Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

Venkatesh, Arjun K.; Scofi, Jean; Rothenberg, Craig; Berdahl, Carl T.; Tarrant, Nalani; Sharma, Dhruv; Goyal, Pawan; Pilgrim, Randy; Klauer, Kevin; Schuur, Jeremiah D.

doi:10.1016/j.ajem.2020.01.029

Cited by 14 publications

(13 citation statements)

References 17 publications

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“…35 However, in the USA, a large national initiative to reduce avoidable imaging found no significant change in imaging rates for non-serious back pain. 36 It is evident that reducing imaging rates in low back pain is a complicated issue. Further studies assessing the appropriateness of imaging, implementing electronic medical record-based clinical decision tools and campaigns such as Choosing Wisely may be helpful in instilling behaviour change and reducing inappropriate lumbar imaging.…”

Section: Possible Explanations and Implications For Clinicians Policy...mentioning

confidence: 99%

Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial

et al. 2021

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BackgroundOveruse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline recommendations for low back pain in the emergency department.MethodsWe conducted a stepped-wedge, cluster-randomised trial in four EDs in New South Wales, Australia. After a 13-month control phase of usual care, the EDs received a multifaceted intervention to support guideline-endorsed care in a random order, based on a computer-generated random sequence, every 4 weeks over a 4-month period. All sites were followed up for at least 3 months. The primary outcome was the proportion of low back pain presentations receiving lumbar imaging. Secondary healthcare utilisation outcomes included prescriptions of opioid and non-opioid pain medicines, inpatient admissions, length of ED stay, specialist referrals and re-presentations. Clinician beliefs and knowledge about low back pain care were measured before and after the intervention. Patient-reported pain, disability, quality of life and satisfaction were measured at 1, 2 and 4 weeks post ED presentation.ResultsA total of 269 ED clinicians and 4625 episodes of care for low back pain (4491 patients) were included. The data did not provide clear evidence that the intervention reduced lumbar imaging (OR 0.77; 95% CI 0.47 to 1.26; p=0.29). It did reduce opioid use (OR 0.57; 95% CI 0.38 to 0.85; p=0.006) and improved clinicians’ beliefs (mean difference (MD), 2.85; 95% CI 1.85 to 3.85; p<0.001; on a scale from 9 to 45) and knowledge about low back pain care (MD, 0.48; 95% CI 0.13 to 0.83; p<0.01; on a scale from 0 to 11). There was no difference in pain scores at 1-week follow-up (MD, 0.04; 95% CI −1.00 to 1.08; p=0.94; on a scale from 0 to 10). A similar trend was observed for all other patient-reported outcomes and time points. This study found no effect on the other secondary healthcare utilisation outcomes.ConclusionIt is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the ED; however, it did reduce opioid prescriptions without adversely affecting patient outcomes.Trial registration number ACTRN12617001160325.

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Section: Possible Explanations and Implications For Clinicians Policy...mentioning

confidence: 99%

Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial

et al. 2021

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“…The data in this study is from 2013-2014 and should be interpreted with caution as various changes have been made since that time. For example, wisely choosing campaigns have emphasized that imaging is rarely needed for acute low back pain and should be used sparingly, resulting in improved imaging stewardship in the ED [ 32 ]. Additionally, providers have become increasingly diligent regarding the prescription of opioids, and rates of opioid prescriptions in the ED have declined significantly [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Factors Associated With Repeat Emergency Department Visits for Low Back Pain

Megalla¹,

Ogedegbe²,

Sanders³

et al. 2022

Cureus

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BackgroundLow back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period. MethodologyWe conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months. ResultsA total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028). ConclusionsPatients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.

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“…There is mixed evidence showing that quality improvement initiatives are associated with decreases in provision of low-value care. 6 Payment changes in Canada 7,8 and national interventions, such as a nationwide initiative in Australia to reduce imaging for low-back pain, 9 were associated with decreased use of LVS. Colla and colleagues demonstrated that LVS provision is associated with certain market-level factors, such as total Medicare spending and the ratio of specialists to primary care physicians (PCPs).…”

Section: Introductionmentioning

confidence: 99%

“…Factors associated with variations in LVS use are widely studied but still not fully understood. There is mixed evidence showing that quality improvement initiatives are associated with decreases in provision of low‐value care 6 . Payment changes in Canada 7,8 and national interventions, such as a nationwide initiative in Australia to reduce imaging for low‐back pain, 9 were associated with decreased use of LVS.…”

Section: Introductionmentioning

confidence: 99%

Assessing patient, physician, and practice characteristics predicting the use of low‐value services

Shin

Fleming

Ghosh

et al. 2022

Health Services Research

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Objective: To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices.Data Sources: This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018. Study Design:We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level.Data Collection/Extraction Methods: The study included 5,074,642 Medicare feefor-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites.Principal Findings: Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level.Conclusions: Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.

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Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

Cited by 14 publications

References 17 publications

Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial

Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial

Factors Associated With Repeat Emergency Department Visits for Low Back Pain

Assessing patient, physician, and practice characteristics predicting the use of low‐value services

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