Nudge Interventions Fail to Reduce Low-Value Care for Back Pain in EDs
A cluster randomised trial published in the Canadian Medical Association Journal has tested two "nudge" interventions aimed at reducing low-value care for low back pain in eight NSW public hospital emergency departments.
The Interventions"The results highlight limitations in existing evidence on nudge interventions." – Lead author Gemma Altinger, University of Sydney
The study deployed two distinct strategies:
- A patient-facing educational poster designed to discourage unnecessary care.
- A clinician-facing electronic health record alert, triggered when imaging or opioid prescriptions were ordered.
During the intervention period, the outcomes were disappointing:
- Opioid prescribing at discharge slightly increased.
- Unnecessary imaging levels remained roughly similar to the control group.
Lead author Gemma Altinger (University of Sydney) noted that many prior studies used weaker before-after designs rather than cluster randomised controlled trials. She also pointed out a critical flaw in previous compliance campaigns:
"They may reduce one type of prescribing while increasing another (e.g., opioid reduction leading to gabapentinoid increase)."
Most past research focused on reducing the total volume of tests or prescriptions, rather than the appropriateness of care for individual patients.
Implementation ChallengesDespite efforts to reduce alert fatigue—such as muting repeats for the same clinician—fewer than half of clinicians recalled seeing the alert.
The alert triggered for all patients with back pain triage, including those for whom opioids or imaging might be appropriate (e.g., elderly or trauma patients), potentially reducing its effectiveness.
Source: Canadian Medical Association Journal, 6 April 2026