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

A Physiotherapy-Led Emergency Department Guideline (PLEDGE) for Patients Presenting With Low Back Pain: Pre- and Post-Implementation Study

OBJECTIVE

We evaluated guideline adherence and healthcare utilisation in an emergency department (ED) pre- and post-implementation of a physiotherapy-led low back pain (LBP) guideline and rapid outpatient follow-up service (collectively termed PLEDGE model).

METHODS

The PLEDGE model was implemented in a metropolitan tertiary hospital. Data from LBP ED presentations were extracted from electronic medical records for 1 year pre- and post-PLEDGE model implementation. To evaluate guideline-adherent care, the primary outcome was the incidence of any opioid analgesia use. Requests for imaging and pathology were secondary outcomes. To evaluate healthcare utilisation, the primary outcome was the ED National Emergency Access Target (NEAT). Secondary outcomes included ED re-presentations within 28 days, short stay unit (SSU) admissions and ED length of stay (LOS).

RESULTS

Overall, 2732 patients were included (1384 post-implementation). For guideline-adherent care, opioid analgesia (χ2 (1, N = 2732) = 17.406, p < 0.001) and pathology ordering (χ2 (1, N = 2732) = 6.363, p = 0.012) significantly reduced post-implementation; however, there was no reduction in imaging requests (χ2 (1, N = 2732) = 1.859, p = 0.173). With respect to healthcare utilisation, measures of ED NEAT and ED LOS worsened. Patients were significantly less likely to be admitted to SSU (χ2 (1, N = 2732) = 6.356, p = 0.012) or re-present to ED (χ2 (1, N = 2732) = 4.098, p = 0.043).

CONCLUSION

Implementation of the PLEDGE model reduced opioid analgesia use, pathology ordering, SSU admissions and ED re-presentations and provided a valuable safety net. ED NEAT worsened, ED LOS increased and imaging requests remained unchanged.

Appropriateness of lumbar spine imaging in patients presenting to the emergency department with low back pain in a Western Australian tertiary hospital

BACKGROUND

The Australian Rheumatology Association identified the use of imaging in patients with low back pain without indication of serious pathology as a low-value practice.

AIMS

To determine the appropriateness of diagnostic lumbar spine imaging requests in patients with low back pain presenting to a Western Australian hospital's emergency department.

METHODS

We conducted a retrospective review of all adult patients (18 years and older) who presented with low back pain to the Fiona Stanley Hospital emergency department from 1 July 2020 to 31 December 2020. The appropriateness of the imaging requests was judged using the American College of Radiology's Appropriateness Criteria. The number and proportion of appropriate and inappropriate lumbar spine imaging requests were reported overall and by imaging modality together with reasons for the judgements.

RESULTS

A total of 1459 patients were included. Three hundred eight patients (21.1%) received lumbar spine imaging requests, with 350 diagnostic imaging requests eligible for analysis. Two hundred eighty (80.0%) imaging requests were judged to be appropriate (194/253 (76.7%) plain radiographs, 57/66 (86.4%) computed tomography, 29/31 (93.5%) magnetic resonance imaging). The most common reasons for an appropriate imaging request were suspected vertebral fracture (n = 223, 79.6%), followed by malignancy (n = 26, 9.3%). Of the 70 inappropriate imaging requests, 62 (88.6%) requests occurred in the absence of alerting features and eight (11.4%) requests were the wrong choice of modality.

CONCLUSIONS

Four in five lumbar spine imaging requests for investigating low back pain were appropriate. Of the inappropriate requests, the most common reason was the absence of alerting features, while a small number were the incorrect imaging modality.

Factors associated with patients' demand for low-value care: a scoping review

BACKGROUND

Low-value care is unnecessary care that contributes to inefficient use of health resources and constitutes a considerable proportion of healthcare expenditures worldwide. Factors contributing to patients' demand for low-value care have often been overlooked and are dispersed in the literature. Therefore, the current study aimed to systematically summarize factors associated with patients' demand for low-value care.

METHODS

In this scoping review, scientific articles were identified based on a search query conducted in Embase and Scopus. We identified articles using search terms related to low-value care and demand-related factors, published in peer-reviewed journals, and written in English or Dutch. The titles, abstracts, results, and conclusions were inspected to only include articles that were deemed relevant for this topic. From these articles we extracted text fragments that contained factors associated with patients' demand for low-value care. Hereafter, a thematic analysis was applied to openly, axially, and selectively code textual fragments to identify themes within the data.

RESULTS

Forty-seven articles were included in this review. We identified eight core themes associated with patients' demand for low-value care: cognitive biases, emotions, preferences and expectations, knowledge-related factors, socio-cultural factors, biomedical and care-related factors, economic factors, and factors related to the interaction with the healthcare provider. Within these core themes, thirty-three subthemes were identified. For example, risk aversion and anticipated regret aversion are sub-themes of cognitive biases, while consumerism and present and future income effects are sub-themes of economic factors.

CONCLUSIONS

Through this review we provide a systematic overview of factors associated with the demand for low-value care. We found that patients' demand for low-value care could relate to a multitude of factors that were clustered into eight core themes and thirty-three subthemes. To understand the demand for low-value care from the patient's perspective in greater detail, future research should focus on the interaction between and importance of these factors in different care contexts.

Interventions to improve the quality of low back pain care in emergency departments: a systematic review and meta-analysis

Low back pain (LBP) is a common reason people visit Emergency Departments (ED). However, the care provided is often not aligned with guideline recommendations. Despite increasing research aiming to promote guideline-based care in EDs, interventions to best implement recommendations are unknown. This study aimed to identify ED LBP implementation interventions that have been trialed and evaluate their effects on ED-relevant outcomes. A systematic review and meta-analysis, including studies that evaluated interventions to improve the quality of care provided to adults presenting to ED with LBP. Databases searched until May 2023 were Cochrane Library, CINAHL, EMBASE (via OVID), and PEDro. Interventions were categorized according to whether they had a patient, clinician, health service, or multiple-level focus. Where possible, meta-analysis was undertaken. Certainty around the results was assessed using the GRADE criteria. Twenty-eight studies were included. Interventions were categorized as patient (n = 2), clinician (n = 8), health service (n = 12), or multiple-level (n = 6) targeted. Overall, interventions successfully reduced the likelihood of receiving an opioid in ED (OR 0.65; 95% CI 0.55-0.75). However, no significant effect on lumbar imaging was demonstrated (OR 0.85; 95% CI 0.64-1.12). Subgroup analyses showed that studies reporting high baseline imaging rates ≥ 36% and those that included systems-based changes significantly reduced imaging (OR 0.60; 95% CI 0.39-0.93; and OR 0.65; 95% CI 0.45-0.94, respectively). A small reduction in ED length of stay was observed in the group exposed to the LBP interventions (mean difference - 0.38 h; 95% CI - 0.58 to - 0.17). Overall, certainty of evidence was deemed low to very low. Interventions were mostly single-system focused with a preference for education-based implementation strategies targeting patients or clinicians. The interventions reduced the use of opioid medication for LBP in ED, but the effects on lumbar imaging rates were uncertain. Further high-quality research is needed to improve LBP care in this setting.

Factors influencing imaging clinical decision-making in low back pain management. A scoping review

BACKGROUND

The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process.

AIM

Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management.

DESIGN

Scoping review.

METHOD

This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories.

RESULTS

After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors.

CONCLUSIONS

The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.

Functional analysis of postural spinal and pelvic parameters using static and dynamic spinometry

Background

Spinometry is a radiation-free method to three-dimensional spine imaging that provides additional information about the functional gait patterns related to the pelvis and lower extremities. This radiation-free technology uses the surface topography of the trunk to analyze surface asymmetry and identify bony landmarks, thereby aiding the assessment of spinal deformity and supporting long-term treatment regimes. Especially reliable dynamic spinometric data for spine and pelvis are necessary to evaluate the management of non-specific back pain.

Research aim

This study aims to generate reliable dynamic spinometric data for spine and pelvis parameters that can serve as reference data for future studies and clinical practice.

Methods

This study assessed 366 subjects (185 females) under static and 360 subjects (181 females) under dynamic (walking on a treadmill at 3 km/h and 5 km/h) conditions. The DIERS Formetric 4Dmotion® system uses stripes of light to detect the surface topography of the spine and pelvis and identifies specific landmarks to analyze the spine during standing and walking.

Results

Relevant gender effects were calculated for lordotic angle (ηp2 = 0.22) and pelvic inclination (ηp2 = 0.26). Under static conditions, female subjects showed larger values for both parameters (lordotic angle: 41.6 ± 8.60°; pelvic inclination: 25.5 ± 7.49°). Regarding speed effects, three relevant changes were observed (sagittal imbalance: ηp2 = 0.74, kyphotic angle: ηp2 = 0.13, apical deviation: ηp2 = 0.11). The most considerable changes were observed between static condition and 3 km/h, especially for sagittal imbalance and lordotic angle. For these parameters, relevant effect sizes (d > 0.8) were calculated between static and 3 km/h for males and females. Concerning clinical vertebral parameters, only lordotic angle and pelvic inclination were correlated with each other (r = 0.722).

Conclusion

This study generated a gender-specific reference database of asymptomatic individuals for static and dynamic spinometry. It demonstrated that the DIERS Formetric 4Dmotion® system could capture natural changes in static and dynamic situations and catalogue functional adaptations of spino-pelvic statics at different speeds. The lordotic angle is an indirect marker of pelvic inclination, allowing spinometry to identify individuals at risk even under dynamic conditions.

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.

Emergency Department Management of Low Back Pain: A Comparative Review of Guidelines and Practices

This narrative review examines the current best practices and guidelines for integrating pharmacologic interventions, imaging, and physiotherapy in the management of low back pain. The review also explores how patient factors such as age, sex, comorbidities, and prevalent pathologies/diagnoses influence the choice and effectiveness of these treatment approaches.

Physical Therapists Are Routinely Performing the Requisite Skills to Directly Refer for Musculoskeletal Imaging: An Observational Study

OBJECTIVES

To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging.

METHODS

An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists.

RESULTS

4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001).

CONCLUSION

Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging.