Background
Low-value care for low back pain in the emergency department (ED) is common and can harm patients. We aimed to determine if patient nudges, clinician nudges or both can reduce low-value care.
Methods
NUDG-ED was a 2×2 factorial, open-label, before-after, cluster-randomised controlled trial. We included 8 ED sites in Sydney, Australia. Participants were ED clinicians, and adult patients presenting to ED with musculoskeletal back pain. EDs were randomly assigned to receive patient nudges, clinician nudges, both interventions or no nudge control. Patient nudges included digital waiting room posters with information addressing misperceptions about the need for imaging and opioids for back pain. Clinician nudges were electronic alerts triggered by ordering imaging and/or opioids for back pain with recommendations and suggested alternatives. The primary outcome was use of low-value care, defined as a non-indicated lumbar imaging test, an opioid at discharge, or both.
Results
There were 3770 encounters for back pain in the study period. Baseline prevalence of low-value care was 41.6%. During the intervention period, the proportion of encounters with low-value care reduced to 36.4% with patient nudges versus 38.1% without, but the difference was not significant (adjusted OR 0.80, 95% confidence interval [CI] 0.51 to 1.27). The proportion of encounters with low-value care was 39.4% with clinician nudges versus 35.0% without (adjusted OR 1.31, 95% CI 0.84 to 2.05).
Conclusion
Nudges including waiting room information posters targeting patients and electronic record alerts targeting clinicians did not reduce low-value care.