Behavioral medicine, clinical health psychology, and cost offset

Evaluation of a Mobile Application for Chronic Low Back Pain Management: Prospective Pilot Study (Preprint)

Background

Chronic low back pain is challenging to manage due to multidisciplinary considerations. It has substantial socioeconomic impacts and cannot be simply treated with pharmacotherapy, nonsurgical intervention, or spine surgery. Medical consensus recommends optimizing conservative self-management therapies (eg, home exercise, wellness strategies, yoga, etc) as first-line treatment options for chronic low back pain. However, access to these modalities is often limited and secondary to cost, convenience, and ease of use. Mobile health apps have emerged as a cost-effective and accessible option for chronic low back pain self-management. Established in-person pain programs can provide the structure for an optimal mobile app adaptation. PainNavigator (PainNavigator, Inc) is an example of a mobile app that is based on an Ascension-Illinois group–based pain program—Pain Rehabilitation Outpatient-Camp.

Objective

This was a prospective pilot clinical trial that evaluated the PainNavigator platform’s utility in low back pain management to inform future trial development.

Methods

A total of 75 participants who used PainNavigator were studied. Pain, Enjoyment, and General Activity (PEG-3) scale scores and scores from a brief anxiety and depression scale based on the Patient Health Questionnaire-4 (PHQ-4) were obtained at baseline and following program completion. The PEG-3 total score was used, in addition to individual items—Average Pain, Pain Effect on Enjoyment, and Pain Effect on Activity. The PHQ-4 total score was also used, in addition to other individual items, including Felt Depressed, Loss of Interest, Felt Anxious, and Difficult to Control Worry. Paired sample t tests (2-tailed) compared mean differences in scores from before and after participants received the intervention.

Results

The analysis found that PEG-3 (n=27) and PHQ-4 (n=27) total scores were significantly lower upon the completion of PainNavigator (P<.001 and P=.001, respectively). The findings showed a 36% reduction in PEG-3 total scores, a 40% reduction in pain intensity, and a 40% reduction in PHQ-4 total scores. Scores for individual PEG-3 scale and PHQ-4 items also significantly decreased. All PEG-3 measures had large effect sizes. The PHQ-4 total score and Difficult to Control Worry item had large effect sizes, while the other three measures had medium effect sizes.

Conclusions

These findings show that PainNavigator has clinical significance in managing chronic low back pain and can be easily utilized to improve patient care. All PEG-3 scale and PHQ-4 measures significantly improved following the use of the platform, supporting the multidimensional, biopsychosocial approach to low back pain management. Differences in effect sizes may inform quality improvement investigations, such as optimizing features that impact measures with only medium effect sizes. This feasibility study demonstrates an effective protocol, and it will inform future, more extensive randomized controlled trials.

Earlier Pediatric Psychology Consultation Predicts Lower Stem Cell Transplantation Hospital Costs

Objective

The purpose of this study was to examine the hypothesis that earlier time to psychology consultation would predict lower costs for the initial stem cell transplant (SCT) hospitalization among patients receiving care at a children's hospital.

Methods

A retrospective medical record review identified 75 patients (ages 0-32 years) with one or more visits by a licensed clinical psychologist during the initial SCT hospitalization from 2010 to 2014. Demographic and clinical variables were obtained from the electronic medical record and hospitalization costs were obtained from patient billing records. A generalized linear model with a gamma distribution and log link function was used to estimate the relationship between time to psychology consultation and cost for the initial SCT hospitalization while controlling for demographic, clinical, and utilization factors.

Results

After controlling for age at SCT, gender, race, insurance status, diagnosis, SCT type, length of stay, and number of psychology visits, earlier time to psychology consultation predicted lower costs for the initial SCT hospitalization (χ2 = 6.83, p = .01). When the effects of covariates were held constant, every day increase in the time to psychology consultation was associated with a 0.3% increase in SCT hospitalization costs (β = 0.003, SE = 0.001).

Conclusions

Results suggest that facilitating consultations with a pediatric psychologist early in the initial SCT hospitalization may reduce costs for patients undergoing SCT at children's hospitals. Future research is needed to determine the optimal timing of psychology consultation and quantify the economic impact of psychological services.

Targeting Health Behaviors to Reduce Health Care Costs in Pediatric Psychology: Descriptive Review and Recommendations

OBJECTIVE

Recent efforts to enhance the quality of health care in the United States while reducing costs have resulted in an increased emphasis on cost containment and the introduction of new payment plans. The purpose of this review is to summarize the impact of pediatric health behavior change interventions on health care costs.

METHODS

A review of PubMed, PsycINFO, and PEDE databases identified 15 articles describing the economic outcomes of pediatric health behavior change interventions. Data describing the intervention, health outcome, and economic outcome were extracted.

RESULTS

All interventions targeting cigarette smoking (n = 3) or the prevention of a chronic medical condition (n = 5) were predicted to avert hundreds of dollars in health care costs per patient. Five of the seven interventions targeting self-management were associated with reductions in health care costs.

CONCLUSIONS

Pediatric health behavior change interventions may be a valuable component of efforts to improve population health while reducing health care costs.

Improving psychologic adjustment to chronic illness in cardiac patients. The role of depression and anxiety

BACKGROUND

Poor mood adjustment to chronic medical illness is often accompanied by decrements in function.

OBJECTIVE

To evaluate the effectiveness of a telephone-based intervention for psychologic distress and functional impairment in cardiac illness.

DESIGN

Randomized, controlled trial.

METHODS

We recruited survivors of acute coronary syndromes using the Hospital and Anxiety Depression Scale (HADS) with scores indicative of mood disturbances at 1-month postdischarge. Recruited patients were randomized to experimental or control status. Intervention patients received 6 30-minute telephone counseling sessions to identify and address illness-related fears and concerns. Control patients received usual care. Patients' responses to the HADS and the Workplace Social Adjustment Scale (WSAS) were collected at baseline, 2, 3, and 6 months using interactive voice recognition technology. At baseline, the PRIME-MD was used to establish diagnosis of depression. We used mixed effects regression to study changes in outcomes.

RESULTS

We enrolled 100 patients. Mean age was 60; 67% of the patients were male. Findings confirmed that the intervention group had a 27% improvement in depression symptoms (P=.05), 27% in anxiety (P=.02), and a 38% improvement in home limitations (P=.04) compared with controls. Symptom improvement tracked those for WSAS measures of home function (P=.04) but not workplace function.

CONCLUSIONS

The intervention had a moderate effect on patient's emotional and functional outcomes that were observed during a critical period in patients' lives. Patient convenience, ease of delivery, and the effectiveness of the intervention suggest that the counseling can help patients adjust to chronic illness.

Factors associated with the use of mind body therapies among United States adults with musculoskeletal pain

OBJECTIVE

To determine the prevalence of mind body therapy use and correlates of use among adults with prolonged musculoskeletal pain, a group for whom mind body therapies are recommended.

DESIGN

The U.S. 1999 National Health Interview Survey. Prolonged musculoskeletal pain was defined as any soft tissue, joint, or bony pain for at least 1 month. Analyses used SUDAAN and reflect national estimates.

MAIN OUTCOME MEASURES

Use of mind body medicine (relaxation techniques, imagery, biofeedback, and hypnosis) and prayer in the previous year.

RESULTS

Respondents (n=6079) with musculoskeletal pain were almost twice as likely as those without (n=24,722) to use mind body medicine (9% versus 5%, respectively, p<.0001) and prayer (20% versus 12%, respectively, p<.0001). After adjustment, men were less likely than women to use mind body medicine (odds ratio 0.55 [0.43-0.71]) and prayer (odds ratio 0.56 [0.48-0.66]). Those who had a high school education were less likely than those with training beyond high school to use mind body medicine (odds ratio 0.36 [0.28-0.47]) and prayer (odds ratio 0.61 [0.52-0.71]).

CONCLUSIONS

Mind body therapies are not used commonly by adults with prolonged musculoskeletal pain. Understanding barriers to their use may facilitate wider application in this population.

The Assessment of Adult Health Care Orientations: Development and Preliminary Validation of the Multidimensional Health Profile-Health Functioning Index (MHP-H) in a National Sample

This paper describes the development and preliminary validation of the Multidimensional Health Profile-Health Functioning Index (MHP-H), a 69-item self-report instrument designed to assess a variety of behaviors, perceptions, attitudes, and beliefs presumed to influence health status and the pursuit of lay and professional health care. The MHP-H briefly measures adult health history, health habits, health care utilization, health beliefs and attitudes, and response to illness (help-seeking behaviors). A national sample of adults (N = 673) was assessed, comprising 3 age groupings (18-32, 33-50, and 51-89) crossed with gender and then further subdivided into several subsamples for purposes of reliability and validity assessment. In addition, a group of spouse "key informants" was also recruited. Preliminary validation of single-item indicators as well as confirmatory factor analyses of multi-item scales was achieved. The present findings support the psychometric and practical utility of the MHP-H and warrant its use by health psychologists in a variety of research and applied settings.

Use of mind-body medical therapies

OBJECT

Research demonstrating connections between the mind and body has increased interest in the potential of mind-body therapies. Our aim was to examine the use of mind-body therapies, using data available from a national survey.

DESIGN

Analysis of a large nationally representative dataset that comprehensively evaluated the use of mind-body therapies in the last year.

SETTING

United States households.

PATIENTS/PARTICIPANTS

A total of 2055 American adults in 1997-1998.

INTERVENTIONS

Random national telephone survey.

MEASURES AND MAIN RESULTS

We obtained a 60% weighted overall response rate among eligible respondents. We found that 18.9% of adults had used at least 1 mind-body therapy in the last year, with 20.5% of these therapies involving visits to a mind-body professional. Meditation, imagery, and yoga were the most commonly used techniques. Factors independently and positively associated with the use of mind-body therapies in the last year were being 40 to 49 years old (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.33 to 3.10), being not married (AOR, 1.78; 95% CI, 1.34 to 2.36), having an educational level of college or greater (AOR, 2.21; 95% CI, 1.57 to 3.09), having used self-prayer for a medical concern (AOR, 2.53; 95% CI, 1.87 to 3.42), and having used another complementary medicine therapy in the last year (AOR, 3.77; 95% CI, 2.74 to 5.20). While used for the full array of medical conditions, they were used infrequently for chronic pain (used by 20% of those with chronic pain) and insomnia (used by 13% of those with insomnia), conditions for which consensus panels have concluded that mind-body therapies are effective. They were also used by less than 20% of those with heart disease, headaches, back or neck pain, and cancer, conditions for which there is strong research support. Mind-body therapies were generally used concomitantly with conventional care: 90% of those using a mind-body therapy in the last year had seen a physician and 80% of mind-body therapies used were discussed with a physician.

CONCLUSIONS

Although mind-body therapies were commonly used, much opportunity exists to increase use of mind-body therapies for indications with demonstrated efficacy.