Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial

2021 ◽  
pp. bmjqs-2020-012337
Author(s):  
Danielle M Coombs ◽  
Gustavo C Machado ◽  
Bethan Richards ◽  
Chris Needs ◽  
Rachelle Buchbinder ◽  
...  
Keyword(s):  
Emergency Department ◽  
Low Back Pain ◽  
Back Pain ◽  
Randomised Trial ◽  
Healthcare Utilisation ◽  
Multifaceted Intervention ◽  
Cluster Randomised Trial ◽  
Low Back ◽  
Patient Reported ◽  
Pain Care

BackgroundOveruse 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.MethodsWe 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.ResultsA 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.ConclusionIt 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.

scholarly journals Use of Physical Therapy for Low Back Pain by Medicaid Enrollees

2015 ◽  
Vol 95 (12) ◽  
pp. 1668-1679 ◽  
Author(s):  
Julie M. Fritz ◽  
Jaewhan Kim ◽  
Anne Thackeray ◽  
Josette Dorius
Keyword(s):  
Emergency Department ◽  
Low Back Pain ◽  
Back Pain ◽  
Physical Therapy ◽  
The United States ◽  
Health Care Use ◽  
Low Back ◽  
Future Health ◽  
Patient Reported ◽  
Future Health Care

Background Medicaid insures an increasing proportion of adults in the United States. Physical therapy use for low back pain (LBP) in this population has not been described. Objective The study objectives were: (1) to examine physical therapy use by Medicaid enrollees with new LBP consultations and (2) to evaluate associations with future health care use and LBP-related costs. Design The study was designed as a retrospective evaluation of claims data. Methods A total of 2,289 patients with new LBP consultations were identified during 2012 (mean age=39.3 years [SD=11.9]; 68.2% women). The settings in which the patients entered care and comorbid conditions were identified. Data obtained at 1 year after entry were examined, and physical therapy use was categorized with regard to entry setting, early use (within 14 days of entry), or delayed use (&gt;14 days after entry). The 1-year follow-up period was evaluated for use outcomes (imaging, injection, surgery, and emergency department visit) and LBP-related costs. Variables associated with physical therapy use and cost outcomes were evaluated with multivariate models. Results Physical therapy was used by 457 patients (20.0%); 75 (3.3%) entered care in physical therapy, 89 (3.9%) received early physical therapy, and 298 (13.0%) received delayed physical therapy. Physical therapy was more common with chronic pain or obesity comorbidities and less likely with substance use disorders. Entering care in the emergency department decreased the likelihood of physical therapy. Entering care in physical medicine increased the likelihood. Relative to primary care entry, physical therapy entry was associated with lower 1-year costs. Limitations A single state was studied. No patient-reported outcomes were included. Conclusions Physical therapy was used often by Medicaid enrollees with LBP. High rates of comorbidities were evident and associated with physical therapy use. Although few patients entered care in physical therapy, this pattern may be useful for managing costs.

scholarly journals Effectiveness and cost-utility of a multifaceted eHealth strategy to improve back pain beliefs of patients with non-specific low back pain: a cluster randomised trial

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e030879 ◽  
Author(s):  
Arnela Suman ◽  
Frederieke G. Schaafsma ◽  
Johanna M. van Dongen ◽  
Petra J.M. Elders ◽  
Rachelle Buchbinder ◽  
...  
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Randomised Trial ◽  
Intervention Group ◽  
Cost Utility ◽  
Secondary Outcome ◽  
Cluster Randomised Trial ◽  
Low Back ◽  
Pain Beliefs ◽  
Cluster Randomised

ObjectivesTo assess the effectiveness and cost-utility of a multifaceted eHealth strategy compared to usual care in improving patients’ back pain beliefs, and in decreasing disability and absenteeism.DesignStepped-wedge cluster randomised trial with parallel economic evaluation.SettingDutch primary healthcare.ParticipantsPatients diagnosed with non-specific low back pain by their general practitioner or physiotherapist. Patients with serious comorbidities or confirmed pregnancy were excluded. 779 patients were randomised into intervention group (n=331, 59% female; 60.4% completed study) or control group (n=448, 57% female; 77.5% completed study).InterventionsThe intervention consisted of a multifaceted eHealth strategy that included a (mobile) website, digital monthly newsletters, and social media platforms. The website provided information about back pain, practical advice (eg, on self-management), working and returning to work with back pain, exercise tips, and short video messages from healthcare providers and patients providing information and tips. The control consisted of a digital patient information letter. Patients and outcome assessors were blinded to group allocation.Primary and secondary outcome measuresThe primary outcome was back pain beliefs. Secondary outcome measures were disability and absenteeism, and for the preplanned economic evaluation quality of life and societal costs were measured.ResultsThere were no between-group differences in back pain beliefs, disability, or absenteeism. Mean intervention costs were €70— and the societal cost difference was €535—in favour of the intervention group, but no significant cost savings were found. The incremental cost-effectiveness ratio indicated that the intervention dominated usual care and the probability of cost-effectiveness was 0.85 on a willingness-to-pay of €10.000/quality adjusted life year (QALY).ConclusionsA multifaceted eHealth strategy was not effective in improving patients’ back pain beliefs or in decreasing disability and absenteeism, but showed promising cost-utility results based on QALYs.Trial registration numberNTR4329.

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