![[Physio Explained] What are nudges and can they improve low back pain care? with Sweekriti Sharma](https://cdn-images-3.listennotes.com/podcasts/physio-network/physio-explained-what-are-GU9vZosdb38-MLUNQDGJnkb.1400x1400.jpg "[Physio Explained] What are nudges and can they improve low back pain care? with Sweekriti Sharma")
WEBVTT
00:00:05.200 --> 00:00:10.640
There was no effect of clinician nudges compared with no clinician nudges as well.
00:00:10.800 --> 00:00:22.719
So in our factorial analysis, we compared hospitals that were randomized to patient nudges with hospitals that were randomized to no patient nudges, and same with the clinician nudges as well.
00:00:22.879 --> 00:00:26.320
The overall rate of low-value care was around 42%.
00:00:27.120 --> 00:00:31.120
We also found no interaction effect between the interventions.
00:00:31.280 --> 00:00:35.119
There was no meaningful differences in secondary outcomes as well.
00:00:36.960 --> 00:00:40.240
Why is low-value care still so common in low back pain?
00:00:40.399 --> 00:00:43.359
Even in emergency departments where evidence is clear.
00:00:43.679 --> 00:00:50.159
Can behavioural nudges or simple changes to the clinical environment actually shift clinical decision making?
00:00:50.320 --> 00:00:54.079
And what happens when we test this at scale in a real-world healthcare system?
00:00:54.320 --> 00:00:54.479
Dr.
00:00:54.640 --> 00:01:05.599
Sweet Kritishama is a postdoctoral researcher at the University of Sydney with a background in public health and a research focus on reducing unnecessary care for low back pain.
00:01:05.840 --> 00:01:16.319
Today we're diving into her recent large cluster RCT published in CMAJ, investigating whether behavioural nudges can reduce low-value care in emergency departments.
00:01:16.480 --> 00:01:22.719
You're going to love this episode if you're interested in not just what the evidence says, but in how we actually change practice.
00:01:22.879 --> 00:01:26.159
I'm Sarah Yule and this is Physio Explained.
00:01:28.079 --> 00:01:31.599
Well, Sweet, thank you so much for joining us today on the podcast.
00:01:31.920 --> 00:01:33.599
Thank you, Sarah, for having me.
00:01:34.000 --> 00:01:50.719
Today we are running through your research article titled Behavioural Nudges to Reduce Low Value Care for Low Back Pain in the Emergency Department, which is a bit of a mouthful, but I'm very curious why did we do this study and what did we test?
00:01:51.200 --> 00:01:56.640
So low back pain is one of the leading reasons for emergency department presentations.
00:01:56.959 --> 00:02:06.319
Last year alone, more than 9 million people presented to Australian emergency departments, and back pain was one of the most common reasons for presentations.
00:02:06.560 --> 00:02:12.479
And many tests and treatments routinely used for back pain in the emergency departments are not recommended.
00:02:12.800 --> 00:02:21.199
For example, one in three patients presenting to emergency departments with back pain received imaging, and two in three receive opioids.
00:02:21.360 --> 00:02:31.360
And both of these are considered low value care in absence of red flags, offering little benefit, and in some cases, exposing patients to unnecessary harm.
00:02:31.599 --> 00:02:41.520
So what we did was nudged was a two by two factorial design cluster randomized control trial across eight hospital emergency departments in Sydney.
00:02:41.759 --> 00:02:52.879
We tested whether behaviorial nudges to reduce unnecessary imaging tests and opioid prescription at discharge for back pain in the emergency department could reduce low value care.
00:02:53.199 --> 00:02:57.199
So we randomized two hospitals to receive patient nudges.
00:02:57.360 --> 00:03:05.919
Two hospitals were randomized to receive clinician nudges, and two were randomized to receive port nudges, and two were randomized to no nudges.
00:03:06.159 --> 00:03:18.639
And our nudges included electronic information posters discouraging unnecessary imaging and opioids displayed in the 55-inch LCD screens in the emergency department waiting rooms.
00:03:18.800 --> 00:03:30.240
And clinician nudges included three electronic medical record alerts that provided indications for lumbar spine imaging and suggested alternatives to opioids.
00:03:30.560 --> 00:03:38.000
So in this context, low-value care sounds like it was imaging that wasn't indicated and opiate prescriptions at discharge.
00:03:38.159 --> 00:03:45.280
And then those patient nudges were the waiting room posters and the clinician nudges for the alerts at key decision points.
00:03:45.599 --> 00:03:46.639
Yes, that's right.
00:03:46.960 --> 00:03:48.479
And what did we find?
00:03:48.800 --> 00:03:58.319
As much as we wanted the nudges to work, what we found was there was no effect of patient nudges on low-value care compared with no patient nudges.
00:03:58.560 --> 00:04:03.599
There was no effect of clinician nudges compared with no clinician nudges as well.
00:04:03.759 --> 00:04:15.680
So in our factorial analysis, we compared hospitals that were randomized to patient nudges with hospitals that were randomized to no patient nudges, and same with the clinician nudges as well.
00:04:15.919 --> 00:04:19.360
The overall rate of low-value care was around 42%.
00:04:20.160 --> 00:04:28.720
We also found no interaction effect between the interventions, and there was no meaningful differences in secondary outcomes as well.
00:04:29.120 --> 00:04:36.160
So, what you're saying is there was no significant reduction in low-value care with the patient or the clinician nudges.
00:04:36.480 --> 00:04:36.879
Yes.
00:04:37.199 --> 00:04:38.959
And what do these findings mean?
00:04:39.360 --> 00:04:50.399
So these results highlight the complexity of back pain as a clinical presentation and broader challenges of improving care in emergency department settings.
00:04:50.800 --> 00:05:01.439
Improving outcomes for patients while reducing pressure on clinicians and health systems will require a broader cultural shift in how back pain is viewed and managed in Australia.
00:05:01.680 --> 00:05:08.560
Yeah, so I think once the patient reaches the emergency department, it may be too late to make a difference.
00:05:08.720 --> 00:05:19.519
So maybe providing some actionable information to help people know when to go to ED and how to effectively manage the pain in the community would be the approach.
00:05:19.600 --> 00:05:26.000
So I think like the future interventions should focus on people before they present to emergency departments.
00:05:26.399 --> 00:05:29.199
Are you struggling to keep up to date with new research?
00:05:29.439 --> 00:05:32.399
Let our research reviews do the hard work for you.
00:05:32.560 --> 00:05:39.279
Our team of experts summarize the latest and most clinically relevant research for instant application in your clinic.
00:05:39.439 --> 00:05:42.319
So you can save time and effort keeping up to date.
00:05:42.560 --> 00:05:47.360
Click the link in the show notes to try Physio Network's research reviews for free today.
00:05:48.079 --> 00:05:52.639
So that that idea of context is very relevant, more so than intention.
00:05:52.800 --> 00:06:01.839
So ED clinicians obviously operate under a high level of diagnostic uncertainty and risk aversion and the high consequences of missing pathology.
00:06:02.319 --> 00:06:10.000
So you're saying that we should look at interventions and education prior to the point of someone entering ED.
00:06:10.319 --> 00:06:11.279
Yes, that's right.
00:06:11.600 --> 00:06:26.399
And just going back to teasing out those key findings a little bit more, going to the effect on the imaging or opioid prescribing, did you notice any changes with those as well?
00:06:26.639 --> 00:06:33.519
So the low value being the unnecessary imaging or the opioids, was there a difference between the two?
00:06:34.000 --> 00:06:43.360
In terms of inappropriate imaging, one of the control groups started with high imaging, inappropriate imaging, about 35%.
00:06:44.639 --> 00:06:50.639
And that drastically dropped in the intervention period, even when they received no intervention.
00:06:50.879 --> 00:07:01.439
By contrast, like the clinician notch group started with a low baseline rate for inappropriate imaging, and they didn't have any like much room for improvement or reduction.
00:07:01.680 --> 00:07:16.560
Yeah, and in terms of opioid as well, about 40% of encounters had inappropriate opioids at baseline on average, and control sites improved over time, even when they received no nudges.
00:07:16.959 --> 00:07:21.439
And some sites exposed to clinician nudge improved and others did not.
00:07:21.920 --> 00:07:32.160
And so clinically, do you think do you think there's some takeaways for us in in terms of beliefs and changing clinical decisions?
00:07:32.879 --> 00:07:36.160
Changing beliefs is really difficult.
00:07:37.040 --> 00:07:37.680
Fair enough.
00:07:38.959 --> 00:07:48.800
And where do you feel like we're best directing the next bit of research to tease this more, tease this out a little bit more, knowing that there's this inherent complexity?
00:07:49.040 --> 00:07:51.600
Where would you like to see the research focused?
00:07:52.000 --> 00:08:12.879
Like I mentioned earlier, I think the next the future research should focus on general public, maybe raising awareness or educating the general public before they present to the emergency department on when to present to the emergency department and how can back pain best be managed at home or in primary care.
00:08:13.279 --> 00:08:16.240
So it sounds like I think the focus should be.
00:08:16.639 --> 00:08:17.519
Yeah, great.
00:08:17.680 --> 00:08:30.480
It's sounding like this study is tipping into what hopefully reinforces as an opportunity for us as physios, not just to deliver care, but to help reshape what good care looks like in the system.
00:08:31.040 --> 00:08:31.439
Yeah.
00:08:31.680 --> 00:08:38.799
And I also think that there are lots of EMR alerts, existing EMR alerts in the emergency department.
00:08:39.039 --> 00:08:53.120
And we don't know whether those alerts are actually helping, or there may be a need to think about whether we need to de-implement some of the existing alerts that may not be based on evidence or may not be effective.
00:08:53.519 --> 00:08:54.480
Really interesting.
00:08:54.720 --> 00:08:58.080
Thank you so much for your summary today, sweet.
00:08:58.159 --> 00:08:59.759
That's been really helpful.
00:08:59.919 --> 00:09:20.639
I think it we're always building on the standing on the shoulders of giants, and I think it's sounding like we're on this ongoing route to discussing more impactful strategies, whether it's increased access to physiotherapy and advice or policy level change or feedback systems or decision aids.
00:09:20.720 --> 00:09:29.919
It'll be really, I'm intrigued to see where the research goes in terms of what results in a reduction in this low value care.
00:09:30.399 --> 00:09:35.039
Well, thank you so much for joining us on the podcast today.
00:09:35.360 --> 00:09:37.759
Thank you so much, Sarah, for having me.
00:00:05.200 --> 00:00:10.640
There was no effect of clinician nudges compared with no clinician nudges as well.
00:00:10.800 --> 00:00:22.719
So in our factorial analysis, we compared hospitals that were randomized to patient nudges with hospitals that were randomized to no patient nudges, and same with the clinician nudges as well.
00:00:22.879 --> 00:00:26.320
The overall rate of low-value care was around 42%.
00:00:27.120 --> 00:00:31.120
We also found no interaction effect between the interventions.
00:00:31.280 --> 00:00:35.119
There was no meaningful differences in secondary outcomes as well.
00:00:36.960 --> 00:00:40.240
Why is low-value care still so common in low back pain?
00:00:40.399 --> 00:00:43.359
Even in emergency departments where evidence is clear.
00:00:43.679 --> 00:00:50.159
Can behavioural nudges or simple changes to the clinical environment actually shift clinical decision making?
00:00:50.320 --> 00:00:54.079
And what happens when we test this at scale in a real-world healthcare system?
00:00:54.320 --> 00:00:54.479
Dr.
00:00:54.640 --> 00:01:05.599
Sweet Kritishama is a postdoctoral researcher at the University of Sydney with a background in public health and a research focus on reducing unnecessary care for low back pain.
00:01:05.840 --> 00:01:16.319
Today we're diving into her recent large cluster RCT published in CMAJ, investigating whether behavioural nudges can reduce low-value care in emergency departments.
00:01:16.480 --> 00:01:22.719
You're going to love this episode if you're interested in not just what the evidence says, but in how we actually change practice.
00:01:22.879 --> 00:01:26.159
I'm Sarah Yule and this is Physio Explained.
00:01:28.079 --> 00:01:31.599
Well, Sweet, thank you so much for joining us today on the podcast.
00:01:31.920 --> 00:01:33.599
Thank you, Sarah, for having me.
00:01:34.000 --> 00:01:50.719
Today we are running through your research article titled Behavioural Nudges to Reduce Low Value Care for Low Back Pain in the Emergency Department, which is a bit of a mouthful, but I'm very curious why did we do this study and what did we test?
00:01:51.200 --> 00:01:56.640
So low back pain is one of the leading reasons for emergency department presentations.
00:01:56.959 --> 00:02:06.319
Last year alone, more than 9 million people presented to Australian emergency departments, and back pain was one of the most common reasons for presentations.
00:02:06.560 --> 00:02:12.479
And many tests and treatments routinely used for back pain in the emergency departments are not recommended.
00:02:12.800 --> 00:02:21.199
For example, one in three patients presenting to emergency departments with back pain received imaging, and two in three receive opioids.
00:02:21.360 --> 00:02:31.360
And both of these are considered low value care in absence of red flags, offering little benefit, and in some cases, exposing patients to unnecessary harm.
00:02:31.599 --> 00:02:41.520
So what we did was nudged was a two by two factorial design cluster randomized control trial across eight hospital emergency departments in Sydney.
00:02:41.759 --> 00:02:52.879
We tested whether behaviorial nudges to reduce unnecessary imaging tests and opioid prescription at discharge for back pain in the emergency department could reduce low value care.
00:02:53.199 --> 00:02:57.199
So we randomized two hospitals to receive patient nudges.
00:02:57.360 --> 00:03:05.919
Two hospitals were randomized to receive clinician nudges, and two were randomized to receive port nudges, and two were randomized to no nudges.
00:03:06.159 --> 00:03:18.639
And our nudges included electronic information posters discouraging unnecessary imaging and opioids displayed in the 55-inch LCD screens in the emergency department waiting rooms.
00:03:18.800 --> 00:03:30.240
And clinician nudges included three electronic medical record alerts that provided indications for lumbar spine imaging and suggested alternatives to opioids.
00:03:30.560 --> 00:03:38.000
So in this context, low-value care sounds like it was imaging that wasn't indicated and opiate prescriptions at discharge.
00:03:38.159 --> 00:03:45.280
And then those patient nudges were the waiting room posters and the clinician nudges for the alerts at key decision points.
00:03:45.599 --> 00:03:46.639
Yes, that's right.
00:03:46.960 --> 00:03:48.479
And what did we find?
00:03:48.800 --> 00:03:58.319
As much as we wanted the nudges to work, what we found was there was no effect of patient nudges on low-value care compared with no patient nudges.
00:03:58.560 --> 00:04:03.599
There was no effect of clinician nudges compared with no clinician nudges as well.
00:04:03.759 --> 00:04:15.680
So in our factorial analysis, we compared hospitals that were randomized to patient nudges with hospitals that were randomized to no patient nudges, and same with the clinician nudges as well.
00:04:15.919 --> 00:04:19.360
The overall rate of low-value care was around 42%.
00:04:20.160 --> 00:04:28.720
We also found no interaction effect between the interventions, and there was no meaningful differences in secondary outcomes as well.
00:04:29.120 --> 00:04:36.160
So, what you're saying is there was no significant reduction in low-value care with the patient or the clinician nudges.
00:04:36.480 --> 00:04:36.879
Yes.
00:04:37.199 --> 00:04:38.959
And what do these findings mean?
00:04:39.360 --> 00:04:50.399
So these results highlight the complexity of back pain as a clinical presentation and broader challenges of improving care in emergency department settings.
00:04:50.800 --> 00:05:01.439
Improving outcomes for patients while reducing pressure on clinicians and health systems will require a broader cultural shift in how back pain is viewed and managed in Australia.
00:05:01.680 --> 00:05:08.560
Yeah, so I think once the patient reaches the emergency department, it may be too late to make a difference.
00:05:08.720 --> 00:05:19.519
So maybe providing some actionable information to help people know when to go to ED and how to effectively manage the pain in the community would be the approach.
00:05:19.600 --> 00:05:26.000
So I think like the future interventions should focus on people before they present to emergency departments.
00:05:26.399 --> 00:05:29.199
Are you struggling to keep up to date with new research?
00:05:29.439 --> 00:05:32.399
Let our research reviews do the hard work for you.
00:05:32.560 --> 00:05:39.279
Our team of experts summarize the latest and most clinically relevant research for instant application in your clinic.
00:05:39.439 --> 00:05:42.319
So you can save time and effort keeping up to date.
00:05:42.560 --> 00:05:47.360
Click the link in the show notes to try Physio Network's research reviews for free today.
00:05:48.079 --> 00:05:52.639
So that that idea of context is very relevant, more so than intention.
00:05:52.800 --> 00:06:01.839
So ED clinicians obviously operate under a high level of diagnostic uncertainty and risk aversion and the high consequences of missing pathology.
00:06:02.319 --> 00:06:10.000
So you're saying that we should look at interventions and education prior to the point of someone entering ED.
00:06:10.319 --> 00:06:11.279
Yes, that's right.
00:06:11.600 --> 00:06:26.399
And just going back to teasing out those key findings a little bit more, going to the effect on the imaging or opioid prescribing, did you notice any changes with those as well?
00:06:26.639 --> 00:06:33.519
So the low value being the unnecessary imaging or the opioids, was there a difference between the two?
00:06:34.000 --> 00:06:43.360
In terms of inappropriate imaging, one of the control groups started with high imaging, inappropriate imaging, about 35%.
00:06:44.639 --> 00:06:50.639
And that drastically dropped in the intervention period, even when they received no intervention.
00:06:50.879 --> 00:07:01.439
By contrast, like the clinician notch group started with a low baseline rate for inappropriate imaging, and they didn't have any like much room for improvement or reduction.
00:07:01.680 --> 00:07:16.560
Yeah, and in terms of opioid as well, about 40% of encounters had inappropriate opioids at baseline on average, and control sites improved over time, even when they received no nudges.
00:07:16.959 --> 00:07:21.439
And some sites exposed to clinician nudge improved and others did not.
00:07:21.920 --> 00:07:32.160
And so clinically, do you think do you think there's some takeaways for us in in terms of beliefs and changing clinical decisions?
00:07:32.879 --> 00:07:36.160
Changing beliefs is really difficult.
00:07:37.040 --> 00:07:37.680
Fair enough.
00:07:38.959 --> 00:07:48.800
And where do you feel like we're best directing the next bit of research to tease this more, tease this out a little bit more, knowing that there's this inherent complexity?
00:07:49.040 --> 00:07:51.600
Where would you like to see the research focused?
00:07:52.000 --> 00:08:12.879
Like I mentioned earlier, I think the next the future research should focus on general public, maybe raising awareness or educating the general public before they present to the emergency department on when to present to the emergency department and how can back pain best be managed at home or in primary care.
00:08:13.279 --> 00:08:16.240
So it sounds like I think the focus should be.
00:08:16.639 --> 00:08:17.519
Yeah, great.
00:08:17.680 --> 00:08:30.480
It's sounding like this study is tipping into what hopefully reinforces as an opportunity for us as physios, not just to deliver care, but to help reshape what good care looks like in the system.
00:08:31.040 --> 00:08:31.439
Yeah.
00:08:31.680 --> 00:08:38.799
And I also think that there are lots of EMR alerts, existing EMR alerts in the emergency department.
00:08:39.039 --> 00:08:53.120
And we don't know whether those alerts are actually helping, or there may be a need to think about whether we need to de-implement some of the existing alerts that may not be based on evidence or may not be effective.
00:08:53.519 --> 00:08:54.480
Really interesting.
00:08:54.720 --> 00:08:58.080
Thank you so much for your summary today, sweet.
00:08:58.159 --> 00:08:59.759
That's been really helpful.
00:08:59.919 --> 00:09:20.639
I think it we're always building on the standing on the shoulders of giants, and I think it's sounding like we're on this ongoing route to discussing more impactful strategies, whether it's increased access to physiotherapy and advice or policy level change or feedback systems or decision aids.
00:09:20.720 --> 00:09:29.919
It'll be really, I'm intrigued to see where the research goes in terms of what results in a reduction in this low value care.
00:09:30.399 --> 00:09:35.039
Well, thank you so much for joining us on the podcast today.
00:09:35.360 --> 00:09:37.759
Thank you so much, Sarah, for having me.
