BackgroundOveruse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential.AimTo explore factors that might influence overuse of lumbar imaging in the Emergency Department.MethodsParticipants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds.ResultsPatients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients’ perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care.Conclusion and key findingsWe found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.
Objective This study explored factors that underpin decisions to seek emergency department (ED) care for chronic non-cancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian-born. Design and Methods A mixed-methods study underpinned by The Behavioural Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilisation and contributing factors for both cohorts. Results ED attendance was a product of escalating distress, influenced by the degree to which a participant’s perceived need outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophising, lower health literacy and greater social challenges present for the CALD cohort. Conclusion This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for healthcare providers to recognise features of higher vulnerability and consider streamlining access to available support services.
Background Few studies have investigated the effects of waiting room communication strategies on healthcare behavior. We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the Emergency Department (ED). Methods We conducted a controlled experimental study with BABA or ‘replicated time series’ design. Design included a 6-week run-in time. Following this there were alternating one-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on the same 55” screen as the standard messaging. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on a 55” LCD screen, and the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction, awarenesss of campaign messages) were collected from a sample of people presenting for any condition who responded to a text message-based survey. Results For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n= 99; control n= 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy (95% CI= 18% to 35%) compared with 29% in those exposed to the standard waiting room messaging (95% CI= 23% to 35%) (OR= 0.83; 95% CI= 0.49 to 1.41). For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n=170; control n=179; response rate =33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR= 2.00, 95% CI= 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages. Conclusion A communication strategy displayed in the emergency department waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging; though there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence healthcare quality. Trial registration : ACTRN12620000300976, 05/03/2020
Background Imaging for low back pain is widely regarded as a target for efforts to reduce low value care. We aimed to estimate the prevalence of overuse and underuse of lumbar imaging in the Emergency Department. Methods Retrospective chart review study of five public hospital Emergency Departments in Sydney, Australia, in 2019/20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse). Results 649 patients presented with a complaint of low back pain of which 158 (24.3%) were referred for imaging. 79 (12.2%) had a combination of features suggesting lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95%CI 6.8% to 11.2%) and 4.3% (28 of 649 cases, 95%CI 3.0% to 6.1%), respectively. 13 cases were classified as underuse because the patient was referred for an uninformative imaging modality (e.g. referred for radiography for suspected cauda equina syndrome). Conclusion In this study of emergency care there was evidence of overuse of lumbar imaging, but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.
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