Use of eHealth technologies to enable the implementation of musculoskeletal Models of Care: Evidence and practice

Participation in a digital self-management intervention for osteoarthritis and socioeconomic inequalities in patient-related outcomes

OBJECTIVE

To investigate changes in socioeconomic inequalities in patient-related outcomes and pain medication use, following participation in a digital self-management intervention for osteoarthritis (OA) in Sweden.

METHOD

Participants with hip/knee OA enrolled in the digital intervention were included. Self-reported outcomes collected were the numerical rating scale (NRS) pain, activity impairment, general health, Knee/Hip injury and Osteoarthritis Outcome Score (KOOS-12, HOOS-12) Pain, Function, and Quality of Life subscales, 5-level EuroQol 5 Dimensions (EQ-5D-5L), Patient Acceptable Symptom State (PASS) for function, walking difficulties, fear of movement, wish for surgery, pain medication use, physical function measured by the 30s chair-stand test, and level of physical activity. Educational attainment was used as a socioeconomic measure and the concentration index was used to assess the magnitude of inequalities at baseline and 3 month follow-up.

RESULTS

The study included 21,688 participants (mean ± sd age 64.1 ± 9.1 years, 74.4% females). All outcomes except for PASS demonstrated inequalities in favour of highly educated participants at both time-points, with highly educated participants reporting better outcomes. At 3 month follow-up, the magnitude of inequality widened for activity impairment, but narrowed for NRS pain, EQ-5D-5L, KOOS-12/HOOS-12 Pain and Function, physical function, and wish for surgery. There were no statistically conclusive changes in the magnitude of inequalities for the remaining outcomes.

CONCLUSIONS

There were inequalities in patient-related outcomes in favour of those with higher education among participants of a digital self-management intervention for OA, although the magnitude of these pre-existing inequalities generally narrowed after the 3 month intervention.

Strengthening the pain care ecosystem to support equitable, person-centered, high-value musculoskeletal pain care

ABSTRACT

Improving health and wellbeing outcomes for people experiencing chronic musculoskeletal pain requires collective efforts across multiple levels of a healthcare ecosystem. System-wide barriers to care equity must however be addressed (eg, lack of co-designed services; overuse of low value care/underuse of high value care; inadequate health workforce; inappropriate funding models; inequitable access to medicines and technologies; inadequate research and innovation). In this narrative review, utilizing a systems' thinking framework, we synthesize novel insights on chronic musculoskeletal pain research contextualized through the lens of this complex, interconnected system, the "pain care ecosystem." We examine the application of systems strengthening research to build capacity across this ecosystem to support equitable person-centred care and healthy ageing across the lifespan. This dynamic ecosystem is characterized by three interconnected levels. At its centre is the person experiencing chronic musculoskeletal pain (micro-level). This level is connected with health services and health workforce operating to co-design and deliver person-centred care (meso-level), underpinned further upstream by contemporary health and social care systems (macro-level context). We provide emerging evidence for how we, and others, are working towards building ecosystem resilience to support quality musculoskeletal pain care: at the macro-level (eg, informing musculoskeletal policy and health strategy priorities); at the meso-level (eg, service co-design across care settings; health workforce capacity); and downstream, at the micro-level (eg, person-centred care). We outline the mechanisms and methodologies utilized and explain the outcomes, insights and impact of this research, supported by real world examples extending from Australian to global settings.

Experiences and perceptions of patients with ankylosing spondylitis: A systematic review and meta-synthesis of qualitative studies

OBJECTIVES

The systematic evaluation of relevant qualitative studies on the experiences of patients with ankylosing spondylitis provides a foundation for the clinical development of personalized disease management programs for this patient category.

METHODS

Multiple databases, including PubMed, Web of Science, Embase, Cochrane Library, CINAHL, Scopus, CNKI, Wanfang, CBM, and VIP, were searched for qualitative research literature on the experiences of patients with ankylosing spondylitis from the inception of databases to March 2024. Eligible studies were included, and quality was assessed using the quality evaluation standard of qualitative research at the Joanna Briggs Institute (JBI), Australia (2016). The results were integrated using the meta-aggregation approach.

RESULTS

A total of 11 papers were included in the review. Four themes and 10 subthemes were synthesized: (1) difficulties in diagnosis and treatment; (2) effects of disease symptoms; (3) maladjustment of social roles; and (4) lack of support for disease response.

CONCLUSION

Medical staff should leverage the advantages of the Internet to enhance knowledge and education on ankylosing spondylitis. They should focus on patients' mental health, assist in active self-management, provide personalized interventions, promote recovery, and improve the quality of life for patients. Additionally, society should offer a diverse range of support.

Effectiveness and Satisfaction with Telemedicine in Geriatric Patients at High Risk of Fragility Fractures

Background: Telemedicine has increasingly widespread to improve the monitoring of patients with chronic diseases. Secondary prevention of fragility fractures is an urgent matter to be addressed by means of available technology, although supported by little evidence so far. We investigated the feasibility, efficacy, and satisfaction of managing older adults at high risk of fragility fractures during the COVID-19 lockdown. Methods: During the period January to July 2021, a prospective observational study for safety and adherence purposes was conducted among older adults (n = 407) with ongoing treatments for secondary prevention of fragility fractures. The study procedures comply with national and regional resolutions related to telemedicine service (TS), including equipment, staff behaviors, and patient reports. Results: A majority (86.48% [n = 352]) of the eligible patients joined the remote visits, mainly women (88.2%), 81.4 ± 8.8 years of age, 49.6% independent in 5 out of 6 BADL, despite high comorbidity (4.9 ± 1.5), and polypharmacy (4.9 ± 3.1). Almost all were on second-line antifracture treatments (95.58%) due to previous major (84.03%) and minor (42.5%) fragility fractures. About 58% reported good and very good reliability of the internet network, allowing easy access to the TS platform, and 54% declared the degree of satisfaction with TS as good and very good. About 75% of clinicians acknowledged the efficacy of TS and expressed willingness to recommend the use of TS to colleagues. Ultimately, 68% of specialists defined the time allocated for patients' remote visits as acceptable. Conclusion: TS may be an opportunity to improve the availability of appropriate health care services to satisfy patients' needs and optimize health care resource allocation.

eHealth interventions to support self-management: Perceptions and experiences of people with musculoskeletal disorders and physiotherapists - 'eHealth: It's TIME': A qualitative study

BACKGROUND

There is increasing interest in the potential role of eHealth interventions to support self-management in people with musculoskeletal disorders (MSDs). The COVID-19 pandemic appears to have been a significant catalyst for the implementation of eHealth modalities into routine practice, providing a unique opportunity for real-world evaluation of this underutilized method of delivering physiotherapy.

OBJECTIVE

To explore the perceptions of eHealth-mediated supported self-management from the perspective of people with MSDs and physiotherapists who work in this clinical area.

METHODS

A qualitative interpretive descriptive approach was used. Semi-structured telephone interviews with 13 musculoskeletal physiotherapists and 13 people with musculoskeletal disorders were undertaken. Transcripts were analyzed using reflexive thematic analysis.

RESULTS

Three main themes were identified: 1) Flexibility within a blended care model; 2) eHealth as a facilitator of self-management support; and 3) Technology: Getting it right. Participants expressed concerns about assessment and diagnosis, establishing a therapeutic relationship and felt eHealth should be reserved for follow-up purposes. There was a consistent view expressed that eHealth could facilitate aspects of self-management support. A lack of resources and suboptimal user experience remains a challenge.

CONCLUSIONS

eHealth-mediated self-management support interventions were broadly acceptably, predominately as a follow-up option.

The Association of Rheumatologist Supply and Multidisciplinary Care With Timely Patient Access to Rheumatologists: Evidence From British Columbia, Canada

OBJECTIVE

The objective was to understand how the expansion of rheumatology supply and the introduction of multidisciplinary care was associated with access to rheumatology services.

METHODS

We accessed Population Data BC, a longitudinal database with de-identified individual-level health data on all residents of British Columbia, Canada, to analyze physician visits and prescribing from 2010-2011 to 2019-2020. We calculated access as the time from referral to first rheumatologist visit and, for people with rheumatoid arthritis (RA), time to first disease-modifying antirheumatic drug (DMARD). Associations between lag time, patient characteristics, and system variables were explored using quantile regression.

RESULTS

Over the study period, there were 149,902 new rheumatologist visits, with 31% more visits in 2019-2020 than in 2010-2011. The proportion of first visits for patients with inflammatory arthritis increased from 28% to 51%. The median time from referral to first visit decreased by 22 days (35%) from 63 days (interquartile range 21-120 days) in 2010-2011. For people with RA, time from referral to DMARD decreased by 4 days (6%) to 62 days. Male sex, living in metropolitan areas, and having a rheumatologist who used a multidisciplinary care assessment code were associated with shorter times from referral to first DMARD.

CONCLUSION

Access to rheumatology care improved, and the increased proportion of patients with IA in the first visits case-mix indicates that rheumatologist supply and incentives for multidisciplinary care may have improved referral patterns. However, time to DMARDs for people with RA remained long, and we found signals of unequal access for female patients and people living outside of metropolitan areas.

Developing a Content Model of a Mobile-Based Application to Manage Patients with Low-Back and Neck Pain

Introduction

As a complementary tool in health, the design of mobile applications to influence care and increase awareness of patients has grown a lot. The purpose of this study is to design and validate the content model of a mobile-based application for managing patients with low-back and neck pain.

Methods

This descriptive-analytical study was conducted in two main stages to determine the content model of the application. The first stage consisted of three steps: finding the right exercise, determining the right scale to assess the pain intensity, and determining the appropriate features of the application. In the second stage, data elements collected from the previous stage were prepared in the form of a questionnaire that was given to 12 experts in physical therapy and sports medicine for validation. After collecting the questionnaire, data elements in all parts were analyzed based on the content validity ratio (CVR) and descriptive statistics indicators.

Result

The content of the application was prepared in the three axes of exercises for low-back and neck pain, assessment of pain intensity, and features of the application. In the axis of sports exercises, 8 exercises for back pain and 3 exercises for neck pain were included according to the reference books. A Functional Rating Index (FRI) scale with 10 elements was selected in the axis of determining pain intensity. Also, 12 features such as the daily exercise section, using the animation, and using an audio file to explain how to do exercises were included in the model.

Conclusion

According to the gaps identified in the existing applications, determining the content model of the application that is based on evidence and according to the opinion of experts is useful in improving the apps. The content model of this study was presented in 3 axes to increase the patient's willingness to do exercises, the correct way to perform exercises, conservative treatment, and check the progress of the treatment. The software developers can use these findings as a basis for designing new apps to manage low-back pain and neck pain.

Describing Perspectives of Telehealth and the Impact on Equity in Access to Health Care from Community and Provider Perspectives: A Multimethod Analysis

Introduction: The rapid adoption of telehealth as a result of the COVID-19 pandemic provided the opportunity to examine perceptions of health care access and use of telehealth for delivery of effective and equitable care in low-income and historically marginalized communities. Methods: Focusing on communities with high social vulnerability, a multimethod analysis of combined perspectives, collected February through August 2022 from 112 health care providers, obtained from surveys and interviews, and 23 community members via 3 focus groups on access to care and telehealth. Qualitative data were analyzed using the Health Equity and Implementation Framework to identify barriers, facilitators, and recommendations for the implementation of telehealth using a health equity lens. Results: Participants perceived that telehealth helped maintain access to health care during the pandemic by addressing barriers including provider shortages, transportation concerns, and scheduling conflicts. Additional benefits suggested were improved care quality and coordination attributed to convenient avenues for care delivery and communication among providers and patients. However, many barriers to telehealth were reported and considered to limit equitable access to care. These included restrictive or changing policies regarding allowable services provided via telehealth, and availability of technology and broadband services to enable telehealth visits. Recommendations provided insight into care delivery innovation opportunities and potential policy changes to address equitable access to care. Conclusion: Integration of telehealth into models of care delivery could improve access to health care services and promote communication among providers and patients to improve care quality. Our findings have implications that are critical for future policy reforms and telehealth research.

Effects of technology-assisted rehabilitation for patients with hip arthroplasty: A meta-analysis

BACKGROUND

To investigate the efficacy of technology-assisted rehabilitation compared to that of usual care programs after total hip arthroplasty (THA) through randomized controlled trials (RCTs).

METHODS

The Medline (PubMed), Cochrane Library, Embase and Web of Science databases were searched for RCTs regarding the efficacy of technology-assisted rehabilitation following THA. Data were analyzed using Stata 12.0 software.

RESULTS

Eleven RCTs involving 1327 patients were included in the meta-analysis. The pooled effect size showed that compared to usual care, telerehabilitation significantly improved the Harris score (standardized mean difference [SMD] 0.74, 95% confidence interval [CI] 0.58 to 0.90) and functional independence measure (FIM) score (SMD 1.26, 95% CI 0.48 to 2.03). In addition, video-based therapy could significantly improve walk test results (SMD 0.43, 95% CI 0.11 to 0.75).

CONCLUSION

The findings suggest that technology-assisted rehabilitation, especially telerehabilitation, have been shown to improve the physical function of patients following THA compared to conventional rehabilitation. More robust studies are needed to validate the long-term efficacy and safety of innovative technology-assisted training strategies.

The feasibility, facilitators, and barriers in the initial implementation phase of 'good life with osteoarthritis in Denmark' (GLA:D®) in Switzerland: a cross-sectional survey

BACKGROUND

The guideline-based, conservative, non-pharmacological management of hip and knee osteoarthritis in clinical practice has been insufficient in Switzerland until now. The implementation of "Good Life with Osteoarthritis in Denmark" (GLA:D®), a programme designed to address this evidence-performance gap, was started in 2019 in Switzerland. This study investigated the acceptance and practicality of the GLA:D® Switzerland programme and identified the facilitators and barriers to its implementation, to support the development of tailored implementation strategies.

METHODS

This is a non-experimental observational study. A cross-sectional survey was performed among the physiotherapists (PTs) of the first five GLA:D® Switzerland certification courses, using the Measurement Instrument for Determinants of Innovations (MIDI) to identify the facilitators and barriers. Descriptive statistics were calculated, and qualitative content analysis was used for open-ended questions.

RESULTS

In the online survey, 86 GLA:D® certified PTs participated (response rate: 61%). The majority of 51 PTs (63.7%) worked in private practices. Of the responding PTs 58 (78.4%) were satisfied with the general concept of the GLA:D® Switzerland programme. Practicality was evaluated positively, particularly the second and third individual session (n = 40 PTs, 83.3%), the 40 m Fast-paced Walk Test (43, 89.6%), the 30 s Chair Stand Test (45, 93.8%), and the exercise programme (40, 83.3%). The marketing (12, 15%), the 'data entry' (5, 10.4%), 'register the patient' (7, 14.6%), and the digital patient questionnaire (9, 14.2%) were rated less positively. In total, 12 facilitators and 12 barriers were identified. The barriers were mainly related to adopting user, e.g., perceived personal disadvantages. Barriers were also found in the organisational context, e.g., time available. Facilitators were associated with the GLA:D® Switzerland programme itself, e.g., completeness, relevance for patients, and the adopting user, e.g., self-efficacy, and in the organisational context, e.g., material resources and facilities. Topics related to the socio-political context were raised in the answers to the open-ended questions, e.g., general awareness level of the GLA:D® Switzerland programme and patient recruitment.

CONCLUSION

The acceptance, practicality and facilitators identified from the initial implementation are encouraging. However, the identified barriers and activities rated with low practicality require tailored strategies to support a successful implementation of the GLA:D® Switzerland programme.

Design and development of an eHealth intervention to support self-management in people with musculoskeletal disorders - 'eHealth: It's TIME': a study protocol

Background: Musculoskeletal disorders (MSDs) are a leading cause of global morbidity, with the burden expected to increase in the near future. Self-management, with the support of healthcare professionals, is recommended for many MSDs. However, frequent clinical contact is not feasible. Previous research has highlighted the need for a co-designed eHealth-mediated self-management follow-up support intervention which integrates remote monitoring and behavioural change. Thus, the current study aims to develop and design a user-centred, eHealth-mediated self-management support prototype for people with MSDs. Methods: A three-step, iterative system development cycle will be utilised to develop and design the "eHealth: It's TIME prototype". The three-step process will include creating website features and content using two sequential focus groups with people with MSDs (n = 6 - 8); heuristic testing using the 10 heuristic principles of Nielsen (n = 5); and usability testing through in-person 60-minute interviews with people with MSDs (n = 3 - 5) and musculoskeletal physiotherapists (n = 3 - 5). Conclusion: The eHealth: It's TIME prototype will be a systematically developed, follow-up self-management support intervention guided by behavioural change theory and the preferences of end users.

Effectiveness of patient education on total knee arthroplasty: A systematic review and meta-analysis

AIMS AND OBJECTIVES

This study was designed to examine the contents and methods of patient educational interventions about total knee arthroplasty (TKA) and their effectiveness in reducing postoperative pain and enhancing range of motion (ROM) in the literature.

BACKGROUND

Patient education has been provided to facilitate recovery after TKA; however, little is known about the contents and methods of the interventions and their effectiveness in reducing postoperative pain and enhancing ROM.

DESIGN

This is a systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

Published studies from June 1998-June 2021 were identified from electronic databases. Two independent investigators assessed the quality of the studies by using the revised Cochrane risk-of-bias tool. Meta-analyses with random-effects models were conducted to assess the effectiveness of the interventions using the Comprehensive Meta-Analysis Software. The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

RESULTS

Among 12 articles that met the inclusion criteria, three interventions provided education on pain management and mobility/exercises. The most common educational methods were the combinations of oral explanation, written materials, and audiovisual materials, group discussion, while four studies used information technology (IT) devices. The meta-analysis demonstrated that the educational interventions using IT devices were effective in improving pain and ROM, but not the interventions that did not use IT devices.

CONCLUSION

Structured education for pain management, communication and/or exercise support programs utilising diverse methods have been provided to patients undergoing TKA. Using IT devices could successfully enhance the effectiveness of educational interventions for patients undergoing TKA.

RELEVANCE TO CLINICAL PRACTICE

Integration of postoperative pain management and mobility/exercises with the use of IT devices should be actively considered in providing patient education in clinical nursing practice.

Design and development of an eHealth intervention to support self-Management in people with musculoskeletal Disorders - ‘eHealth: It’s TIME’: a study protocol

Background: Musculoskeletal disorders (MSDs) are a leading cause of global morbidity, with the burden expected to increase in the near future. Self-management, with the support of healthcare professionals, is recommended for many MSDs. However, frequent clinical contact is not feasible. Previous research has highlighted the need for a co-designed eHealth-mediated self-management follow-up support intervention which integrates remote monitoring and behavioural change. Thus, the current study aims to develop and design a user-centred, eHealth-mediated self-management support prototype for people with MSDs. Methods: A three-step, iterative system development cycle will be utilised to develop and design the “eHealth: It’s TIME prototype”. The three-step process will include creating website features and content using two sequential focus groups with people with MSDs (n = 6 – 8); heuristic testing using the 10 heuristic principles of Nielsen (n = 5); and usability testing through in-person 60-minute interviews with people with MSDs (n = 3 – 5) and musculoskeletal physiotherapists (n = 3 – 5). Conclusion: The eHealth: It’s TIME prototype will be a systematically developed, follow-up self-management support intervention guided by behavioural change theory and the preferences of end users.

The Codevelopment of "My Kidneys & Me": A Digital Self-management Program for People With Chronic Kidney Disease

BACKGROUND

Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality.

OBJECTIVE

This work describes the systematic codevelopment of "My Kidneys & Me" (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND).

METHODS

A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource.

RESULTS

The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M.

CONCLUSIONS

Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial.

Community-based pain programs commissioned by primary health networks: key findings from an online survey and consultation with program managers

OBJECTIVE

There is an increasing demand for tertiary pain services, with long waiting times compounded by limited reach to regional and remote areas. Community-based pain programs are a feasible evidence-based model of care to improve access to multidisciplinary care. Australian primary health networks (PHNs) are well placed to commission pain programs to reduce the growing burden of chronic pain. The aim of this study was to support PHN decision-making by: (1) describing current PHN community-based pain programs; (2) assessing their alignment to key elements and implementation enablers of pain programs identified by an expert consensus process; and (3) describing PHN pain program adaptations during the COVID-19 pandemic.

METHODS

PHN program managers of community-based pain programs (n  = 9) were invited to participate in an online survey and follow-up email consultation about their pain program. Six PHN program managers (representing South Eastern NSW PHN, Nepean Blue Mountains PHN, North Western Melbourne PHN, Gold Coast PHN, Adelaide PHN and the WA Primary Health Alliance) participated in the study with three PHNs commissioning two different types of pain programs.

RESULTS

PHN community-based pain programs are multidisciplinary programs underpinned by a biopsychosocial model of pain, and focus on self-management (e.g. exercise, psychological strategies) and pain education. Most PHN pain programs are group-based programs that target adults with chronic non-cancer pain, provide individual allied health referrals as required and are evaluated as part of the electronic Persistent Pain Outcomes Collaboration. Gaps include pain programs for Aboriginal and Torres Strait Islander people, and people from culturally and linguistically diverse backgrounds, with one notable exception of a PHN pain program for people from culturally and linguistically diverse and refugee backgrounds co-designed with consumers and relevant services. Programs targeting subacute pain to prevent progression to chronic pain are, with one exception, another gap area. PHN pain programs demonstrated a high level of alignment with expert-agreed key elements and implementation enablers. The COVID-19 pandemic precipitated the rapid adaptation of PHN pain programs using available methods for the delivery of digitally enabled care.

CONCLUSIONS

The findings provide a greater understanding for researchers and PHN decision-makers of the key features of PHN community-based pain programs, their alignment with expert-agreed key elements and implementation enablers, the target-population gaps, and the types of program adaptations during the COVID-19 pandemic. The findings also illustrate the potential for using digitally enabled delivery methods to increase accessibility to pain programs with further research warranted.

The current role of telehealth in the management of patients with osteoporosis

INTRODUCTION

Telehealth is the use of electronic technologies for communication, storage, and analysis of health-related information. Telemedicine is a form of telehealth that involves remote patient care. This is a review and update of the use of these modalities as they apply to the education of healthcare professionals who provide care for patients with osteoporosis and the delivery of their care.

AREAS COVERED

This review focuses on technology-enabled collaborative learning and its prototype model, Project ECHO (Extension for Community Healthcare Outcomes). Bone Health TeleECHO and similar programs apply the ECHO model of learning to mentor healthcare professionals on implementation of best practice care for patients with osteoporosis and other skeletal diseases. Telemedicine, which has seen widespread uptake during the COVID-19 pandemic, is an alternative to in-person visits for patients with osteoporosis as well as for those with other conditions.

EXPERT OPINION

Remote education of healthcare professionals and the remote delivery of patient care provides opportunities, as well as challenges, for achieving the goal of reducing the global burden of osteoporotic fractures.

An evidence-based tailored eHealth patient education tool for patients with knee osteoarthritis: protocol for a randomized controlled trial

BACKGROUND

Osteoarthritis is a common and disabling condition that places heavy burden to individuals and healthcare systems. Patient education is a facilitator in the treatment decision making process, aiming to develop a treatment plan for the disease management. Electronic health (eHealth) is an alternative forum for the delivery of patient education and given the prevailing of eHealth in healthcare, introducing patient education programs using the technology has the potential to improve patient engagement, self-management and outcomes in patients with osteoarthritis. The study will evaluate the efficacy of eHealth patient education tool on patients' perception of knee osteoarthritis and treatment options, satisfaction and compliance to treatments.

METHODS

This study is a prospective randomized controlled trial with a 1:1 allocation in two groups. We will recruit 216 patients diagnosed with knee osteoarthritis from the outpatient physiatry/physiotherapy clinic at West China Hospital, Sichuan University in Southwest China. Both groups will receive usual care and additionally, the intervention group will use eHealth patient education tool during the process. Measurements will be taken at baseline, post-intervention, 1 month, 3- and 6-months follow-up. Primary outcome will be patients' knowledge about disease and treatment options, measured by the validated osteoarthritis patient knowledge questionnaire. Secondary outcomes include patients' satisfaction with the consultation, the eHealth patient education tool, and their trust of the physiotherapist.

DISCUSSION

The eHealth patient education tool is designed to provide participants with an innovative model of care delivery and this trial will assess the efficacy of the tool and whether this new model of patient education will have the potential to increase patient knowledge and empower self-management. Results collected from this study will further inform future research employing eHealth tool as interventions for the management of a range of other chronic conditions and help participants in communities or rural areas having the equal access to health care services.

TRIAL REGISTRATION

This study was prospectively registered on the Chinese Clinical Trials Registry ( ChiCTR2100051083 ) registered 12.09.2021.

Use, and acceptability, of digital health technologies in musculoskeletal physical therapy: A survey of physical therapists and patients

Objectives

Determine (a) frequency of digital health use to obtain/record clinical information (pre‐COVID‐19); (b) willingness to use digital technologies among physical therapists and patients with musculoskeletal conditions.

Methods

102 physical therapists, and 103 patients were recruited in Australia. An electronic survey ascertained (a) demographic/clinical characteristics, (b) frequency of methods to obtain and record clinical information; (c) willingness to use digital technologies to support musculoskeletal care.

Results

Physical therapists mostly used non‐digital methods to obtain subjective (e.g., face‐to‐face questioning, n = 98; 96.1%) and objective information (e.g., visual estimation, n = 95; 93.1%). The top three digital health technologies most frequently used by therapists: photo‐based image capture (n = 19; 18.6%), accessing information logged/tracked by patients into a mobile app (n = 14; 13.7%), and electronic systems to capture subjective information that the patient fills in (n = 13; 12.7%). The top three technologies used by patients: activity trackers (n = 27; 26.2%), logging/tracking health information on mobile apps or websites (n = 12; 11.7%), and entering information on a computer (n = 12; 7.8%). Physical therapists were most willing to use technologies for: receiving diagnostic imaging results (n = 99; 97.1%), scheduling appointments (n = 92; 90.2%) and capturing diagnostic results (n = 92; 90.2%). Patients were most willing to use technologies for receiving notifications about health test results (n = 91; 88.4%), looking up health information (n = 83; 80.6%) and receiving personalised alerts/reminders (n = 80; 77.7%).

Conclusions

Physical therapists and patients infrequently use digital health technologies to support musculoskeletal care, but expressed some willingness to consider using them for select functions.

Barriers and facilitators perceived by healthcare professionals for implementing lifestyle interventions in patients with osteoarthritis: a scoping review

OBJECTIVE

To provide an overview of barriers and facilitators that healthcare professionals (HCPs) perceive regarding the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA).

DESIGN

Scoping review.

DATA SOURCES

The databases PubMed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception up to January 2021.

ELIGIBILITY CRITERIA

Primary research articles with a quantitative, qualitative or mixed-methods design were eligible for inclusion if they reported: (1) perceptions of primary and/or secondary HCPs (population); (2) on implementing LIs with physical activity and/or weight management as key components (concept) and (3) on conservative management of hip and/or knee OA (context). Articles not published in English, German or Dutch were excluded.

DATA EXTRACTION AND SYNTHESIS

Barriers and facilitators were extracted by two researchers independently. Subsequently, the extracted factors were linked to a framework based on the Tailored Implementation for Chronic Diseases checklist.

RESULTS

Thirty-six articles were included. In total, 809 factors were extracted and subdivided into nine domains. The extracted barriers were mostly related to non-optimal interdisciplinary collaboration, patients' negative attitude towards LIs, patients' low health literacy and HCPs' lack of knowledge and skills around LIs or promoting behavioural change. The extracted facilitators were mostly related to good interdisciplinary collaboration, a positive perception of HCPs' own role in implementing LIs, the content or structure of LIs and HCPs' positive attitude towards LIs.

CONCLUSIONS

Multiple individual and environmental factors influence the implementation of LIs by HCPs in patients with hip and/or knee OA. The resulting overview of barriers and facilitators can guide future research on the implementation of LIs within OA care. To investigate whether factor frequency is related to the relevance of each domain, further research should assess the relative importance of the identified factors involving all relevant disciplines of primary and secondary HCPs.

PROSPERO REGISTRATION NUMBER

CRD42019129348.

Applications of Wearable Technology in a Real-Life Setting in People with Knee Osteoarthritis: A Systematic Scoping Review

With the growing number of people affected by osteoarthritis, wearable technology may enable the provision of care outside a traditional clinical setting and thus transform how healthcare is delivered for this patient group. Here, we mapped the available empirical evidence on the utilization of wearable technology in a real-world setting in people with knee osteoarthritis. From an analysis of 68 studies, we found that the use of accelerometers for physical activity assessment is the most prevalent mode of use of wearable technology in this population. We identify low technical complexity and cost, ability to connect with a healthcare professional, and consistency in the analysis of the data as the most critical facilitators for the feasibility of using wearable technology in a real-world setting. To fully realize the clinical potential of wearable technology for people with knee osteoarthritis, this review highlights the need for more research employing wearables for information sharing and treatment, increased inter-study consistency through standardization and improved reporting, and increased representation of vulnerable populations.

'I think there is nothing . . . that is really comprehensive': healthcare professionals' views on recommending online resources for pain self-management

Objectives

To explore healthcare professionals' views on, and attitudes, towards recommending online resources for persistent pain self-management.

Methods

This study was the qualitative phase of a two-phase mixed method study. Thirty-one New Zealand health professionals involved in the management of persistent pain were interviewed via focus groups and individual interviews. Data were analysed using the general inductive approach.

Results

The major themes were as follows: (1) risks and limits of online information outweigh benefits, (2) a blended model, of online resources with healthcare professional support, could work, (3) only trustworthy resources can be recommended, (4) need for personalisation and (5) perceived barriers to adoption.

Conclusion

Online resources were perceived as a useful adjunct to support pain self-management; however, due to potential risks of misinterpretation and misinformation, healthcare professionals proposed a 'blended model' where curated online resources introduced during face-to-face consultations could be used to support self-management. Participants needed 'trustworthy online resources' that provide evidence-based, updated information that is personalised to clients' health literacy and cultural beliefs.

Practice implications

Training for healthcare professionals on critical appraisal of online resources or curation of evidence-based online resources could increase recommendation of online resources to support pain self-management as an adjunct to in-person care.

Perceived Usefulness of Telerehabilitation of Musculoskeletal Disorders: A Belgium-France Pilot Study during Second Wave of COVID-19 Pandemic

BACKGROUND

COVID-19 has affected the practice of physiotherapy, and telerehabilitation (TR) may be seen as an alternative model of care if it is accepted by patients and physiotherapists. This study investigates the perceived usefulness of TR and the intention to use it among physiotherapists and patients from Belgium and France concerned with musculoskeletal disorders (MSDs) during the pandemic period.

METHODS

An online questionnaire based on the technology-acceptance model was designed. Sociodemographic data were collected and Likert scales were proposed to assess perceived ease-of-use, perceived usefulness and intention to use TR. Data were collected between 17 January and 17 March 2021; 68 patients and 107 physiotherapists answered.

RESULTS

In total, 88% of patients and 76% physiotherapists had not used TR at the time they answered. Only 12% of patients and 1% of physiotherapists are willing to use TR, and 50% of physiotherapists think they will never use TR compared to 25% of patients. A total of 98% of participants agreed that they had a good mastery of the technological tools requested.

CONCLUSIONS

Physiotherapists are more reluctant to use TR than patients, regardless of convincing EBM results. This is related to their own representation of proper MSD management, which must include the use of hands-on techniques.

Digital Health Interventions in Physiotherapy: Development of Client and Health Care Provider Survey Instruments

BACKGROUND

The advancement of digital health has widened the scope of technology use across multiple frontiers of health care services, including personalized therapeutics, mobile health, eHealth record management, and telehealth consultations. The World Health Organization (WHO) responded to this in 2018 by publishing an inaugural broad classification framework of digital health interventions (DHIs) used to address contemporary health system needs.

OBJECTIVE

This study aims to describe the systematic development of dual survey instruments (clinician and patient) to support data collection, administered in a physiotherapy setting, about perceptions toward DHIs. This is achieved by adapting the WHO framework classification for DHIs for application in real-world research.

METHODS

Using a qualitative item review approach, WHO DHI descriptors were adapted and refined systematically to be used in a survey form. This approach was designed to align with the processes of delivering and receiving care in clinical practice, using musculoskeletal physiotherapy as a practical case scenario.

RESULTS

Complementary survey instruments (for health care providers and clients) were developed by adapting descriptor items. These instruments will be used in a larger study exploring the willingness of physiotherapists and patients to use digital technologies in the management of musculoskeletal conditions.

CONCLUSIONS

This study builds on the WHO-standardized DHI framework. We developed dual novel survey instruments by adapting and refining the functions of DHIs. These may be deployed to explore the perceived usefulness and application of DHIs for different clinical care functions. Researchers may wish to use these survey instruments to examine digital health use systematically in a variety of clinical fields or technology scenarios in a way that is standardized and generalizable.

"A coalition of the willing": experiences of co-designing an online pain management programme (iSelf-help) for people with persistent pain

BACKGROUND

Participatory approaches to developing health interventions with end-users are recommended to improve uptake and use. We aimed to explore the experiences of co-designing an online-delivered pain management programme (iSelf-help) for people with persistent pain.

METHODS

A modified participatory action research (PAR) framework was used to co-design contents and delivery of iSelf-help. The PAR team included: (1) a patient advisory group consisting of people living with persistent pain (n = 8), (2) pain management service clinicians (n = 2), (3) health researchers (n = 3), (4) digital health experts (n = 2), (5) a health literacy expert, and (6) two Māori health researchers and our community partner who led the cultural appropriateness of iSelf-help for Māori (the Indigenous population of New Zealand). The iSelf-help co-design processes and activities of the 'PAR' team is reported in another paper. In this paper, all PAR team members were invited to share their experiences of the co-design process. Individual interviews were held with 12 PAR team members. Interview transcripts were analysed using the General Inductive Approach.

RESULTS

Five common themes were identified from the interviews: (1) Shared understanding and values of the co-design process, (2) Mismatched expectations with content creation, (3) Flexibility to share power and decision making, (4) Common thread of knowledge, and (5) Shared determination. Sustaining these themes was an overarching theme of "A coalition of the willing".

CONCLUSIONS

PAR team members valued the shared determination and responsibility to co-design iSelf-help. They also acknowledged the complexities and challenges during the process related to mismatched expectations, power sharing and establishing a common thread of knowledge. Successful co-design requires a shared commitment and responsibility as a coalition to meet the aspirations of end-users, within the boundaries of time and budget.

eHealth interventions to support self-management in people with musculoskeletal disorders: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to explore existing literature related to the role of eHealth interventions in supporting self-management in those with musculoskeletal disorders in order to investigate and chart the evidence, and identify any gaps within the literature.

INTRODUCTION

Musculoskeletal disorders are one of the leading causes of disability worldwide. Self-management interventions are consistently recommended as a core component of treatment for people with musculoskeletal disorders. Given limited health care resources, there is increasing interest in the potential role of eHealth interventions to support self-management in this population.

INCLUSION CRITERIA

Studies that include adult participants (older than 18 years) with a musculoskeletal disorder will be considered. Studies that include participants with pain of specific pathological origin (eg, infection, malignancy, osteoporosis, inflammatory disease, fracture), those who are pregnant, or individuals following surgery will be excluded. The concept is eHealth interventions that support self-management conducted in any setting and geographical location. All settings and locations will be included.

METHODS

The following electronic databases will be searched with no limit on publication date: MEDLINE, CINAHL, PsycINFO, Embase, Scopus and the Cochrane Database of Systematic Reviews. A structured search of the gray literature will also be conducted. Studies will be limited to those published in English. Two reviewers will undertake title and abstract screening, followed by full-text screening. Data extraction will be conducted utilizing a standardized form for included studies, and a narrative summary will accompany the charted results and will describe how the results relate to the review's objective.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (https://osf.io/29rd6).

Midwives' views towards women using mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature

INTRODUCTION

There are many mobile telephone apps to help women self-monitor aspects of pregnancy and maternal health. This literature review aims to understand midwives’ perspectives on women self-monitoring their pregnancy using eHealth and mHealth, and establish gaps in research.

METHODS

MEDLINE, PubMed, Scopus, CINAHL and PsycINFO were systematically searched on midwifery, eHealth/mHealth and perspectives. Qualitative, quantitative and mixed-methods studies published in English were considered for inclusion in the review, without geographical limitations. Relevant articles were critically appraised and narrative synthesis was conducted.

RESULTS

Twelve relevant papers covering midwives’ perspectives of the use of eHealth and mHealth by pregnant women were obtained for inclusion in this review. Seven of these publications focused on midwives’ views of eHealth, and five on their perspectives of mHealth interventions. The studies included demonstrate that midwives generally hold ambivalent views towards the use of eHealth and mHealth technologies in antenatal care. Often, midwives acknowledged the potential benefits of such technologies, such as their ability to modernise antenatal care and to help women make more informed decisions about their pregnancy. However, midwives were quick to point out the risks and limitations of these, such as the accuracy of conveyed information, and negative impacts on the patient-professional relationship.

CONCLUSIONS

Post-COVID-19, where technology is continuously developing, there is a compelling need for studies that investigate the role of eHealth and mHealth in self-monitoring pregnancy, and the consequences this has for pregnant women, health professionals and organisations, as well as midwifery curricula.

Clinical and cost-effectiveness of an online-delivered group-based pain management programme in improving pain-related disability for people with persistent pain-protocol for a non-inferiority randomised controlled trial (iSelf-help trial)

INTRODUCTION

Persistent non-cancer pain affects one in five adults and is more common in Māori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability.

METHODS AND ANALYSIS

Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA).

ETHICS AND DISSEMINATION

The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent.

TRIAL REGISTRATION NUMBER

ACTRN 12619000771156.

EHealth to empower patients with musculoskeletal pain in rural Australia (EMPoweR) a randomised clinical trial: study protocol

BACKGROUND

Low back pain (LBP) and knee osteoarthritis (OA) are major contributors to disability worldwide. These conditions result in a significant burden at both individual and societal levels. Engagement in regular physical activity and exercise programs are known to improve physical function in both chronic LBP and knee OA populations. For people residing in rural areas, musculoskeletal conditions are often more frequent and disabling compared to urban populations, which could be the result of reduced access to appropriate health services and resources in rural settings. EHealth is an innovative solution to help provide equitable access to treatment for people with musculoskeletal pain living in rural settings.

METHODS/DESIGN

We will conduct a randomised clinical trial investigating the effects of an eHealth intervention compared to usual care, for people with chronic non-specific LBP or knee OA in rural Australia. We will recruit 156 participants with non-specific chronic LBP or knee OA. Following the completion of baseline questionnaires, participants will be randomly allocated to either the eHealth intervention group, involving a tailored physical activity and progressive resistance exercise program remotely delivered by a physiotherapist (n = 78), or usual care (n = 78) involving referral to a range of care practices in the community. Outcomes will be measured at baseline, 3 and 6 months post-randomisation. The primary outcome will be physical function assessed by the Patient-Specific Functional Scale (PSFS). Secondary outcomes include pain intensity, physical activity levels, activity limitations, quality of life, pain coping. We will also collect process evaluation data such as recruitment rate, attendance and adherence, follow-up rate, participants' opinions and any barriers encountered throughout the trial.

DISCUSSION

The findings from this trial will establish the effectiveness of eHealth-delivered interventions that are known to be beneficial for people with LBP and knee OA when delivered in person. As a result, this trial will help to inform health care policy and clinical practice in Australia and beyond for those living in non-urban areas.

TRIAL REGISTRATION

This study was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12618001494224 ) registered 09.05.2018.

"Context, content, and system" supporting digital health hub (DHH)-enabled models of care (MoCs) for fragility hip fractures: perspectives of diverse multidisciplinary stakeholders in South Australia from qualitative in-depth interviews

Combining thematic analysis and a human-computer persuasive systems framework suggests that hip fracture recovery among older people can be enhanced through person-centered digital health hub models of care focused on behavior change education and integrated care. The findings intend to guide settings involving comorbid conditions and low- and middle-income countries in developing innovative digital health solutions.

PURPOSE

The purpose of this study was to understand stakeholders' perspectives on the development of a digital health-enabled model of care for fragility hip fractures and to map out factors that could influence the design and implementation of such a model.

METHODS

Qualitative in-depth interviews were conducted with stakeholders from various clinical disciplines, allied health, and computer science. A hybrid process involving thematic analysis of the raw data using inductive coding was the first step. In the second step, the tenets of a theoretical framework (health behavior change supporting systems) were deductively applied to the thematic constructs generated as part of the first step of the analysis.

RESULTS

In total, 24 in-depth interviews were conducted with stakeholders. We identified 18 thematic constructs presented under the categories of context, content, and system. Context covered patient characteristics such as frailty, digital literacy, and patient or carer participation, whereas healthcare delivery aspects included the structure and culture of existing practice and the need for innovative holistic models of care. Content outlines the active ingredients and approach in developing a digital health hub, and it highlights the importance of targeted education and behavior change. The system is a complicated matrix crossing different aspects of healthcare and offering a value proposition design through personalization across modes of content delivery. This must foster trust, ensure adequate financing, and support ownership and privacy by establishing appropriate mechanisms for embedding change.

CONCLUSION

The findings from this study provide insights around potential factors related to patients, community support, and healthcare delivery influencing the design and next-stage implementation of a digital health hub model of care for fragility hip fractures.

Issues in reporting of systematic review methods in health app-focused reviews: A scoping review

No guidelines exist for the conduct and reporting of manuscripts with systematic searches of app stores for, and then appraisal of, mobile health apps ('health app-focused reviews'). We undertook a scoping review including a systematic literature search for health app-focused reviews describing systematic app store searches and app appraisal, for apps designed for patients or clinicians. We created a data extraction template which adapted data elements from the PRISMA guidelines for systematic literature reviews to data elements operationalised for health app-focused reviews. We extracted the data from included health app-focused reviews to describe: (1) which elements of the adapted 'usual' methods of systematic review are used; (2) methods of app appraisal; and (3) reporting of clinical efficacy and recommendations for app use. From 2798 records, the 26 included health app-focused reviews showed incomplete or unclear reporting of review protocol registration; use of reporting guidelines; processes of screening apps; data extraction; and appraisal tools. Reporting of clinical efficacy of apps or recommendations for app use were infrequent. The reporting of methods in health app-focused reviews is variable and could be improved by developing a consensus reporting standard for health app-focused reviews.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

Identifying and managing osteoporosis before and after COVID-19: rise of the remote consultation?

The COVID-19 pandemic is influencing methods of healthcare delivery. In this short review, we discuss the evidence for remote healthcare delivery in the context of osteoporosis.

INTRODUCTION

The COVID-19 pandemic has undoubtedly had, and will continue to have, a significant impact on the lives of people living with, and at risk of, osteoporosis and those caring for them. With osteoporosis outpatient and Fracture Liaison Services on pause, healthcare organisations have already moved to delivering new and follow-up consultations remotely, where staffing permits, by telephone or video.

METHODS

In this review, we consider different models of remote care delivery, the evidence for their use, and the possible implications of COVID-19 on osteoporosis services.

RESULTS

Telemedicine is a global term used to describe any use of telecommunication systems to deliver healthcare from a distance and encompasses a range of different scenarios from remote clinical data transfer to remote clinician-patient interactions. Across a range of conditions and contexts, there remains unclear evidence on the acceptability of telemedicine and the effect on healthcare costs. Within the context of osteoporosis management, there is some limited evidence to suggest telemedicine approaches are acceptable to patients but unclear evidence on whether telemedicine approaches support informed drug adherence. Gaps in the evidence pertain to the acceptability and benefits of using telemedicine in populations with hearing, cognitive, or visual impairments and in those with limited health literacy.

CONCLUSION

There is an urgent need for further health service evaluation and research to address the impact of remote healthcare delivery during COVID-19 outbreak on patient care, and in the longer term, to identify acceptability and cost- and clinical-effectiveness of remote care delivery on outcomes of relevance to people living with osteoporosis.

Personal digital health hubs for multiple conditions

Multimorbidity is the presence of more than one chronic disease condition in an individual. Health-related, socioeconomic, cultural and environmental factors, as well as patient behaviour, all influence the outcomes of multimorbidity. Addressing these complex and often interacting biopsychosocial factors therefore requires a shift in treatment from a physical damage model towards person-centred integrated care with increased patient agency. Education influences behaviour and can be used to empower patients and their carers with greater agency, thus allowing greater responsibility for and control over the management of patient care. In this paper we reflect on our own learning as a community of health practitioners from different disciplines. Recognizing the increasing importance of patient agency in driving the evolution of health care, we describe the concept of a web-based personal digital health hub for integrated patient care. Informed by collaboration between patient, health and education communities, we share our early experience in the implementation of a health hub around a cohort of patients with hip fractures. We also describe a vision for future health care based on the co-creation of digital health hubs centred on patients' and carers' needs. The health hub could allow important advances and efficiencies to be achieved in workforce practice and education; patient and carer engagement in self-care; and the collection of patient-reported health data required for ongoing research and improvements in health care.

Digital Self-Management Interventions for People With Osteoarthritis: Systematic Review With Meta-Analysis

BACKGROUND

Osteoarthritis (OA) is not curable, but the symptoms can be managed through self-management programs (SMPs). Owing to the growing burden of OA on the health system and the need to ensure high-quality integrated services, delivering SMPs through digital technologies could be an economic and effective community-based approach.

OBJECTIVE

This study aims to analyze the effectiveness of digital-based structured SMPs on patient outcomes in people with OA.

METHODS

A total of 7 web-based and 3 gray literature databases were searched for randomized controlled trials assessing digital-based structured SMPs on self-reported outcomes including pain, physical function, disability, and health-related quality of life (QoL) in people with OA. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk of bias sensitivity analysis, and subgroup analysis were performed where appropriate. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence.

RESULTS

A total of 8 studies were included in this review involving 2687 patients with knee (n=2); knee, hip, or both (n=5); and unspecified joint (n=1) OA. SMPs were delivered via telephone plus audio and video, internet, or mobile apps. Studies reported that digital-based structured SMPs compared with the treatment as usual control group (n=7) resulted in a significant, homogeneous, medium reduction in pain and improvement in physical function (standardized mean difference [SMD] -0.28, 95% CI -0.38 to -0.18 and SMD -0.26, 95% CI -0.35 to -0.16, respectively) at posttreatment. The digital-based structured SMP effect on pain and function reduced slightly at the 12-month follow-up but remained to be medium and significant. The posttreatment effect of digital-based structured SMPs was small and significant for disability, but nonsignificant for QoL (SMD -0.10, 95% CI -0.17 to 0.03 and SMD -0.17, 95% CI -0.47 to 0.14, respectively; each reported in 1 study only). The 12-month follow-up effect of the intervention was very small for disability and QoL. The quality of evidence was rated as moderate for pain and physical function and low and very low for disability and QoL, respectively, using the GRADE approach.

CONCLUSIONS

Digital-based structured SMPs may result in improvement in pain and physical function that is largely sustained at the 12-month follow-up in people with knee and hip OA. The effects on disability and QoL are smaller and less clear. The quality of evidence is moderate to low, and further research is required to confirm the findings of the review and assess the effects of digital-based structured SMPs on other health-related outcomes.

[Implementation of a new referral model for the musculoskeletal care pathway: Does it improve healthcare outcomes?]

OBJECTIVE

To evaluate the impact of an organisational change in the musculoskeletal referral pathway in our health management area (HMA) by identifying changes in the ability to improve healthcare outcomes by facilitating referral to the most suitable specialty.

DESIGN

This prospective descriptive study aimed to evaluate referral trends from primary care services (PCS) and hospital care (PHS) to musculoskeletal services from 2012 to 2018.

MATERIALS AND METHODS

We included all patients who were referred to any of the 3 musculoskeletal services from our HMA catchment area, without specifying sample size. The variables studied were PCS, PHS, service of origin and destination. We used the SPSS programme for the statistical analysis and obtained absolute frequency data.

RESULTS

The total number of referrals from PCS increased from 25,575 in 2012 to 24,871 in 2018. PHS referrals decreased from 17,207 in 2012 to 9,803 in 2018. With regards to PCS referrals, the service most increasing the number of referrals to the musculoskeletal team was the Rehabilitation Service, from 8.2% in 2012 to 47% in 2018. Regarding PHSs referrals by specialty, the service that most reduced the number of referrals to the musculoskeletal team was the Traumatology Service, from 10,587 in 2012 to 3,911 in 2018.

CONCLUSIONS

The redesign of the musculoskeletal referral pathway improved healthcare outcomes by improving the quality of the referral process. In this organisational change, the Rehabilitation Service took the leadership from the point of view of healthcare and management of the musculoskeletal process, collaborating in the improvement of the healthcare outcomes of these processes.

Evaluation of Digital Technologies Tailored to Support Young People's Self-Management of Musculoskeletal Pain: Mixed Methods Study

BACKGROUND

Digital technologies connect young people with health services and resources that support their self-care. The lack of accessible, reliable digital resources tailored to young people with persistent musculoskeletal pain is a significant gap in the health services in Australia. Recognizing the intense resourcing required to develop and implement effective electronic health (eHealth) interventions, the adaptation of extant, proven digital technologies may improve access to pain care with cost and time efficiencies.

OBJECTIVE

This study aimed to test the acceptability and need for adaptation of extant digital technologies, the painHEALTH website and the iCanCope with Pain app, for use by young Australians with musculoskeletal pain.

METHODS

A 3-phased, mixed methods evaluation was undertaken from May 2019 to August 2019 in Australia. Young people aged 15 to 25 years with musculoskeletal pain for >3 months were recruited. Phases were sequential: (1) phase 1, participant testing (3 groups, each of n=5) of co-designed website prototypes compared with a control website (painHEALTH), with user tasks mapped to eHealth quality and engagement criteria; (2) phase 2, participants' week-long use of the iCanCope with Pain app with engagement data captured using a real-time analytic platform (daily check-ins for pain, interference, sleep, mood, physical activity, and energy levels; goal setting; and accessing resources); and (3) phase 3, semistructured interviews were conducted to gain insights into participants' experiences of using these digital technologies.

RESULTS

Fifteen young people (12/15, 80% female; mean age 20.5 [SD 3.3] years; range 15-25 years) participated in all 3 phases. The phase 1 aggregated group data informed the recommendations used to guide 3 rapid cycles of prototype iteration. Adaptations included optimizing navigation, improving usability (functionality), and enhancing content to promote user engagement and acceptability. In phase 2, all participants checked in, with the highest frequency of full check-ins attributed to pain intensity (183/183, 100.0%), pain interference (175/183, 95.6%), and mood (152/183, 83.1%), respectively. Individual variability was evident for monitoring progress with the highest frequency of history views for pain intensity (51/183, 32.3%), followed by pain interference (24/183, 15.2%). For the goals set feature, 87% (13/15) of participants set a total of 42 goals covering 5 areas, most frequently for activity (35/42, 83%). For phase 3, metasynthesis of qualitative data highlighted that these digital tools were perceived as youth-focused and acceptable. A total of 4 metathemes emerged: (1) importance of user-centered design to leverage user engagement; (2) website design (features) promoting user acceptability and engagement; (3) app functionality supporting self-management; and (4) the role of wider promotion, health professional digital prescriptions, and strategies to ensure longer-term engagement.

CONCLUSIONS

Leveraging extant digital tools, with appropriate user-informed adaptations, can help to build capacity tailored to support young people's self-management of musculoskeletal pain.

"Mobile Health" for the Management of Spondyloarthritis and Its Application in China

PURPOSE OF THE REVIEW

Spondyloarthritis (SpA) is a group of inflammatory diseases characterized by inflammation in the spine, peripheral joints, and entheses that usually start at the prime of one's life and lead to impaired physical function and reduced quality of life. Ankylosing spondylitis (AS) is prototype of SpA. This article reviews the opportunities and challenges of using mobile health (mHealth) in managing SpA, and report some of our experiences using a mHealth solution for management of SpA patients and performing related research in China.

RECENT FINDINGS

The recent rapid development of mobile communications and the common use of intelligent electronic devices have led to the increasing application of mHealth for chronic disease management by healthcare providers and patients alike. This is a promising new technology that can help mitigate limitations in time and space for patient management, promote easier communication between patients and their healthcare providers, reduce medical expenses, and optimize medical services. We have developed a smartphone-based mHealth SpA management system (SpAMS) that also helps the patients to monitor, manage, and share information on their disease with their physician at regular intervals. There is a shift from a paternalistic model of healthcare to more personalized healthcare in which disease management is conducted by the patient together with their healthcare providers. The increasing utility of mHealth is expected to benefit disease management, promote patient-doctor communication, reduce medical expenses, and optimize medical services.

Electronic Health Self-Management Interventions for Patients With Chronic Kidney Disease: Systematic Review of Quantitative and Qualitative Evidence

BACKGROUND

Chronic kidney disease (CKD) poses a major challenge to public health. In CKD patients, adequate disease self-management has been shown to improve both proximal and distal outcomes. Currently, electronic health (eHealth) interventions are increasingly used to optimize patients' self-management skills.

OBJECTIVE

This study aimed to systematically review the existing evidence regarding the implementation and effectiveness of eHealth self-management interventions for patients with CKD.

METHODS

Following a search in 8 databases (up to November 2017), quantitative and qualitative data on process and effect outcomes were extracted from relevant studies. Quality was appraised using the Crowe Critical Appraisal Tool; narrative synthesis was performed to analyze the data extracted.

RESULTS

Of the 3307 articles retrieved, 24 (comprising 23 studies) were included in this review; of these, almost half were appraised to be of low to moderate quality. There was considerable heterogeneity in the types of interventions used and the outcomes measured. A total of 10 effect and 9 process outcome indicators were identified. The most frequently reported effect outcome indicators were specific laboratory tests and blood pressure (BP), whereas satisfaction was the most frequently reported process outcome indicator. Positive effects were found for proximal outcomes (eg, BP control and medication adherence), and mixed effects were found for more distal outcomes (eg, quality of life). High feasibility, usability, and acceptability of and satisfaction with eHealth self-management interventions were reported. The determinant ability of health care professionals to monitor and, if necessary, anticipate on patient measurements online was mostly cited to influence patients' adherence to interventions.

CONCLUSIONS

eHealth self-management interventions have the potential to improve disease management and health outcomes. To broaden the evidence base and facilitate intervention upscaling, more detailed descriptions and thorough analysis of the intervention components used are required. In addition, our review reveals that outcomes closely related to the scope and duration of the intervention implemented are most likely to be impacted. For instance, if a 4-week Web-based training to optimize disease management skills is implemented, the outcome perceived control would more likely be affected than kidney function. Although this seems obvious, most studies evaluate only distal outcomes and thereby fail to capture intervention effects that might contribute to long-term health improvement. We advise future researchers to carefully consider their choice of outcomes based on their sensitivity for change. In this way, we ensure that relevant effects are captured and legitimate conclusions are drawn.

Do pain management websites foster self-management support for people with persistent pain? A scoping review

OBJECTIVES

To evaluate if the contents of pain management websites include the current best practice self-management support strategies for people with persistent pain, are cultural tailored and to determine the website quality.

METHODS

Websites were searched from three major search engines (Google, Bing, and Yahoo). Websites providing information on self-management strategies and websites that were freely available to the public were included. The website contents were evaluated using a 14-item self-management support (SMS-14) checklist. Website quality was assessed using the Health On the Net code (HONcode) certification.

RESULTS

Of the twenty-seven websites evaluated, the websites scored a median of nine items (range 1-13) from the SMS-14 checklist. The websites LivePlanBe, ACI Pain Management Network and MyJointPain top-scored (13/14) from the SMS-14 checklist. One website (ACI Pain Management Network) provided culturally tailored information and HONcode certification was present in six websites.

CONCLUSIONS

The review identified 27 contemporary pain management websites that could be used for self-management skills training.

PRACTICE IMPLICATIONS

Clinicians could refer people with persistent pain to top ranked websites - LivePlanBe, ACI Pain Management Network, and MyJointPain for enabling self-management skills, with the caveats that most websites lacked cultural tailoring, and have limited or no evidence of clinical efficacy.

Current practices of health care providers in recommending online resources for chronic pain self-management

Purpose

Online health resources (websites, apps and social media) may be an adjunct to provide self-management support for people with persistent or chronic pain. Endorsement of online health resources by health care providers is crucial for uptake by end-users. The aim of this study was to investigate the current practices of New Zealand (NZ) health care providers in recommending online resources for persistent pain management, and to identify what factors predict health care providers’ recommendations and to explore the common concerns.

Methods

An online survey of NZ health care providers (ie, chiropractors, general practitioners, nurses, occupational therapists, osteopaths, physiotherapists, psychologists, specialist consultants, and social workers) involved in the management of persistent pain was conducted. The recruitment strategy was tailored to each occupation via occupation-specific professional organizations, and by approaching multidisciplinary professional organizations.

Results

Data from 213 health care providers were used in the final analysis. Most of the health care providers were physiotherapists (n=71), followed by chiropractors (n=39) and general practitioners (n=31). Fifty three percent (111/210) of health care providers reported currently recommending online resources. A multivariate logistic regression model showed that specialist interest in treating pain (OR=3.84; 95% CI: 1.66, 8.87; P=0.002), and level of confidence in recommending online resources (OR=1.05; CI: 1.04, 1.07; P<0.001), positively influenced recommending online resources. The majority of the health care providers (65%, 138/213) were concerned about the safety issues related to the risk of patients misinterpreting online information and to the lack of evidence-based information.

Conclusion

Half of the health care providers surveyed reported recommending online resources, which may suggest limited confidence in recommending, or knowledge of, existing online resources for persistent pain management. Ongoing education for health care providers on evidence-based online resources is required to recommend online resources as a self-management support tool for people with persistent pain.

The Pain Course: Exploring the Feasibility of an Internet-delivered Pain Management Program When Offered by a Tertiary Pain Management Service

BACKGROUND

This study examined the acceptability and preliminary outcomes of an internet-delivered pain management program, the Pain Course, when offered by a specialist pain management clinic in a large public hospital.

METHODS

A single-group feasibility open-trial design was used and 39 patients participated in the program, which ran for 8 weeks. Participants were supported through the program with weekly contact from a Clinical Psychologist at the clinic.

RESULTS

All participants provided data at posttreatment and >90% of participants completed all 5 lessons of the course. High levels of satisfaction were observed and relatively little clinician time (M=71.99 min/participant; SD=32.82 min) was required to support patients through the program. Preliminary evidence of clinical improvements in depression symptoms (avg. improvement=38%; Cohen d=0.74), but not disability levels or anxiety symptoms, was observed in the overall sample. However, evidence of improvements was observed across all the primary outcomes among patients who had clinical levels of difficulties with disability (n=20; avg. improvement=11%; Cohen d=0.64), depression (n=17; avg. improvement=35%; Cohen d=1.24) and anxiety (n=8; avg. improvement=29%; Cohen d=0.57).

CONCLUSIONS

These findings highlight the potential value of internet-delivered programs when provided by specialist pain management clinics as a part of their services and the value of larger scale studies in this area.

Improvement of Disease Management and Cost Effectiveness in Chinese Patients with Ankylosing Spondylitis Using a Smart-Phone Management System: A Prospective Cohort Study

Objectives

Ankylosing spondylitis (AS) is a chronic disease that decreases mobility, function, and quality of life. This study introduced the "Smart-phone SpondyloArthritis Management System" (SpAMS), an interactive mobile health (mHealth) tool designed for AS/spondyloarthritis (SpA) disease management and used SpAMS data to evaluate clinical characteristics of Chinese patients with AS.

Methods

SpAMS integrates patient's and physician's portals in a smart phone application. The Chinese Ankylosing Spondylitis Prospective Imaging Cohort was launched using SpAMS in April 2016. Patient self-assessments were completed online at baseline and at every subsequent clinic visit. Physician-reported assessments and treatments were recorded by rheumatologists during each visit.

Results

In total, 1201 patients with AS [mean (SD) age, 30.6 (8.7) years; male, 82.6%] were recruited. Mean (SD) disease duration was 8.4 (6.1) years. Past or current symptoms of acute anterior uveitis (AAU), psoriasis, and inflammatory bowel disease (IBD) were observed in 21.0%, 3.7%, and 9.4% of patients, respectively. AAU and IBD occurred significantly more in patients with symptom duration > 10 years. The most commonly used medications at baseline were nonsteroidal anti-inflammatory drugs (98.2%). Patients using tumour necrosis factor inhibitors accounted for 20.8%, and 66.4% of patients used conventional synthetic disease-modifying antirheumatic drugs. At baseline, 57.2% of patients had inactive disease (ID)/low disease activity (LDA); this rate significantly improved to 79.2% after a mean follow-up of 13.3 (5.9) months. Compared with relapsed patients, new achievers of ID/LDA underwent more online patient assessments (P < .001). Problems solved in SpAMS caused 29.1% of clinic visits to a tertiary hospital unnecessary. SpAMS saved an average of 5.3 hours and 327.4 RMB per person on traffic expenses; these expenses equalled 16% of the Chinese monthly disposable personal income.

Conclusions

SpAMS is a time- and cost-saving disease management tool that can help patients with AS perform self-management and provide valuable data to clinicians.

Evaluation of Self-Management Support Functions in Apps for People With Persistent Pain: Systematic Review

Background

Smartphone apps are a potential mechanism for development of self-management skills in people with persistent pain. However, the inclusion of best-practice content items in available pain management apps fostering core self-management skills for self-management support is not known.

Objective

The aim of the study was to evaluate the contents of smartphone apps providing information on pain management strategies for people with persistent pain facilitating self-management support and to appraise the app quality.

Methods

A systematic search was performed in the New Zealand App Store and Google Play Store. Apps were included if they were designed for people with persistent pain, provided information on pain self-management strategies, and were available in English. App contents were evaluated using an a priori 14-item self-management support (SMS-14) checklist. App quality was assessed using the 23-item Mobile Apps Rating Scale.

Results

Of the 939 apps screened, 19 apps met the inclusion criteria. Meditation and guided relaxation were the most frequently included self-management strategies. Overall, the included apps met a median of 4 (range 1-8) of the SMS-14 checklist. A total of 3 apps (Curable, PainScale-Pain Diary and Coach, and SuperBetter) met the largest number of items (8 out of 14) to foster self-management of pain. Self-monitoring of symptoms (n=11) and self-tailoring of strategies (n=9) were frequently featured functions, whereas a few apps had features facilitating social support and enabling communicating with clinicians. No apps provided information tailored to the cultural needs of the user. The app quality mean scores using Mobile Apps Rating Scale ranged from 2.7 to 4.5 (out of 5.0). Although use of 2 apps (Headspace and SuperBetter) has been shown to improve health outcomes, none of the included apps have been evaluated in people with persistent pain.

Conclusions

Of the 3 apps (Curable, PainScale-Pain Diary and Coach, and SuperBetter) that met the largest number of items to support skills in self-management of pain, 2 apps (PainScale-Pain Diary and Coach and SuperBetter) were free, suggesting the potential for using apps as a scalable, wide-reaching intervention to complement face-to-face care. However, none provided culturally tailored information. Although 2 apps (Headspace and SuperBetter) were validated to show improved health outcomes, none were tested in people with persistent pain. Both users and clinicians should be aware of such limitations and make informed choices in using or recommending apps as a self-management tool. For better integration of apps in clinical practice, concerted efforts are required among app developers, clinicians, and people with persistent pain in developing apps and evaluating for clinical efficacy.

Qualitative study to elicit patients' and primary care physicians' perspectives on the use of a self-management mobile health application for knee osteoarthritis

OBJECTIVE

To elicit perspectives of family physicians and patients with knee osteoarthritis (KOA) on KOA, its treatment/management and the use of a mobile health application (app) to help patients self-manage their KOA.

DESIGN

A qualitative study using Cognitive Task Analysis for physician interviews and peer-to-peer semistructured interviews for patients according to the Patient and Community Engagement Research (PaCER) method.

SETTING

Primary care practices and patient researchers at an academic centre in Southern Alberta.

PARTICIPANTS

Intentional sampling of family physicians (n=4; 75% women) and patients with KOA who had taken part in previous PaCER studies and had experienced knee pain on most days of the month at any time in the past (n=5; 60% women).

RESULTS

Physician and patient views about KOA were starkly contrasting. Patient participants expressed that KOA seriously impacted their lives and lifestyles, and they wanted their knee pain to be considered as important as other health problems. In contrast, physicians uniformly conceptualised KOA as a relatively minor health problem, although they still recognised it as a painful condition that often limits patients' activities. Consequently, physicians did not regard KOA as a condition to be proactively and aggressively managed. The gap between physicians' and patients' conceptualisation of KOA and its treatment extended to the use of an app for self-management. While patients were supportive of the app, physicians were sceptical of its use and focused more on accountability and patient resources.

CONCLUSIONS

The clear discord between physicians' mental models and patients' lived experience and perceived needs around KOA emphasised a gap in understanding and communication about treatment and management of KOA. As such, this preliminary and formative research will inform a codesign approach to develop an app that will act as a communications tool between patients and physicians, enabling patient-physician discussions regarding modifiable self-management options based on a patient's perspectives and needs.

The Pain Course: 12- and 24-Month Outcomes From a Randomized Controlled Trial of an Internet-Delivered Pain Management Program Provided With Different Levels of Clinician Support

Little is known about the long-term outcomes of emerging Internet-delivered pain management programs. The current study reports the 12- and 24-month follow-up data from a randomized controlled trial (n = 490) of an Internet-delivered pain management program, the Pain Course. The initial results of the trial to the 3-month follow-up have been reported elsewhere. There were significant improvements in disability, depression, anxiety, and pain levels across 3 treatment groups receiving different levels of clinician support compared with a treatment as the usual control. No marked or significant differences were found between the treatment groups either after treatment or at the 3-month follow-up. The current study obtained long-term follow-up data from 78% and 79% of participants (n = 397) at the 12-month and 24-month follow-up marks, respectively. Clinically significant decreases (average percent reduction; Cohen's d effect sizes) were maintained at the 12- and 24-month follow-ups for disability (average reduction ≥27%; d ≥ .67), depression (average reduction ≥36%; d ≥ .80), anxiety (average reduction ≥38%; d ≥ .66), and average pain levels (average reduction ≥21%; d ≥ .67). No marked or consistent differences were found among the 3 treatment groups. These findings suggest that the outcomes of Internet-delivered programs may be maintained over the long term. PERSPECTIVE: This article presents the long-term outcome data of an established Internet-delivered pain management program for adults with chronic pain. The clinical improvements observed during the program were found to be maintained at the 12- and 24-month follow-up marks. This finding indicates that these programs can have lasting clinical effects.