Title: Low back pain in the emergency department: A mixed methods study exploring the perceptions of people who attend the emergency department for low back pain and the feasibility of running an observational study which compares the outcomes and costs of care for low back pain in the emergency department to care in other/ usual NHS settings.
Funder: Health Education England

Abstract: Background: Low back pain is the global leading cause of disability and it is crucial to manage it well. Clinical guidelines recommended that low back pain should be treated in primary care. However, each day in the UK, over 2,500 people attend the emergency department (A&E) for low back pain, less than 1% require emergency treatment. Reducing demand for emergency care is a UK policy priority. Research is therefore urgently required to understand why some people choose A&E for low back pain. Also, to optimise use of healthcare resources, a study is needed to compare the outcomes and costs of care that includes A&E, to care in other/ usual NHS settings. Feasibility work is required to design this study, before leading it as a post-doctoral project. Research questions: Why do people choose A&E for low back pain? Is it feasible to run an observational study that compares the outcomes and costs of care for low back pain that includes A&E, to care in other/ usual NHS settings? The objectives are to: Systematically review previously published research which compares the outcomes and costs of care for low back pain in different settings. Explain why people choose A&E for low back pain, their experience of this service, and what responsive care comprises. Estimate the important parameters needed to design the main study. Finalise the design of the main study.Methods This is an exploratory, sequential, mixed methods feasibility study. Phase 1: A systematic review (months 1-9) will be undertaken of previously published research that compares the outcomes and costs of treating low back pain in different settings. Ethical and governance approvals for phase 2 will be attained.Phase 2: Semi-structured individual interviews (months 10-21) with 40 adults presenting to A&E with low back pain (all types/ durations) will explore why people chose A&E for low back pain, their experiences of this service and what responsive care for low back pain comprises. Subgroup analysis will identify similarities/ differences across subpopulations. Analysis will be thematic, managed using a framework approach. Phase 3: A feasibility study (months 22-39) will assess the parameters needed to design the main study, including recruitment/ retention rates; acceptability of outcome measures/ study processes; and variability in clinical outcomes/ costs within each setting. To do this I will follow 80-100 adults with low back pain (all types/ durations), who present to A&E and other/ usual NHS settings and measure their outcomes and costs of care over 12 months, using text messaging and self-completion postal questionnaires. Phase 4: Finalise the main study (months 40-48) The design of the main study will be finalised using the data from phases 1-3. Dissemination will be through presentations, published articles and social media.Anticipated impact: To inform policy makers, commissioners and care providers about what responsive care comprises for people who currently choose A&E for low back pain. Also, to estimate the parameters needed to design the main study, which will inform decisions about the optimal use of scarce healthcare resources.

Lay abstract: Background: Low back pain is the most common reason that people find it difficult to do everyday things including work. It is therefore crucial that it is managed well. Clinical guidelines recommend that low back pain should be managed in primary care, usually by the family doctor or a physiotherapist. However, each day in the UK, more than 2,500 people attend the emergency department (A&E) for low back pain. Less than 1 in 100 require emergency treatment. The overall number of people using A&E is rising at an unsustainable rate and the UK government wishes to reduce this. It also recognises the significant pressures on family doctors and the need to provide care that meets peoples' needs. Research is therefore urgently needed to understand why people choose to go to A&E for low back pain. To make the best use of healthcare resources, research is also needed to investigate the outcomes (how much better people get) and costs of care for low back pain. This should compare care that includes A&E, to care in other/ usual NHS settings. To understand how best to design this study, feasibility work (preparation) is needed. Therefore, this project will explore why people choose A&E for low back pain and identify the information needed to design the main study, which I plan to conduct as a post-doctoral project. Methods The project will be undertaken in 4 stages: Stage 1: A literature review Firstly, I will summarise existing published research that compares the outcomes and costs of treating people with low back pain in different settings. Stage 2 Interviews. I will then interview 40 adults who recently went to A&E with low back pain. I will ask them about why they chose A&E, their experiences of this service, and what they think care should include to best meet their needs. Stage 3: Feasibility study I will then conduct a limited version of the main study, including 80-100 adults with low back pain, recruited from A&E and also from other/ usual NHS settings. I will collect data from patients about outcomes and costs, using text messaging and questionnaires. This will test how well the study recruits/ retains participants and how variable the findings are within each setting. I will telephone 12 of these participants to discuss what they think of the outcome measures/ study processes. Stage 4 Finalise the main study Finally, I will use the information collected in stages 1-3, to finalise the research questions and methods of the main study.Patient involvement: Patients with low back pain helped to develop the draft interview topic guide and advised that, for the main study, recovering quickly was the most important outcome. At each stage of this project, I will meet with a group of patients to discuss my plans and findings, to take account of the issues that patients consider to be important. This group will review the information I give to participants, help me to understand and share the project findings, and to develop the main study. Anticipated impact: In the short-term, this project will benefit patients and the NHS by identifying how care can better meet the needs of people who currently choose to attend A&E with low back pain. It will also provide the information needed to design the main study. This would show the costs and outcomes of care for low back pain that includes A&E, compared to care in other/ usual NHS settings. Dissemination: I will share the findings through teaching sessions, presentations, published articles and social media.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MUSCULOSKELETAL