Redesigning care for back pain in an Australian hospital setting: A service evaluation to identify need for change

OBJECTIVE

This needs assessment study examined current processes of physiotherapy care for adults with back pain in a large teaching hospital serving a multicultural community in Sydney, Australia. Evaluation of current practices is a necessary first step in the design of a patient-centred, multidisciplinary service that promotes best practice in back pain management.

METHODS

We conducted a retrospective service evaluation in the physiotherapy outpatient department by reviewing clinical data on episode of care and processes of care for adults managed for back pain over a 6-month period using a defined protocol (n = 252).

RESULTS

Patients (median age = 56 years; 72.2% born outside of Australia) were referred from various internal and external sources, with 79.8% having chronic back pain. The median length of episode of care was 8 weeks. Active interventions were almost universally used (98.4% of records). Key aspects of assessment were frequently recorded (84.5%-98% of records), but psychosocial risk assessment was not routinely recorded. Aspects of longitudinal management planning, including goal setting, outcome measurement, and routine follow-up, were also not routinely recorded.

CONCLUSIONS

This study demonstrated that physiotherapy processes of care in this setting followed key messages of best practice particularly with regard to interventions, in contrast to other settings and jurisdictions. However, the brief episodes of care and less evident focus on psychosocial aspects might not align with the needs of the majority with chronic back pain. These findings suggest the need to reframe processes of care with a biopsychosocial approach and structure episodes of care towards long-term management solutions.

Needs assessment for health service design for people with back pain in a hospital setting: A qualitative study

BACKGROUND

There is a need for effective health service solutions to provide greater structure and support for implementing evidence-based practice in back pain care. Patient involvement in developing these solutions is crucial to increase relevance, acceptability and uptake.

OBJECTIVES

To determine patients' perceived needs and barriers to best-practice back pain care, and potential solutions to better address care needs. The study is the third in a series of needs assessment studies feeding into the 'idea generation' for service design in a large teaching hospital in a culturally and linguistically diverse community in metropolitan Sydney, Australia.

DESIGN

We conducted a combination of focus groups and in-depth interviews using an interpretive description approach. We used inductive thematic analysis to identify the main themes.

SETTING AND PARTICIPANTS

We purposively sampled patients with diverse characteristics from the neurosurgery and physiotherapy outpatient clinics, in particular those whose primary language was English, Arabic, Persian or Mandarin. Non-English audio recordings were translated and transcribed by bilingual researchers.

RESULTS

There were 24 participants (focus groups = 9; individual interviews = 15) when data saturation was reached. The analysis identified three key themes with several subthemes around what service designers needed to understand in helping people with back pain in this setting: (1) This is who I am; (2) It's not working for me; and (3) What I think I need.

DISCUSSION AND CONCLUSION

This study highlights that perceived unmet needs of patients are underpinned by unhelpful beliefs about the causes of and solutions for back pain, misaligned care expectations, unclear expectations of the hospital role and fragmentations in the health system. To design and implement a service that can deliver better back pain care, several solutions need to be integrated around: developing new resources that challenge unhelpful beliefs and set realistic expectations; improving access to education and self-management resources; focusing on individualized care; using a collaborative multidisciplinary approach within the hospital; and better connecting with and directing primary health care services.

PATIENT OR PUBLIC CONTRIBUTION

A consumer representative of the Western Sydney Local Health District provided input during study conceptualisation and is duly recognized in the Acknowledgements section.

Fetal programming of hepatic lobular architecture in the rat demonstrated ex vivo with magnetic resonance imaging

We demonstrate that MRI imaging at sub-millimetre resolution can distinguish between periportal and perivenous zones of the rat liver lobule. This made it possible to measure the hepatic lobular radius in ex-vivo perfused fixed livers using MRI. Comparisons of histomorphometric and MRI measurements of lobular radius were in good agreement, although MRI measurements were significantly smaller (P< 0.001). Male rats whose mothers were fed 40% of the protein of controls during gestation and lactation, had a significantly larger hepatic lobular radius than that of controls [449+/-11 microm vs. 373+/-9 microm (mean +/- SEM), respectively, p<0.001, n = 12; histomorphometry data]. The proton T(2) in periportal and perivenous zones was mapped both before and after antegrade or retrograde perfusion of 10 ml of digitonin (4 mg ml(-1)). Only the T(2) of the hypointense regions increased significantly following antegrade perfusion of digitonin and conversely only that of the intense regions following retrograde perfusion. Digitonin causes permeabilization of cells in specific hepatic zones, determined by the direction of perfusion. The intense and hypointense regions of the hepatic MR images thus arise from the perivenous and periportal zones of the hepatic lobule, respectively.

Making a difference to A&E: analysis of the operational inefficiencies in A&E departments in major acute hospitals in Dublin

There are six accident and emergency departments in major acute hospitals in Dublin. Each year they deal with approximately 300,000 visits. The primary objective of this study was to identify operational inefficiencies which exist in these departments and to recommend improvements.

Allocare, predation risk, social structure and natal coat colour in anthropoid primates

Many primate species have a natal coat coloured differently from the coat colour of adults and, in some cases, the natal coat is very different from that of older animals with the infant being conspicuous and/or brightly coloured. This study uses data from 82 anthropoid species to investigate possible correlates of conspicuous natal coat colour (CNC), using comparative, phylogenetically controlled analyses. Five hypotheses were tested using statistical tests on both species data and phylogenetically controlled data. The analyses show some support for the hypothesis that CNCs have evolved to promote allocare but the degree of CNC does not correlate with predation rates, arboreality, or relative testes size.

Practice nurses need to adapt

Nurses working in union and community health clinics have pioneered the development of the independent nurse practitioner role. One of those pioneers offers her views on future directions for practice nurses.

Ambient monitoring of airborne radioactivity near a former thorium processing plant

Twenty-four hour sampling for airborne radioactivity near a former thorium and rare-earth extraction facility was conducted for approx. 2 months with high-volume and dichotomous air samplers. Thoron ( 220Rn ) daughters were identified in the air and confirmed to be originating from the waste storage site. High-volume samplers near the facility measured average 212Pb concentrations of 177, 43, and 237 pCi/m3 with corresponding ranges of (1.9-1351), (1.5-301) and (0.73-2201)pCi/m3. Simultaneous measurements with dichotomous samplers at the same sites measured average 212Pb concentrations on coarse particulates (2.5-15 microns dia.) of 14, 4 and 10 pCi/m3 and on fine particulates (less than 2.5 microns dia.) of 94, 9 and 214 pCi/m3, respectively. Corresponding ranges were (0.2-109), (0.1-63) and (0.1-94) pCi/m3 for coarse particulates and (0.7-1094), (0.4-101) and (0.5-2685) pCi/m3 for fine particulates. Uranium, thorium and radium radionuclides were not identified as being present in significant concentrations in the particulate samples.