{
  "abstract": "Objectives Imaging and opioids are not recommended for most people with low back pain as they can lead to overdiagnosis and overtreatment. Yet around 1 in 3 people presenting to emergency departments (ED) will receive imaging, and 2 in 3 will receive an opioid. Non-indicated imaging can correlate poorly with symptoms, cause overdiagnosis and trigger a cascade of unnecessary treatments. Overtreatment with opioids can have serious consequences including adverse events, overdose and death.NUDG-ED aims to determine the effectiveness of behavioural ‘nudge’ interventions on rates of imaging and opioid prescriptions at discharge for low back pain patients the ED.Methods NUDG-ED is a recently completed 2×2 factorial, open-label, before-after, cluster randomised controlled trial. Eight EDs in Sydney, Australia were randomly assigned to receive (i) patient nudge, (ii) clinician nudges, (iii) both nudges, or (iv) no nudge. Participants were ED clinicians, and adult patients presenting to ED with back pain. The patient nudge included 6 posters with information correcting misperceptions about the need for imaging for low back pain. Patients were encouraged to ask their doctor if they really needed a scan, if there were risks involved and what would happen if they did not have the scan.The clinician nudge were multimodal, co-designed interruptive alerts within the electronic health system that was triggered when clinicians attempted to order lumbar imaging or opioids for a patient with back pain. The imaging alert provided clinicians with information about the red flags that would indicate imaging was necessary. This alert aimed to support clinicians to more accurately identify when imaging was needed and reduce fear of missed diagnosis. The alert also linked to a discussion guide to help clinicians manage patient expectations and discuss evidence-based treatment strategies. The opioid alert suggested trying non-steroidal anti-inflammatory medicines before opioids and take-home opioids should not be offered.The primary outcome is the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. Secondary outcomes include unintended consequences and patient-reported outcomes.Results Our 36-week recruitment period concluded on 29 January 2025. After a 12-week baseline period, we launched the interventions on 13 August 2025. Patient nudges showed for 96% of the intended intervention period and clinician nudges for 99% of the intended intervention period. We exceeded our sample size target of 2416 encounters for musculoskeletal back pain (>3500 enrolled) and 456 patient surveys (507 completed). We will conduct patient and clinician interviews in February 2025 to explore their experience of the interventions. We will have completed our analysis in March 2025.Conclusions NUDG-ED is a large clinical trial embedded in routine care. We are testing a potential solution that could reduce overdiagnosis and improve patient outcomes in the ED at scale. This will be the first international presentation of the completed trial results, which had its protocol paper presented at Preventing Overdiagnosis 2023 with support from the Lisa Schwartz Scholarship.Trial registration ACTRN12623001000695.Funding NHMRC (2015173).",
  "authors": [
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia"
      ],
      "name": "Gemma Altinger"
    },
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia"
      ],
      "name": "Sweekriti Sharma"
    },
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia"
      ],
      "name": "Chris G Maher"
    },
    {
      "affiliations": [
        "Royal Brisbane and Woman’s Hospital Health Service District, Queensland, Australia"
      ],
      "name": "Louise Cullen"
    },
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia"
      ],
      "name": "Kirsten McCaffery"
    },
    {
      "affiliations": [
        "Northwestern University Feinberg School of Medicine, Chicago, USA"
      ],
      "name": "Jeffrey A Linder"
    },
    {
      "affiliations": [
        "Monash University, Melbourne, Australia"
      ],
      "name": "Rachelle Buchbinder"
    },
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia",
        "Ingham Institute, Sydney, Australia"
      ],
      "name": "Ian A Harris"
    },
    {
      "affiliations": [
        "Macquarie University, Sydney, Australia"
      ],
      "name": "Enrico Coiera"
    },
    {
      "affiliations": [
        "George Institute for Global Health, Sydney, Australia"
      ],
      "name": "Qiang Li"
    },
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia"
      ],
      "name": "Kirsten Howard"
    },
    {
      "affiliations": [
        "The University of Sydney School of Medicine, Sydney, Australia"
      ],
      "name": "Andrew Coggins"
    },
    {
      "affiliations": [
        "Ingham Institute for Applied Medical Research, Sydney, Australia",
        "The University of New South Wales, Sydney, Australia"
      ],
      "name": "Paul M Middleton"
    },
    {
      "affiliations": [
        "The University of Sydney School of Medicine, Sydney, Australia",
        "Western Sydney Local Health District, Sydney, Australia"
      ],
      "name": "Naren Gunja"
    },
    {
      "affiliations": [
        "The University of New South Wales, Sydney, Australia",
        "Liverpool Hospital, Sydney, Australia"
      ],
      "name": "Ian Ferguson"
    },
    {
      "affiliations": [
        "The Agency for Clinical Innovation, City of Willoughby, Australia"
      ],
      "name": "Trevor Chan"
    },
    {
      "affiliations": [
        "Consumer Advisor, University of Sydney Institute for Musculoskeletal Health, Sydney, Australia"
      ],
      "name": "Karen Tambree"
    },
    {
      "affiliations": [
        "University of Sydney, Sydney, Australia"
      ],
      "name": "Adrian C Traeger"
    }
  ],
  "title": "062 NUDG-ED: a 2x2 factorial, before-after, cluster randomised trial using behavioural nudges to reduce overdiagnosis and overtreatment of back pain in the emergency department",
  "uid": "9954ef8c-bb72-523b-a031-4fe761a4327c"
}