[Physio Explained] What are nudges and can they improve low back pain care? with Sweekriti Sharma

In this episode with Sweekriti, we discuss her research on low back pain and using nudges to decrease low value care. We explore:

• The definition of a patient “nudge” and clinician “nudge"
• How to help people with LBP in the community before presenting to emergency department
• Further research in managing low back pain
• Reducing alerts in EMR

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Dr Sweekriti Sharma is a Postdoctoral Research Fellow at the Institute for Musculoskeletal Health, a partnership between the University of Sydney and Sydney Local Health District. A public health researcher with expertise in clinical trials and public health approaches to common conditions such as low back pain, she examines how health systems can better support effective, equitable care. Her work aims to strengthen evidence‑based practice and improve population health outcomes.

 Reference to article discussed:

Altinger G, Sharma S, Maher CG et al. (2026) NUDG-ED Study Group. Behavioural nudges to reduce low-value care for low back pain in the emergency department (NUDG-ED): a 2 × 2 factorial, pragmatic cluster randomized trial. CMAJ, 198(13):E486-E499. 

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Transcript

SPEAKER_01 0:05

There was no effect of clinician nudges compared with no clinician nudges as well. So in our factorial analysis, we compared hospitals that were randomized to patient nudges with hospitals that were randomized to no patient nudges, and same with the clinician nudges as well. The overall rate of low-value care was around 42%. We also found no interaction effect between the interventions. There was no meaningful differences in secondary outcomes as well.

SPEAKER_02 0:36

Why is low-value care still so common in low back pain? Even in emergency departments where evidence is clear. Can behavioural nudges or simple changes to the clinical environment actually shift clinical decision making? And what happens when we test this at scale in a real-world healthcare system? Dr. Sweet Kritishama is a postdoctoral researcher at the University of Sydney with a background in public health and a research focus on reducing unnecessary care for low back pain. Today we're diving into her recent large cluster RCT published in CMAJ, investigating whether behavioural nudges can reduce low-value care in emergency departments. You're going to love this episode if you're interested in not just what the evidence says, but in how we actually change practice. I'm Sarah Yule and this is Physio Explained. Well, Sweet, thank you so much for joining us today on the podcast. Thank you, Sarah, for having me. Today we are running through your research article titled Behavioural Nudges to Reduce Low Value Care for Low Back Pain in the Emergency Department, which is a bit of a mouthful, but I'm very curious why did we do this study and what did we test?

SPEAKER_01 1:51

So low back pain is one of the leading reasons for emergency department presentations. Last year alone, more than 9 million people presented to Australian emergency departments, and back pain was one of the most common reasons for presentations. And many tests and treatments routinely used for back pain in the emergency departments are not recommended. For example, one in three patients presenting to emergency departments with back pain received imaging, and two in three receive opioids. And both of these are considered low value care in absence of red flags, offering little benefit, and in some cases, exposing patients to unnecessary harm. So what we did was nudged was a two by two factorial design cluster randomized control trial across eight hospital emergency departments in Sydney. We tested whether behaviorial nudges to reduce unnecessary imaging tests and opioid prescription at discharge for back pain in the emergency department could reduce low value care. So we randomized two hospitals to receive patient nudges. Two hospitals were randomized to receive clinician nudges, and two were randomized to receive port nudges, and two were randomized to no nudges. And our nudges included electronic information posters discouraging unnecessary imaging and opioids displayed in the 55-inch LCD screens in the emergency department waiting rooms. And clinician nudges included three electronic medical record alerts that provided indications for lumbar spine imaging and suggested alternatives to opioids.

SPEAKER_02 3:30

So in this context, low-value care sounds like it was imaging that wasn't indicated and opiate prescriptions at discharge. And then those patient nudges were the waiting room posters and the clinician nudges for the alerts at key decision points.

SPEAKER_01 3:45

Yes, that's right. And what did we find? As much as we wanted the nudges to work, what we found was there was no effect of patient nudges on low-value care compared with no patient nudges. There was no effect of clinician nudges compared with no clinician nudges as well. So in our factorial analysis, we compared hospitals that were randomized to patient nudges with hospitals that were randomized to no patient nudges, and same with the clinician nudges as well. The overall rate of low-value care was around 42%. We also found no interaction effect between the interventions, and there was no meaningful differences in secondary outcomes as well.

SPEAKER_02 4:29

So, what you're saying is there was no significant reduction in low-value care with the patient or the clinician nudges.

SPEAKER_01 4:36

Yes. And what do these findings mean? So these results highlight the complexity of back pain as a clinical presentation and broader challenges of improving care in emergency department settings. Improving outcomes for patients while reducing pressure on clinicians and health systems will require a broader cultural shift in how back pain is viewed and managed in Australia. Yeah, so I think once the patient reaches the emergency department, it may be too late to make a difference. So maybe providing some actionable information to help people know when to go to ED and how to effectively manage the pain in the community would be the approach. So I think like the future interventions should focus on people before they present to emergency departments.

SPEAKER_00 5:26

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SPEAKER_02 5:48

So that that idea of context is very relevant, more so than intention. So ED clinicians obviously operate under a high level of diagnostic uncertainty and risk aversion and the high consequences of missing pathology. So you're saying that we should look at interventions and education prior to the point of someone entering ED. Yes, that's right. And just going back to teasing out those key findings a little bit more, going to the effect on the imaging or opioid prescribing, did you notice any changes with those as well? So the low value being the unnecessary imaging or the opioids, was there a difference between the two?

SPEAKER_01 6:34

In terms of inappropriate imaging, one of the control groups started with high imaging, inappropriate imaging, about 35%. And that drastically dropped in the intervention period, even when they received no intervention. By contrast, like the clinician notch group started with a low baseline rate for inappropriate imaging, and they didn't have any like much room for improvement or reduction. Yeah, and in terms of opioid as well, about 40% of encounters had inappropriate opioids at baseline on average, and control sites improved over time, even when they received no nudges. And some sites exposed to clinician nudge improved and others did not.

SPEAKER_02 7:21

And so clinically, do you think do you think there's some takeaways for us in in terms of beliefs and changing clinical decisions? Changing beliefs is really difficult. Fair enough. And where do you feel like we're best directing the next bit of research to tease this more, tease this out a little bit more, knowing that there's this inherent complexity? Where would you like to see the research focused?

SPEAKER_01 7:52

Like I mentioned earlier, I think the next the future research should focus on general public, maybe raising awareness or educating the general public before they present to the emergency department on when to present to the emergency department and how can back pain best be managed at home or in primary care. So it sounds like I think the focus should be.

SPEAKER_02 8:16

Yeah, great. It's sounding like this study is tipping into what hopefully reinforces as an opportunity for us as physios, not just to deliver care, but to help reshape what good care looks like in the system.

SPEAKER_01 8:31

Yeah. And I also think that there are lots of EMR alerts, existing EMR alerts in the emergency department. And we don't know whether those alerts are actually helping, or there may be a need to think about whether we need to de-implement some of the existing alerts that may not be based on evidence or may not be effective.

SPEAKER_02 8:53

Really interesting. Thank you so much for your summary today, sweet. That's been really helpful. I think it we're always building on the standing on the shoulders of giants, and I think it's sounding like we're on this ongoing route to discussing more impactful strategies, whether it's increased access to physiotherapy and advice or policy level change or feedback systems or decision aids. It'll be really, I'm intrigued to see where the research goes in terms of what results in a reduction in this low value care. Well, thank you so much for joining us on the podcast today. Thank you so much, Sarah, for having me.