology, Data curation, Formal analysis, Writing \u0026ndash; original draft.\u003c/p\u003e\n\u003cp\u003eKE: Conceptualisation, Methodology, Validation, Formal analysis, Writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eTR: Conceptualisation, Methodology, Validation, Formal analysis, Writing \u0026ndash; review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge all the health practitioners who volunteered their time to participate in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiu S, Wang B, Fan S, Wang Y, Zhan Y, Ye D. 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BMC Prim Care. 2022;23(1):143.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaunders B, Foster NE, Mullis R, Ong BN, Hill JC, Pincus T, et al. Risk-based stratified primary care for common musculoskeletal pain presentations: qualitative findings from the STarT MSK cluster RCT. BMC Prim Care. 2022;23(1):61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDakin HA, Gray A, Fitzpatrick R, Maclennan G, Murray D, Wyatt M, et al. Who gets referred for knee or hip replacement? BMJ Open. 2020;10(1):e033833.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMedicina Red-Flags Working Group. Standardized definition of red flags in musculoskeletal care. Med (Kaunas). 2025;61(2):345.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiddle J, Clemson L, Mackenzie L, Lovarini M, Tan A, Sherrington C. Influences on general practitioner referral to allied health practitioners for fall prevention in primary care. 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BMJ Open. 2020;10:e037820.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHollins J, Veitch C, Hays R. Interpractitioner communication: telephone consultations between rural general practitioners and specialists. Aust J Rural Health. 2000;8:227\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSutherland BL, Pecanac K, LaBorde TM, Oldenburg CE, Carnes M, Barnato AE. Good working relationships: how healthcare system proximity influences trust between healthcare workers. J Interprof Care. 2022;36:331\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFatahi N, Krupic F, Hellstr\u0026ouml;m M. Difficulties and possibilities in communication between referring clinicians and radiologists: perspective of clinicians. J Multidiscip Healthc. 2019;12:555\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGregory PA, Austin Z. 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BMC Health Serv Res. 2022;22(1):529.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoyle EM, Evans K, Coates S, Rebbeck T. Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain. Physiother Theory Pract. 2022;1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16:10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Dongen JJJ, Lenzen SA, van Bokhoven MA, Daniels R, van der Weijden T, Beurskens A. Interprofessional collaboration regarding patients\u0026rsquo; care plans in primary care: a focus group study into influential factors. BMC Fam Pract. 2016;17:58.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Referral, Musculoskeletal, Interprofessional collaboration, Trust, Primary Care, Pathways","lastPublishedDoi":"10.21203/rs.3.rs-8033842/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8033842/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical pathways that increase utilization of specialist allied health practitioners (AHPs) are proposed as a solution to the increasing burden of musculoskeletal (MSK) conditions amidst an overwhelmed medical workforce. However, despite clinical recommendations, referral and collaboration between AHPs and medical practitioners (MPs) in primary care remains limited. Gaining insight into factors that influence referral decisions may improve collaboration and inform the design of more effective care pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Describe referral practices of Australian AHPs and MPs managing people with MSK conditions in primary care.\u003c/p\u003e\n\u003cp\u003e2. Explore practitioners’ perceptions of optimal referral pathways, and the barriers and facilitators to implementing a proposed clinical pathway of care (PACE-MSK).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nSemi-structured interviews were conducted with 58 Australian AHPs (physiotherapists, exercise physiologists, psychologists) and MPs (orthopaedic and neurosurgeons, physicians, general practitioners (GPs)). Practitioners in primary care managing MSK conditions on at least two days per week were invited to participate. Participants discussed current referral practices and identified barriers and facilitators to involving specialist AHPs in a proposed care pathway. Data collection and analysis were iterative. Themes were generated using reflexive thematic analysis, refined through team discussion and consensus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReferral practices of both AHPs and MPs were prompted by the patient’s presentation and preferences, but the choice of whom to refer was shaped by trusted professional relationships. System-level constraints, such as service affordability and access for both practitioners and patients, determined whether referrals occurred and were identified as barriers to optimal and proposed care pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nReferral practices of Australian AHPs and MPs are influenced by patient, practitioner and system-level factors. Clarifying interprofessional roles, building trusted professional relationships and reforming funding models to improve affordability and access for patients and practitioners are likely to be key to improving referral pathways and patient outcomes in MSK primary care.\u003c/p\u003e","manuscriptTitle":"Factors influencing referrals amongst allied health and medical practitioners managing people with musculoskeletal conditions in Australian primary care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 16:33:04","doi":"10.21203/rs.3.rs-8033842/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-01T05:53:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T00:03:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14930932423882055535004619226234606469","date":"2025-11-30T21:51:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-30T18:08:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"72824426695236872563323125482785822385","date":"2025-11-27T11:54:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139405038969629926546606110992991103560","date":"2025-11-27T11:45:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T09:29:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333083282811580007205954534668381331673","date":"2025-11-27T08:55:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-27T08:03:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-19T06:27:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-19T06:02:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-19T06:00:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-11-05T03:46:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1198345b-693b-4f7f-8ac8-a5042f3222d9","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:13:17+00:00","versionOfRecord":{"articleIdentity":"rs-8033842","link":"https://doi.org/10.1186/s12913-026-14205-x","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-03-09 16:00:07","publishedOnDateReadable":"March 9th, 2026"},"versionCreatedAt":"2025-12-01 16:33:04","video":"","vorDoi":"10.1186/s12913-026-14205-x","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14205-x","workflowStages":[]},"version":"v1","identity":"rs-8033842","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8033842","identity":"rs-8033842","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}