A prospective study of patients with low back pain attending a Canadian emergency department: Why they came and what happened?

A prospective study of patients with low back pain attending a Canadian emergency department: Why they came and what happened?

Low back pain is a common presentation to emergency departments, but the reasons why people choose to attend the emergency department have not been explored. We aimed to fill this gap with this study to understand why persons with low back pain choose to attend the emergency department. Between July 4, 2017 and October 1, 2018, consecutive patients with a complaint of low back pain presenting to the University of Alberta Hospital emergency department were screened. Those enrolled completed a 13-item questionnaire to assess reasons and expectations related to their presentation. Demographics, acuity and disposition were obtained electronically. Factors associated with admission were examined in a logistic regression model. After screening 812 patients, 209 participants met the study criteria. The most common Canadian Triage and Acuity Scale score was 3 (73.2%). Overall, 37 (17.7%) received at least one consultation, 89.0% of participants were discharged home, 9.6% were admitted and 1.4% were transferred. Participants had a median pain intensity of 8/10 and a median daily functioning of 3/10. When asked, 64.6% attended for pain control while 44.5% stated ease of access. Most participants expected to obtain pain medication (67%) and advice (56%). Few attended because of cost savings (3.8%). After adjustment, only advanced age and ambulance arrival were significantly associated with admission. In conclusion, most low back pain patients came to the emergency department for pain control yet few were admitted and the majority did not receive a consultation. Timely alternatives for management of low back pain in the emergency department appear needed, yet are lacking.

Funding: This study was supported by the Emergency Medicine Research Group (EMeRG) in the Department of Emergency Medicine at the University of Alberta. At the time of the study, Dr. Rowe’s research was supported by a Tier I Canada Research Chair in Evidence-based Emergency Medicine from the Canadian Institutes of Health Research (CIHR) through the Government of Canada (Ottawa, ON). At the present time, Dr. Rowe’s research is supported by a Scientific Director’s Grant (168483) from CIHR. At the time of the study, Dr. Kawchuk received support through the Canadian Chiropractic Research Foundation (CCRF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Low back pain (LBP), a leading cause of disability in Canada [1], affects over 540 million people globally. With that impact and distribution, there is no shortage of settings in which LBP is evaluated whether in rehabilitation practices, primary care practice or hospitals (out-patient and in-patient settings). Indeed, LBP is a very common presentation to emergency departments (EDs). A recent systematic review by Edwards et al. reported that “LBP is consistently a top presenting complaint” within EDs [2]. In Canada, a multi-year analysis [3] showed the prevalence of LBP in a Canadian ED to be approximately 3% and the sixth most common reason for acute presentations [4]. From these studies, a considerable amount of LBP ED presentation characteristics is known including patient demographics, triage scores, length of stay (LOS), use of resources (e.g., imaging, consultations) and outcomes. This includes recent knowledge that the common practice of admitting patients with non-serious low back pain for inpatient care comes at great expense to the healthcare system [5] while many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause [6].

Despite this information, little is known about why people with LBP choose to come to the ED when other options are available in the community. In counties with universal publicly–funded health care like Canada, these options include no-cost access to primary care providers in the community and access to fee-for-service allied health care professions (e.g. chiroprators, physical therapists). This is an important question as very few patients with LBP who present to the ED are admitted to hospital. In many hospital settings, less than 10% of LBP cases presenting to the ED are admitted [3]. These low admittance rates suggest that the majority of ED LBP cases could be managed effectively by primary care providers; an important point as evaluating LBP in the ED can be associated with a higher frequency of imaging and opioid prescription [7–9] as Canadian EDs lacks national guidelines regarding LBP evaluation [10].

Given the above, the objective of this study was to document the reasons that persons with LBP present to the ED as they pertain to accessibility, social and economic domains. In addition, factors associated with admission were examined in an effort to generate future hypotheses. To our knowledge, the answers to these questions have not been reported previously in the emergency literature.

This was a prospective observational, monocentric study whose target population was those presenting to the University of Alberta Hospital Emergency Department (UAHED) with a complaint of LBP. The UAHED is a major urban teaching center located in Edmonton, Alberta, Canada (population = 1.3 million {2017}), with approximately 75,000 adult patient visits per year. It is a trauma, burns, transplant and pediatric centre staffed by full time emergency physicians and learners from a variety of specialty programs. A total of 11 clinical shifts of eight hours duration are employed to staff the adult side of the UAHED. At the time of the study, no other health care professionals (e.g., nurse practitioners, paramedics, physicians’ assistants, etc.) were employed at this site. At this institution, the on-call spine service alternates daily between Orthopedic and Neurosurgical services.

Included participants were persons aged 18 years of age or older visiting the UAHED with who self-reported LBP. Those who were deemed competent to provide informed consent were eligible for the study. At triage, Canadian Triage and Acuity Scale (CTAS) scores [11] were assigned by an experienced triage nurse. The CTAS includes a five-level triage scoring system: Resuscitation (CTAS 1), Emergent (CTAS 2), Urgent (CTAS 3), Less Urgent (CTAS 4), and Non-Urgent (CTAS 5).

Those excluded from the study were considered to have cognitive impairment, were enrolled previously in the study, attended for direct consultations, or were patients presenting to UAHED under police escort. Further, patients who were unable to read or communicate in English were also excluded, unless a friend or family member was able to assist in the completion of the collection of study materials. Patients who were feeling too unwell, due to nausea, pain, emotional instability, or intoxication, but improved before the end of the study recruitment shift, were approached to participate in the study. A Refused, Missed, and Other exclusion (RMO) minimal data log was maintained (e.g., age, sex, time of day, triage score, reason for exclusion). In addition to those patients approached directly by the research assistants, a sign was approved and posted in the ED informing those in the waiting room about the study. Interested patients followed the informed consent process detailed above.

The study questionnaire was developed from a prior pilot mailout survey with a subsequent response rate of ~ 15% [11]. Based on this low response rate, we modified the mailout survey to be used as an onsite questionnaire in the ED at the time of patient presentation. The final questions used in this questionnaire were a subset from the prior mailout survey and selected by the expert panel of collaborators as those related directly to the main research question. The questionnaire had face and content validity and was pilot tested prior to use; however, this is the first use of the questionnaire and no formal validation study was conducted. Questionnaire access was closed in that it was made available only to those persons who provided consent and met the enrollment criteria.

On most occasions, the research assistant approached and interviewed the patient prior to an emergency physician seeing the patient. During the interview, if a physician or nurse needed to assess the patient, the interview was completed after their assessment. Participation in the study was voluntary, no incentives were offered to patients for participation, and completion did not delay direct patient care. The questionnaire was taken only by those who provided consent and in no way affected their care.

All responses were collected on paper forms and checked for completeness by our research staff. All data were then entered into a password protected Research Electronic Data Capture (REDCap) website (Vanderbilt University license to the Women and Children’s Health Research Institute—WCHRI, University of Alberta) located on a secure University of Alberta server. The only unique participant identifier was the participant study number.

Participant names and identifying characteristics were not recorded on the study materials; however, a master form was retained until data capture was complete. All data were entered into the electronic repository as de-identified data following verification and stored on secure servers within the Faculty of Medicine & Dentistry at the University of Alberta.

The study questionnaire was designed to answer our research question within the shortest period of time [11]. Questionnaires required approximately 10 minutes to complete, and included 13 questions (Fig 1). Participants were asked to answer questions relating to their reasons for presentation at the ED (e.g., pain management vs. a lack of alternative options), their expectations, primary care provider visit history, urgency of the ED visit, scale of pain, and preventive health practices prior to the ED visits.

In addition to data collected from the questionnaire, de-identified administrative data for the study period were provided by Data Information and Measurement Reporting (DIMR) within Alberta Health Services (AHS). Additional data contained information on demographics (e.g., age {in years}, sex {male/female}), ED arrival information (e.g., arrival mode, CTAS), ED visit times (e.g., triage, physician initial assessment time {PIA}, consult time, and disposition time), disposition (e.g., admission/discharge; Left without being seen {LWBS}; left against medical advice {LAMA}; death), and post-ED outcomes (e.g., return to ED visits with or without admission within 72 hours).

There was a need to balance research effort and available resources with sample size. For example, enrollment of ~250 participants would provide reasonable precision around mid-range observations (e.g., at 50%, the 95% CI for 250 observations would be ± 6%) as well as low (e.g., at 10%, the 95% CI for 250 observations would be 4%) incidence observations. To obtain 95% CIs approximating ±1% at the mid-range of estimates, enrollment of more than 5000 participants would be needed, which was not feasible.

All study data were exported from REDCap into STATA® (Version 12.0; STATA Corp. LP, College Station, TX) for analysis. Dichotomous results are reported using proportions and comparisons were conducted using Chi-square (χ2) statistics. Parametric continuous data are reported as means with standard deviations (SD) and comparisons were completed using unpaired t-test. Nonparametric continuous data are reported as medians with interquartile range (IQR: P75, P25), and comparisons were completed using Wilcoxon rank-sum tests. Factors associated with admission were examined in a logistic regression model using univariate associations at the p 0.05 in the combined model. Odds ratios (OR) and 95% CIs are reported for unadjusted and adjusted comparisons. Significance for all tests will be set at p

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