Cost-effectiveness analysis of the SHaPED trial testing a multifaceted implementation strategy of a model of care to improve emergency department care of low back pain.

Objectives When low back pain is managed in the emergency department overdiagnosis and overtreatment are common. Key problems are overuse of imaging, opioid medicines and hospital admission. The overall aim of the Sydney Health Partners Emergency Department (SHaPED) trial is to implement and evaluate an evidence-based model of care for acute low back pain. The outcomes of the trial reflect the key messages in the model: (1) patients with non-specific low back pain do not require imaging; (2) where medicines are used, simple analgesics should be the first option; (3) patients with non-specific low back pain should be managed as outpatients. Method A stepped-wedge cluster randomised controlled trial will be conducted to implement and evaluate the model of care for acute low back pain at four emergency departments in New South Wales, Australia. Clinician participants will be emergency physicians, nurses and physiotherapists. Codes from the Systematised Nomenclature of Medicine—Clinical Terms—Australian version will be used to identify low back pain presentations. We anticipate ~2000 patient participants. The intervention, targeting emergency clinicians, will comprise educational materials and seminars and an audit and feedback approach. Health service delivery outcomes are routinely collected measures of imaging (primary outcome), opioid use and inpatient admission A random subsample of 200 patient participants from each trial period will be included to measure patient outcomes (pain intensity, physical function, quality of life and experience with emergency service). An economic evaluation will be undertaken from the health system perspective. Results The SHaPED trial received ethical approval from the RPAH HREC (reference: X17–0043). The trial is registered with the Australia New Zealand Clinical Trials Registry: ACTRN 12617001160325.The conference presentation will discuss the design and rationale for the trial. Conclusions We hypothesised that active implementation of an evidence-based model of care for low back pain will improve emergency care by reducing inappropriate overuse of tests and treatments (i.e. imaging, opioids, admission to hospital) and improving patient outcomes.

The competitive worldwide economic environment and ever-increasing costs of health care have created a setting in which understanding costs and making sure that we achieve good value in health care are paramount. One approach to seeking value is through the use of cost-effectiveness analysis. Although this science is now several decades old, it has been refined over the last several years, with increasingly sophisticated statistical and standardized methods.1,2 Is cost-effectiveness analysis useful? Does it help in medical decision making and in allocation of scarce resources? In the accompanying article, “Cost, Effectiveness, and Cost-Effectiveness” Diamond and Kaul3 argue that cost-effectiveness analysis is not a useful approach. Although we agree with many of the points that Diamond and Kaul raise, we do not agree with their conclusion. Cost-effectiveness analysis involves an assessment of both cost and effectiveness. The distribution of each needs to be understood. A cost-effectiveness analysis is only as valid as its underlying measures of effectiveness and cost, a discussion that is beyond the scope of this article. However, the methods to make these assessments vary considerably. There are standards for cost-effectiveness, but at times, perfectly adhering to these standards is not realistic, and compromises are often made that may be entirely scientifically legitimate.4 Cost-effectiveness is, by nature, incremental. Thus, it is necessary to look at the added costs compared with a control group. Selection of the appropriate control group is a challenge itself. At times, the appropriate control is placebo, and at other times, it is active therapy; the appropriate control is dependent on the clinical question being asked. However, when cost-effectiveness analysis is conducted using data from a clinical trial, the selection of the control group will not be a decision that the analyst can affect (at least after the trial has been completed). When …

Cost Effectiveness of Achieving Targets of Low-Density Lipoprotein Particle Number Versus Low-Density Lipoprotein Cholesterol Level

IntroductionPatients 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...

Healthcare costs due to low back pain in the emergency department and inpatient setting in Sydney, Australia

Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge. This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.

The biopsychosocial model is currently considered by most researchers and clinicians to be the best approach to low back pain (LBP) care. The model was popularised in LBP care in response to some clear deficiencies in earlier biomedical approaches and is now widely recommended in clinical guidelines and policy statements. Yet the biopsychosocial approach has also been critiqued for its narrow conceptualisation and application. In this article, we explore how attending to the multidimensionality of LBP in practice goes beyond a biopsychosocial approach. We engaged with 90 ethnographic observations of clinical practices, 22 collaborative dialogues with clinicians, and eight consultatory meetings with people with experience of LBP to consider the sociomaterialities of clinical practices in two settings: a private physiotherapy practice and a public multidisciplinary pain clinic. Drawing on the work of Annemarie Mol and Rosi Braidotti, our analyses suggest that sociomaterial practices, involving human and non‐human actors, produced multiple objects of clinical attention and ethical concerns about how to attend to this multiplicity well. We argue that the multiplicity of LBP is attended well by reimagining: (1) clinical settings as ‘becoming more‐than‐sterile environments’ where objects, furniture and elements such as tears and laughter help to provide a relational, welcoming and comfortable space to all bodies with LBP; (2) differences through ‘becoming minoritarian’ where considering power relations allows actions towards connectiveness and belonging; and (3) disciplinary boundaries through ‘becoming interdisciplinary within’ where actions expand traditional scopes of practice. The flux of these multiple becomings moves clinical practice and conceptualisations beyond the biopsychosocial approach to consider a new ethico‐onto‐epistemological approach to LBP care. They invite clinical practices that engage with an ethical multiplicity of LBP care, providing a better understanding of how places, objects, emotions, power, bodies and professions are interconnected and come together in everyday practice.

BackgroundOveruse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline...

Patient Perspectives on Seeking Emergency Care for Acute Low Back Pain and Access to Physical Therapy in the Emergency Department.

ABSTRACTBackground: Changes in substance use patterns stemming from opioid misuse, ongoing drinking problems, and marijuana legalization may result in new populations of patients with substance use disorders (SUDs) using emergency department (ED) resources. This study examined ED admission trends in a large sample of patients with alcohol, marijuana, and opioid use disorders in an integrated health system. Methods: In a retrospective design, electronic health record (EHR) data identified patients with ≥1 of 3 common SUDs in 2010 (n = 17,574; alcohol, marijuana, or opioid use disorder) and patients without SUD (n = 17,574). Logistic regressions determined odds of ED use between patients with SUD versus controls (2010–2014); mixed-effect models examined 5-year differences in utilization; moderator models identified subsamples for which patients with SUD may have a greater impact on ED resources. Results: Odds of ED use were higher at each time point (2010–2014) for patients with alcohol (odds ratio [OR] range: 5.31–2.13, Ps < .001), marijuana (OR range: 5.45–1.97, Ps < .001), and opioid (OR range: 7.63–4.19, Ps < .001) use disorders compared with controls; odds decreased over time (Ps < .001). Patients with opioid use disorder were at risk of high ED utilization; patients were 7.63 times more likely to have an ED visit in 2010 compared with controls and remained 5.00 (average) times more likely to use ED services. ED use increased at greater rates for patients with alcohol and opioid use disorders with medical comorbidities relative to controls (Ps < .045). Conclusions: ED use is frequent in patients with SUDs who have access to private insurance coverage and integrated medical services. ED settings provide important opportunities in health systems to identify patients with SUDs, particularly patients with opioid use disorder, to initiate treatment and facilitate ongoing care, which may be effective for reducing excess medical emergencies and ED encounters.

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Background: Immunotherapy for Alzheimer’s disease(AD) has gained momentum in recent years. One of the concerns over its application pertains to Cost-Effectiveness Analysis (CEA) from population average and specific subgroup differences, as such a therapy is imperative for health decision-makers to allocate limited resources. However, this sort of CEA model considering heterogeneous population with risk factors adjustment has been rarely addressed.Methods: We aimed to show the heterogeneity of CEA in immunotherapy for AD in comparison with the comparator without intervention. Economic evaluation was performed via incremental Cost-Effectiveness Ratio (ICER) and Cost-Effectiveness Acceptability Curve (CEAC) in terms of the Quality-Adjusted Life Years (QALY). First, population-average CEA was performed with and without adjustment for age and gender. Secondly, sub-group CEA was performed with the stratification of gender and age based on Markov process. Results: Given the threshold of $20,000 of willingness to pay, the results of ICER without and with adjustment for age and gender revealed similar results ($14,691/QALY and $17,604/QALY). The sub-group ICER results by different age groups and gender showed substantial differences. The CEAC showed that the probability of being cost-effective was only 48.8%-53.3% in terms of QALY at population level but varied from 83.5% in women aged 50-64 years, following women aged 65-74 years and decreased to 0.2% in men≥ 75 years. Conclusion: There were considerable heterogeneities observed in the CEA of vaccination for AD. As with the development of personalized medicine, the CEA results assessed by health decision-maker should not only be considered by population-average level but also specific sub-group levels.

Relationship Between Pain Management Modality and Return Rates for Lower Back Pain in the Emergency Department.

Introducing Australia's clinical care standard for low back pain.

Health technology assessment (HTA) increasingly important in spine research