A patient activation intervention in primary care for patients with chronic pain on long term opioid therapy: results from a randomized control trial

BACKGROUND

Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy.

METHODS

The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015-August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months.

RESULTS

At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18-0.87); higher overall health (OR = 3.14, 95%CI 1.64-6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42-4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29-5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61-4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29-3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27-2.98).

CONCLUSION

This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system.

TRIAL REGISTRATION

The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223).

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

Health care providers' understanding of self-management support for people with chronic low back pain in Ethiopia: an interpretive description

BACKGROUND

Healthcare providers play a key role in supporting people with chronic low back pain to self-manage their condition. The study aimed at exploring how health care providers understand and conceptualize self-management and how they provide self-management support for people with chronic low back pain in Ethiopia.

METHODS

Health care providers who have supported people with low back pain, including medical doctors and physiotherapists, were approached and recruited from three hospitals in Ethiopia. This study employed an interpretive descriptive approach using semi-structured interviews.

FINDINGS

Twenty-four participants (7 women; 17 men) with a median age of 28 (range 24 to 42) years and a median of 9.5 years (range 1 to 11 years) of helping people with chronic low back pain were interviewed. Seven major themes related to health care providers' understanding of self-management support for people with chronic low back pain in Ethiopia emerged. The findings show that self-management was a new concept to many and health care providers' had a fragmented understanding of self-management. They used or suggested several self-management support strategies to help people with CLBP self-manage their condition without necessarily focusing on enhancing their self-efficacy skills. The participants also discussed several challenges to facilitate self-management support for people with chronic low back pain. Despite the lack of training on the concept, the providers discussed the potential of providing self-management support for people with the condition.

CONCLUSIONS

Self-management was a new concept to health care providers. The providers lack the competencies to provide self-management support for people with chronic low back pain. There is a need to enhance the health care providers' self-management support competencies through training.

Exploring changes, and factors associated with changes, in behavioural determinants from a low-cost, scalable education intervention about knee osteoarthritis: An observational cohort study

OBJECTIVE

To explore the relationships between participant characteristics, perceptions of a short educational video about osteoarthritis and its management, and immediate changes in behavioural determinants for effective self-management behaviours.

METHODS

Seventy-eight participants with knee OA (77% female, mean age 63.0 ± 8.7) watched the 9-min video that included evidence-based content and was designed to foster empowerment to self-manage effectively. Data were collected by online questionnaire at baseline and immediately after watching the video. Associations were tested between baseline health and information processing characteristics (health literacy, need for cognition), perceptions of the video (enjoyment, helpfulness, believability, novelty and relevance) and pre-post changes in behavioural determinants (self-efficacy for managing arthritis, attitude to self-management or 'activation', and importance/confidence for physical activity).

RESULTS

All behavioural determinants improved immediately after watching the video. Positive perceptions were associated with greater improvements in self-efficacy for arthritis (Spearman's rho, ρ = 0.26-0.47). Greater perceived relevance was associated with increased self-rated importance of being physically active (ρ = 0.43). There were small positive associations between health literacy domains related to health information and positive viewer perceptions of the video. People with higher need for cognition may achieve greater improvement in confidence to be physically active (ρ = 0.27).

CONCLUSION

The educational video may help achieve outcomes important for increasing self-management behaviours in people with knee osteoarthritis. Positive perceptions appear to be important in achieving these improvements. People with lower health literacy and lower need for cognition may respond less well to this information about knee osteoarthritis delivered in this way.

A systematic review and meta-analysis of patient activation in people living with chronic conditions

OBJECTIVE

The objectives of this review are to (1) describe the state of the science of patient activation interventions for the self-management of chronic conditions; (2) identify effective intervention elements for improving patient activation; and (3) compare intervention effectiveness across chronic conditions.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). PubMed, CINAHL, and Web of Science databases were searched.

RESULTS

Thirty-two articles published between 2005 and 2019 were identified with intervention elements of self-management, disease management, and education. Meta-analysis of a subset of seven randomized controlled trials (n = 7) that used the 13-item version of the Patient Activation Measure with data collection points at 6 months demonstrated that patient activation did not change significantly in comparison with controls (MD = 0.25, 95 % CI = 0.02-0.47).

CONCLUSION

Most interventions reported significant improvement in patient activation and were linked to tasks such as regular exercise and monitoring glucose. However, the meta-analysis of RCTs did not confirm these findings.

PRACTICE IMPLICATIONS

Patient activation can be assessed and addressed uniformly across all chronic conditions to improve patient engagement in care.

Patient Activation: A Key Component of Successful Advance Care Planning

Background: Patient activation-or knowledge, confidence, and skill managing overall health-is associated with improved health behaviors such as exercise; it is unknown whether it is associated with advance care planning (ACP). Objective: To determine whether patient activation is associated with ACP. Design: This is a cross-sectional study. Setting/Subjects: A total of 414 veterans (≥60 years) with serious and chronic illness enrolled in an ACP trial. Measures: Patient characteristics and self-report surveys included the validated 13-item patient activation measure (PAM, five-point Likert) (e.g., "Taking an active role in your own healthcare is the most important factor…") categorized into four levels (e.g., Level 1: "disengaged and overwhelmed" to Level 4: "maintaining behaviors"). ACP was measured with the ACP Engagement Survey including 57-item process scores (i.e., knowledge, contemplation, self-efficacy, readiness, 5-point Likert scale) and 25-item action scores (i.e., surrogate designation, yes/no items). Associations were determined with linear regression. Results: Participants were 71.1 ± 7.8 years of age, 43% were non-white, 9% were women, and 20% had limited health literacy. Higher PAM levels were associated with higher finances, having adult children, lower comorbidity, and more social support (p < 0.05). After adjusting for these characteristics, higher PAM (Level 4 vs. Level 1) was associated with higher ACP engagement (ACP process scores, 2.8 ± 0.7 vs. 3.8 ± 0.7 and action scores 9.7 ± 4.4 vs. 15.1 ± 6.0, p < 0.001). Conclusions: Higher patient activation to manage one's overall healthcare is associated with higher engagement in ACP. Interventions designed to foster general patient activation and self-efficacy to engage in health behaviors and disease management may also improve engagement in the ACP process.

What Is the Proportion of Studies Reporting Patient and Practitioner Satisfaction with Software Support Tools Used in the Management of Knee Pain and Is This Related to Sample Size, Effect Size, and Journal Impact Factor?

INTRODUCTION

E-health software tools have been deployed in managing knee conditions. Reporting of patient and practitioner satisfaction in studies regarding e-health usage is not widely explored. The objective of this review was to identify studies describing patient and practitioner satisfaction with software use concerning knee pain.

MATERIALS AND METHODS

A computerized search was undertaken: four electronic databases were searched from January 2007 until January 2017. Keywords were decision dashboard, clinical decision, Web-based resource, evidence support, and knee. Full texts were scanned for effect of size reporting and satisfaction scales from participants and practitioners. Binary regression was run; impact factor and sample size were predictors with indicators for satisfaction and effect size reporting as dependent variables.

RESULTS

Seventy-seven articles were retrieved; 37 studies were included in final analysis. Ten studies reported patient satisfaction ratings (27.8%): a single study reported both patient and practitioner satisfaction (2.8%). Randomized control trials were the most common design (35%) and knee osteoarthritis the most prevalent condition (38%). Electronic patient-reported outcome measures and Web-based training were the most common interventions. No significant dependency was found within the regression models (p > 0.05).

DISCUSSION AND CONCLUSIONS

The proportion of reporting of patient satisfaction was low; practitioner satisfaction was poorly represented. There may be implications for the suitability of administering e-health, a medium for capturing further meta-evidence needs to be established and used as best practice for implicated studies in future. This is the first review of its kind to address patient and practitioner satisfaction with knee e-health.