The current study identified the demographic, practice and clinical management characteristics of Australian osteopaths who report sending referrals to podiatrists, compared to their colleagues who do not report referring. A significant observation was the number of Australian osteopaths reporting sending referrals to podiatrists - approximately two-thirds reported sending referrals to podiatrists [5]. This observation, alongside the large association with receiving referrals from a podiatrist, suggests that a strong referral relationship exists between Australian osteopaths and osteopaths are utilising the expertise of podiatrists for patient care. These observations also potentially reflect a shared understanding between osteopaths and podiatrists of the role that each profession plays in patient care. Data from some studies indicate instances of multidisciplinary care involving podiatrists as part of the team [24,25,26]. These studies describe podiatrists positively contributing to the multidisciplinary care team for arthritic and ulcerative conditions; however, there is little literature describing multidisciplinary care involving osteopaths [27] and none in Australia.
Through secondary analysis of data from a national osteopathy PBRN, it appears that Australian osteopaths who report sending referrals to podiatrists are likely to engage in referrals with other allied health and complementary medicine professions. This finding is encouraging given the need for interprofessional patient care of musculoskeletal complaints [28], and has rarely been demonstrated in the literature describing the Australian osteopathy profession. The data presented here may be useful for informing health policy development around multidisciplinary care for musculoskeletal complaints (i.e. how best to utilise available health resources for patient care), and in patient care for chronic conditions given their significant cost to the healthcare system [29]. There is also an opportunity to use the data in the current study to inform the pre-registration education of Australian osteopaths and podiatrists, particularly focusing on interprofessional care.
Regarding practitioner characteristics, the current study identified two significant variables. The first was that female osteopaths were approximately 30% less likely to send referrals to podiatrists compared to their male counterparts in the unadjusted modelling. The reason for this difference in referrals based on gender requires additional exploration. Secondly, younger osteopaths were also more likely to report sending referrals to podiatrists compared to older colleagues. Whether this reflects an increase in knowledge of the role of podiatrists in musculoskeletal complaint care through pre-professional education, or experience from practice (or both) would need additional research. However, the finding is encouraging from the multidisciplinary care perspective.
Australian osteopaths who reported sending referrals to podiatrists were over seven times more likely to utilise orthopaedic testing in patient assessment, compared to osteopaths who did not report referring. Orthopaedic testing is based on stressing musculoskeletal tissues and may be utilised to assist in developing a working diagnosis for the patient’s complaint. Further, these tests are utilised by both podiatrists [30] and osteopaths [31]. It may be that this shared understanding of the orthopaedic tests relevant to the respective professions practice may be being captured in the current secondary analysis. Again, such an assertion would benefit from additional research to explore this potential shared understanding of musculoskeletal examination procedures.
From a clinical management perspective, Australian osteopaths who send referrals to podiatrists were over 70% more likely to report treating postural disorders. Studies have described the relationship between the prescription of foot orthoses and changes in posture in both healthy [32, 33] and clinical populations [34]. Although a direct relationship cannot be established from the current dataset, it may be that postural disorders are a commonly referred issue for shared management of patients given they are reported to be managed by over one-third of Australian osteopaths [7]. Whether postural disorders are a key driver of referrals would be an interesting avenue for further research. It would be valuable to understand the clinical reasoning of osteopaths and podiatrists in the management of postural disorders. Additional research could also be directed towards understanding other conditions that may result in frequent referrals between the two professions.
Australian osteopaths who reported sending referrals to podiatrists were less likely, than their non-referring colleagues, to report treating non-musculoskeletal conditions. The dominant practice of Australian osteopaths relates to the management of musculoskeletal complaints [5, 6]. However, there is a subsection of the Australian osteopathic profession that apply manual therapy techniques to assist in the management of non-musculoskeletal complaints [5]. There is varying evidence to support the effectiveness of osteopathy care for non-musculoskeletal complaints [35, 36]. It may be that the nature of the non-musculoskeletal complaints managed by some Australian osteopaths does not require referral to a podiatrist. Rather, osteopaths appear to be referring to podiatrists for musculoskeletal complaints. The nature of the conditions resulting in referral to a podiatrist requires further investigation.
The bivariate analysis undertaken indicates the payment processes that might be associated with osteopathy and podiatry co-management of patients. Australian osteopaths who send referrals to podiatrists were over 40% more likely to use the Medicare EasyClaim service than osteopaths who do not send referrals. Both professions are eligible to treat patients under the CDM scheme, whereby patients with chronic diseases can access government funded care for up to five consultations with allied health professionals [13]. Medicare EasyClaim allows patients to claim the rebate at the time of the consultation upon referral from the patients’ general practitioner. It may be that patients under this CDM scheme are utilising both osteopathy and podiatry services, and the increased use of Medicare EasyClaim reflects this. This assertion may be supported by the large association observed in the current secondary analysis with osteopaths sending referrals to general practitioners. Additional investigations would assist in testing these assertions to understand how osteopathy and podiatry services are used under the CDM scheme.
The limitation of the current research is associated with the cross-sectional nature of the questionnaire. Questionnaires used with these study designs are potentially susceptible to social desirability and acquiescence biases [37], and the latter may have influenced responses to the send and receive referral items on the questionnaire. Further, it is not possible to comment on the frequency of referrals between the two professions given the dichotomous nature of the responses to these items.