Short waits, happy patients and expert care, moving basic musculoskeletal care from the emergency department to a physiotherapist-led diversion pathway.

OBJECTIVE: Patients with musculoskeletal conditions (MSKCs) are highly prevalent in ED. This project explores the impact of the pilot phase of a 'diversion pathway', which directed patients with MSKCs from the ED waiting room to an outpatient clinic led by advanced-scope physiotherapists. METHODS: A prospective intervention study comparing care outcomes between patients in the 'diversion pathway' with usual ED care. The characteristics of patients considered eligible and non-eligible are described. RESULTS: Between May and December 2022, 1099 patients were diverted. For diverted patients, mean length of stay (LOS) in ED was reduced by 110 (95% confidence interval [CI]: 99-120) min and 4 h rule compliance improved by 19.3% compared to usual ED care. There were fewer patients who 'did not wait' (DNW) with the diversion pathway. The diverted group was young (median age 22 years and 41% paediatric), mostly low urgency, self-referred and arrived by private transport with minor limb trauma. The diversion pathway triage process appropriately identified 182 patients ineligible for diversion. 96.7% of patients reported satisfaction with care received from the diversion pathway. There was no change in ED representation rates for diverted patients. CONCLUSIONS: A new pathway resulted in reduced LOS, reduced DNW, high patient satisfaction and more people being discharged within 4 h for diverted patients compared to usual ED care. The pathway increased ED capacity, improved key ED performance metrics and safely expedited care delivery for patients.

A systematic search and narrative review of Aboriginal and Torres Strait Islander women and men pelvic health care: demonstrated need for improvement.

Warning:This article contains terms, descriptions and opinions that may be culturally sensitive for Aboriginal and Torres Strait Islander peoples. BACKGROUND: Pelvic health conditions among Aboriginal and Torres Strait Islander women and men are under-recognised and under-reported despite indication of the significant burden of these conditions. Access to effective management provided in a culturally safe manner appears lacking. The study aims were to: (1) summarise the burden of pelvic health conditions among Aboriginal and Torres Strait Islander peoples; (2) explore barriers and enablers to Aboriginal and Torres Strait Islander peoples accessing pelvic healthcare services; and (3) provide considerations on how to implement culturally safe pelvic healthcare services for Aboriginal and Torres Strait Islander peoples. METHODS: This study involved a systematic literature search informing a narrative review. RESULTS: Fourteen specific articles were identified. Burden related to pelvic health conditions was identified for both women and men, noting high likelihood of under-reporting. Barriers to effective culturally safe treatment included racism, shame and stigma associated with women's and men's business, lack of culturally safe services and geographical distance. Enablers included building trust with local communities, using yarning principles and codesign of pelvic health services with Aboriginal health workers and services. Strategies to improve pelvic health care for Aboriginal and Torres Strait Islander peoples were described at the systems, health service and clinician levels. CONCLUSION: Efforts are needed to improve the diagnosis and management of pelvic health conditions for Aboriginal and Torres Strait Islander peoples. Actions are required to engage with local Aboriginal Community Controlled Aboriginal Community Controlled Health Organisations, professionals overseeing service provision and healthcare providers to address the burden of these conditions among Aboriginal and Torres Strait Islander peoples.

Clinical yarning education: development and pilot evaluation of an education program to improve clinical communication in Aboriginal health care - participant, and health manager perspectives.

BACKGROUND: Effective communication between health care clinicians and Aboriginal patients is critical to delivering high quality, accessible, culturally secure health care. Despite this, ineffective communication is a well-documented barrier, and few studies have reported interventions to improve communication. Clinical Yarning is a patient centred communication framework for Aboriginal health care. Building on this framework, this study reports the development and evaluation of a Clinical Yarning education program. METHODS: A Clinical Yarning education program was developed, underpinned by the principles of cultural security and adult learning, informed by a behavioural skills approach. The program was delivered in five health/education settings in one rural Western Australian region. Mixed-methods evaluation included a retrospective pre/post questionnaire to ascertain changes in participants' knowledge, confidence, competence and their perceptions about communication in Aboriginal health care, and the program. Qualitative semi-structured interviews were undertaken with health service managers who oversaw each health care setting and who had not participated in the education program, to explore perceptions about the program and implementation considerations. RESULTS: Twenty-eight health care clinicians and six students completed training and the evaluation survey. There were significant improvements in self-rated communication skills, ability, confidence, knowledge, and perceived importance of communication training from pre to post-program. Participants strongly recommended the program to others, and most commonly valued the simulation/interactive learning activities. Health service managers acknowledged the limitations in most existing cultural training, and felt Clinical Yarning addressed a need; both the concept of Clinical Yarning and the education program provided were valued. Considerations identified for future implementation included: building multilevel partnerships within health services, offering alternate training options such as eLearning or train-the-trainer approaches, and integrating into existing development programs. Workforce transiency and availability were a barrier, particularly in remote areas. CONCLUSIONS: This study offers preliminary support for the Clinical Yarning education program and provides a foundation for further development of this training approach. A future priority is implementation research to investigate the impact of the Clinical Yarning education program on health care and patient outcomes.

Yarning about pain: Evaluating communication training for health professionals at persistent pain services in Queensland, Australia.

Background: Providing cultural education to health professionals is essential in improving the quality of care and outcomes for Aboriginal and Torres Strait Islander patients. This study reports the evaluation of a novel training workshop used as an intervention to improve communication with Aboriginal and Torres Strait Islander patients of persistent pain services. Methods: In this single-arm intervention study, health professionals undertook a one-day workshop, which included cultural capability and communication skills training based on a clinical yarning framework. The workshop was delivered across three adult persistent pain clinics in Queensland. At the end of the training, participants completed a retrospective pre/post evaluation questionnaire (5 points Likert scale, 1 = very low to 5 = very high), to rate their perceived importance of communication training, their knowledge, ability and confidence to communicate effectively. Participants also rated their satisfaction with the training and suggested improvements for future trainings. Results: Fifty-seven health professionals were trained (N = 57/111; 51% participation rate), 51 completed an evaluation questionnaire (n = 51/57; 90% response rate). Significant improvements in the perceived importance of communication training, knowledge, ability and confidence to effectively communicate with Aboriginal and Torres Strait Islander patients were identified (p < 0.001). The greatest increase was in the perceived confidence pre-training mean of 2.96 (SE = 0.11) to the post-training mean of 4.02 (SE = 0.09). Conclusion: This patient-centred communication training, delivered through a novel model that combines cultural capability and the clinical yarning framework applied to the pain management setting, was highly acceptable and significantly improved participants' perceived competence. This method is transferrable to other health system sectors seeking to train their clinical workforce with culturally sensitive communication skills.

What are the core recommendations for gout management in first line and specialist care? Systematic review of clinical practice guidelines.

BACKGROUND: Gout is the most common inflammatory arthritis, increasing in prevalence and burden. Of the rheumatic diseases, gout is the best-understood and potentially most manageable condition. However, it frequently remains untreated or poorly managed. The purpose of this systematic review is to identify Clinical Practice Guidelines (CPG) regarding gout management, evaluate their quality, and to provide a synthesis of consistent recommendations in the high-quality CPGs. METHODS: Gout management CPGs were eligible for inclusion if they were (1) written in English and published between January 2015-February 2022; focused on adults aged ≥ 18 years of age; and met the criteria of a CPG as defined by the Institute of Medicine; and (2) were rated as high quality on the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Gout CPGs were excluded if they required additional payment to access; only addressed recommendations for the system/organisation of care and did not include interventional management recommendations; and/or included other arthritic conditions. OvidSP MEDLINE, Cochrane, CINAHL, Embase and Physiotherapy Evidence Database (PEDro) and four online guideline repositories were searched. RESULTS: Six CPGs were appraised as high quality and included in the synthesis. Clinical practice guidelines consistently recommended education, commencement of non-steroidal anti-inflammatories, colchicine or corticosteroids (unless contraindicated), and assessment of cardiovascular risk factors, renal function, and co-morbid conditions for acute gout management. Consistent recommendations for chronic gout management were urate lowering therapy (ULT) and continued prophylaxis recommended based on individual patient characteristics. Clinical practice guideline recommendations were inconsistent on when to initiate ULT and length of ULT, vitamin C intake, and use of pegloticase, fenofibrate and losartan. CONCLUSION: Management of acute gout was consistent across CPGs. Management of chronic gout was mostly consistent although there were inconsistent recommendations regarding ULT and other pharmacological therapies. This synthesis provides clear guidance that can assist health professionals to provide standardised, evidence-based gout care. TRIAL REGISTRATION: The protocol for this review was registered with Open Science Framework (DOI https://doi.org/10.17605/OSF.IO/UB3Y7 ).

What are the core recommendations for rheumatoid arthritis care? Systematic review of clinical practice guidelines.

Systematic r eview to evaluate the quality of the clinical practice guidelines (CPG) for rheumatoid arthritis (RA) management and to provide a synthesis of high-quality CPG recommendations, highlighting areas of consistency, and inconsistency. Electronic searches of five databases and four online guideline repositories were performed. RA management CPGs were eligible for inclusion if they were written in English and published between January 2015 and February 2022; focused on adults ≥ 18 years of age; met the criteria of a CPG as defined by the Institute of Medicine; and were rated as high quality on the Appraisal of Guidelines for Research and Evaluation II instrument. RA CPGs were excluded if they required additional payment to access; only addressed recommendations for the system/organization of care and did not include interventional management recommendations; and/or included other arthritic conditions. Of 27 CPGs identified, 13 CPGs met eligibility criteria and were included. Non-pharmacological care should include patient education, patient-centered care, shared decision-making, exercise, orthoses, and a multi-disciplinary approach to care. Pharmacological care should include conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), with methotrexate as the first-line choice. If monotherapy conventional synthetic DMARDs fail to achieve a treatment target, this should be followed by combination therapy conventional synthetic DMARDs (leflunomide, sulfasalazine, hydroxychloroquine), biologic DMARDS and targeted synthetic DMARDS. Management should also include monitoring, pre-treatment investigations and vaccinations, and screening for tuberculosis and hepatitis. Surgical care should be recommended if non-surgical care fails. This synthesis offers clear guidance of evidence-based RA care to healthcare providers. TRIAL REGISTRATION: The protocol for this review was registered with Open Science Framework ( https://doi.org/10.17605/OSF.IO/UB3Y7 ).

'I thought they would do it on the spot': why do people with non-traumatic musculoskeletal pain present to emergency departments?

Objective To investigate the reasons patients with non-traumatic musculoskeletal pain (NTMSP) present to an emergency department (ED), their experience of care and perceptions about managing their condition in the future. Methods A qualitative study using semi-structured interviews with patients with NTMSP presenting to a suburban ED. A purposive sampling strategy included participants with different pain characteristics, demographics and psychological factors. Results Eleven patients with NTMSP who presented to an ED were interviewed, reaching saturation of major themes. Seven reasons for ED presentation were identified: (1) desire for pain relief, (2) inability to access other healthcare, (3) expecting comprehensive care at the ED, (4) fear of serious pathology/outcome, (5) influence of a third party, (6) desire/expecting radiological imaging for diagnosis and (7) desire for 'ED specific' interventions. Participants were influenced by a unique combination of these reasons. Some expectations were underpinned by misconceptions about health services and care. While most participants were satisfied with their ED care, they would prefer to self-manage and seek care elsewhere in the future. Conclusions The reasons for ED presentation in patients with NTMSP are varied and often influenced by misconceptions about ED care. Most participants reported that, in future, they were satisfied to access care elsewhere. Clinicians should assess patient expectations so misconceptions about ED care can be addressed.

Core Recommendations for Osteoarthritis Care: A Systematic Review of Clinical Practice Guidelines.

OBJECTIVE: To evaluate the quality of clinical practice guidelines (CPGs) for interventions in management of osteoarthritis (OA) and to provide a synthesis of high-quality CPG recommendations. METHODS: Five databases (OvidSP Medline, Cochrane, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Embase, and the Physiotherapy Evidence Database [PEDro]) and 4 online guideline repositories were searched. CPGs for the management of OA were included if they were 1) written in English and published from January 2015 to February 2022, focused on adults age ≥18 years, and met the criteria of a CPG as defined by the Institute of Medicine; and 2) were rated as high quality on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. CPGs for OA were excluded if they were available via institutional access only, only addressed recommendations for the system/organization of care and did not include interventional management recommendations, and/or included other arthritic conditions. RESULTS: Of 20 eligible CPGs, 11 were appraised as high quality and included in the synthesis. Of interest were the hip, knee, hand, and glenohumeral joints and/or polyarticular OA. Consistent recommendations were that care should be patient centered and include exercise, education, and weight loss (where appropriate). Nonsteroidal antiinflammatory drugs and surgical interventions were recommended for disabling OA that had not improved with nonsurgical care. Hand orthoses should be recommended for patients with hand OA. CONCLUSION: This synthesis of high-quality CPGs for OA management offers health care providers with clear, simple guidance of recommended OA care to improve patient outcomes.

Understanding the Impact and Tackling the Burden of Osteoarthritis for Aboriginal and Torres Strait Islander People.

OBJECTIVE: The aim of this study was to understand and describe the lived experience of Aboriginal and Torres Strait Islander people with osteoarthritis. METHODS: Qualitative study guided by cultural security, which ensures that research is conducted in a way that will not compromise the cultural values, beliefs, and expectations of Aboriginal and Torres Strait Islander people. Participants were purposively sampled through the networks of project staff. Research yarns (a cultural form of conversation used as a data gathering tool) were conducted with 25 Aboriginal and Torres Strait Islander adults with self-reported osteoarthritis in Western Australia and Victoria, Australia. Data were analyzed using a framework approach and presented through composite storytelling (hypothetical stories representing an amalgam of participants' experiences). RESULTS: Two composite stories were constructed to reflect themes relating to beliefs and knowledge, impact, coping, and health care experiences. Common beliefs held by participants were that osteoarthritis is caused by previous physically active lifestyles. Many participants feared for their future, increasing disability and needing a wheelchair. Pain associated with osteoarthritis impacted daily activities, sleep, work, family, and social life and cultural activities. Multidimensional impacts were often experienced within complex health or life circumstances and associated with increased anxiety and depression. Most participants reported negative health care experiences, characterized by poor patient-provider communication. CONCLUSION: Our findings highlight that osteoarthritis is a multidimensional issue for Aboriginal and Torres Strait Islander people that permeates all aspects of life and highlights the need for integrated, multidisciplinary care that is culturally informed and individualized to patient need.

Communication and access to healthcare: Experiences of Aboriginal and Torres Strait Islander people managing pain in Queensland, Australia.

Background: Pain management requires a multidisciplinary approach and a collaborative relationship between patient-provider in which communication is crucial. This study examines the communication experiences of Aboriginal and Torres Strait Islander patients and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs), to improve understanding of how pain is managed in and through patient-health professional communication. Methods: This qualitative study involved a purposive sample of patients attending three persistent pain clinics and ATSIHLOs working in two hospitals in Queensland, Australia. Focus groups and in-depth interviews explored the communication experiences of patients managing pain and ATSIHLOs supporting patients with pain. This study adopted a descriptive phenomenological methodology, as described by Colaizzi (1978). Relevant statements (patient and ATSIHLOs quotes) about the phenomenon were extracted from the transcripts to formulate meanings. The formulated meanings were subsequently sorted into thematic clusters and then integrated into themes. The themes were then incorporated into a concise description of the phenomenon of communication within pain management. Findings were validated by participants. Results: A total of 21 Aboriginal and Torres Strait Islander participants were involved in this study. Exploration of the communication experiences of patients and ATSIHLOs revealed overlapping themes of important barriers to and enablers of communication that affected access to care while managing pain. Acknowledging historical and cultural factors were particularly important to build trust between patients and health professionals. Some patients reported feeling stigmatized for identifying as Aboriginal and Torres Strait Islander, while others were reluctant to disclose their background for fear of not having the same opportunity for treatment. Differences in the expression of pain and the difficulty to use standard pain measurement scales were identified. Communication was described as more than the content delivered, it is visual and emotional expressed through body language, voice intonation, language and the speed of the conversation. Conclusion: Communication can significantly affect access to pain management services. Aboriginal and Torres Strait Islander patients highlighted the burden of emotional pain caused by historical factors, negative stereotypes and the fear of discrimination. Pain management services and their health professionals need to acknowledge how these factors impact patients trust and care.

Study protocol: Clinical yarning, a communication training program for clinicians supporting aboriginal and Torres Strait Islander patients with persistent pain: A multicentre intervention feasibility study using mixed methods.

Objectives: Ineffective communication between healthcare clinicians and Aboriginal and Torres Strait Islander patients with persistent pain is a significant barrier to optimal pain management. This manuscript is a study protocol and describes the development and evaluation methods of a tailored, culturally-informed training program, to improve clinicians' communication with patients. Study design: This is a single-arm, multicentre (2 metropolitan and 1 regional persistent pain service) intervention feasibility study that will be evaluated using mixed methods. Methods: A communication training program will be developed informed by qualitative interviews with key stakeholders, and adapt the patient-centred 'clinical yarning' framework for the Queensland context. Evaluation of the effectiveness of the training will involve the analysis of quantitative data collected at three study sites over a 12-month period. At the patient level, communication experience will be rated at differing times of the training rollout to reflect participants' experience of communication either prior to or following the treating clinician attending the communication training. At the clinician level, evaluation of the training program will be based on changes of ratings in the importance of training, knowledge, ability and confidence to communicate with Aboriginal and Torres Strait Islander patients; satisfaction, acceptance and relevance to their clinical practice. This study will be grounded in the needs and preferences of communication of Aboriginal and Torres Strait Islander people living with pain. Conclusion: It is hypothesized that the patient-centred intervention will have immediate benefits for patients, improving patient experience of care. This research will focus on an area of unmet need in addressing persistent pain.

Total joint replacement may be a valuable treatment for Aboriginal and Torres Strait Islander people with osteoarthritis, but uptake is low.

BACKGROUND: Despite bearing a higher burden of osteoarthritis, little research has examined disparities in the access, utilisation and surgical outcomes associated with total joint replacement (TJR) among Aboriginal and Torres Strait Islander people. METHODS: We conducted a retrospective cohort study to compare the sociodemographic and clinical characteristics of all Aboriginal and Torres Strait Islander and non-Aboriginal patients who underwent primary hip and knee replacement at St Vincent's Hospital Melbourne between 1996 and 2019. RESULTS: A total of 10 277 primary total knee or hip replacements were performed in the 1996-2019 study period, of which 49 (0.5%) patients identified as either Aboriginal and/or Torres Strait Islander. Aboriginal and Torres Strait Islander patients were younger (61.7 ± 11.8 vs. 68.3 ± 10.3 years; P < 0.001), recorded higher Body Mass Index scores (median (IQR), 36.0 (29.5-41.4) vs. 30.8 (27.0-35.3); P < 0.001) and were more likely to experience multiple co-morbidities at the time of surgery. Despite these findings, Aboriginal and Torres Strait Islander patients did not experience higher complication rates and experienced comparable, clinically meaningful quality of life improvements 12-months post-surgery. CONCLUSIONS: TJR appears to be a valuable treatment option for Aboriginal and Torres Strait Islander people with end-stage osteoarthritis. Our study was limited by the small number of procedures conducted in patients who identify as Aboriginal and Torres Strait Islander. Further research is needed to understand why uptake of TJR by Aboriginal and Torres Strait Islander people is low.

Laying the foundations of community engagement in Aboriginal health research: establishing a community reference group and terms of reference in a novel research field.

BACKGROUND: Community engagement or community involvement in Aboriginal health research is a process that involves partnering, collaborating and involving Aboriginal and Torres Strait Islander people or potential research participants to empower them to have a say in how research with Aboriginal communities is conducted. In the context of Aboriginal health, this is particularly important so that researchers can respond to the priorities of the community under study and conduct research in a way that is respectful of Aboriginal cultural values and beliefs. One approach to incorporating the principals of community engagement and to ensure cultural oversight and guidance to projects is to engage a community reference group. The aim of this study was to describe the process of establishing an Aboriginal community reference group and terms of reference. The community reference group was established to guide the research activities of a newly formed research collaboration aiming to to develop osteoarthritis care that meets the needs of Aboriginal and Torres Strait Islander people in Australia. METHODS: Adopting a Participatory Action Research approach, this two-phase study was conducted in Victoria, Australia. In phase one, semi-structured research yarns (a cultural form of conversation used as a data gathering tool) were conducted collaboratively by Aboriginal and non-Aboriginal co-investigators to explore Aboriginal health stakeholder perspectives on establishing a community reference group and terms of reference. In phase two, recommendations in phase one were identified to invite members to participate in the community reference group and to ratify the terms of reference through a focus group. Data were analyzed using a framework analysis approach. RESULTS: Thirteen people (eight female, four male) participated in phase one. Participants represented diverse professional backgrounds including physiotherapy, nursing, general practice, health services management, hospital liaison, cultural safety education, health research and the arts. Three themes were identified in phase one; Recruitment and Representation (trust and relationships, in-house call-outs, broad-spectrum expertise and Aboriginal majority); Purpose (community engagement, research steering, knowledge dissemination and advocacy) and; Function and Logistics (frequency and format of meetings, size of group, roles and responsibilities, authority, communication and dissemination). In phase two, six Aboriginal people were invited to become members of the community reference group who recommended changes which were incorporated into the seven domains of the terms of reference. CONCLUSION: The findings of this study are captured in a 10-step framework which describes practical strategies for establishing a community reference group and terms of reference in Aboriginal health research.

Community engagement or community involvement in Aboriginal health research is a process that involves partnering with Aboriginal and Torres Strait Islander people or potential research participants to empower them to have a say in how research with Aboriginal communities is carried out. In the context of Aboriginal health, this is particularly important so that researchers can respond to the priorities of the community and conduct research in a way that respectful of Aboriginal cultural values and beliefs. One approach to community engagement in research is to form a community reference group to provide input to the research project. Although using a community reference group is considered to be an effective way to involve community members in research, often there are practical challenges in setting up and sustaining such a group. In this paper, we set out to describe an approach used to set up a community reference group for a new Aboriginal health research project exploring joint pain in Aboriginal and Torres Strait Islander people. This involved interviewing 13 health professionals and researchers (12 who identified as Aboriginal and one who identified as Aboriginal and Torres Strait Islander) about how to best go about setting up a community reference group. We used recommendations from these participants to inform who we approached to be members of the group and how the group would function. In describing the process we used to establish a community reference group, we were able to design a 10-step practical guide which may help other research groups who are looking to conduct new, ethical Aboriginal health research projects.

Clinician Perspectives of Communication with Aboriginal and Torres Strait Islanders Managing Pain: Needs and Preferences.

Poor communication is an important factor contributing to health disparity. This study sought to investigate clinicians' perspectives about communicating with Aboriginal and Torres Strait Islander patients with pain. This multi-site and mixed-methods study involved clinicians from three pain management services in Queensland, Australia. Clinicians completed a survey and participated in focus groups. Clinicians rated the importance of communication training, their knowledge, ability, and confidence in communicating with Aboriginal and Torres Strait Islander patients using a 5-point Likert scale. Rating scores were combined into low (scores 1-2); moderate (score 3) and high (scores 4-5). Informed by an interpretive description methodology, thematic analysis of focus group data was used to identify the communication needs and training preferences of clinicians. Overall (N = 64), 88% of clinicians rated the importance of communication training when supporting Aboriginal and Torres Strait Islander patients as "high". In contrast, far fewer clinicians rated as "high" their knowledge (28%), ability (25%) and confidence (28%) in effectively communicating with Aboriginal and Torres Strait Islander patients. Thematic analysis identified three areas of need: knowledge of Aboriginal and Torres Strait Islander cultures, health beliefs, and understanding cross-cultural cues. Communication skills can be learned and training, in the form of a tailored intervention to support quality engagement with Aboriginal and Torres Strait Islander patients, should combine cultural and communication aspects with biomedical knowledge.

What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project).

STUDY DESIGN: Multiround wiki-based Delphi expert panel survey. OBJECTIVE: To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care." METHODS: Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators. RESULTS: From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided. CONCLUSION: These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

Staying moving, staying strong: Protocol for developing culturally appropriate information for Aboriginal people with osteoarthritis, rheumatoid arthritis, lupus and gout.

INTRODUCTION: Addressing disparities in arthritis care is an important yet unmet health need for Aboriginal and Torres Strait Islander people in Australia (respectfully Aboriginal people herewith). Despite the significant prevalence and burden of arthritis within Aboriginal communities, access to care for arthritis is low. One means to reduce existing disparities in health care is to address current challenges relating to the appropriateness and acceptability of health care information resources for Aboriginal people. Health information sources can help to empower patients and their families to have greater involvement in their care and to engage in self-management of their condition. Despite an extensive range of arthritis information resources being available, currently no resources have been culturally adapted and developed in collaboration with Aboriginal consumers with arthritis. This paper outlines the processes that will be undertaken within the Staying Moving, Staying Strong project. This project aims to develop culturally secure arthritis information for Aboriginal people with osteoarthritis, rheumatoid arthritis, lupus and gout. METHODS AND ANALYSIS: The overarching principle guiding this project is cultural security, referring to the incorporation of processes such that the research will not compromise the cultural rights, values and expectations of Aboriginal people. This project will prioritise partnerships, community engagement, community benefit, sustainability, transferability, and capacity building and therefore uphold the cultural rights and values of Aboriginal people. In this six-phase project we will; 1) Establish a community reference group and advisory committee; 2) Explore the health information needs and preferences of Aboriginal people with arthritis; 3) Synthesise the existing key recommendations in high quality clinical practice guidelines on arthritis care; 4) Culturally adapt key clinical recommendations; 5) Develop culturally appropriate arthritis resources and; 6) Qualitatively evaluate the developed resources.

Healing Right Way: study protocol for a stepped wedge cluster randomised controlled trial to enhance rehabilitation services and improve quality of life in Aboriginal Australians after brain injury.

INTRODUCTION: Despite higher incidence of brain injury among Aboriginal compared with non-Aboriginal Australians, suboptimal engagement exists between rehabilitation services and Aboriginal brain injury survivors. Aboriginal patients often feel culturally insecure in hospital and navigation of services post discharge is complex. Health professionals report feeling ill-equipped working with Aboriginal patients. This study will test the impact of a research-informed culturally secure intervention model for Aboriginal people with brain injury. METHODS AND ANALYSIS: Design: Stepped wedge cluster randomised control trial design; intervention sequentially introduced at four pairs of healthcare sites across Western Australia at 26-week intervals.Recruitment: Aboriginal participants aged ≥18 years within 4 weeks of an acute stroke or traumatic brain injury.Intervention: (1) Cultural security training for hospital staff and (2) local, trial-specific, Aboriginal Brain Injury Coordinators supporting participants.Primary outcome: Quality-of-life using EuroQOL-5D-3L (European Quality of Life scale, five dimensions, three severity levels) Visual Analogue Scale score at 26 weeks post injury. Recruitment of 312 participants is estimated to detect a difference of 15 points with 80% power at the 5% significance level. A linear mixed model will be used to assess the between-condition difference.Secondary outcome measures: Modified Rankin Scale, Functional Independence Measure, Modified Caregiver Strain Index, Hospital Anxiety and Depression Scale at 12 and 26 weeks post injury, rehabilitation occasions of service received, hospital compliance with minimum care processes by 26 weeks post injury, acceptability of Intervention Package, feasibility of Aboriginal Brain Injury Coordinator role.Evaluations: An economic evaluation will determine the potential cost-effectiveness of the intervention. Process evaluation will document fidelity to study processes and capture changing contexts including barriers to intervention implementation and acceptability/feasibility of the intervention through participant questionnaires at 12 and 26 weeks. ETHICS AND DISSEMINATION: The study has approvals from Aboriginal, university and health services human research ethics committees. Findings will be disseminated through stakeholder reports, participant workshops, peer-reviewed journal articles and conference papers. TRIAL REGISTRATION NUMBER: ACTRN12618000139279.

Addressing surgical inequity for Aboriginal and Torres Strait Islander people in Australia's universal health care system: a call to action.

Aboriginal and Torres Strait Islander people continue to experience health inequity within the Australian health care system. Little research has examined how disparities in surgical care access and outcomes contribute to Aboriginal health. In this narrative review and call to action, we discuss five care points along the journey to high-quality surgical care: health care seeking, primary health care services, specialist services, surgery and surgical outcomes. We highlight barriers and disparities that exist along this journey, drawing examples from the field of joint replacement surgery. Finally, we present opportunities for change at the health system, health service and clinician level, calling upon researchers, clinicians and policy makers to confront the surgical disparities experienced by Aboriginal and Torres Strait Islander people.

Tackling the Burden of Osteoarthritis as a Health Care Opportunity in Indigenous Communities-A Call to Action.

Osteoarthritis is a highly prevalent and disabling disease, causing a significant individual and socioeconomic burden worldwide. Until now, there has been a dearth of research exploring the impact of osteoarthritis in global Indigenous communities. Osteoarthritis has a similar risk factor profile to many chronic diseases that disproportionately affect Indigenous peoples. In this editorial, we argue that osteoarthritis and associated mobility restrictions play a central role in the chronic disease profile of Indigenous peoples. We present a call to action for clinicians and health care providers, researchers and policymakers to begin to recognise the interrelated nature of osteoarthritis and chronic disease. We have an opportunity to change the way we do business, to improve access to culturally secure osteoarthritis care and the health and wellbeing of Indigenous communities.