Co-Design of the VIRtual physiotherapist-led Triage of referrals to shoUlder surgEons (VIRTUE) model of care: a study protocol
- 1Institute for Musculoskeletal Health, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
Abstract
Background: Rotator cuff-related shoulder pain accounts for up to 85% of shoulder pain. Guidelines recommend 6 months of non-surgical care before considering surgery, yet many are referred to a surgeon before trying it. High referral rates to public hospital shoulder surgery clinics in Australia mean many patients wait 1-2 years to see a surgeon, during which symptoms may become more complex and costly to manage. A promising solution is the VIRtual physiotherapist-led Triage of referrals to shoUlder surgEons (VIRTUE) model of care, in which physiotherapists screen new referrals and determine suitability for non-surgical care or surgical review. However, no such model has been co-designed to incorporate virtual care nor evaluated in a randomised controlled trial. Aims: The broad aim of this study is to co-design the VIRTUE model of care ready for evaluation in a randomised controlled trial conducted in public hospital shoulder surgery clinics in Australia. Specifically, this study has two aims (two stages): i) explore stakeholders perceptions of the feasibility, acceptability and implementation of the VIRTUE model of care for adults with rotator cuff-related shoulder pain who are referred to public hospital shoulder surgery clinics; and ii) co-design the VIRTUE model of care so that it is user-centred and acceptable to patients, clinicians and key stakeholders. Methods: Stage 1 is a qualitative descriptive study using semi-structured online interviews with patients, clinicians and key stakeholders, recruited using purposive, maximum variation sampling. Interviews will explore experiences of current care, perceptions of the proposed model, and barriers and facilitators to implementation, guided by the Theoretical Framework for Acceptability and Consolidated Framework for Implementation Research. Stage 2 will use Experience-Based Co-Design methodology and involves three online workshops: separate workshops for patients, and for clinicians and key stakeholders, then a combined workshop. Workshops will explore Stage 1 findings, perceptions of the proposed model, and refinements needed to finalise it, with data mapped to the Framework for Reporting Adaptations and Modifications-Expanded. Conclusion: Co-designing VIRTUE with patients, clinicians and key stakeholders will ensure it is user-centred, acceptable and feasible within Australian public health services, ready for evaluation in a randomised controlled trial. By facilitating timely and equitable access to evidence-based care, VIRTUE could improve outcomes for patients, ensure specialist services are available for those most in need, and improve health system performance.
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BibTeX
@misc{gamble2026codesign,
title = {{Co-Design of the VIRtual physiotherapist-led Triage of referrals to shoUlder surgEons (VIRTUE) model of care: a study protocol}},
author = {A. R. Gamble and G. E. Ferreira and C. G. Maher and S. Whittle and C. Avdalis and I. A. Harris and A. Langford and C. M. Williams and K. Tambree and L. Hassett and A. Haynes and P. Malliaras and D. B. Anderson and J. R. Zadro},
howpublished = {medRxiv},
year = {2026},
month = nov,
doi = {10.64898/2026.11.05.26367222},
url = {https://www.medrxiv.org/content/10.64898/2026.11.05.26367222v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Co-Design of the VIRtual physiotherapist-led Triage of referrals to shoUlder surgEons (VIRTUE) model of care: a study protocol
AU - A. R. Gamble
AU - G. E. Ferreira
AU - C. G. Maher
AU - S. Whittle
AU - C. Avdalis
AU - I. A. Harris
AU - A. Langford
AU - C. M. Williams
AU - K. Tambree
AU - L. Hassett
AU - A. Haynes
AU - P. Malliaras
AU - D. B. Anderson
AU - J. R. Zadro
PY - 2026
DA - 2026/11/05
PB - medRxiv
DO - 10.64898/2026.11.05.26367222
UR - https://www.medrxiv.org/content/10.64898/2026.11.05.26367222v1
AB - Background: Rotator cuff-related shoulder pain accounts for up to 85% of shoulder pain. Guidelines recommend 6 months of non-surgical care before considering surgery, yet many are referred to a surgeon before trying it. High referral rates to public hospital shoulder surgery clinics in Australia mean many patients wait 1-2 years to see a surgeon, during which symptoms may become more complex and costly to manage. A promising solution is the VIRtual physiotherapist-led Triage of referrals to shoUlder surgEons (VIRTUE) model of care, in which physiotherapists screen new referrals and determine suitability for non-surgical care or surgical review. However, no such model has been co-designed to incorporate virtual care nor evaluated in a randomised controlled trial. Aims: The broad aim of this study is to co-design the VIRTUE model of care ready for evaluation in a randomised controlled trial conducted in public hospital shoulder surgery clinics in Australia. Specifically, this study has two aims (two stages): i) explore stakeholders perceptions of the feasibility, acceptability and implementation of the VIRTUE model of care for adults with rotator cuff-related shoulder pain who are referred to public hospital shoulder surgery clinics; and ii) co-design the VIRTUE model of care so that it is user-centred and acceptable to patients, clinicians and key stakeholders. Methods: Stage 1 is a qualitative descriptive study using semi-structured online interviews with patients, clinicians and key stakeholders, recruited using purposive, maximum variation sampling. Interviews will explore experiences of current care, perceptions of the proposed model, and barriers and facilitators to implementation, guided by the Theoretical Framework for Acceptability and Consolidated Framework for Implementation Research. Stage 2 will use Experience-Based Co-Design methodology and involves three online workshops: separate workshops for patients, and for clinicians and key stakeholders, then a combined workshop. Workshops will explore Stage 1 findings, perceptions of the proposed model, and refinements needed to finalise it, with data mapped to the Framework for Reporting Adaptations and Modifications-Expanded. Conclusion: Co-designing VIRTUE with patients, clinicians and key stakeholders will ensure it is user-centred, acceptable and feasible within Australian public health services, ready for evaluation in a randomised controlled trial. By facilitating timely and equitable access to evidence-based care, VIRTUE could improve outcomes for patients, ensure specialist services are available for those most in need, and improve health system performance.
ER -