Behavioural Nudges to Reduce Low-Value Care for Low Back Pain in the Emergency Department

06 Apr 20265 min read0 viewsJournal Feed

GIST

This pragmatic cluster randomized trial evaluated whether patient-directed or clinician-directed nudges could reduce low-value care for low back pain in emergency departments. Eight EDs were randomized to implement patient nudges (electronic posters discouraging unnecessary imaging and opioid use displayed in waiting areas), clinician nudges (electronic health record alerts outlining indications for lumbar imaging and alternatives to opioids), both nudges, or none.

The primary outcome was the proportion of encounters with low-value care, defined as non-indicated lumbar spine imaging, opioid prescription at discharge, or both. Across 3,770 encounters, the baseline prevalence of low-value care was 41.6%.

During intervention, low-value care fell to 36.4% with patient nudges versus 38.1% without, but this difference was not statistically significant (adjusted OR 0.80; 95% CI 0.51–1.27). For clinician nudges, low-value care was 39.4% with nudges versus 35.0% without (adjusted OR 1.31; 95% CI 0.84–2.05).

No interaction between interventions was detected (p=0.4). The study notes potential attenuation of strong patient beliefs about imaging with patient nudges, but overall no reduction in low-value care was observed.

Trial registered at ANZCTR (ACTRN12623001000695).

Clinical Editorial

Study Focus and Design

The report evaluates whether behavioral nudges directed at patients or clinicians can lower low-value care for low back pain in emergency departments.
Design was a pragmatic 2 x 2 factorial, cluster randomized trial across eight EDs, with randomization to: patient nudges, clinician nudges, both, or neither.
The trial targeted encounters for low back pain and used a primary outcome defined as the share of encounters with low-value care, operationalized as either a non-indicated lumbar spine imaging test, an opioid prescription at discharge, or both.

Population and Setting

The analysis encompassed 3,770 encounters for low back pain during the study window.
Baseline prevalence of low-value care across the study period was 41.6%.

Interventions and Implementation

Patient nudges: Electronic information posters displayed in waiting rooms via 55-inch screens, designed to discourage unnecessary imaging and opioid use.
Clinician nudges: Electronic health record alerts presenting indications for lumbar spine imaging and suggesting alternatives to opioid therapy.
The factorial design allowed assessment of each intervention independently and in combination, with an additional assessment for interaction effects.

Primary Outcome and Statistical Approach

Primary outcome: proportion of encounters with low-value care (imaging without indication, opioid prescription at discharge, or both).
Analyses used adjusted odds ratios, accounting for clustering and baseline values.

Key Findings on Effectiveness

Patient nudges: Reduced low-value care to 36.4% versus 38.1% without nudges, but this difference did not reach statistical significance (adjusted OR 0.80; 95% CI 0.51 to 1.27).
Clinician nudges: Encounter low-value care was 39.4% with nudges versus 35.0% without (adjusted OR 1.31; 95% CI 0.84 to 2.05), suggesting no reduction and a non-significant trend toward higher low-value care.
Interaction: No evidence of a meaningful interaction between patient and clinician nudges (P = 0.4).

Contextual Notes and Limitations

The study observed no net reduction in low-value care with either intervention strategy.
The report notes a potential effect of the patient nudge on reducing strong patient beliefs about the value of imaging, though this did not translate into a measurable clinical outcome.
Secondary outcomes did not reveal important differences.