Management of low back pain in Australian emergency departments

Abstract

BackgroundTo describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by ambulance, received imaging, opioids and were admitted to hospital; and to explore factors associated with these four outcomes.MethodsIn this retrospective study, we analysed electronic medical records for all adults presenting with LBP at three Australian EDs from January 2016 to June 2018. Outcomes included discharge diagnoses and key aspects of care (ambulance transport, lumbar spine imaging, provision of opioids, admission). We explored factors associated with these care outcomes using multilevel mixed-effects logistic regression models and reported data as ORs.ResultsThere were 14 024 presentations with a ‘visit reason’ for low back pain, of which 6393 (45.6%) had a diagnosis of a lumbar spine condition. Of these, 31.4% arrived by ambulance, 23.6% received lumbar imaging, 69.6% received opioids and 17.6% were admitted to hospital. Older patients (OR 1.79, 95% CI 1.56 to 2.04) were more likely to be imaged. Opioids were less used during working hours (OR 0.81, 95% CI 0.67 to 0.98) and in patients with non-serious LBP compared with patients with serious spinal pathology (OR 1.65, 95% CI 1.07 to 2.55). Hospital admission was more likely to occur during working hours (OR 1.74, 95% CI 1.48 to 2.05) and for those who arrived by ambulance (OR 2.98, 95% CI 2.53 to 3.51).ConclusionMany ED presentations of LBP were not due to a lumbar spine condition. Of those that were, we noted relatively high rates of lumbar imaging, opioid use and hospital admission.

Management of patients with low back pain in the emergency department: Is it feasible to follow evidence‐based recommendations?

“…In our cohort, the proportion of patients admitted to the hospital (3.08%) was comparable to studies performed in North America, 3,12 but very low compared to studies performed in Australia, which have shown proportions up to 34% 11,13,14 (Table 1). Previous studies showing admission rates of less than 3% 3,12 evaluated younger cohorts than studies presenting admission rates over 17%.…”

“…Previous studies showing admission rates of less than 3% 3,12 evaluated younger cohorts than studies presenting admission rates over 17%. 11,13,14 In our cohort, age was not significantly different comparing patients admitted to the hospital and those not admitted; however, that lack of significance may reflect a type II error, as the number of patients admitted in our cohort (n = 16) was small. In fact, our patients admitted to the hospital (mean age 50.4 years) exhibited an age similar to the mean age of patients in studies with larger admission rates, 11,13,14 and those not admitted (mean age 43.6 years) had similar age to cohorts exhibiting lower admission rates.…”

“…According to the American College of Emergency Physicians Choosing Wisely campaign, 15 management at the ED should avoid lumbar spine imaging in patients with non-traumatic back pain unless there is a suspicion of a serious underlying condition or if the patient presents severe or progressive neurological impairment; moreover, the proportion of patients undergoing imaging studies has been proposed as the main outcome evaluating an adequate management of patients visiting the ED for LBP. 4 Several studies have shown that imaging testing is performed in close to 30% of patients presenting to the ED, in investigations conducted in Australia, Canada or the USA 3,[12][13][14]16 ( Table 3). We showed that in an academic health network in Chile, in which LBP at the ED is treated with an emphasis on evidence-based care, the proportion of patients undergoing an imaging study can be restricted to less than 20% (18.9%).…”

Hospital admission and associated factors among individuals presenting to healthcare facilities for low back pain in Ethiopia

“…In high-income countries, such as the USA and Australia, the epidemiology of LBP is well studied and the data show that a significant proportion of LBP patients being admitted to hospital following presentation to emergency departments. 3,21 For example, the USA study showed that between 1998 and 2007, LBP accounted for a total of 183 151 individuals to be admitted to hospital across the country, of which 118 962 (65%) were admitted after presentation to emergency departments. 3 The study in Australia also indicated that the rate of hospital admission through emergency departments was 17.6%.…”

“…3 The study in Australia also indicated that the rate of hospital admission through emergency departments was 17.6%. 21 Evidence also demonstrates that the rate of hospital admission for LBP following presentation to emergency departments is increasing over time. 22 Population-based epidemiological studies also estimated that the impact of LBP, including a frequent and a large deal of ambulatory medical care visits and hospitalization will increase with time.…”