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ObjectivesTo describe the available literature on the epidemiology and factors associated with osteoporosis, falls and fractures in four chronic inflammatory rheumatic diseases (CIRD): rheumatoid arthritis (RA); psoriatic arthritis (PsA); ankylosing spondylitis (AS); and systemic lupus erythematosus (SLE).DesignScoping review, using the Joanna Briggs Institute framework.Data sourcesMEDLINE, Embase and CINAHL from January 2000 to December 2023.Eligibility criteriaObservational studies reporting on the epidemiology and/or associated factors for osteoporosis, falls and fractures in RA, PsA, AS or SLE.Data extraction and synthesisTwo independent reviewers used a standard data extraction form including report methods, definitions, outcomes and associated factors. Results are summarised with descriptive statistics.Results288 studies met inclusion criteria, with 170 studies on RA, 19 on PsA, 49 on AS and 60 on SLE. Most studies were cross-sectional, with Europe and Asia having the greatest output. Most papers reported on osteoporosis and fractures as outcomes, with only 27 reporting falls, of which 24 were in RA. Participants’ demographics and disease-related parameters were the most frequently explored potential associated factors.ConclusionsRA was the most well-studied CIRD with regard to the epidemiology and associated factors for osteoporosis, fractures and falls. Cross-sectional was the most common study design, with a higher proportion of cohort studies in RA. There is a paucity of studies assessing falls in CIRDs other than RA. Future observational research should be conducted with large prospective CIRD cohorts, with falls as an outcome and associated factor for fractures. This may enable better understanding of the risk and consequences of osteoporosis, fractures and falls, which may improve preventive care.

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.

Background One in 6 patients with low back pain (LBP) presenting to emergency departments (EDs) are subsequently admitted to hospital each year, making LBP the ninth most common reason for hospital admission in Australia. No studies have investigated and quantified the extent of clinical variation in hospital admission following an ED presentation for LBP. Methods We used routinely collected ED data from public hospitals within the state of New South Wales, Australia, to identify presentations of patients aged between 18 and 111 with a discharge diagnosis of LBP. We fitted a series of random effects multilevel logistic regression models adjusted by case-mix and hospital variables. The main outcome was the hospital-adjusted admission rate (HAAR). Data were presented as funnel plots with 95% and 99.8% confidence limits. Hospitals with a HAAR outside the 95% confidence limit were considered to have a HAAR significantly different to the state average. Results We identified 176,729 LBP presentations across 177 public hospital EDs and 44,549 hospital admissions (25.2%). The mean (SD) age was 51.8 (19.5) and 52% were female. Hospital factors explained 10% of the variation (ICC = 0.10), and the median odds ratio (MOR) was 2.03. We identified marked variation across hospitals, with HAAR ranging from 6.9 to 65.9%. After adjusting for hospital variables, there was still marked variation between hospitals with similar characteristics. Conclusion We found substantial variation in hospital admissions following a presentation to the ED due to LBP even after controlling by case-mix and hospital characteristics. Given the substantial costs associated with these admissions, our findings indicate the need to investigate sources of variation and to determine instances where the observed variation is warranted or unwarranted.

Platelet-rich plasma (PRP) is a commonly used treatment for tendinopathies such as tennis elbow despite the questionable evidence of its efficacy. A recent Cochrane review suggests that it likely does not provide clinically meaningful benefits in people with tennis elbow. In this viewpoint, we discuss how lack of regulation allowed aggressive marketing and clinical use without normal phases of drug development and approval process or rigorous evidence of benefits. Since several phases of development were bypassed, we still do not know the optimal preparation method and dosing of PRP for tendinopathies. Furthermore, several clinical trials compared PRP with other interventions although it was unclear if PRP was better than placebo and these comparisons created distraction rather than improved understanding of its effects.

High quality clinical research that addresses important questions requires significant resources. In resource-constrained environments, projects will therefore need to be prioritized. The Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network aimed to develop a stakeholder-based, transparent, easily implementable tool that provides a score for the 'importance' of a research question which could be used to rank research projects in order of importance. Using a mixed-methods, multi-stage approach that included a Delphi survey, consensus workshop, inter-rater reliability testing, validity testing and calibration using a discrete-choice methodology, the Research Question Importance Tool (ANZMUSC-RQIT) was developed. The tool incorporated broad stakeholder opinion, including consumers, at each stage and is designed for scoring by committee consensus. The ANZMUSC-RQIT tool consists of 5 dimensions (compared to 6 dimensions for an earlier version of RQIT): (1) extent of stakeholder consensus, (2) social burden of health condition, (3) patient burden of health condition, (4) anticipated effectiveness of proposed intervention, and (5) extent to which health equity is addressed by the research. Each dimension is assessed by defining ordered levels of a relevant attribute and by assigning a score to each level. The scores for the dimensions are then summed to obtain an overall ANZMUSC-RQIT score, which represents the importance of the research question. The result is a score on an interval scale with an arbitrary unit, ranging from 0 (minimal importance) to 1000. The ANZMUSC-RQIT dimensions can be reliably ordered by committee consensus (ICC 0.73-0.93) and the overall score is positively associated with citation count (standardised regression coefficient 0.33, p<0.001) and journal impact factor group (OR 6.78, 95% CI 3.17 to 14.50 for 3rd tertile compared to 1st tertile of ANZMUSC-RQIT scores) for 200 published musculoskeletal clinical trials. We propose that the ANZMUSC-RQIT is a useful tool for prioritising the importance of a research question.

BackgroundPain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines.ObjectivesThe aim of this study was to investigate what influences GPs’ decision to prescribe pain medicines for LBP.DesignQualitative study with in-depth interviews.SettingAustralian primary care.ParticipantsWe interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes.Data analysisWe summarised GP’s choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP’s decision-making.ResultsGPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient’s pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process.ConclusionsWe identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.

IntroductionPatient falls in hospitals lead to patient harm, staff distress and economic burden on health systems. There are few strategies with robust evidence demonstrating benefit for the prevention of falls, especially in acute hospital settings. Education and multicomponent fall prevention approaches are promising. Rigorous systematic measurement of implementation has been lacking in most hospital fall prevention trials. This paper describes the protocol for a trial that will evaluate the impact of supported implementation of tailored multicomponent fall prevention interventions on patient falls in hospital.Methods and analysisA stepped-wedge hybrid type I effectiveness implementation cluster randomised trial will be conducted. Twelve inpatient wards across four metropolitan hospitals will be enrolled in the trial, clustered into groups of four and randomised to commence the intervention at one of three time periods. Patients and ward staff will be recruited to complete pre-implementation surveys, which, combined with analysis of routinely collected local falls data and staff brainstorming, will inform tailored multicomponent fall prevention interventions for each ward. Wards will receive quality improvement training, clinical facilitation and staff education for at least 4 months to support implementation of their fall prevention interventions. The primary outcome—rate of falls—will be measured using routinely collected hospital falls data from the incident management system and medical records. Pre-implementation and post-implementation patient and staff surveys, qualitative interviews and bedside audits will measure secondary effectiveness and implementation outcomes. Healthcare utilisation from hospital data will inform the cost-effectiveness analysis.Ethics and disseminationThe Sydney Local Health District Human Research Ethics Committee (RPAH Zone) approved this trial (protocol number X24-0087 and 2024/ETH00583). The trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12624000896572). Data collection commenced in October 2024, due for completion in May 2026. Results will be published in reputable international journals and presented at relevant conferences.Trial registration numberAustralian and New Zealand Clinical Trials Registry (ACTRN12624000896572).

Objective To test the cost effectiveness of an implementation strategy to promote evidence-based practice for low back pain in the emergency department. Methods An economic evaluation was conducted alongside a stepped-wedge cluster-randomised controlled trial. The trial aimed to evaluate a strategy to implement a guideline-endorsed model of care in four emergency departments in New South Wales, Australia. The intervention targeted emergency clinicians and was compared to usual emergency care. The main trial outcomes were healthcare use that aligns with the main principles of the model of care. The outcomes explored in this economic evaluation were lumbar imaging referrals, opioid use, and hospital admissions for low back pain. Costs related to implementation development, delivery and healthcare utilisation were included. Bivariate linear multilevel regression analyses were conducted, adjusting for clustering, time and the correlation between cost and outcome to calculate incremental cost and effects and incremental cost-effectiveness ratios. Non-parametric bootstrapping with 5,000 replications of incremental cost and effect pairs was carried out and plotted on cost-effectiveness planes for each of the outcomes. Cost-effectiveness acceptability curves were generated to explore the probability of being cost-effective based on a range of willingness to pay thresholds for each of the outcomes. Sensitivity analyses were carried out to determine to what extent the decision to exclude episodes of care missing healthcare costs and including inpatients costs impacted the results. Results The implementation was more effective but more costly when considering the three key outcomes. The implementation was cost-effective in reducing opioid use with an incremental cost-effectiveness ratio of $3,574.29 per episode of care where opioids were avoided. The incremental cost effectiveness ratios for avoiding imaging and hospitalisation were $26,298.50 and $49,290.00 per episode of care, respectively. The first sensitivity analysis highlighted uncertainty with the hospital admission result and the second sensitivity analysis found that the implementation was more likely to be cost-effective when considering emergency department costs only. Conclusion This implementation of the model of care may be cost-effective for reducing opioid use in patients who present to emergency with low back pain, however more research into willingness to pay to avoid opioid use in emergency departments is required. Key messages What is already known on this topic. Low value care for low back pain is prevalent in the emergency department. A multifaceted implementation strategy of an evidence-based model of care did not change the primary outcome imaging, however it reduced opioid use in the emergency department without adversely impacting pain outcomes and satisfaction with care. What this study adds. This study illustrates that in addition to this multifaceted implementation strategy being effective in reducing opioid use within the Emergency department, it is also likely to be cost effective in reducing opioid use. How this study might affect research, practice or policy. This study gives a clearer picture to policy makers about whether implementing this model of care is cost-effective, and should be adopted by other hospitals.

ObjectiveDescribe research methods used in priority-setting exercises for musculoskeletal conditions and synthesise the priorities identified.DesignScoping review.Setting and populationStudies that elicited the research priorities of patients/consumers, clinicians, researchers, policy-makers and/or funders for any musculoskeletal condition were included.Methods and analysisWe searched MEDLINE and EMBASE from inception to November 2017 and the James Lind Alliance top 10 priorities, Cochrane Priority Setting Methods Group, and Cochrane Musculoskeletal and Back Groups review priority lists. The reported methods and research topics/questions identified were extracted, and a descriptive synthesis conducted.ResultsForty-nine articles fulfilled our inclusion criteria. Methodologies and stakeholders varied widely (26 included a mix of clinicians, consumers and others, 16 included only clinicians, 6 included only consumers or patients and in 1 participants were unclear). Only two (4%) reported any explicit inclusion criteria for priorities. We identified 294 broad research priorities from 37 articles and 246 specific research questions from 17 articles, although only four (24%) of the latter listed questions in an actionable format. Research priorities for osteoarthritis were identified most often (n=7), followed by rheumatoid arthritis (n=4), osteoporosis (n=4) and back pain (n=4). Nearly half of both broad and specific research priorities were focused on treatment interventions (n=116 and 111, respectively), while few were economic (n=8, 2.7% broad and n=1, 0.4% specific), implementation (n=6, 2% broad and n=4, 1.6% specific) or health services and systems research (n=15, 5.1% broad and n=9, 3.7% specific) priorities.ConclusionsWhile many research priority-setting studies in the musculoskeletal field have been performed, methodological limitations and lack of actionable research questions limit their usefulness. Future studies should ensure they conform to good priority-setting practice to ensure that the generated priorities are of maximum value.PROSPERO registration numberCRD42017059250.

IntroductionSciatica is a debilitating condition that often becomes chronic, and for which there are few effective treatment options. Treatments such as the anti-depressant duloxetine have shown promise, but the evidence is inconclusive. We are describing a high quality, definitive trial to investigate the efficacy, safety and cost-effectiveness of duloxetine in chronic sciatica.Methods and analysisThe duloxetine for chronic sciatica (DREAM) trial is a randomised, superiority, parallel-group, placebo-controlled, triple-blinded (participant, clinician, assessor) trial with an adaptive group sequential design investigating the efficacy and safety of duloxetine in participants with chronic sciatica of at least 3 months duration. Participants will be randomised at a 1:1 ratio to duloxetine or placebo. 332 participants will be recruited on presentation to general practices, specialist clinics and hospital emergency departments or from hospital in-patient wards and from the community. In the active treatment group, participants will receive duloxetine 60 mg per day for 12 weeks, including 1 week of titration at 30 mg/day. The treatment phase will be followed by a 2-week tapering phase where they will receive duloxetine 30 mg/day. Participants will be followed-up for 1 year, with outcomes being measured 4, 8, 12, 16, 26, and 52 weeks post-randomisation. The primary outcome is leg pain intensity at 12 weeks post-randomisation. Secondary outcomes include back pain intensity, disability, time to recovery, quality of life, depressive and anxiety symptoms, and sleep disturbance. Adverse events will be recorded, and a cost-effectiveness analysis will be conducted.Ethics and disseminationEthical approval has been granted by the University of Sydney Human Research Ethics Committee. Trial results will be disseminated by publications, conference presentations and via the media.Trial registration numberACTRN12624000919516.