Pippa Flanagan, Robert Waller, Ivan Lin, Karen Richards, Piers Truter, Gustavo C. Machado, Vinicius Cavalheri
{"title":"Interventions to improve the quality of low back pain care in emergency departments: a systematic review and meta-analysis","authors":"Pippa Flanagan, Robert Waller, Ivan Lin, Karen Richards, Piers Truter, Gustavo C. Machado, Vinicius Cavalheri","doi":"10.1007/s11739-024-03736-y","DOIUrl":null,"url":null,"abstract":"<p>Low back pain (LBP) is a common reason people visit Emergency Departments (ED). However, the care provided is often not aligned with guideline recommendations. Despite increasing research aiming to promote guideline-based care in EDs, interventions to best implement recommendations are unknown. This study aimed to identify ED LBP implementation interventions that have been trialed and evaluate their effects on ED-relevant outcomes. A systematic review and meta-analysis, including studies that evaluated interventions to improve the quality of care provided to adults presenting to ED with LBP. Databases searched until May 2023 were Cochrane Library, CINAHL, EMBASE (via OVID), and PEDro. Interventions were categorized according to whether they had a patient, clinician, health service, or multiple-level focus. Where possible, meta-analysis was undertaken. Certainty around the results was assessed using the GRADE criteria. Twenty-eight studies were included. Interventions were categorized as patient (<i>n</i> = 2), clinician (<i>n</i> = 8), health service (<i>n</i> = 12), or multiple-level (<i>n</i> = 6) targeted. Overall, interventions successfully reduced the likelihood of receiving an opioid in ED (OR 0.65; 95% CI 0.55–0.75). However, no significant effect on lumbar imaging was demonstrated (OR 0.85; 95% CI 0.64–1.12). Subgroup analyses showed that studies reporting high baseline imaging rates ≥ 36% and those that included systems-based changes significantly reduced imaging (OR 0.60; 95% CI 0.39–0.93; and OR 0.65; 95% CI 0.45–0.94, respectively). A small reduction in ED length of stay was observed in the group exposed to the LBP interventions (mean difference − 0.38 h; 95% CI − 0.58 to − 0.17). Overall, certainty of evidence was deemed low to very low. Interventions were mostly single-system focused with a preference for education-based implementation strategies targeting patients or clinicians. The interventions reduced the use of opioid medication for LBP in ED, but the effects on lumbar imaging rates were uncertain. Further high-quality research is needed to improve LBP care in this setting.</p>","PeriodicalId":13662,"journal":{"name":"Internal and Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.2000,"publicationDate":"2024-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Internal and Emergency Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1007/s11739-024-03736-y","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"MEDICINE, GENERAL & INTERNAL","Score":null,"Total":0}
引用次数: 0
Abstract
Low back pain (LBP) is a common reason people visit Emergency Departments (ED). However, the care provided is often not aligned with guideline recommendations. Despite increasing research aiming to promote guideline-based care in EDs, interventions to best implement recommendations are unknown. This study aimed to identify ED LBP implementation interventions that have been trialed and evaluate their effects on ED-relevant outcomes. A systematic review and meta-analysis, including studies that evaluated interventions to improve the quality of care provided to adults presenting to ED with LBP. Databases searched until May 2023 were Cochrane Library, CINAHL, EMBASE (via OVID), and PEDro. Interventions were categorized according to whether they had a patient, clinician, health service, or multiple-level focus. Where possible, meta-analysis was undertaken. Certainty around the results was assessed using the GRADE criteria. Twenty-eight studies were included. Interventions were categorized as patient (n = 2), clinician (n = 8), health service (n = 12), or multiple-level (n = 6) targeted. Overall, interventions successfully reduced the likelihood of receiving an opioid in ED (OR 0.65; 95% CI 0.55–0.75). However, no significant effect on lumbar imaging was demonstrated (OR 0.85; 95% CI 0.64–1.12). Subgroup analyses showed that studies reporting high baseline imaging rates ≥ 36% and those that included systems-based changes significantly reduced imaging (OR 0.60; 95% CI 0.39–0.93; and OR 0.65; 95% CI 0.45–0.94, respectively). A small reduction in ED length of stay was observed in the group exposed to the LBP interventions (mean difference − 0.38 h; 95% CI − 0.58 to − 0.17). Overall, certainty of evidence was deemed low to very low. Interventions were mostly single-system focused with a preference for education-based implementation strategies targeting patients or clinicians. The interventions reduced the use of opioid medication for LBP in ED, but the effects on lumbar imaging rates were uncertain. Further high-quality research is needed to improve LBP care in this setting.
期刊介绍:
Internal and Emergency Medicine (IEM) is an independent, international, English-language, peer-reviewed journal designed for internists and emergency physicians. IEM publishes a variety of manuscript types including Original investigations, Review articles, Letters to the Editor, Editorials and Commentaries. Occasionally IEM accepts unsolicited Reviews, Commentaries or Editorials. The journal is divided into three sections, i.e., Internal Medicine, Emergency Medicine and Clinical Evidence and Health Technology Assessment, with three separate editorial boards. In the Internal Medicine section, invited Case records and Physical examinations, devoted to underlining the role of a clinical approach in selected clinical cases, are also published. The Emergency Medicine section will include a Morbidity and Mortality Report and an Airway Forum concerning the management of difficult airway problems. As far as Critical Care is becoming an integral part of Emergency Medicine, a new sub-section will report the literature that concerns the interface not only for the care of the critical patient in the Emergency Department, but also in the Intensive Care Unit. Finally, in the Clinical Evidence and Health Technology Assessment section brief discussions of topics of evidence-based medicine (Cochrane’s corner) and Research updates are published. IEM encourages letters of rebuttal and criticism of published articles. Topics of interest include all subjects that relate to the science and practice of Internal and Emergency Medicine.