None listed
Conditions
Brief summary
NUDG-ED is a randomised trial that will investigate behavioural strategies to reduce the use of low-value care for low back pain in emergency department (ED). We will recruit ED clinicians who manage back pain, and patients 18 years or over presenting to ED with back pain with a musculoskeletal condition. We will randomly allocate hospital sites to receive i) waiting room messaging for patients on best care for back pain, ii) computer prompts reminding clinicians of the indications for imaging and opioids, iii) both interventions, or iv) no intervention. The primary outcome will be the proportion of low back pain encounters where a person received low-value diagnostic imaging or an opioid prescription at discharge from ED.
Interventions
We will randomly allocate the 8 hospitals (clusters) into one of four groups: i) no intervention; ii) patient nudges; iii) clinician nudges; iv) patient nudges and clinician nudges for six months after the control period.
Patient nudges: Making decision information salient
Patient nudges will include 6 digital posters displayed on 55-inch LCD screens located in the ED waiting room. The messaging on the posters focuses on the lack of benefits and potential harms of non-indicated imaging and opi
We will randomly allocate the 8 hospitals (clusters) into one of four groups: i) no intervention; ii) patient nudges; iii) clinician nudges; iv) patient nudges and clinician nudges for six months after the control period. Patient nudges: Making decision information salient Patient nudges will include 6 digital posters displayed on 55-inch LCD screens located in the ED waiting room. The messaging on the posters focuses on the lack of benefits and potential harms of non-indicated imaging and opioids. Patients will also have access to a more detailed information leaflet on imaging and opioids for back pain. The information materials were designed specifically for this study and have been tested in our pilot studies before. Clinician nudges: computer alerts At ED sites randomised to receive clinician nudges, we will implement three computer alerts that are triggered only for patients who are flagged in the workflow as presenting with back pain. Alert #1 appears when a clinician attempts to order any lumbar imaging test for a person with back pain. The alert reminds clinicians that imaging is not recommended without features of serious pathology and provides them clear guidance on what pathologies would warrant imaging. Alert #2 appears when a clinician attempts to administer an opioid medicine for a person with back pain. Before proceeding with the administration, the alert reminds clinicians that opioids are not recommended for back pain and provides a list of suggested non-steroidal anti-inflammatory drugs (NSAIDs) medicines to choose from instead. Alert #3 appears when patients with back pain are being discharged. This alert reminds clinicians that take home opiods are not recommended for uncomplicated back pain. This alerts also provides evidence-based advice on non-opioid care for patients at home. To measure fidelity of the intervention, we will engagement with computerised nudges including number of overrides. This will be measured using routine workflow data and assessing the number of computerised alerts shown vs number of computerised alerts overridden (i.e. the decision to prescribe opioids/imaging was unchanged). We will also measure clinicians' awareness and opinion of interventions via a survey in both intervention and control groups.
Sponsors
The University of Sydney
Study design
Allocation
Randomised controlled trial
Intervention model
Factorial
Primary purpose
Treatment
Masking
Blinded (masking used) (Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
Clinician participants will be ED staff at study sites who are involved in the care of patients presenting to ED with a primary complaint of low back pain. This includes physicians (Junior Medical Officer, Registrar, Consultant), nurses, and physiotherapists). Patient participants will be 18 years or older, presenting with low back pain and diagnosed with back pain due to a musculoskeletal condition.
Exclusion criteria
Patients diagnosed with a non-musculoskeletal condition e.g. renal colic. People who required a translator service, and those without mobile number recorded will be excluded from the patient survey.
Outcome results
None listed