- Title
- Improving the care of musculoskeletal conditions within the public health system of Australia
- Creator
- Davidson, Simon Robert Emanuel
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2024
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Musculoskeletal conditions, particularly spinal pain (low back and neck pain) and osteoarthritis, are common disabling conditions. People suffering from musculoskeletal conditions are seen in primary, secondary and tertiary care across the health system. In Australia the health system is divided into three main sectors: i) primary care- typically a person’s first contact with the health service, and may be delivered in a variety of settings (e.g., general practice, or community health centres); secondary care- which is provided by a specialist or other health clinician, usually upon referral from a primary care physician (e.g., an outpatient appointment with a specialist doctor in a private clinic or a public/private hospital outpatient department); and iii) tertiary care- where specialised care is provided as a hospital inpatient (e.g., emergency surgery for appendicitis). Musculoskeletal conditions have a considerable individual, societal and economic burden worldwide. Several evidence gaps currently exist in the care of people with musculoskeletal conditions. Exercise is a common treatment used by clinicians in primary care settings; however, limited information is available on the reporting quality of exercise interventions for low back pain, which may impact the translation of research findings into practice. Many people living with musculoskeletal conditions are also referred to secondary care for consideration for surgery by primary care clinicians. In Australia, extended waiting times often exist for those people awaiting orthopaedic surgical review, during which they often receive inadequate care for their musculoskeletal condition. Unfortunately, there is limited information about the health and clinical course of people awaiting orthopaedic specialist consultation, including the presence of chronic disease risk factors. There is growing evidence that chronic disease risk factors can impact the clinical course of musculoskeletal conditions. Many people that cannot access timely care in primary care may also present to the emergency department for care. Gaps exist in understanding the perspectives of emergency department clinicians on managing people with low back pain, how to improve the care of these people in the emergency department, and whether low back pain presentations differ between different facilities or locations. The studies reported in this thesis address the identified evidence gaps and aim to improve the care of people with musculoskeletal conditions across the health system. Exercise is recommended in clinical practice guidelines for people with low back pain and is used routinely in clinical practice. However, for clinicians to be able to implement new evidence into practice, research must be adequately reported. Poor reporting has been previously identified in both pharmacological and non-pharmacological clinical trials, limiting the implementation of interventions and contributing to research waste. While reporting checklists have been introduced to address this issue, poor reporting continues. Chapter Two details a systematic review that uses the Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) to assess the reporting quality of exercise interventions for people with low back pain. We searched five online databases and Clinical Trial Registries up to October 2018. We included 582 randomised controlled trials that reported exercise-based interventions for low back pain and assessed a random sample of 100. We found poor reporting of exercise interventions. The overall completeness of reporting (median [inter-quartile range]) using the TIDieR was 59.2% (45.5% to 72.7%), and using the CERT, it was 33.3% (22.2% to 52.6%). Journals should introduce reporting policies to improve the reporting quality of exercise interventions for low back pain that will enable them to be reproduced in other studies and the clinical setting. People with musculoskeletal conditions are often referred for specialist orthopaedic consultation and consideration for surgical intervention within secondary care. In Australia, the referral rate from primary care to orthopaedic specialists is 11.9 per 100 people for knee osteoarthritis (OA) and 13.3 per 100 for hip OA. Currently, people often wait for extended periods, in a large part due to poor cohesion between primary and secondary care. Many people report that during this waiting time, they receive little care for their musculoskeletal condition. Chapter Three describes a repeated measure longitudinal cohort study of people with musculoskeletal conditions referred to orthopaedic specialists. Over a three-year period, we collected a range of measures, including condition-specific indicators (e.g., pain and disability) and chronic disease risk factors (e.g., weight, poor diet, low physical activity, smoking and alcohol). We found back (43.1%) and knee (35.0%) pain were the most common conditions. At baseline, people reported a mean pain level of 6.4/10 (SD 2.4) and a mean Quality of Life of 32.7 (SD 10.7) (Physical Component Score) and 46.6 (SD 13.3) (Mental Component Score). The prevalence of chronic disease risk factors was high; 74.6% of people had three or more risks. Quantitative results indicate that the health of people on the wait list did not change over their wait period. People with musculoskeletal conditions have a complex clinical picture with numerous modifiable chronic disease risk factors. The waiting period for surgical consultation is an opportunity to provide good quality care that may have wide-ranging health benefits. Poor access to primary and secondary care means that people with musculoskeletal disorders often present to hospital emergency departments. Low back pain is the fifth most common reason for presentation to Australian emergency departments. Unfortunately, people that access care in the emergency department for low back pain often receive low-quality care that is not aligned with evidence-based management guidelines. There is currently limited information investigating how to improve care for this patient group. Key to improving care is understanding the clinician’s perspective. Chapter Four describes a qualitative exploratory study investigating the perspectives of emergency department clinicians in caring for people with low back pain. We collected data in focus groups and individual interviews with 21 emergency department clinicians (including medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia. We used thematic analysis to synthesise data. Clinicians identified a range of barriers and enablers to caring for people with low back pain in the emergency department, which we categorised into patient-, clinician- and service-level factors. Clinicians also suggested several possible strategies to improve the care of this patient group in the emergency department. Strategies included a low back pain pathway, clinician and patient resources, timely follow-up options, and better communication between the emergency department and primary care. We used the information described in Chapter Four to co-design and test a range of strategies to improve the care of people with low back pain in the same emergency department. The protocol for this study is described in Chapter Five, and the results are presented in Chapter Six. We undertook an interrupted time series study to test the effect of four strategies on hospital service-level indicators. Our four strategies were: i) a local emergency department guideline for low back pain, ii) an evidence-based patient handout, iii) an education program for emergency department clinicians, and iv) a rapid-access physiotherapy clinic. We compared pre-implementation (July 2014 – December 2019), transition (July 2020 – February 2021), and post-implementation (March 2021– November 2021) phases. Our primary outcome was the rate of change (incidence rate ratio) in the proportion of hospital admissions between phases, particularly pre-post. Secondary outcomes included emergency department length of stay, presentation cost, proportion of re-presentations within five days and admission length of stay. There were 5,301, 752 and 732 emergency department presentations for low back pain in the pre-, transition and post-implementation phases, respectively. Our strategies resulted in a small reduction (2%) in the change in the proportion of admissions per month and a monthly decrease of 1.5 minutes in the average emergency department length of stay from post-implementation to pre-implementation. The differences were not statistically significant for either variable. The strategies implemented in this study did not appear to have a considerable impact on service-level indicators or patient flow through the emergency department. Emergency departments in regional and rural areas often provide care to people with low back pain. Facilities in regional and rural areas face different challenges to metropolitan facilities, including staffing shortages and retention, fewer available resources, and differences in staffing portfolios. While details of low back pain presentations to metropolitan emergency departments are well reported, there is limited information about presentations to regional and rural facilities. Chapter Seven presents a retrospective observational study of emergency department presentations and related hospital admission data over a five-year period (July 2014 – June 2019) in 37 emergency departments. We describe low back pain presentations to emergency departments by remoteness areas, hospital delineation level and staffing portfolios. Outcomes included emergency department presentation and associated admission service-level measures (e.g., length of stay and admission rate). There were 26,509 emergency department presentations for low back pain during the five years. Data varied across geographical locations and staffing portfolios. The emergency department length of stay was 206 minutes in major cities, 146 minutes in inner regional areas, and 89 minutes in outer regional areas. In facilities staffed by emergency department staff, the emergency department length of stay was 192 minutes, compared to 94 minutes in departments staffed by General Practitioners. Data showed that emergency department presentations for low back pain appear to follow different pathways that result in different service-level outcomes depending on the facility location and staffing portfolio. The findings of Chapter Seven highlight the need to consider the local context of facilities when implementing service targets or treatment recommendations. People with musculoskeletal conditions access care across the breadth of the health system. The studies included in this thesis identified that the reporting quality of exercise interventions used by clinicians in primary care appears to be poor, possibly limiting the uptake of beneficial interventions. It also measured the wider health (including chronic disease risk factors) of those people with musculoskeletal conditions referred for specialist consultation in secondary care. Lastly, studies within this thesis also identified the challenges in caring for people with low back pain in the emergency department, the high numbers of presentations across geographical areas, and tests several strategies to improve care for this patient group.
- Subject
- musculoskeletal; back pain; osteoarthritis; public health system; emergency department; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1512532
- Identifier
- uon:56628
- Rights
- Copyright 2024 Simon Robert Emanuel Davidson
- Language
- eng
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| View Details Download | ATTACHMENT01 | Thesis | 11 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 264 KB | Adobe Acrobat PDF | View Details Download |