Research - SHaPED
Research Project Overview
SHaPED: Sydney Health Partners Emergency Department trial.
Coombs DM, Machado GC, Richards B, Needs C, Buchbinder R, Harris IA, et al. Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial. BMJ Qual Saf; 2021.
Patients with low back pain often seek care in emergency departments, but the problem is that many patients receive unnecessary or ineffective interventions and at the same time miss out on the basics of care, such as advice on self-management. Examples of low-value care of low back pain in emergency departments include inappropriate overuse of imaging, liberal use of opioid analgesics and unnecessary admission to hospital. This pattern of care has important consequences for the healthcare system (expensive and inefficient) and for patients (poor health outcomes). We hypothesised that the implementation of the NSW Agency for Clinical Innovation (ACI) model of care for low back pain will improve emergency care by reducing inappropriate overuse of tests and treatments while not adversely affecting patient outcomes.
The overall aim of the SHaPED trial was to implement the ACI model of care for acute low back pain and evaluate the use of a multi-faceted intervention on outcomes that reflect the key messages in the model:
- Patients with non-specific low back pain do not require imaging
- Where medicines are used, simple analgesics should be the first option
- Patients with non-specific low back pain should be managed as outpatients
We measured the proportion of patients presenting with non-serious low back pain who received imaging in the emergency department, opioids and subsequent hospital admission.
- 2019 Sydney Local Health District Quality Award
- 2019 Finalist Award, NSW Health Awards for Value Based Health Care
- 2018 Qlik Patient-centred App Innovation Award
- 2018 NPS Medicinewise Award for Excellence in eHealth Resources
- 2018 Lyn March Award for Excellence (ACI)
We used a stepped-wedge cluster randomised trial design which enabled us to compare the use of the new model with the usual emergency care provided for low back pain. SNOMED codes were used to identify low back pain presentations to the emergency departments. The Sydney Local Health District (SLHD) Targeted Activity and Reporting System (STARS) was used to access and extract outcome data from participating emergency departments. STARS is data analytics programme that captures in near real-time routinely collected emergency department measures stored in electronic medical records and other hospital databases, including number of presentations, use of diagnostic imaging tests, use of medications, length of emergency stay and admissions to hospital. Clinician and patient-reported outcomes were collected via paper-based and online questionnaires before and after the intervention.
A total of 269 emergency department 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). It did reduce opioid use (OR 0.57; 95% CI 0.38 to 0.85) and improved clinicians’ beliefs (MD 2.85; 95% CI 1.85 to 3.85) and knowledge about low back pain care (MD 0.48; 95% CI 0.13 to 0.83). There was no difference in pain scores at 1-week follow-up (MD 0.04; 95% CI −1.00 to 1.08). A similar trend was observed for all other patient-reported outcomes and time points.
It is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the emergency department; however, it did reduce opioid prescriptions by up to 24% without adversely affecting patient outcomes.