Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

INTRODUCTION

Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain.

METHODS AND ANALYSIS

NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time.

ETHICS AND DISSEMINATION

This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.

TRIAL REGISTRATION NUMBER

ACTRN12623001000695.

Opioids for Acute Musculoskeletal Pain: A Systematic Review with Meta-Analysis

OBJECTIVE

To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo.

STUDY DESIGN

Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h).

DATA SOURCES

Multiple databases were searched from their inception to February 22nd, 2023.

DATA SYNTHESIS

Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed.

RESULTS

We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%).

DISCUSSION

Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits.

PROSPERO REGISTRATION

CRD42021249346.

Clinical care standards for the management of low back pain: a scoping review

The objective of this study is to compare and contrast the quality statements and quality indicators across clinical care standards for low back pain. Searches were performed in Medline, guideline databases, and Google searches to identify clinical care standards for the management of low back pain targeting a multidisciplinary audience. Two independent reviewers reviewed the search results and extracted relevant information from the clinical care standards. We compared the quality statements and indicators of the clinical care standards to identify the consistent messages and the discrepancies between them. Three national clinical care standards from Australia, Canada, and the United Kingdom were included. They provided from 6 to 8 quality statements and from 12 to 18 quality indicators. The three standards provide consistent recommendations in the quality statements related to imaging, and patient education/advice and self-management. In addition, the Canadian and Australian standards also provide consistent recommendations regarding comprehensive assessment, psychological support, and review and patient referral. However, the three clinical care standards differ in the statements related to psychological assessment, opioid analgesics, non-opioid analgesics, and non-pharmacological therapies. The three national clinical care standards provide consistent recommendations on imaging and patient education/advice, self-management of the condition, and two standards (Canadian and Australian) agree on recommendations regarding comprehensive assessment, psychological support, and review and patient referral. The standards differ in the quality statements related to psychological assessment, opioid prescription, non-opioid analgesics, and non-pharmacological therapies.

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study

BACKGROUND

Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia.

OBJECTIVE

The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model.

METHODS

This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes.

RESULTS

As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024).

CONCLUSIONS

This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50146.

Development of low back pain curriculum content standards for entry-level clinical training

BACKGROUND

The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs.

METHODS

The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group.

RESULTS

Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described.

CONCLUSION

We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

A content analysis of the interventions for low back pain promoted on the websites of Australian pain clinics

BACKGROUND

The Internet is a widely used source of health information, yet the accuracy of online information can be low. This is the case for low back pain (LBP), where much of the information about LBP treatment is poor.

METHODS

This research conducted a content analysis to explore what pain treatments for LBP are presented to the public on websites of Australian pain clinics listed in the PainAustralia National Pain Services Directory. Websites providing information relevant to the treatment of LBP were included. Details of the treatments for LBP offered by each pain service were extracted.

RESULTS

In total, 173 pain services were included, with these services linking to 100 unique websites. Services were predominantly under private ownership and located in urban areas, with limited services in non-urban locations. Websites provided detail on a median of six (IQR 3-8) treatments, with detail on a higher number of treatments provided by services in the private sector. Physical, psychological and educational treatments were offered by the majority of pain services, whereas surgical and workplace-focused treatments were offered by relatively few services. Most services provided details on multidisciplinary care; however, interdisciplinary, coordinated care characterised by case-conferencing was infrequently mentioned.

CONCLUSIONS

Most websites provided details on treatments that were largely in-line with recommended care for LBP, but some were not, especially in private clinics. However, whether the information provided online is a true reflection of the services offered in clinics remains to be investigated.

Development of the Reporting Infographics and Visual Abstracts of Comparative studies (RIVA-C) checklist and guide

People often use infographics (also called visual or graphical abstracts) as a substitute for reading the full text of an article. This is a concern because most infographics do not present sufficient information to interpret the research appropriately and guide wise health decisions. The Reporting Infographics and Visual Abstracts of Comparative studies (RIVA-C) checklist and guide aims to improve the completeness with which research findings of comparative studies are communicated and avoid research findings being misinterpreted if readers do not refer to the full text. The primary audience for the RIVA-C checklist and guide is developers of infographics that summarise comparative studies of health and medical interventions. The need for the RIVA-C checklist and guide was identified by a survey of how people use infographics. Possible checklist items were informed by a systematic review of how infographics report research. We then conducted a two-round, modified Delphi survey of 92 infographic developers/designers, researchers, health professionals and other key stakeholders. The final checklist includes 10 items. Accompanying explanation and both text and graphical examples linked to the items were developed and pilot tested over a 6-month period. The RIVA-C checklist and guide was designed to facilitate the creation of clear, transparent and sufficiently detailed infographics which summarise comparative studies of health and medical interventions. Accurate infographics can ensure research findings are communicated appropriately and not misinterpreted. By capturing the perspectives of a wide range of end users (eg, authors, informatics editors, journal editors, consumers), we are hopeful of rapid endorsement and implementation of RIVA-C.

Prevalence of disabling musculoskeletal pain in children and adolescents in Brazil: A cross-sectional study

BACKGROUND

Estimates of prevalence of musculoskeletal pain in children and adolescents vary considerably and the impact of pain on children's life is often not considered.

OBJECTIVE

To determine the one-month prevalence of disabling musculoskeletal pain in children and adolescents. The secondary aims are to: 1) determine the body region with the highest prevalence; 2) understand the characteristics of the children with disabling musculoskeletal pain; and 3) describe the parents' perception of the prevalence.

METHODS

This cross-sectional study was conducted in public and private schools in the states of São Paulo and Ceará, Brazil. Children self-reported presence and impact of pain, pain intensity, psychosomatic symptoms, and quality of life. Parents completed parent-proxy versions and perception of the child's sleep quality. Descriptive statistics were used to summarise the data.

RESULTS

A total of 2,688 children and adolescents were included in this study. The prevalence of disabling musculoskeletal pain in the previous month was 27.1%. The back was the region most often affected (51.8%). Children with disabling musculoskeletal pain were older, heavier, had worse relationships with their family, perceived their backpacks as heavy, carried their backpacks more with one shoulder, had more negative psychosomatic symptoms, had poorer quality of life, and had higher pain intensity. Parents tended to underestimate the presence of pain in their children.

CONCLUSION

The one-month prevalence of activity limiting musculoskeletal pain in children and adolescents was 27.1% with the back being the most often affected body region. Parents tended to underestimate the presence of pain in their children.

Clinicians' Perspective on Implementing Virtual Hospital Care for Low Back Pain: Qualitative Study

BACKGROUND

Alternate "hospital avoidance" models of care are required to manage the increasing demand for acute inpatient beds. There is currently a knowledge gap regarding the perspectives of hospital clinicians on barriers and facilitators to a transition to virtual care for low back pain. We plan to implement a virtual hospital model of care called "Back@Home" and use qualitative interviews with stakeholders to develop and refine the model.

OBJECTIVE

We aim to explore clinicians' perspectives on a virtual hospital model of care for back pain (Back@Home) and identify barriers to and enablers of successful implementation of this model of care.

METHODS

We conducted semistructured interviews with 19 purposively sampled clinicians involved in the delivery of acute back pain care at 3 metropolitan hospitals. Interview data were analyzed using the Theoretical Domains Framework.

RESULTS

A total of 10 Theoretical Domains Framework domains were identified as important in understanding barriers and enablers to implementing virtual hospital care for musculoskeletal back pain. Key barriers to virtual hospital care included patient access to videoconferencing and reliable internet, language barriers, and difficulty building rapport. Barriers to avoiding admission included patient expectations, social isolation, comorbidities, and medicolegal concerns. Conversely, enablers of implementing a virtual hospital model of care included increased health care resource efficiency, clinician familiarity with telehealth, as well as a perceived reduction in overmedicalization and infection risk.

CONCLUSIONS

The successful implementation of Back@Home relies on key stakeholder buy-in. Addressing barriers to implementation and building on enablers is crucial to clinicians' adoption of this model of care. Based on clinicians' input, the Back@Home model of care will incorporate the loan of internet-enabled devices, health care interpreters, and written resources translated into community languages to facilitate more equitable access to care for marginalized groups.

Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge.

METHODS

Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

RESULTS

Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge.

CONCLUSIONS

Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days.

PROTOCOL REGISTRATION

10.31219/osf.io/w4z3u.

Do national health priorities align with Global Burden of Disease estimates on disease burden? An analysis of national health plans and official governmental websites

OBJECTIVE

To investigate the alignment of national health priorities with a country's burden of disease as measured by disability-adjusted life years (DALYs).

METHODS

We identified priorities in national health plans and the 20 most burdensome conditions measured by DALYs from the 2017 Global Burden of Disease Study. We computed point-biserial correlations (rpb) between DALYs and being nominated as a health priority and the pooled proportion (95% confidence intervals [CIs]) of the 20 most burdensome conditions nominated as a priority across countries.

RESULTS

We identified national health plans and official governmental websites in 145 countries. There was little to no correlation (rpb = 0.06, 95% CI: 0.02 to 0.09) between national DALY data and whether a condition was nominated as a health priority. The pooled proportion of the 20 most burdensome conditions nominated as priorities across countries was 46%. HIV/AIDS had the greatest number of nominations as a national health priority (62 countries) as well as the greatest match with the burden of disease (among the top 20 most burdensome conditions in 51 [82%] countries). Low back pain, headache disorders and congenital birth defects had the lowest proportion of nominations as health priorities in countries where they were in the top 20 most burdensome conditions (6%, 6% and 11%, respectively).

CONCLUSION

Globally, there were low correlations between national health priorities and GBD estimates on disease burden. Failing to prioritise health priorities according to burden may mean that insufficient resources have been directed to improve health outcomes for people with those health conditions.

Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments

BACKGROUND

The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care.

DESIGN

A qualitative study.

METHODS

The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods.

RESULTS

Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity).

CONCLUSIONS

Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts.

Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial

BACKGROUND

Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain.

METHODS

OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone-naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000775516).

FINDINGS

Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI -0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group).

INTERPRETATION

Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions.

FUNDING

National Health and Medical Research Council, University of Sydney Faculty of Medicine and Health, and SafeWork SA.

Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review

Background

The accuracy of diagnostic tests available in primary care to identify the disc, sacroiliac joint, and facet joint as the source of low back pain is uncertain.

Methods

Systematic review of diagnostic tests available in primary care. MEDLINE, CINAHL, and EMBASE were searched between March 2006 and 25th January 2023. Pairs of reviewers independently screened all studies, extracted data, and assessed risk of bias using QUADAS-2. Pooling was performed for homogenous studies. Positive likelihood ratios (+LR) ≥2 and negative likelihood ratios (-LR) ≤0.5 were considered informative. This review is registered with PROSPERO (CRD42020169828).

Findings

We included 62 studies: 35 investigated the disc, 14 the facet joint, 11 the sacroiliac joint, and 2 investigated all three structures in patients with persistent low back pain. For risk of bias, the domain 'reference standard' scored worst, however approximately half the studies were of low risk of bias for every other domain. For the disc, pooling demonstrated MRI findings of disc degeneration and annular fissure resulted in informative +LRs: 2.53 (95% CI: 1.57-4.07) and 2.88 (95% CI: 2.02-4.10) and -LRs: 0.15 (95% CI: 0.09-0.24) and 0.24 (95% CI: 0.10-0.55) respectively. Pooled results for Modic type 1, Modic type 2, and HIZ on MRI, and centralisation phenomenon yielded informative +LRs: 10.00 (95% CI: 4.20-23.82), 8.03 (95% CI: 3.23-19.97), 3.10 (95% CI: 2.27-4.25), and 3.06 (95% CI: 1.44-6.50) respectively, but uninformative -LRs: 0.84 (95% CI: 0.74-0.96), 0.88 (95% CI: 0.80-0.96), 0.61 (95% CI: 0.48-0.77), and 0.66 (95% CI: 0.52-0.84) respectively. For the facet joint, pooling demonstrated facet joint uptake on SPECT resulted in informative +LRs: 2.80 (95% CI: 1.82-4.31) and -LRs: 0.44 (95% CI: 0.25-0.77). For the sacroiliac joint, a combination of pain provocation tests and absence of midline low back pain resulted in informative +LRs of 2.41 (95% CI: 1.89-3.07) and 2.44 (95% CI: 1.50-3.98) and -LRs of 0.35 (95% CI: 0.12-1.01) and 0.31 (95% CI: 0.21-0.47) respectively. Radionuclide imaging yielded an informative +LR 7.33 (95% CI: 1.42-37.80) but an uninformative -LR 0.74 (95% CI: 0.41-1.34).

Interpretation

There are informative diagnostic tests for the disc, sacroiliac joint, and facet joint (only one test). The evidence suggests a diagnosis may be possible for some patients with low back pain, potentially guiding targeted and specific treatment approaches.

Funding

There was no funding for this study.

Management of low back pain in Australian emergency departments for culturally and linguistically diverse populations from 2016 to 2021

BACKGROUND

Disparate care in the ED for minority populations with low back pain is a long-standing issue reported in the USA. Our objective was to compare care delivery for low back pain in Australian EDs between culturally and linguistically diverse (CALD) and non-CALD patients.

METHODS

This is a retrospective review of medical records of the ED of three public hospitals in Sydney, New South Wales, Australia from January 2016 to October 2021. We included adult patients diagnosed with non-serious low back pain at ED discharge. CALD status was defined by country of birth, preferred language and use of interpreter service. The main outcome measures were ambulance transport, lumbar imaging, opioid administration and hospital admission.

RESULTS

Of the 14 642 included presentations, 7656 patients (52.7%) were born overseas, 3695 (25.2%) preferred communicating in a non-English language and 1224 (8.4%) required an interpreter. Patients born overseas were less likely to arrive by ambulance (adjusted OR (aOR) 0.68, 95% CI 0.63 to 0.73) than Australian-born patients. Patients who preferred a non-English language were also less likely to arrive by ambulance (aOR 0.82, 95% CI 0.75 to 0.90), yet more likely to be imaged (aOR 1.12, 95% CI 1.01 to 1.23) or be admitted to hospital (aOR 1.16, 95% CI 1.04 to 1.29) than Native-English-speaking patients. Patients who required an interpreter were more likely to receive imaging (aOR 1.43, 95% CI 1.25 to 1.64) or be admitted (aOR 1.49, 95% CI 1.29 to 1.73) compared with those who communicated independently. CALD patients were generally less likely to receive weak opioids than non-CALD patients (aOR range 0.76-0.87), yet no difference was found in the use of any opioid or strong opioids.

CONCLUSION

Patients with low back pain from a CALD background, especially those lacking English proficiency, are significantly more likely to be imaged and admitted in Australian EDs. Future interventions improving the quality of ED care for low back pain should give special consideration to CALD patients.

Racial and ethnic differences in the use of lumbar imaging, opioid analgesics and spinal surgery for low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

There is a substantial gap between evidence and clinical care for low back pain (LBP) worldwide despite recommendations of best practice specified in clinical practice guidelines. The aim of this systematic review was to identify disparities associated with race or ethnicity in the use of lumbar imaging, opioid analgesics, and spinal surgery in people with LBP.

DATABASES AND DATA TREATMENT

We included observational studies which compared the use of lumbar imaging, opioid analgesics, and spinal surgery for the management of non-serious LBP between people from different racial/ethnic populations. We searched in MEDLINE, EMBASE and CINAHL from January 2000 to June 2021. Risk of bias of included studies was appraised in six domains. For each type of care, we pooled data stratified by race and ethnicity using random effects models.

RESULTS

We identified 13 eligible studies; all conducted in the United States. Hispanic/Latino (OR 0.69, 95%CI 0.49-0.96) and Black/African American (OR 0.59, 95%CI 0.46-0.75) people with LBP were less likely to be prescribed opioid analgesics than White people. Black/African Americans were less likely to undergo or be recommended spinal surgery for LBP (OR 0.47, 95%CI 0.33-0.67) than White people. There was a lack of high certainty evidence on racial/ethnic disparities in the use of lumbar imaging.

CONCLUSION

This review reveals lower rate of the use of guideline-discordant care, especially opioid prescription and spinal surgery, in racial/ethnic minority populations with LBP in the United States. Future studies in other countries evaluating care equity for LBP are warranted. PROSPERO Registration ID: CRD42021260668.

SIGNIFICANCE

This systematic review and meta-analysis revealed that people with low back pain from the minority racial/ethnic backgrounds were less likely to be prescribed opioid analgesics and undergo spinal surgery than the majority counterparts. Strategic interventions to improve the access to, and the value of, clinical care for minority populations with low back pain are warranted.

Australian emergency department care for older adults diagnosed with low back pain of lumbar spine origin: a retrospective analysis of electronic medical record system data (2016-2019)

BACKGROUND

In Australian emergency departments, 30% of all back pain presentations are for older adults. Relatively little is known about the care that this population receives during an emergency department stay, including admission to hospital. The aim of this study is to describe emergency department management of older adults diagnosed with a lumbar spine condition and to determine predictors of healthcare use in this population.

METHODS

A retrospective analysis of electronic medical record data of adults aged ≥ 65 years with a lumbar spine discharge diagnosis. Demographic, clinical care (date and time of presentation and discharge, length of stay in the emergency department, mode of arrival, triage category, re-presentations to the emergency department (within 48 h), discharge mode, the administration of pain-relieving medicines, lumbar imaging, and laboratory tests) and costs data were extracted from the electronic medical record system. Descriptive analyses and multilevel mixed-effects logistic regression models were performed.

RESULTS

Over the period January 2016 to December 2019 there were 4,093 presentations to emergency departments by older adults with a lumbar spine discharge diagnosis (82.0% were non-specific low back pain). Most were female (58.3%), 39.9% had some form of lumbar imaging, and 34.1% were admitted to hospital. The most administered pain medicines were opioid analgesics (67.1%), followed by paracetamol (63.9%) and NSAIDs (33.0%). Predictors of healthcare use and hospital inpatient admission were receiving a laboratory test and receiving any opioid. For the financial period 2019-20, the mean (SD) total cost of care per presentation was $5,629 ($11,982).

CONCLUSION

In the emergency department, more than two thirds of older adults with a lumbar spine condition received opioid analgesics. They often received imaging and laboratory tests, had high costs and were admitted to hospital. Alternative pathways of care are needed to support older adults with low back pain, to receive guideline-concordant emergency department care and have good health outcomes.

Management of patients with low back pain admitted to hospital: An observational study of usual care

BACKGROUND

Knowledge gaps exist around diagnostic and treatment approaches for patients admitted to hospital with low back pain.

METHODS

Medical record review of patients admitted to three Sydney teaching hospitals with a provisional emergency department diagnosis of non-serious low back pain, from 2016 to 2020. Data on demographic variables, hospital costs, length of stay (LOS), diagnostic imaging and analgesic administration were extracted. Logistic regression was used to identify predictors of longer hospital stay, advanced imaging, and concomitant use of sedating medicines.

RESULTS

Median inpatient LOS for non-specific low back pain was 4 days (interquartile range [IQR] 2-7), and for radicular low back pain was 4 days (IQR 3-10). Older patients with non-serious low back pain were more likely to stay longer, as were arrivals by ambulance. Plain lumbar radiography was used in 8.3% of admissions, whereas 37.6% of patients received advanced lumbar imaging (computed tomography or magnetic resonance imaging). Opioids were administered in ~80% of admissions; 49% of patients with radicular low back pain were given an antiepileptic in addition to an opioid. In all, 18.4% of admissions resulted in at least one hospital-acquired complication, such as an accidental fall (3.1%) or a medication-related adverse effect (13.3%). Physiotherapists saw 82.6% of low back pain admissions. Costs of inpatient care were estimated at a mean of AU$ 14 000 per admission.

CONCLUSIONS

We noted relatively high rates of concomitant use of sedating pain medicines and referrals for advanced lumbar imaging and laboratory tests. Strategies to address these issues in inpatient care of low back pain are needed.

Which clinical research questions are the most important? Development and preliminary validation of the Australia & New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network Research Question Importance Tool (ANZMUSC-RQIT)

BACKGROUND AND AIMS

High quality clinical research that addresses important questions requires significant resources. In resource-constrained environments, projects will therefore need to be prioritized. The Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network aimed to develop a stakeholder-based, transparent, easily implementable tool that provides a score for the 'importance' of a research question which could be used to rank research projects in order of importance.

METHODS

Using a mixed-methods, multi-stage approach that included a Delphi survey, consensus workshop, inter-rater reliability testing, validity testing and calibration using a discrete-choice methodology, the Research Question Importance Tool (ANZMUSC-RQIT) was developed. The tool incorporated broad stakeholder opinion, including consumers, at each stage and is designed for scoring by committee consensus.

RESULTS

The ANZMUSC-RQIT tool consists of 5 dimensions (compared to 6 dimensions for an earlier version of RQIT): (1) extent of stakeholder consensus, (2) social burden of health condition, (3) patient burden of health condition, (4) anticipated effectiveness of proposed intervention, and (5) extent to which health equity is addressed by the research. Each dimension is assessed by defining ordered levels of a relevant attribute and by assigning a score to each level. The scores for the dimensions are then summed to obtain an overall ANZMUSC-RQIT score, which represents the importance of the research question. The result is a score on an interval scale with an arbitrary unit, ranging from 0 (minimal importance) to 1000. The ANZMUSC-RQIT dimensions can be reliably ordered by committee consensus (ICC 0.73-0.93) and the overall score is positively associated with citation count (standardised regression coefficient 0.33, p<0.001) and journal impact factor group (OR 6.78, 95% CI 3.17 to 14.50 for 3rd tertile compared to 1st tertile of ANZMUSC-RQIT scores) for 200 published musculoskeletal clinical trials.

CONCLUSION

We propose that the ANZMUSC-RQIT is a useful tool for prioritising the importance of a research question.

Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis

PURPOSE

An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations.

METHODS

In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses.

RESULTS

Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain.

CONCLUSION

Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP.

General practitioner experiences using a low back pain management booklet aiming to decrease non-indicated imaging for low back pain

Background

Imaging is overused in the management of low back pain, resulting in overdiagnosis, increased healthcare utilisation, and increased costs. Few effective interventions to decrease inappropriate use have been developed and have typically not been developed using behaviour change theory. An intervention to reduce non-indicated imaging for low back pain was developed using behavioural change theory, incorporating a novel low back pain management booklet to facilitate patient education and reassurance. The aim of this study was to assess the adoption and feasibility of use of the developed intervention within clinical practice and to determine appropriate implementation strategies to address identified barriers to use.

Methods

Fourteen general medical practitioners were recruited and trained to use the booklet with low back pain patients over a minimum 5-month period. Quantitative data on use of the booklet were collected and analysed descriptively. Qualitative data on use of the booklet and training session were collected in general medical practitioner interviews and thematically analysed. Barriers to use were identified and mapped to suitable implementation strategies using the Behaviour Change Wheel.

Results

Practitioners used the booklet with 73 patients. The booklet was used with 63% of patients presenting with low back pain. Facilitators for using the booklet included patient’s requesting imaging and lower practitioner confidence in managing low back pain. Barriers included accessible storage and remembering to use the booklet. Implementation strategies were identified to increase adoption and feasibility of use, including development of a digital version of the booklet.

Conclusions

General medical practitioners reported that the low back pain management booklet and training were useful for clinical practice, particularly with patients requesting imaging. Barriers to use were identified and implementation strategies to address these barriers will be incorporated into future effectiveness studies. This study forms one of a series of studies to thoroughly develop and test an intervention to reduce non-indicated imaging for low back pain; a successful intervention would decrease healthcare costs and improve patient management.

Commentary: collaborative systematic review may produce and share high-quality, comparative evidence more efficiently

Systematic reviews are necessary to synthesize available evidence and inform clinical practice and health policy decisions. There has been an explosion of evidence available in many fields; this makes it challenging to keep evidence syntheses up to date and useful. Comparative effectiveness systematic reviews are informative; however, producing these often-large reviews bring intense time and resource demands. This commentary describes the implementation of a systematic review using a collaborative model of evidence synthesis. We are implementing the collaborative review model to update a large Cochrane review investigating the efficacy and comparative effectiveness of the design, delivery, and type of exercise treatment for people with chronic low-back pain. Three key benefits of the collaborative review model for evidence synthesis are (1) team coordination and collaboration, (2) quality control measures, and (3) advanced comparative and other analyses. This new collaborative review model is developed and implemented to produce and share high-quality, comparative evidence more efficiently while building capacity and community within a research field.

The environmental impact of health care for musculoskeletal conditions: A scoping review

BACKGROUND

Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions.

METHODS

We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed.

RESULTS

Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1).

CONCLUSION

Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.

Reliability and validity of subjective radiologist reporting of temporal changes in lumbar spine MRI findings

BACKGROUND

The importance of lumbar findings on magnetic resonance imaging (MRI) remains controversial. Changes in lumbar MRI findings over time may provide important insights into the causes of low back pain. However, the reliability and validity of temporal changes are unknown.

OBJECTIVE

To (1) investigate the interrater reliability of subjective radiologist reporting of temporal changes in lumbar spine MRI findings and (2) determine how commonly temporal changes are reported when two scans are conducted 30 minutes apart (considered false positives).

DESIGN

Cross-sectional study.

SETTING

Radiology clinic.

PARTICIPANTS

Forty volunteers (mean age 40; 53% female) with current (n = 31) or previous (n = 9) low back pain underwent initial lumbar MRI on a single 3T scanner. Participants then lay on a bed for 30 minutes before undergoing an identical MRI. In addition, we purposely selected five participants from a previous study with repeat lumbar MRI scans where temporal changes were reported in at least one MRI finding (1-12 weeks after initial scan) and another five participants where no temporal change was reported. The 10 participants were included in analyses for aim 1 only.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Two blinded radiologists reported on temporal changes between the baseline and repeat scan for 12 different MRI findings (eg, disk herniation, annular fissure) at five levels.

RESULTS

The interrater reliability of subjective reporting of temporal changes was poor for all MRI findings based on Kappa values (≤ 0.24), but agreement was relatively high (≥ 90.8%). This is explained by the low prevalence of temporal changes as demonstrated by high values for Prevalence and Bias Adjusted Kappa (≥ 0.82). "False positive" temporal changes were reported by at least one radiologist for most MRI findings, but the rate was generally low.

CONCLUSIONS

Caution is required when interpreting temporal changes in lumbar MRI findings owing to low reliability and some false positive reporting.

Paramedic management of back pain: a scoping review

BACKGROUND

Research examining paramedic care of back pain is limited.

OBJECTIVE

To describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics.

METHODS

We included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews.

RESULTS

From 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data.

CONCLUSION

Paramedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.

Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

The effects of altered neural processing, defined as altering neural networks responsible for perceptions of pain and function, on chronic pain remains unclear.

OBJECTIVE

To estimate the effect of a graded sensorimotor retraining intervention (RESOLVE) on pain intensity in people with chronic low back pain.

DESIGN, SETTING, AND PARTICIPANTS

This parallel, 2-group, randomized clinical trial recruited participants with chronic (>3 months) nonspecific low back pain from primary care and community settings. A total of 276 adults were randomized (in a 1:1 ratio) to the intervention or sham procedure and attention control groups delivered by clinicians at a medical research institute in Sydney, Australia. The first participant was randomized on December 10, 2015, and the last was randomized on July 25, 2019. Follow-up was completed on February 3, 2020.

INTERVENTIONS

Participants randomized to the intervention group (n = 138) were asked to participate in 12 weekly clinical sessions and home training designed to educate them about and assist them with movement and physical activity while experiencing lower back pain. Participants randomized to the control group (n = 138) were asked to participate in 12 weekly clinical sessions and home training that required similar time as the intervention but did not focus on education, movement, and physical activity. The control group included sham laser and shortwave diathermy applied to the back and sham noninvasive brain stimulation.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity at 18 weeks, measured on an 11-point numerical rating scale (range, 0 [no pain] to 10 [worst pain imaginable]) for which the between-group minimum clinically important difference is 1.0 point.

RESULTS

Among 276 randomized patients (mean [SD] age, 46 [14.3] years; 138 [50%] women), 261 (95%) completed follow-up at 18 weeks. The mean pain intensity was 5.6 at baseline and 3.1 at 18 weeks in the intervention group and 5.8 at baseline and 4.0 at 18 weeks in the control group, with an estimated between-group mean difference at 18 weeks of -1.0 point ([95% CI, -1.5 to -0.4]; P = .001), favoring the intervention group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings.

TRIAL REGISTRATION

ANZCTR Identifier: ACTRN12615000610538.

Spinal Cord Stimulators: An Analysis of the Adverse Events Reported to the Australian Therapeutic Goods Administration

BACKGROUND

Spinal cord stimulators are used to treat intractable pain. Placebo-controlled trials of spinal cord stimulators typically involve short-term treatment and follow-up, so long-term safety and efficacy are unclear.

AIM

The aim of the study was to describe the adverse events relating to spinal cord stimulators reported to the Therapeutic Goods Administration of Australia between July 2012 and January 2019.

METHODS

Adverse events were coded by seriousness, severity, body system affected, type of event, action taken, and attribution of fault. Data on the number of stimulators implanted and removed were sourced from the Admitted Patient Care Minimum Data Set.

RESULTS

Five hundred twenty adverse events were reported for spinal cord stimulators. Most events were rated as severe (79%) or life-threatening (13%). Device malfunction was the most common event (56.5%). The most common action taken in response to an adverse event was surgical intervention with or without antibiotics (80%). The ratio of removals to implants was 4 per every 10 implanted.

CONCLUSIONS

Spinal cords stimulators have the potential for serious harm, and each year in Australia, many are removed. In view of the low certainty evidence of their long-term safety and effectiveness, our results raise questions about their role in providing long-term management of intractable pain.

Effectiveness of clinical dashboards as audit and feedback or clinical decision support tools on medication use and test ordering: a systematic review of randomized controlled trials

BACKGROUND

Clinical dashboards used as audit and feedback (A&F) or clinical decision support systems (CDSS) are increasingly adopted in healthcare. However, their effectiveness in changing the behavior of clinicians or patients is still unclear. This systematic review aims to investigate the effectiveness of clinical dashboards used as CDSS or A&F tools (as a standalone intervention or part of a multifaceted intervention) in primary care or hospital settings on medication prescription/adherence and test ordering.

METHODS

Seven major databases were searched for relevant studies, from inception to August 2021. Two authors independently extracted data, assessed the risk of bias using the Cochrane RoB II scale, and evaluated the certainty of evidence using GRADE. Data on trial characteristics and intervention effect sizes were extracted. A narrative synthesis was performed to summarize the findings of the included trials.

RESULTS

Eleven randomized trials were included. Eight trials evaluated clinical dashboards as standalone interventions and provided conflicting evidence on changes in antibiotic prescribing and no effects on statin prescribing compared to usual care. Dashboards increased medication adherence in patients with inflammatory arthritis but not in kidney transplant recipients. Three trials investigated dashboards as part of multicomponent interventions revealing decreased use of opioids for low back pain, increased proportion of patients receiving cardiovascular risk screening, and reduced antibiotic prescribing for upper respiratory tract infections.

CONCLUSION

There is limited evidence that dashboards integrated into electronic medical record systems and used as feedback or decision support tools may be associated with improvements in medication use and test ordering.

Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment

Background

Diagnostic labels may influence treatment intentions. We examined the effect of labelling low back pain (LBP) on beliefs about imaging, surgery, second opinion, seriousness, recovery, work, and physical activities.

Methods

Six‐arm online randomized experiment with blinded participants with and without LBP. Participants received one of six labels: ‘disc bulge’,‘degeneration’,‘arthritis’,‘lumbar sprain’,‘non‐specific LBP’, ‘episode of back pain’. The primary outcome was the belief about the need for imaging.

Results

A total of 1375 participants (mean [SD] age, 41.7 years [18.4 years]; 748 women [54.4%]) were included. The need for imaging was rated lower with the labels ‘episode of back pain’ (4.2 [2.9]), ‘lumbar sprain’ (4.2 [2.9]) and ‘non‐specific LBP’ (4.4 [3.0]) compared to the labels ‘arthritis’ (6.0 [2.9]), ‘degeneration’ (5.7 [3.2]) and ‘disc bulge’ (5.7 [3.1]). The same labels led to higher recovery expectations and lower ratings of need for a second opinion, surgery and perceived seriousness compared to ‘disc bulge’,‘degeneration’ and ‘arthritis’. Differences were larger amongst participants with current LBP who had a history of seeking care. No differences were found in beliefs about physical activity and work between the six labels.

Conclusions

‘Episode of back pain’,‘lumbar sprain’ and ‘non‐specific LBP’ reduced need for imaging, surgery and second opinion compared to ‘arthritis’,‘degeneration’ and ‘disc bulge’ amongst public and patients with LBP as well as reducing the perceived seriousness of LBP and enhancing recovery expectations. The impact of labels appears most relevant amongst those at risk of poor outcomes (participants with current LBP who had a history of seeking care).

Continued opioid use following an emergency department presentation for low back pain

OBJECTIVE

To investigate the proportion of patients with low back pain who receive an opioid analgesic prescription on hospital discharge, the proportion using opioid analgesics 4 weeks after discharge, and to identify predictors of continued opioid analgesic use at 4 weeks after an ED presentation in opioid-naïve patients.

METHODS

An observational cohort study nested within a randomised controlled trial in four EDs in New South Wales, Australia. Participants were adults who presented to the ED with non-specific low back pain or low back pain with lower limb neurological signs and symptoms. Electronic medical records supplemented the patient-reported pain and use of opioid analgesics at 4-week follow up.

RESULTS

Of the 104 patients included, 33 (31.7%, 95% confidence interval [CI] 22.9-41.6) received an opioid analgesic prescription at hospital discharge and 38 (36.5%, 95% CI 27.3-46.6) reported taking an opioid analgesic for pain 4 weeks after the ED presentation. Among opioid-naïve patients (n = 85), older age (odds ratio [OR] 1.04, 95% CI 1.00-1.08, P = 0.031) was the only predictor for continued opioid analgesic use at 4 weeks post-ED presentation.

CONCLUSION

About one-third of patients who present to the ED with low back pain receive an opioid analgesic prescription on discharge and are taking an opioid analgesic 4 weeks later. These findings justify future research to identify strategies to reduce the risk of long-term opioid use in patients who present to the ED with low back pain.

Second opinions for spinal surgery: a scoping review

BACKGROUND

Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain.

METHODS

We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.

RESULTS

We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections).

CONCLUSIONS

Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.

OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain—a statistical analysis plan

Background

Low back and neck pain are a leading cause of disease burden globally. Opioids are recommended in guidelines for acute low back and neck pain; however, there is a lack of compelling efficacy data to support this.

Methods

The OPAL trial is a prospectively registered, triple-blinded, randomised, placebo-controlled trial. Patients with acute (≤12 weeks duration) back and/or neck pain receive guideline care plus either an opioid (oxycodone + naloxone, up to 20 mg per day) or a placebo for up to 6 weeks or earlier, if pain is resolved. The primary outcome is pain measured using the Pain Severity Score of the Brief Pain Inventory with the primary time point being 6 weeks. Secondary outcomes include physical function, time to recovery, quality of life, adverse events and risk of opioid misuse. Outcomes are collected at weeks 2, 4, 6, 12, 26 and 52. Analysis will be done on an intention-to-treat principle. p values of < 0.05 will be considered significant and 95% confidence intervals will be reported. Repeated-measures linear mixed models will be used to assess the effect of the treatment group on the primary outcome and continuous secondary outcomes. Adverse events will be compared between groups using Fisher’s exact test. Cost-effectiveness analyses will be conducted if a treatment effect on pain is seen at week 6. Subgroup analyses will be performed to assess whether pain duration and pain location are treatment effect modifiers.

Discussion

The OPAL trial will provide important evidence about whether a short course of opioids is effective in the treatment of acute non-specific low back and/or neck pain. This pre-specified statistical analysis plan details the methodology for the analysis of the OPAL trial results.

Trial registration

ACTRN12615000775516. The trial has completed recruitment. Follow-up on the last patient will be completed in March 2022.

Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause

To determine the proportion of patients admitted to the hospital for back pain who have nonserious back pain, serious spinal, or serious other pathology as their final diagnosis. The proportion of nonserious back pain admissions will be used to plan for future 'virtual hospital' admissions. Electronic medical record data between January 2016 and September 2020 from three emergency departments (ED) in Sydney, Australia were used to identify inpatient admissions. SNOMED-CT-AU diagnostic codes were used to select ED patients aged 18 and older with an admitting diagnosis related to nonserious back pain. The inpatient discharge diagnosis was determined from the primary ICD-10-AM codes by two independent clinician-researchers. Inpatient admissions were then analysed by sociodemographic and hospital admission variables. A total of 38.1% of patients admitted with a provisional diagnosis of nonserious back pain were subsequently diagnosed with a specific pathology likely unsuitable for virtual care; 14.2% with a serious spinal pathology (e.g., fracture and infection) and 23.9% a serious pathology beyond the lumbar spine (e.g., pathological fracture and neoplasm). A total of 57% of admissions were identified as nonserious back pain, likely suitable for virtual care. A challenge for implementing virtual care in this setting is screening for patients with serious pathology. Protocols need to be developed to reduce the risk of patients being admitted to virtual hospitals with serious pathology as the cause of their back pain. Key Points • Among admitted patients provisionally diagnosed in ED with non-serious back pain, 38.1% were found to have 'serious spinal pathologies' or 'serious pathologies beyond the lumbar spine' at discharge. • Spinal fractures were the most common serious spinal pathology, accounting for 9% of all provisional 'non-serious back pain' admissions from ED. • 57% of back pain admissions were confirmed to be non-serious back pain and may be suitable to virtual hospital care; the challenge is discriminating these patients from those with serious pathology.

Effect of a waiting room communication strategy on imaging rates and awareness of public health messages for low back pain

BACKGROUND

Few studies have investigated the effects of waiting room communication strategies on health-care behavior.

OBJECTIVE

We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED).

METHODS

We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55" LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55" LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey.

RESULTS

For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n = 99; control n = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI) = 18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI = 23% to 35%; odds ratio (OR) = 0.83, 95% CI = 0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n = 170; control n = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR = 2.00, 95% CI = 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages.

CONCLUSION

A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality.

TRIAL REGISTRATION

ACTRN12620000300976, 05/03/2020.

Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: a systematic review

QUESTIONS

What is the effect of advice/education compared with placebo or no advice/education on pain and disability in people with non-specific spinal pain? To what extent do characteristics of the patients, trial or intervention modify the estimate of the treatment effects?

DESIGN

A systematic review with meta-analyses of randomised controlled trials.

PARTICIPANTS

Adults with non-specific back and/or neck pain with or without radiating leg/arm pain of any duration were included. Trials recruiting pregnant women or surgical patients in the immediate postoperative phase were ineligible.

INTERVENTION

Advice or education.

OUTCOME MEASURES

The primary outcomes were self-reported pain and disability, and the secondary outcome was adverse events. The following potential effect modifiers were examined: risk of bias, duration of pain, location of pain, intensity of intervention and mode of intervention.

RESULTS

Twenty-seven trials involving 7,006 participants were included. Eighteen of the included trials were assessed as being at low risk of bias (≥ 6 on the PEDro scale). There was low-quality evidence that advice had a small effect on pain (MD -8.2, 95% CI -12.5 to -3.9, n = 2,241) and moderate-quality evidence that advice had a small effect on disability (MD -4.5, 95% CI -7.9 to -1.0, n = 2,579) compared with no advice or placebo advice in the short-term. None of the items that were assessed modified the treatment effects.

CONCLUSION

Advice provides short-term improvements in pain and disability in non-specific spinal pain, but the effects are small and may be insufficient as the sole treatment for patients with spinal pain.

REGISTRATION

PROSPERO CRD42020162008.

Do patients with acute low back pain in emergency departments have more severe symptoms than those in general practice? A systematic review with meta-analysis

INTRODUCTION

There is a common belief that patients presenting to emergency departments have more severe pain levels and functional limitations than those in general practice. The aim of this systematic review was to compare pain and disability levels of patients with acute low back pain presenting to general practice versus those presenting to emergency departments.

METHODS

Electronic searches were conducted in MEDLINE, EMBASE and CINAHL from inception to February 2019. Observational studies including patients with acute non-specific low back pain presenting to emergency departments and/or general practice were eligible. Pain and/or disability scores expressed on a 0-100 scale were the primary outcomes. Risk of bias was evaluated using a validated tool for observational studies and the overall quality of evidence was assessed using GRADE. Meta-analysis using random effects and meta-regression were used to test for differences between the two settings.

RESULTS

We included 12 records reporting results for 10 unique studies with a total of 6,999 participants from general practice (n = 6) and emergency departments (n = 4). There was low quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher pain scores than those in general practice with a mean difference of 17.3 points (95%CI: 8.8 to 25.9 on a 0-100 scale). Similarly, there was low quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher disability scores than those in general practice (mean difference: 21.7, 95%CI: 4.6 to 38.7 on a 0-100 scale).

CONCLUSION

Patients with acute non-specific low back pain presenting to emergency departments may report higher levels of pain and disability than those seen in general practice.

PROSPERO REGISTRATION NUMBER

CRD42017076806.

Appropriateness of imaging decisions for low back pain presenting to the emergency department: a retrospective chart review study

BACKGROUND

Imaging for low back pain is widely regarded as a target for efforts to reduce low-value care.

OBJECTIVE

We aimed to estimate the prevalence of the overuse and underuse of lumbar imaging in patients presenting with low back pain to the emergency department (ED).

METHODS

This was a retrospective chart review study of five public hospital EDs in Sydney, Australia, in 2019-20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse).

RESULTS

Six hundred and forty-nine patients presented with a complaint of low back pain, of which 158 (24.3%) were referred for imaging. Seventy-nine (12.2%) had a combination of features suggesting that lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95% CI 6.8-11.2%) and 4.3% (28 of 649 cases, 95% CI 3.0-6.1%), respectively. Thirteen cases were classified as underuse because the patients were referred for uninformative imaging modalities (e.g. referred for radiography for suspected cauda equina syndrome).

CONCLUSION

In this study of emergency care, there was evidence of not only overuse of lumbar imaging but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.

Journalists' views on media coverage of medical tests and overdiagnosis: a qualitative study

OBJECTIVE

Promotional media coverage of early detection tests is an important driver of overdiagnosis. Following research evidence that global media coverage presents the benefits of testing healthy people far more frequently than harms, and gives little coverage to overdiagnosis, we sought to examine journalists' views on media reporting of tests, overdiagnosis, and strategies to improve critical reporting on tests.

DESIGN

Qualitative study using semistructured telephone interviews. Interviews were conducted between February and March 2020 and were audiorecorded and transcribed verbatim. Framework thematic analysis was used to analyse the data.

PARTICIPANTS AND SETTING

Twenty-two journalists (mainly specialising in health reporting, average 14.5 years' experience) based in Australia.

RESULTS

This sample of journalists acknowledged the potential harms of medical tests but felt that knowledge of harms was low among journalists and the public at large. Most were aware of the term overdiagnosis, but commonly felt that it is challenging to both understand and communicate in light of strong beliefs in the benefits of early detection. Journalists felt that newsworthiness in the form of major public health impact was the key ingredient for stories about medical tests. The journalists acknowledged that factors, like the press release and 'click bait culture' in particular, can influence the framing of coverage about tests. Lack of knowledge and training, as well as time pressures, were perceived to be the main barriers to critical reporting on tests. Journalists felt that training and better access to information about potential harms would enable more critical reporting.

CONCLUSIONS

Effectively communicating overdiagnosis is a challenge in light of common beliefs about the benefits of testing and the culture of current journalism practices. Providing journalists with training, support and better access to information about potential harms of tests could aid critical reporting of tests.

Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study

BACKGROUND

Overuse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential.

AIM

To explore factors that might influence overuse of lumbar imaging in the Emergency Department.

METHODS

Participants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds.

RESULTS

Patients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients' perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care.

CONCLUSION AND KEY FINDINGS

We found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.

"I would not go to him": Focus groups exploring community responses to a public health campaign aimed at reducing unnecessary diagnostic imaging of low back pain

BACKGROUND

Community awareness of the harms of overdiagnosis remains low.

OBJECTIVE

To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain.

METHODS

We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes.

RESULTS

Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging.

CONCLUSIONS

Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully.

PATIENT OR PUBLIC CONTRIBUTION

We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation.