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Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial
  1. Danielle M Coombs1,2,
  2. Gustavo C Machado1,
  3. Bethan Richards1,3,
  4. Chris Needs3,
  5. Rachelle Buchbinder4,5,
  6. Ian A Harris1,6,7,
  7. Kirsten Howard8,
  8. Kirsten McCaffery9,
  9. Laurent Billot10,
  10. James Edwards11,
  11. Eileen Rogan12,
  12. Rochelle Facer13,
  13. Qiang Li10,
  14. Christopher G Maher1
  1. 1Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
  2. 2Physiotherapy Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  3. 3Rheumatology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  4. 4Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  5. 5Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
  6. 6Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
  7. 7Orthopaedic Department, South Western Sydney Local Health District, Liverpool Hospital, Sydney, New South Wales, Australia
  8. 8School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  9. 9Wiser Healthcare, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  10. 10The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
  11. 11Emergency Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  12. 12Emergency Department, Canterbury Hospital, Campsie, New South Wales, Australia
  13. 13Emergency Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  1. Correspondence to Dr Gustavo C Machado, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; gustavo.machado{at}sydney.edu.au

Abstract

Background Overuse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline recommendations for low back pain in the emergency department.

Methods We conducted a stepped-wedge, cluster-randomised trial in four EDs in New South Wales, Australia. After a 13-month control phase of usual care, the EDs received a multifaceted intervention to support guideline-endorsed care in a random order, based on a computer-generated random sequence, every 4 weeks over a 4-month period. All sites were followed up for at least 3 months. The primary outcome was the proportion of low back pain presentations receiving lumbar imaging. Secondary healthcare utilisation outcomes included prescriptions of opioid and non-opioid pain medicines, inpatient admissions, length of ED stay, specialist referrals and re-presentations. Clinician beliefs and knowledge about low back pain care were measured before and after the intervention. Patient-reported pain, disability, quality of life and satisfaction were measured at 1, 2 and 4 weeks post ED presentation.

Results A total of 269 ED clinicians and 4625 episodes of care for low back pain (4491 patients) were included. The data did not provide clear evidence that the intervention reduced lumbar imaging (OR 0.77; 95% CI 0.47 to 1.26; p=0.29). It did reduce opioid use (OR 0.57; 95% CI 0.38 to 0.85; p=0.006) and improved clinicians’ beliefs (mean difference (MD), 2.85; 95% CI 1.85 to 3.85; p<0.001; on a scale from 9 to 45) and knowledge about low back pain care (MD, 0.48; 95% CI 0.13 to 0.83; p<0.01; on a scale from 0 to 11). There was no difference in pain scores at 1-week follow-up (MD, 0.04; 95% CI −1.00 to 1.08; p=0.94; on a scale from 0 to 10). A similar trend was observed for all other patient-reported outcomes and time points. This study found no effect on the other secondary healthcare utilisation outcomes.

Conclusion It is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the ED; however, it did reduce opioid prescriptions without adversely affecting patient outcomes.

Trial registration number ACTRN12617001160325.

  • emergency department
  • implementation science
  • continuing education
  • continuing professional development

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Footnotes

  • DMC and GCM are joint first authors.

  • Twitter @gustavocmachado, @CGMMaher

  • Collaborators The SHaPED Investigators: Danielle M Coombs, Gustavo C Machado, Bethan Richards, Chris Needs, Rachelle Buchbinder, Ian A Harris, Kirsten Howard, Kirsten McCaffery, Laurent Billot, James Edwards, Eileen Rogan, Rochelle Facer, Qiang Li, Chris G Maher, Hannah Storey, Lorraine Ho, Noel Baidya, Marco Reedyk, Alfred van der Walt, Sharon Taylor, Matthew Oliver, Helen Broughton, Leonard Ladia, Boris Waldman, Matthew Chu, Timothy Tan, Mona Marabani, Glenn Wiseman, David Roberts, Lindy Collins, Randall Greenberg, David Lord-Cowell, Sokol Nushaj, Kristy Hatswell, Melinda Collett, Jeniffer Fiore-Chapman, Robyn Speerin, Teresa Anderson.

  • Contributors GM, BR, CN, RB, IAH, KH, KM, LB, JE, ER, RF and CM contributed to protocol development and design of the SHaPED trial. DC, GM, BR, CN and CM designed and delivered the SHaPED multifaceted intervention with input from JE, ER and RF. LB and QL led the statistical analysis with input from DC, GM, RB, IAH and CM. DC, GM, BR and CN were responsible for the conduct of the trial. GM and DC are the guarantors. All authors read and approved the final manuscript.

  • Funding This was an investigator-initiated study funded by Sydney Health Partners and the NSW Agency for Clinical Innovation. FlexEze Australia supplied the heat wraps used in the trial at no cost.

  • Competing interests GM, CM, RB and KM report grants from the Australian National Health and Medical Research Council during the conduct of this trial.

  • Patient consent for publication Not required.

  • Ethics approval The trial protocol was approved by the Sydney Local Health District Human Research Ethics Committee (protocol number X17-0043).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Due to information governance restrictions imposed by organisations governing data access, we are unable to share the trial data unless applicants secure the relevant permissions.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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