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.

Overcoming Overuse Part 4: Small Business Survival.

SUMMARY: The challenge of overuse raises important questions for those in the business of musculoskeletal health care. What is the right number of physical therapy visits for a given condition? Can a practice provide "less" but still be profitable? In this, the editorial on overcoming overuse of musculoskeletal health care, we consider the economic drivers of overuse in the private sector. We propose actions that could support small business leaders to overcome overuse and build profitable, high-quality services. J Orthop Sports Phys Ther 2021;51(1):1-4. doi:10.2519/jospt.2021.0101.

Overcoming Overuse: Improving Musculoskeletal Health Care.

SUMMARY: This is the first article in a series on "Overcoming Overuse" in musculoskeletal health care. Overuse is the use of services that are unlikely to improve patient outcomes, result in more harm than benefit, and would not be desired by an informed patient. The Overcoming Overuse series explores the myriad ways diagnostic tests and treatments are overused in musculoskeletal health care, and proposes ways to ensure patients receive appropriate care. We focus on strategies to promote guideline-concordant care in rehabilitation practice and strategies to overcome overuse. J Orthop Sports Phys Ther 2020;50(3):113-115. doi:10.2519/jospt.2020.0102.

Care for low back pain: can health systems deliver?

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.

Les lombalgies sont la principale cause d'années de vie vécues avec une incapacité dans le monde. En 2018, un groupe de travail international a invité l'Organisation mondiale de la Santé à attirer l'attention sur la charge que représentent les lombalgies et sur la nécessité d'éviter le recours excessif aux solutions médicales. En effet, selon les dernières recommandations cliniques internationales, de nombreux cas de lombalgie ne nécessitent pas ou peu de traitement formel. Lorsqu'un traitement est requis, il est recommandé de limiter la prise d'analgésiques, les injections de stéroïdes et la chirurgie rachidienne, et d'encourager plutôt les thérapeutiques physiques et psychologiques. Très souvent, les systèmes de santé ne sont pas conçus pour appliquer cette approche. Dans cet article, nous abordons les raisons pour lesquelles un changement des systèmes s'impose si l'on veut prendre en charge les lombalgies suivant les recommandations. Nous détaillons les principales difficultés de la prise en charge des lombalgies dans le cadre des systèmes de santé. Il s'agit notamment des intérêts financiers des laboratoires pharmaceutiques, entre autres; des systèmes de paiement obsolètes qui privilégient la prise en charge médicale à l'autogestion par les patients; et de croyances et traditions médicales profondément ancrées parmi les médecins et la population. Nous donnons des exemples internationaux de solutions, de politiques et de pratiques prometteuses pour les systèmes de santé confrontés de plus en plus souvent à une prise en charge inefficace des lombalgies. Nous suggérons des politiques qui, sans incidence sur les coûts, en transférant les ressources allouées aux soins inutiles vers des soins conformes aux recommandations, pourraient avoir un impact considérable. De petits ajustements des politiques de santé ne suffiront cependant pas. Les systèmes des milieux professionnels, les cadres juridiques, les croyances personnelles, les politiques et le contexte sociétal global dans lequel s'inscrit la santé devront également changer.

El dolor lumbar es la causa principal de vivir con discapacidad durante años en todo el mundo. En 2018, un grupo de trabajo internacional pidió a la Organización Mundial de la Salud que prestara más atención a la carga del dolor lumbar y a la necesidad de evitar soluciones excesivamente médicas. De hecho, las principales directrices clínicas internacionales reconocen ahora que muchas personas con dolor lumbar requieren poco o ningún tratamiento formal. Cuando se requiere tratamiento, el enfoque recomendado es desalentar el uso de analgésicos, inyecciones de esteroides y cirugía de la columna vertebral y, en su lugar, promover las terapias físicas y psicológicas. Muchos sistemas de salud no están diseñados para apoyar este enfoque. En este documento, se expone por qué el cuidado del dolor lumbar de acuerdo con las directrices requiere cambios en todo el sistema. Se detallan los retos clave de la atención del dolor lumbar en los sistemas de salud. Estos incluyen los intereses financieros de las compañías farmacéuticas y de otro tipo, los sistemas de pago obsoletos que favorecen la atención médica por encima del autocuidado de los pacientes, así como las tradiciones y las creencias médicas profundamente arraigadas sobre la atención del dolor de espalda entre los médicos y el público general. Se presentan ejemplos internacionales de soluciones prometedoras y de políticas y prácticas para los sistemas de salud que se enfrentan a una carga cada vez mayor de la atención ineficaz para el dolor lumbar. Se sugieren políticas que, al desplazar los recursos de la atención innecesaria a la atención acorde con las directrices para el dolor lumbar, podrían ser neutras en cuanto a costes y tener un impacto generalizado. Sin embargo, los pequeños ajustes en la política sanitaria no funcionarán de forma aislada. Los sistemas del lugar de trabajo, los marcos jurídicos, las creencias personales, la política y el contexto social general en el que vivimos la salud también tendrán que cambiar.

Review article: A scoping review of physiotherapists in the adult emergency department.

To provide an overview of the literature that considers physiotherapists working in the ED in relation to their roles, training levels, patient profile, safety, effectiveness, efficiency, cost-effectiveness and the provision of low-value care. We performed a scoping review of the literature. Four databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched from their inception to December 2016 and we updated searches on PubMed in September 2017. Two reviewers independently screened studies for eligibility. We performed a narrative synthesis of quantitative data. We included 27 studies: five randomised controlled trials (n = 1434), 12 prospective observational studies (n = 153 767), six retrospective studies (n = 9968), two survey studies (n = 61), one case report (n = 3) and one qualitative study (n = 11). Physiotherapists primarily managed patients with low urgency musculoskeletal conditions. Physiotherapists appeared to have similar clinical effectiveness and costs compared to other health providers (four randomised controlled trials). Physiotherapists were associated with increased efficiency (eight observational studies) and reduced low-value care (one observational study). Three observational studies reported very low adverse event rates. However, none of the studies followed participants to measure adverse events that became apparent after the ED visit, nor did they consider unsafe discharge decisions or suboptimal follow-up care. The available evidence suggests that physiotherapists may be as effective as other health providers in managing low urgency musculoskeletal conditions in the ED. There is uncertainty about appropriate training and a lack of robust studies investigating the efficiency, safety and cost-effectiveness of this model of care.

An embedded randomised controlled trial of a Teaser Campaign to optimise recruitment in primary care.

BACKGROUND: Marketing communication and brand identity is a fundamental principle of advertising and end-user engagement. Health researchers have begun to apply this principle to trial recruitment in primary care. The aim of this study was to evaluate whether a Teaser Campaign using a series of postcards in advance of a conventional mail-out increases the number of primary care clinics that engage with a clinical trial. METHODS: Embedded randomised recruitment trial across primary care clinics (general practitioners and physiotherapists) in the Sydney metropolitan area. Clinics in the Teaser Campaign group received a series of branded promotional postcards in advance of a standard letter inviting them to participate in a clinical trial. Clinics in the Standard Mail group did not receive the postcards. RESULTS: From a total of 744 clinics that were sent an invitation letter, 46 clinics in the Teaser Campaign group and 40 clinics in the Standard Mail group responded (11.6% total response rate). There was no between-group difference in the odds of responding to the invitation letter (odds ratio = 1.18, 95% confidence interval = 0.75-1.85, p = 0.49). For physiotherapy clinics and general practice clinics, the odds ratios were 1.43 (confidence interval = 0.82-2.48, p = 0.21) and 0.77 (confidence interval = 0.34-1.75, p = 0.54), respectively. CONCLUSION: A Teaser Campaign using a series of branded promotional postcards did not improve clinic engagement for a randomised controlled trial in primary care.