Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial
Rachelle Buchbinder,
Matthew Smith,
Ian A Harris,
Enrico Coiera,
Adrian C Traeger,
Chris G Maher,
Kirsten Howard,
Qiang Li,
Jeffrey A Linder,
James McAuley,
Louise Cullen,
Ian Ferguson,
Sweekriti Sharma,
Elise Tcharkhedian,
Janet Harrison,
Naren Gunja,
Gustavo Machado,
Richard McNulty,
Mark Salter,
Paul M Middleton,
Ahilan Parameswaran,
Kitty Duong,
Andrew Coggins,
Zoe Michaleff,
Gemma Altinger,
Trevor Chan,
Karen Tambree,
Ajay Varshney,
Jeremy Lawrence,
Kevin Pile,
Richard Cracknell,
Kara Goon,
Daryn Mitford,
Raymond Morgan,
James Mallows,
Kelly Bivona,
Helen Zaouk,
Brendon Shapter,
Jim Basilakis,
Helen Badge,
Michael Meller,
Robyn Linder
Affiliations
Rachelle Buchbinder
3 Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Matthew Smith
Ian A Harris
2 Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
Enrico Coiera
7 Centre for Health Informatics, Macquarie University, Sydney, New South Wales, Australia
Adrian C Traeger
1 Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
Chris G Maher
1 Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
Kirsten Howard
9 Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, New South Wales, Australia
Qiang Li
8 George Institute for Global Health, Sydney, New South Wales, Australia
Jeffrey A Linder
4 Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
James McAuley
Louise Cullen
12 Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
Ian Ferguson
12 South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
Sweekriti Sharma
1 Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
Elise Tcharkhedian
Janet Harrison
Naren Gunja
10 Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
Gustavo Machado
Richard McNulty
Mark Salter
Paul M Middleton
11 South Western Emergency Research Institute, Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, New South Wales, Australia
Ahilan Parameswaran
Kitty Duong
Andrew Coggins
10 Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
Zoe Michaleff
Gemma Altinger
1 Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
Trevor Chan
15 Emergency Care Institute, The Agency for Clinical Innovation, St Leonards Sydney, City of Willoughby, Australia
Karen Tambree
16 Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
Ajay Varshney
16 Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
Introduction Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural ‘nudge’ interventions on low-value care for ED patients with low back pain.Methods and analysis NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time.Ethics and dissemination This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.Trial registration number ACTRN12623001000695.
