Effect of direct access to physiotherapy on prescribing and imaging in primary care for musculoskeletal disorders: a systematic review and meta-analysis.

Abstract (English)

BACKGROUND: Direct access (DA) to physiotherapy enables patients with musculoskeletal disorders (MSDs) to consult physiotherapists without prior GP referral. Despite its growing implementation, no quantitative synthesis has assessed its impact on prescribing outcomes relevant to GP workload. OBJECTIVE: To estimate the pooled effect of DA versus GP-led care on medication and imaging prescriptions for adults with MSDs in primary care. METHODS: This PRISMA-compliant meta-analysis, based on a registered review (OSF: 897ub), searched MEDLINE, Embase, CINAHL, Cochrane Library, and PEDro up to November 2025. Eligible studies compared DA with GP-referred care and reported medication and/or imaging prescriptions. Risk ratios (RRs) were pooled using random-effects models; shared-comparator correlation was managed by combining relevant arms, with sensitivity analyses examining them separately. RESULTS: Four studies (2993 participants) contributed to medication outcomes. Compared with GP-led pathways, DA was associated with fewer medication prescriptions (RR 0.57, 95% CI 0.40-0.83, I2 60%; sensitivity: RR 0.56, 95% CI 0.43-0.73, I2 45%; GRADE: low certainty). Evidence for imaging was insufficient. The planned X-ray-only analysis was uninformative due to sparse, zero-event data. A multi-modality sensitivity analysis suggested reduced imaging but without statistical significance (RR 0.48, 95% CI 0.16-1.41; very low certainty). CONCLUSION: DA may reduce medication prescribing in MSDs, though evidence certainty remains low. Imaging results are inconclusive. Further high-quality, adequately powered trials with prespecified prescribing and imaging endpoints are warranted to guide equitable primary care workforce planning.