Associate ProfessorGustavo Machado

Title: Harnessing the power of electronic medical records with data analytics in back pain

Summary of opportunity:

This program of research will evaluate the use of digital technology and data analytics to drive practice change and improve healthcare for back pain.

Opportunity synopsis:

Every year, there are more than 50,000 presentations of low back pain to NSW emergency departments, which generates huge costs to the healthcare system ($560 million). Despite high quality evidence being available, it is well known that management of these patients is suboptimal. Imaging is over ordered, and opioid medications are over prescribed. Better management of low back pain in the emergency department, therefore, has the potential to reduce harms to a large volume of patients and save health dollars. Prior to the development of the STARS Back Pain Application with Qlik Sense®, time poor, front-line clinicians did not receive clinically relevant feedback about their management of these patients. Lack of real-time feedback has meant a lost opportunity to identify clinical variation, drive practice change, and conduct low cost, high-quality, patient- centred research in this area. Clinicians can now access detailed and real-time data and interact with the data according to their needs. Our innovation is also an opportunity to hugely accelerate the translation of evidence-based medicine into clinical practice.The PhD/MPhil students will be based at King George V Building, Royal Prince Alfred Hospital and working with a large dataset collected using the STARS Back Pain Application. They will also be involved in projects evaluating the use of this technology in driving practice change in hospital and emergency settings.

--------------------------------------------------

Title: RESHAP-ED: a randomised controlled trial comparing primary-contact physiotherapy versus usual care for musculoskeletal pain in emergency departments

Summary of opportunity:

This is a PhD opportunity to work on a MRFF-funded trial evaluating primary contact physiotherapy in emergency departments.

Opportunity synopsis:

Musculoskeletal conditions, including back pain, are in the top 10 reason for presentation to Australian emergency departments (ED). There is some evidence that timely access to physiotherapy in EDs reduces wait-time, and ED length of stay. Primary contact physiotherapists have been present in some Australian EDs for approximately 20 years, however the level of service provision varies across sites and access is inequitable. This may be because strong evidence of effectiveness is lacking, i.e. predominately observational studies. The trial aims to test the effectiveness, cost-effectiveness, and scalability of a primary contact physiotherapy service in managing musculoskeletal conditions in the ED. This is a two-arm, parallel randomised controlled trial with nested process and economic evaluations. 620 participants will be randomised to receive primary contact physiotherapy management or usual care (i.e. managed predominantly by doctors and nursing staff). Inclusion criteria will be any adult patient (>18 years) that presents to the ED with a simple musculoskeletal condition. This would include but not limited to low back and neck pain, joint pain, muscle sprains and strains. The primary outcome will be ED length of stay to measure patient flow. Secondary outcomes include patient reported measures of pain intensity (numeric rating scale 0-10), quality of life (Euro-Qol 5D-5L), satisfaction with care (scale 0-10), adverse events or unintended consequences, and health services outcomes of healthcare use and costs. Process measures will explore the scalability of this intervention, if shown to be effective and cost-effective. These include acceptability, appropriateness, and fidelity. Process outcomes will be measured through trial logs and semi-structured interviews with the ED clinicians and managers. If the intervention is effective, we plan to work with our partners at the Emergency Care Institute (ECI) to implement across NSW. A successful intervention to improve patient flow would reduce the pressure emergency departments are facing.

--------------------------------------------------

Title: ADAPT-ED: adaptive trial of emergency department interventions for back pain

Summary of opportunity:

Back pain is the 5th most common presentation to Australian emergency departments. Overuse of strong opioids medicines like oxycodone (50% stronger than morphine) is a problem. Current back pain trials do not examine the effects of non-opioid analgesics such as ibuprofen or muscle relaxants in this setting. We propose a trial across five large, diverse emergency departments in NSW and QLD testing multiple non-opioid treatments against the most used opioid to manage back pain in Australia. This trial is funded by an MRFF Acute Care Grant ($3.2 million, CIA Machado).

Opportunity synopsis:

Back pain is a major health issue and one of the most common presentations to Australian emergency departments. The challenge is to provide rapid pain relief to relieve patient distress and avoid delays in discharge and unnecessary hospitalisations. The problem is that potentially harmful opioids like oxycodone remain widely used and we lack relevant trial data to guide emergency clinicians’ choice of pain medicines.

We propose a multi-arm multi-stage, non-inferiority, randomised trial including 520 participants with moderate-severe back pain across five emergency departments in NSW and QLD. In ADAPT-ED, we are testing the comparative effectiveness of five active analgesic medicines for back pain in the emergency department. We will randomly allocate participants to receive three days of regular doses of paracetamol 1g plus naproxen 500mg (twice per day), regular doses of naproxen 500mg alone (twice per day), regular doses of prednisolone 25mg (twice per day), or as-needed doses of oxycodone 5mg (maximum 30mg per day). The primary outcome is change in pain intensity assessed on an 11-point numeric rating scale (NRS) in which 0 denotes no pain and 10 denotes worst imaginable pain, measured from the time of emergency triage (baseline) to two hours after ingestion of study medicine (primary time point). Our team has extensive experience in back pain and emergency medicine trials and will work closely with consumers and partners to deliver this project.

--------------------------------------------------

Title: Redesigning Ambulance Management for Back-pain Outcomes (RAMBO)

Summary of opportunity:

Opportunity for a PhD student to join a collaborative research project to implement and test a virtual care referral pathway for paramedics to manage people with back pain. The project is a collaboration between the Institute for Musculoskeletal Health, and established health services, including Royal Prince Alfred Virtual Hospital and NSW Ambulance.

Opportunity synopsis:

Back pain is a common presentation to Australian ambulance services. Currently, ~30% of patients with back pain who are managed, discharged to stay at home and referred by paramedics to community health services for follow-up care reconnect with emergency health services. Virtual care services are a new alternative to in-person hospital care, providing high-quality care remotely to patients with back pain, to reduce hospital admission.

This research program will involve a number of projects including a proposed randomised controlled trial and economic evaluation, and qualitative research. The research project aims; to implement and test a virtual care referral pathway for paramedics to manage people with back pain. The project will explore the effectiveness of the virtual care pathway on health service outcomes, such as presentation to the emergency department, patient re-contact with ambulance service, re-presentation to the emergency department and admission to hospital, and patient outcomes, like disability. The nested qualitative will explore clinician perspectives of the virtual care referral pathway, and enablers and barriers to its use. Another qualitative project will explore patient views and satisfaction with the virtual care that they received for their back pain. The nested economic evaluation aims to evaluate the cost-effectiveness of the virtual care referral pathway compared to usual care delivered by paramedics (e.g. transport to hospital) from a healthcare funder perspective.

The findings from the program of research will be translated into practice, through our partnership with health services and the Sydney Local Health District.

--------------------------------------------------

Title: ELDERS BACK@HOME: development and evaluation of virtual care for older people admitted to hospital with low back pain

Summary of opportunity:

Opportunity for a PhD student to join a research project to develop and test in a randomised controlled trial the ELDERS BACK@HOME model of care for older people. This model of care will specifically cater for older people presenting to ED with back pain as a hybrid virtual and in-person model of care to facilitate early hospital discharge.

Opportunity synopsis:

Back pain is the fifth most common reason for ED visits in Australia, with one out of four patients being subsequently admitted to hospital. Older patients account for ~64% of hospital admissions for back pain. Facilitating early discharge from hospital is essential to improve health outcomes, especially for older patients who face an increased risk of hospital-acquired complications, such as infections and falls.

Our group has led the implementation of a new model of care, comprising virtual hospital support in the Sydney Local Health District (BACK@HOME). However, older patients (i.e. those aged over 70 yrs) are currently not eligible for the service due to a lack of evidence on its safety and effectiveness in this population. This study will evaluate the (cost-)effectiveness and safety of the ELDERS BACK@HOME model of care designed to cater to the needs of older people with back pain.

This research project will be conducted in two stages: (1) development of the new model of care to cater to the needs of older people with back pain; and (2) evaluation of the (cost-)effectiveness and safety of the ELDERS BACK@HOME in older people with back pain admitted to the hospital. Project 1 consists of a qualitative study with interviews and focus groups with older people with back pain, ED clinicians, geriatricians and physiotherapists providing virtual care to revise the BACK@HOME model of care for older patients. Project 2 will be a 2-arm, randomised trial in three hospitals from the Sydney Local Health District.

--------------------------------------------------

Title: SMART-ED: a trial in emergency departments testing optimal implementation strategies of back pain guidelines

Summary of opportunity:

Opportunity for a PhD student to join a research project to assess the comparative effectiveness of four implementation strategies (alone or in combination) for reducing emergency physician provision of opioids to patients with back pain. This design will allow us to identify optimal implementation strategies to reduce opioid prescribing at scale.

Opportunity synopsis:

Back pain affects 4 million Australians each year, with direct healthcare costs estimated at $3.4 billion - half of which is attributed to hospital care. Back pain is costly and a common presentation in emergency departments. In 2022-23, back pain was the 6th most common reason for all emergency department presentations in Australia. A key problem is that opioids are overprescribed - given to 70-85% of patients with back pain in emergency departments. However, we lack trial data about which implementation strategies should be used to reduce opioid prescribing at scale.

We propose a sequential multiple assignment randomised trial in emergency departments in NSW, including 8,800 patients, to test implementation strategies to reduce opioid prescribing. The trial will take place in 44 emergency departments across nine Local Health Districts (LHD) in NSW. We have investigators and active collaborations across each of these health services. The diversity of sites also ensures we investigate the process of change, where readiness to adopt guidelines is expected to vary at site level, including sites where change is resisted versus early adopters. Our primary outcome will examine the proportion of patients with back pain who receive an opioid in the emergency department. This outcome reflects the adoption of back pain guidelines and aligns with Australian indicators for judicious use of opioids.