Late-breaking Poster Sydney Spinal Symposium 2023

NUDG-ED: A randomised trial using behavioural nudges to reduce low-value care in Emergency Department clinical practice (#37)

Gemma Altinger 1 , Sweekriti Sharma 1 , Louise Cullen , Kirsten McCaffery 2 , Jeffrey A Linder 3 , Rachelle Buchbinder 4 , Ian Harris 1 5 , Enrico Coiera 6 , Qiang Li 7 8 , Kirsten Howard 9 , Andrew Coggins 10 , Paul Middleton 10 11 , Naren Gunja 12 , Trevor Chan 13 , Ian Ferguson 14 , Chris G Maher 1 , Adrian C Traeger 1 , Karen Tambree 15
  1. Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Sydney
  2. Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney
  3. Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago
  4. School of Public Health and Preventive Medicine, Monash University, Melbourne
  5. Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney
  6. Centre for Health Informatics, Macquarie University, Sydney
  7. The George Institute for Global Health, UNSW , Sydney
  8. The George Institute for Global Health, UNSW , Sydney
  9. Menzies Centre for Health Policy and Economics, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney
  10. Discipline of Emergency Medicine, Sydney Medical School, The University of Sydney, Sydney
  11. South Western Emergency Research Institute, Liverpool Hospital, Liverpool
  12. Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney
  13. Emergency Care Institute, The Agency for Clinical Innovation, St Leonards, Sydney
  14. Emergency Department, Liverpool Hospital, Liverpool
  15. NUDG-ED Consumer Advisor, Sydney

BACKGROUND:

  • In busy Australian emergency departments (ED), 75% of patients presenting with low back pain without red flags will receive unnecessary imaging, opioids, or both. 
  • Neither is recommended as they offer little benefit and have short- and long-term harms and are considered low-value in this context. 
  • This is the first study to test if visual and social cues (nudges) reduce imaging and opioid prescribing for uncomplicated low back pain in ED.

METHODS:

  • Design: A 2x2 factorial, open label, before-after, cluster randomised controlled trial design measuring the effectiveness of nudges in reducing low-value care.
  • Participants: ED clinicians who manage back pain, and approx. 2416 patients 18 years or over presenting to ED with uncomplicated back pain will be recruited from 8 hospitals across 3 Sydney local health districts. 
  • Interventions: Hospitals will be randomised into 1 of 4 groups:
    • Clinician nudges in the electronic medical record
    • Patient nudges in the ED waiting room
    • Both nudges combined
    • No intervention
  • There will be a 3-month before period, followed by a 6-month intervention period.
  • Outcomes: The primary outcome will be the proportion of low back pain encounters where a person received low-value imaging tests in ED or an opioid prescription at discharge, assessed by chart review. 
  • Secondary outcomes include clinician knowledge; patient reported outcomes; and cost-effectiveness of the intervention. 

RESULTS:

  • The trial will commence in early 2024. We will discuss the complexity of designing a trial of behavioural interventions to reduce low-value care. 

CONCLUSION:

  • This study will be the first to test the impact of clinician and patient nudges on reducing low-value care. NUDG-ED has the potential to improve health outcomes for patients presenting to the ED with low back pain, reducing overdiagnosis, overtreatment and improving the stewardship of health resources.