Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review

Development and Validation of a Treatment Algorithm for Osteoarthritis Pain Management in Patients With End-Stage Kidney Disease Undergoing Hemodialysis

Background

Although osteoarthritis is common in the hemodialysis population and leads to poor health outcomes, pain management is challenged by the absence of clinical guidance. A treatment algorithm was developed and validated to aid hemodialysis clinicians in managing osteoarthritis pain.

Objective

The objective was to develop and validate a treatment algorithm for managing osteoarthritis pain in patients undergoing hemodialysis.

Design

A validation study was conducted based on Lynn's method for content validation.

Setting

To develop and validate a treatment algorithm, interviews were conducted virtually by the primary researcher with clinicians from various institutions across the Greater Toronto and Hamilton Area in Ontario.

Patients

The treatment algorithm was developed and validated for the management of osteoarthritis pain in patients on hemodialysis. Patients were not involved in the development or validation of the tool.

Measurements

The algorithm was measured for content and face validity. Content validity was measured by calculating the content validity index of each component (I-CVI) of the algorithm and the overall scale validity index (S-CVI). Face validity was assessed by calculating the percentage of positive responses to the face validity statements.

Methods

A draft algorithm was developed based on literature searches and expert opinion and validated by interviewing nephrology and pain management clinicians. Through consecutive rounds of 1:1 interviews, content and face validity were assessed by asking participants to rate the relevance of each component of the algorithm and indicate their level of agreeability with a series of statements. Following each round, the I-CVI of the algorithm as well as the S-CVI was calculated and the percentage of positive responses to the statements was determined. The research team revised the algorithm in response to the findings. The final algorithm provides a stepwise approach to the non-pharmacologic and pharmacologic management of pain, including topical, oral, and opioid use.

Results

A total of 18 clinicians from 7 institutions across the Greater Toronto and Hamilton Area were interviewed (10 pharmacists, 5 nurse practitioners, and 3 physicians). The average S-CVI of the algorithm across all 3 rounds was 0.93. At least 78% of participants provided positive responses to the face validity statements.

Limitations

An algorithm was developed based on input from clinicians working in the province of Ontario, limiting the generalizability of the algorithm across provinces. In addition, the algorithm did not include the perspectives of primary care providers or patients/caregivers.

Conclusions

An algorithm for the management of osteoarthritis pain in the hemodialysis population was developed and validated through expert review to standardize practices and encourage clinicians to use evidence-based treatments and address the psychosocial symptoms of pain. As the algorithm possesses a high degree of content and face validity, it may improve osteoarthritis pain management among patients undergoing hemodialysis. Future research will assess the implementation of the algorithm across hemodialysis settings.

Injured worker participation in assessment during the acute phase of workers compensation rehabilitation: a scoping review

PURPOSE

Rates of return to work (RTW) are declining in the Australian workers compensation system alongside significant economic and social costs, disputes, and secondary psychological injury. Non-medical assessment of workplace injuries now considers psychosocial and workplace factors, and worker participation in the assessment process is limited. This scoping review examines studies regarding non-medical assessment during the acute phase of rehabilitation in terms of costs, disputes, secondary psychological injury, and worker participation.

METHOD

An electronic and manual search of relevant articles across four databases was conducted using PRISMA guidelines, followed by quality assessment.

RESULTS

Of the 1,630 studies retrieved, 12 met the inclusion criteria with most focused on assessment for risk of obstructed or delayed RTW.

CONCLUSIONS

Non-medical assessment in the acute stage of rehabilitation identifies risk for delayed or complicated RTW, overlooking potential for the process of assessment to contribute to disputes and development of secondary psychological injury. Doubt around the capacity of workers to participate objectively in assessment persists. These are aspects of assessment worthy of further exploration for their impact on RTW outcomes.

Acceptance and use of a clinical decision support system in musculoskeletal pain disorders - the SupportPrim project

BACKGROUND

We have developed a clinical decision support system (CDSS) based on methods from artificial intelligence to support physiotherapists and patients in the decision-making process of managing musculoskeletal (MSK) pain disorders in primary care. The CDSS finds the most similar successful patients from the past to give treatment recommendations for a new patient. Using previous similar patients with successful outcomes to advise treatment moves management of MSK pain patients from one-size fits all recommendations to more individually tailored treatment. This study aimed to summarise the development and explore the acceptance and use of the CDSS for MSK pain patients.

METHODS

This qualitative study was carried out in the Norwegian physiotherapy primary healthcare sector between October and November 2020, ahead of a randomised controlled trial. We included four physiotherapists and three of their patients, in total 12 patients, with musculoskeletal pain in the neck, shoulder, back, hip, knee or complex pain. We conducted semi-structured telephone interviews with all participants. The interviews were analysed using the Framework Method.

RESULTS

Overall, both the physiotherapists and patients found the system acceptable and usable. Important findings from the analysis of the interviews were that the CDSS was valued as a preparatory and exploratory tool, facilitating the therapeutic relationship. However, the physiotherapists used the system mainly to support their previous and current practice rather than involving patients to a greater extent in decisions and learning from previous successful patients.

CONCLUSIONS

The CDSS was acceptable and usable to both the patients and physiotherapists. However, the system appeared not to considerably influence the physiotherapists' clinical reasoning and choice of treatment based on information from most similar successful patients. This could be due to a smaller than optimal number of previous patients in the CDSS or insufficient clinical implementation. Extensive training of physiotherapists should not be underestimated to build understanding and trust in CDSSs.

Using Presurgical Biopsychosocial Features to Develop an Advanced Clinical Decision-Making Support Tool for Predicting Recovery Trajectories in Patients Undergoing Total Knee Arthroplasty: Protocol for a Prospective Observational Study

BACKGROUND

Following total knee arthroplasty (TKA), 10% to 20% of patients report dissatisfaction with procedural outcomes. There is growing recognition that postsurgical satisfaction is shaped not only by the quality of surgery but also by psychological and social factors. Surprisingly, information on the psychological and social determinants of surgical outcomes is rarely collected before surgery. A comprehensive collection of biopsychosocial information could assist clinicians in making recommendations in relation to rehabilitation, particularly if there is robust evidence to support the ability of presurgical constructs to predict postsurgical outcomes. Clinical decision support tools can help identify factors influencing patient outcomes and support the provision of interventions or services that can be tailored to meet individuals' needs. However, despite their potential clinical benefit, the application of such tools remains limited.

OBJECTIVE

This study aims to develop a clinical decision tool that will assist with patient stratification and more precisely targeted clinical decision-making regarding prehabilitation and rehabilitation for TKA, based on the identified individual biopsychosocial needs.

METHODS

In this prospective observational study, all participants provided written or electronic consent before study commencement. Patient-completed questionnaires captured information related to a broad range of biopsychosocial parameters during the month preceding TKA. These included demographic factors (sex, age, and rurality), psychological factors (mood status, pain catastrophizing, resilience, and committed action), quality of life, social support, lifestyle factors, and knee symptoms. Physical measures assessing mobility, balance, and functional lower body strength were performed via video calls with patients in their home. Information related to preexisting health issues and concomitant medications was derived from hospital medical records. Patient recovery outcomes were assessed 3 months after the surgical procedure and included quality of life, patient-reported knee symptoms, satisfaction with the surgical procedure, and mood status. Machine learning data analysis techniques will be applied to determine which presurgery parameters have the strongest power for predicting patient recovery following total knee replacement. On the basis of these analyses, a predictive model will be developed. Predictive models will undergo internal validation, and Bayesian analysis will be applied to provide additional metrics regarding prediction accuracy.

RESULTS

Patient recruitment and data collection commenced in November 2019 and was completed in June 2022. A total of 1050 patients who underwent TKA were enrolled in this study.

CONCLUSIONS

Our findings will facilitate the development of the first comprehensive biopsychosocial prediction tool, which has the potential to objectively predict a patient's individual recovery outcomes following TKA once selected by an orthopedic surgeon to undergo TKA. If successful, the tool could also inform the evolution rehabilitation services, such that factors in addition to physical performance can be addressed and have the potential to further enhance patient recovery and satisfaction.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48801.

The effects of computerised decision support systems on nursing and allied health professional performance and patient outcomes: a systematic review and user contextualisation

Background

Computerised decision support systems (CDSS) are widely used by nurses and allied health professionals but their effect on clinical performance and patient outcomes is uncertain.

Objectives

Evaluate the effects of clinical decision support systems use on nurses', midwives' and allied health professionals' performance and patient outcomes and sense-check the results with developers and users.

Eligibility criteria

Comparative studies (randomised controlled trials (RCTs), non-randomised trials, controlled before-and-after (CBA) studies, interrupted time series (ITS) and repeated measures studies comparing) of CDSS versus usual care from nurses, midwives or other allied health professionals.

Information sources

Nineteen bibliographic databases searched October 2019 and February 2021.

Risk of bias

Assessed using structured risk of bias guidelines; almost all included studies were at high risk of bias.

Synthesis of results

Heterogeneity between interventions and outcomes necessitated narrative synthesis and grouping by: similarity in focus or CDSS-type, targeted health professionals, patient group, outcomes reported and study design.

Included studies

Of 36,106 initial records, 262 studies were assessed for eligibility, with 35 included: 28 RCTs (80%), 3 CBA studies (8.6%), 3 ITS (8.6%) and 1 non-randomised trial, a total of 1318 health professionals and 67,595 patient participants. Few studies were multi-site and most focused on decision-making by nurses (71%) or paramedics (5.7%). Standalone, computer-based CDSS featured in 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile or handheld technology. Care processes - including adherence to guidance - were positively influenced in 47% of the measures adopted. For example, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling, and documenting care were improved if they used CDSS. Patient care outcomes were statistically - if not always clinically - significantly improved in 40.7% of indicators. For example, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity, and accurate triaging were features of professionals using CDSS compared to those who were not.

Evidence limitations

Allied health professionals (AHPs) were underrepresented compared to nurses; systems, studies and outcomes were heterogeneous, preventing statistical aggregation; very wide confidence intervals around effects meant clinical significance was questionable; decision and implementation theory that would have helped interpret effects - including null effects - was largely absent; economic data were scant and diverse, preventing estimation of overall cost-effectiveness.

Interpretation

CDSS can positively influence selected aspects of nurses', midwives' and AHPs' performance and care outcomes. Comparative research is generally of low quality and outcomes wide ranging and heterogeneous. After more than a decade of synthesised research into CDSS in healthcare professions other than medicine, the effect on processes and outcomes remains uncertain. Higher-quality, theoretically informed, evaluative research that addresses the economics of CDSS development and implementation is still required.

Future work

Developing nursing CDSS and primary research evaluation.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in Health and Social Care Delivery Research; 2023. See the NIHR Journals Library website for further project information.

Registration

PROSPERO [number: CRD42019147773].

The Effectiveness of Workplace Musculoskeletal Injury Risk Factor Screening Tools for Reducing Injury: A Systematic Review

INTRODUCTION

Musculoskeletal injury (MSI) contributes to global health burdens. Effective MSI prevention is necessary. MSI risk factor screening tools can be used by employers to identify and mitigate occupational hazards. Rigorous synthesis of the effectiveness of these tools has not taken place. We synthesized literature on effectiveness of MSI risk factor screening tools for reducing injury through informing prevention interventions.

MATERIALS AND METHODS

A literature search of Medline, Embase, Cochrane Library (Trials), CINAHL, Scopus and PsycINFO databases was performed. Included studies required an analytic design, used an MSI risk factor screening tool to inform an intervention in a working-age population and reported an outcome of MSI development, injury or compensation/work absence. Data extraction and study quality rating (Downs and Black criteria) were completed. Studies were sub-categorized as having used a single MSI screening tool (single-tool) to inform an injury prevention intervention or involving multiple simultaneous screening tools (multiple-tool). Study outcomes were synthesized when possible.

RESULTS

Eighteen articles representing fourteen studies met our inclusion criteria. No high-quality studies were identified (maximum Downs and Black score of 19). Studies did not employ previously validated tools but instead, typically, those purpose-built for a single use. The results were inconsistent both when using tools alone and in combination with other tools. Outcome measure heterogeneity precluded meaningful meta-analysis.

CONCLUSIONS

There is limited evidence regarding use of MSI risk factor screening tools for preventing injury. Rigorous studies that utilize previously validated tools are needed.

A physical therapist-led clinical decision-making program reduced risk of adverse events after total knee arthroplasty over 3 years: A retrospective review

CONTEXT

Reducing adverse events after total knee arthroplasty has implications for newly developed bundled payment models.

OBJECTIVE

To examine the impact of a physical therapist-led clinical decision-making program on the risk of adverse events, function, visits used, or reaching knee range of motion (ROM) goals in patients after total knee arthroplasty.

METHODS

The decision-making program consisted of quarterly meetings and recommendations for early risk identification and evidence-based intervention. A retrospective review of electronic records included adult patients who underwent total knee arthroplasty postoperative rehabilitation in an 18-month baseline period from 2014 to 2015 and an intervention period from 2015 to 2018. Relative risk reduction (RRR) determined whether a reduction in risk had occurred. Discharge function was measured with the Lower Extremity Functional Scale.

RESULTS

A total of 160 patients were included, 69 from the 18-month baseline period and 91 from the 36-month intervention period. Mean (SD) age was 68 (9.2) years in the baseline period and 72 (9.7) years in the intervention period. There was an 8.4% (95% CI, 1.1%-64.9%) RRR in adverse events. The RRR for patients not reaching full knee extension was 70.5% (95% CI, 33.4%-87.0%) and the RRR for patients not reaching 120° of knee flexion was 65.5% (95% CI, 5.4%-87.4%). There was significant improvement in the discharge function score (P = 0.05), but not the number of visits used (P = 0.29).

CONCLUSION

The physical therapist-led clinical decision-making program reduced the risk of adverse events after total knee arthroplasty. The risk of not reaching ROM goals by discharge was also substantially reduced.

Selective acceptance of acute whiplash guidelines: a qualitative analysis of perceptions of health professionals in Australia

PURPOSE

To explore health professionals' acceptance of the guidelines for acute whiplash associated disorders (WAD), and to identify barriers and facilitators to adherence.

MATERIALS AND METHODS

Qualitative descriptive study involving focus group discussions among health professionals who treat people with WAD in primary and secondary care settings in New South Wales and Queensland, Australia. Twenty-eight health professionals (physiotherapists = 19; chiropractors = 6; osteopaths = 3) participated in six semi-structured focus group discussions that were held in independent offices in Sydney and Brisbane, Australia between September and December 2015. Discussions were audio recorded and verbatim, de-identified transcripts produced. Thematic analysis was conducted using an inductive approach to identify commonly held beliefs.

RESULTS

Acceptance of guideline recommendations appeared to be influenced by factors related to the guideline itself, practitioner and practice characteristics, and patient-related factors. Specifically, acceptance was hindered by conflicting belief systems, ambiguity in guideline recommendations, and patient characteristics and expectations.

CONCLUSIONS

Practitioners demonstrated a positive attitude towards the use of the guidelines in general; however, in some cases, acceptance of key recommendations appeared selective. Future guideline revision and implementation might focus on explaining the underlying principles of the guidelines, providing more detailed recommendations, and involving strategies that challenge inconsistent beliefs and promote informed decision-making. IMPLICATIONS FOR REHABILITATIONSelective acceptance of guideline recommendations in favour of those not requiring practice change may present a challenge for the implementation of evidence-based practice in the management of whiplash.Participants demonstrated variable, sometimes polar attitudes to guideline key messages and recommendations.Guideline developers need to focus more strongly on changing practitioner beliefs and attitudes, as well as better explaining the underlying principles of the guidelines, and providing more detailed recommendations.

Accuracy of the Örebro Musculoskeletal Pain Questionnaire and Work Assessment Triage Tool for selecting interventions in workers with spinal conditions

BACKGROUND

Accurate clinical decision support tools may help clinicians select appropriate interventions for patients with spinal conditions. The Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) is a screening questionnaire extensively studied as a predictive tool. The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed to help select interventions for injured workers.

OBJECTIVE

To compare the classification accuracy of the ÖMPQ and WATT to clinician recommendations for selecting interventions leading to a successful return to work in patients with spinal conditions.

METHODS

A secondary analysis was undertaken of data from injured workers with spinal conditions assessed between 2013 and 2016. We considered it a success if the workers did not receive wage replacement benefits 30 days after assessment. Analysis included positive likelihood ratio (LR+) as an indicator of predictive accuracy.

RESULTS

Within the database, 2,872 patients had complete data on the ÖMPQ, WATT, and clinician recommendations. At 30 days, the ÖMPQ was most accurate for identifying treatments that lead to successful outcomes with a LR+= 1.51 (95% Confidence Interval 1.26-1.82) compared to 1.05 (95% Confidence Interval 1.02-1.09) for clinicians, and 0.85 (95% Confidence Interval 0.79-0.91) for the WATT.

CONCLUSIONS

All tool recommendations had poor accuracy, however the ÖMPQ demonstrated significantly better results.

Subgroups of Long-Term Sick-Listed Based on Prognostic Return to Work Factors Across Diagnoses: A Cross-Sectional Latent Class Analysis

Comorbidity is common among long-term sick-listed and many prognostic factors for return to work (RTW) are shared across diagnoses. RTW interventions have small effects, possibly due to being averaged across heterogeneous samples. Identifying subgroups based on prognostic RTW factors independent of diagnoses might help stratify interventions. The aim of this study was to identify and describe subgroups of long-term sick-listed workers, independent of diagnoses, based on prognostic factors for RTW. Latent class analysis of 532 workers sick-listed for eight weeks was used to identify subgroups based on seven prognostic RTW factors (self-reported health, anxiety and depressive symptoms, pain, self-efficacy, work ability, RTW expectations) and four covariates (age, gender, education, physical work). Four classes were identified: Class 1 (45% of participants) was characterized by favorable scores on the prognostic factors; Class 2 (22%) by high anxiety and depressive symptoms, younger age and higher education; Class 3 (16%) by overall poor scores including high pain levels; Class 4 (17%) by physical work and lack of workplace adjustments. Class 2 included more individuals with a psychological diagnosis, while diagnoses were distributed more proportionate to the sample in the other classes. The identified classes illustrate common subgroups of RTW prognosis among long-term sick-listed individuals largely independent of diagnosis. These classes could in the future assist RTW services to provide appropriate type and extent of follow-up, however more research is needed to validate the class structure and examine how these classes predict outcomes and respond to interventions.

Clinical Decision Support Tools for Predicting Outcomes in Patients Undergoing Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Total knee arthroplasty is the standard surgical treatment for end-stage osteoarthritis. Although widely accepted as a successful procedure, approximately 30% of patients are not satisfied due to non-optimal postoperative outcomes. Clinical decision support tools that are able to accurately predict post-surgery outcomes would assist in providing individualized advice or services to help alleviate possible issues, resulting in significant benefits to both the healthcare system and individuals.

METHODS

Five databases (Ovid Medline, Ovid EMBASE, CINAHL complete, Cochrane Library, and Scopus) were searched for the key phrases "knee replacement" or "knee arthroplasty" and "decision support tool," "decision tool," "predict∗ tool," "predict∗ model," "algorithm" or "nomogram." Searches were limited to peer-reviewed journal articles published between January 2000 and June 2019. Reference lists of included articles were examined. Authors came to a consensus on the final list of included articles.

RESULTS

Eighteen articles were included for review. Most models reported low predictive success and inability to externally validate. Both candidate and final predictor variables were inconsistent between studies. Only 1 model was considered strongly predictive (AUROC >0.8), and only 2 studies were able to externally validate their developed model. In general, models that performed well used large patient numbers, were tested on similar demographics, and used either nonlinear input transformations or a completely nonlinear model.

CONCLUSION

Some models do show promise; however, there remains the question of whether the reported predictive success can continue to be replicated. Furthermore, clinical applicability and interpretation of predictive tools should be considered during development.

Implications for the design of a Diagnostic Decision Support System (DDSS) to reduce time and cost to diagnosis in paediatric shoulder instability

Background

Currently the diagnosis of shoulder instability, particularly in children, is difficult and can take time. These diagnostic delays can lead to poorer outcome and long-term complications. A Diagnostic Decision Support System (DDSS) has the potential to reduce time to diagnosis and improve outcomes for patients. The aim of this study was to develop a concept map for a future DDSS in shoulder instability.

Methods

A modified nominal focus group technique, involving three clinical vignettes, was used to elicit physiotherapists decision-making processes.

Results

Twenty-five physiotherapists, (18F:7 M) from four separate clinical sites participated. The themes identified related to ‘Variability in diagnostic processes and lack of standardised practice’ and ‘Knowledge and attitudes towards novel technologies for facilitating assessment and clinical decision making’.

Conclusion

No common structured approach towards assessment and diagnosis was identified. Lack of knowledge, perceived usefulness, access and cost were identified as barriers to adoption of new technology. Based on the information elicited a conceptual design of a future DDSS has been proposed. Work to develop a systematic approach to assessment, classification and diagnosis is now proposed.

Trial Registraty This was not a clinical trial and so no clinical trial registry is needed.

Which Exercise for Low Back Pain? (WELBack) trial predicting response to exercise treatments for patients with low back pain: a validation randomised controlled trial protocol

INTRODUCTION

Exercise therapy is the most recommended treatment for chronic low back pain (LBP). Effect sizes for exercises are usually small to moderate and could be due to the heterogeneity of people presenting with LBP. Thus, if patients could be better matched to exercise based on individual factors, then the effects of treatment could be greater. A recently published study provided evidence of better outcomes when patients are matched to the appropriate exercise type. The study demonstrated that a 15-item questionnaire, the Lumbar Spine Instability Questionnaire (LSIQ), could identify patients who responded best to one of the two exercise approaches for LBP (motor control and graded activity). The primary aim of the current study isill be to evaluate whether preidentified baseline characteristics, including the LSIQ, can modify the response to two of the most common exercise therapies for non-specific LBP. Secondary aims include an economic evaluations with a cost-effectiveness analysis.

METHODS AND ANALYSIS

Participants (n=414) will be recruited by primary care professionals and randomised (1:1) to receive motor control exercises or graded activity. Participants will undergo 12 sessions of exercise therapy over an 8-week period. The primary outcome will be physical function at 2 months using the Oswestry Disability Index. Secondary outcomes will be pain intensity, function and quality of life measured at 2, 6 and 12 months. Potential effect modifiers will be the LSIQ, self-efficacy, coping strategies, kinesiophobia and measures of nociceptive pain and central sensitisation. We will construct linear mixed models with terms for participants (fixed), treatment group, predictor (potential effect modifier), treatment group×predictor (potential effect modifier), physiotherapists, treatment group×physiotherapists and baseline score for the dependent variable.

ETHICS AND DISSEMINATION

This study received ethics approval from the Hamilton Integrate Research Ethics Board. Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04283409.

Validity of the Work Assessment Triage Tool for Selecting Rehabilitation Interventions for Workers' Compensation Claimants with Musculoskeletal Conditions

Purpose The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions for patients with musculoskeletal disorders. The WATT categorizes patients based on individual characteristics according to likelihood of successful return to work following rehabilitation. A previous validation showed acceptable classification accuracy, but we re-examined accuracy using a new dataset drawn from the same system 2 years later. Methods A population-based cohort design was used, with data extracted from a Canadian compensation database on workers considered for rehabilitation between January 2013 and December 2016. Data were obtained on demographic, clinical, and occupational characteristics, type of rehabilitation undertaken, and return to work outcomes. Analysis included classification accuracy statistics of WATT recommendations. Results The sample included 28,919 workers (mean age 43.9 years, median duration 56 days), of whom 23,124 experienced a positive outcome within 30 days following return to work assessment. Sensitivity of the WATT for selecting successful programs was 0.13 while specificity was 0.87. Overall accuracy was 0.60 while human recommendations were higher at 0.72. Conclusions Overall accuracy of the WATT for selecting successful rehabilitation programs declined in a more recent cohort and proved less accurate than human clinical recommendations. Algorithm revision and further validation is needed.

Development and Pilot Assessment of the PACE Tool: Helping Case Managers Identify and Respond to Risk Factors in Workers' Compensation Case Management

Purpose The aim was to develop a tool to be applied by workers' compensation case managers to guide intervention and avoid delayed return to work. Methods The Plan of Action for a CasE (PACE) tool was developed based on a review of existing literature, focus groups with case managers and analysis of existing claims data. Combined with analysis of existing case manager practice, these sources were used to determine key constructs for inclusion in the tool to be aligned with the demands of case manager workload. Mapping of existing interventions was used to match risk identified by the tool with appropriate intervention. Results The final PACE tool consisted of 41 questions divided into Ready (worker), Set (employer) and Go (treating practitioner) categories. Questions in the tool were linked to appropriate case manager actions. Data collection was completed by case managers for 524 claims within the first 2 weeks of the claim being accepted. The most commonly identified risks for delayed RTW included both worker and employer expectations of RTW, as well as certification of capacity. Factor analysis identified two factors operating across the tool categories. Case managers reported benefits in using the tool, but reported it also increased their workload. Conclusions The PACE tool is a unique example of the implementation of risk identification in case management practice. It demonstrates that case managers are ideally placed to collect information to identify risk of delayed RTW. Future work will establish the impact of case-manager led intervention based on identified risks on outcomes for injured workers.

Identifying Acute Low Back Pain Episodes in Primary Care Practice From Clinical Notes: Observational Study

BACKGROUND

Acute and chronic low back pain (LBP) are different conditions with different treatments. However, they are coded in electronic health records with the same International Classification of Diseases, 10th revision (ICD-10) code (M54.5) and can be differentiated only by retrospective chart reviews. This prevents an efficient definition of data-driven guidelines for billing and therapy recommendations, such as return-to-work options.

OBJECTIVE

The objective of this study was to evaluate the feasibility of automatically distinguishing acute LBP episodes by analyzing free-text clinical notes.

METHODS

We used a dataset of 17,409 clinical notes from different primary care practices; of these, 891 documents were manually annotated as acute LBP and 2973 were generally associated with LBP via the recorded ICD-10 code. We compared different supervised and unsupervised strategies for automated identification: keyword search, topic modeling, logistic regression with bag of n-grams and manual features, and deep learning (a convolutional neural network-based architecture [ConvNet]). We trained the supervised models using either manual annotations or ICD-10 codes as positive labels.

RESULTS

ConvNet trained using manual annotations obtained the best results with an area under the receiver operating characteristic curve of 0.98 and an F score of 0.70. ConvNet's results were also robust to reduction of the number of manually annotated documents. In the absence of manual annotations, topic models performed better than methods trained using ICD-10 codes, which were unsatisfactory for identifying LBP acuity.

CONCLUSIONS

This study uses clinical notes to delineate a potential path toward systematic learning of therapeutic strategies, billing guidelines, and management options for acute LBP at the point of care.

An Interactive Website for Whiplash Management (My Whiplash Navigator): Process Evaluation of Design and Implementation

Background

Whiplash is a health and economic burden worldwide. Contributing to this burden is poor guideline adherence and variable management by health care professionals (HCPs). Web-based tools that facilitate clinical pathways of care are an innovative solution to improve management.

Objective

The study aimed to develop, implement, and evaluate a Web-based tool to support whiplash management following a robust process.

Methods

This study followed the first 3 processes of a research translation framework (idea generation, feasibility, and efficacy) to inform the development, implementation, and evaluation of a website that supports HCPs in whiplash management. Development followed the idea generation and feasibility processes to inform the content, design, features, and functionality of the website. This involved stakeholder (eg, industry partners, website developers, and HCPs) consultations through face-to-face meetings, surveys, and focus group discussions. Implementation followed the feasibility process to determine the practicality of the website for clinical use and the most effective strategy to promote wider uptake. Implementation strategies included classroom education, educational meetings, educational outreach, reminders, and direct phone contact. The analysis of website use and practicality of implementation involved collection of website metrics. Evaluation followed the feasibility and efficacy processes to investigate the acceptability and extent to which the website assisted HCPs in gaining knowledge about whiplash management. Surveys were conducted among student, primary, and specialist HCPs to explore ease of access, use, and satisfaction with the website, as well as self-rated improvements in knowledge of risk assessment, management, and communication between HCPs. Website logs of specialist management decisions (eg, shared care, specialist care, and referred care) were also obtained to determine actual practice.

Results

The development process delivered an interactive, user-friendly, and acceptable website, My Whiplash Navigator, tailored to the needs of HCPs. A total of 260 registrations were recorded from June 2016 to March 2018, including 175 student, 65 primary, and 20 specialist HCPs. The most effective implementation strategies were classroom education for students (81% uptake, 175/215) and educational meetings for primary HCPs (43% uptake, 47/110). Popular pages visited included advice and exercises and risk assessment. Most HCPs agreed that their knowledge about risk management (79/97, 81%) and exercises (85/97, 88%) improved. The specialists’ most common management decision was shared care, an improvement from a previous cohort. Areas to improve were navigation and access to outcome measures.

Conclusions

A robust process resulted in an innovative, interactive, user-friendly, and acceptable website, the My Whiplash Navigator. Implementation with HCPs was best achieved through classroom education and educational meetings. Evaluation of the website showed improved knowledge and practice to be more consistent with a risk-based clinical care pathway for whiplash. The positive results provide sufficient evidence to scale implementation nationally and involve other target markets such as people with whiplash, insurers, and insurance regulators.

Assessing the Effectiveness of Evidence-Based Medicine in Practice: A Case Study of First-Time Anterior Shoulder Dislocations

BACKGROUND

The dissemination of evidence-based information into medical practice is essential to provide patients with optimal care and realize society's substantial investments in medical research. Effective information delivery and treatment utilization may lead to improvements in patient outcome, reductions in cost, and an overall lower burden on the health-care system. This study examines the dissemination of medical evidence following a first-time anterior shoulder dislocation (FTASD) and assesses the impact of potential dissemination strategies.

METHODS

The state of evidence dissemination into clinical practice for FTASD was evaluated with use of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The treatment pathway for patients with FTASDs was mapped and evaluated using data that were collected through an orthopaedic shoulder-specialist survey and with review of a claims database.

RESULTS

A total of 1,755 patients with an FTASD were identified through a national claims database; 50% of patients followed up with a care provider within 30 days after an emergency department (ED) or urgent care visit. Based on shoulder-specialist survey data, physician estimates of the risk of redislocation within a 2-year window aligned with medical evidence 59% of the time. Only 29% of patients obtained information for FTASD that aligns with high-level medical evidence.

CONCLUSIONS

There are gaps and deficiencies in the dissemination and application of evidence in the treatment of FTASDs. Specifically, patients have limited exposure to health-care encounters where appropriate information related to low rates of follow-up following ED or urgent care visits may be communicated. Evaluating the current state of practice and identifying areas of improvement for the dissemination of evidence regarding FTASDs can be achieved through application of the RE-AIM framework. Greater consideration and resourcing of dissemination and implementation strategies may improve the dissemination and the impact of existing medical evidence.

Understanding the Etiology of Chronic Pain From a Psychological Perspective

The etiology of chronic pain-related disability is not fully understood, particularly from a clinical perspective. Investigations to date have identified risk factors and elucidated some important processes driving the development of persistent pain problems. Yet this knowledge and its application are not always accessible to practicing physical therapists or other clinicians. This article aims to summarize the main psychological processes involved in the development of chronic pain disability and to derive some guidelines for treatment and future research. To this end, the focus is on the paradox of why coping strategies that are helpful in the short term continue to be used even when-ironically-they maintain the problem in the long term. To aid in summarizing current knowledge, 4 tenets that elucidate the etiology of chronic pain are described. These tenets emphasize that chronic pain disability is a developmental process over time, contextual factors set the stage for this development, underlying transdiagnostic psychological factors fuel this development, and the principles of learning steer the development of pain behaviors. With these tenets, an explanation of how a chronic problem develops for one person but not another is provided. Finally, hypotheses that can be empirically tested to guide clinical application as well as basic research are generated. In conclusion, understanding the psychological processes underlying the etiology of chronic pain provides testable ideas and a path forward for improving treatment interventions.

Rehabilitation management of low back pain - it's time to pull it all together!

In the past, rehabilitation research initiatives for low back pain (LBP) have targeted outcome enhancement through personalized treatment approaches, namely through classification systems (CS). Although the use of CS has enhanced outcomes, common management practices have not changed, the prevalence of LBP is still high, and only selected patients meet the CS profile, namely those with a nociceptive context. Similarly, although practice guidelines propose some level of organization and occasionally a timeline of care provision, each mainly provides best practice for isolated treatment approaches. Moreover, there is no theoretical framework that has been proposed that guides the rehabilitation management process of mechanical LBP. In this commentary, we propose a model constituted of five domains (nociceptive drivers, nervous system dysfunction drivers, comorbidities drivers, cognitive–emotional drivers, and contextual drivers) grounded as mechanisms driving pain and/or disability in LBP. Each domain is linked to the International Classification of Functioning, Disability and Health, where once a patient is deemed suitable for rehabilitation, the clinician assesses elements of each domain in order to identify where the relative treatment efforts should be focused. This theoretical model is designed to provide a more comprehensive management overview, by appreciating the relative contribution of each domain driving pain and disability. Considering that the multiple domains driving pain and disability, and their interaction, requires a model that is comprehensive enough to identify and address each related issue, we consider that the proposed model has several positive implications for rehabilitation of this painful and highly prevalent musculoskeletal disorder.

Does shared decision making results in better health related outcomes for individuals with painful musculoskeletal disorders? A systematic review

Background: Shared Decision-Making (SDM) is a dynamic process by which the health care professional and the patient influence each other in making health-related choices or decisions. SDM is strongly embedded in today's health care approaches, and is advocated as an ideal model since it renders individuals more control towards the health care they choose to receive, and has been shown to improve patient outcomes. Objectives: The goal of this systematic review was to investigate the added-value of SDM on clinical health-related outcomes in patients with a variety of musculoskeletal conditions. Data sources: PubMed and CINAHL. Study selection: PRISMA guidelines were followed for this review. To be considered for review, the study had to meet all the following criteria: (1) prospective studies that involved treatment decision-making; (2) randomized controlled trial design; (3) involving patients faced with having to make a treatment decision; (4) comparing SDM with a control intervention and (5) including one or more of the following outcome measures: well-being, costs, health-related pain or disability measures, or quality of life. Study appraisal: A priori, we determined to perform methodological quality assessment using the Cochrane Risk of Bias tool for randomized controlled trials. Results: We did not find a single study that looked at the true effect of SDM on patient reported outcomes in a population with musculoskeletal pain. Conclusion: For the management of painful musculoskeletal conditions, in the light of the current evidence (none), we estimate that it would be wise to explore the effectiveness of SDM before forcing its large-scale implementation in rehabilitation.