1
|
Ponce H, Lentz TA, Bozic K, Jayakumar P. Value-based Healthcare: The Value of Multiskilled Clinicians in Delivering Whole-person Musculoskeletal Care. Clin Orthop Relat Res 2024; 482:1304-1306. [PMID: 39105383 DOI: 10.1097/corr.0000000000003152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/21/2024] [Indexed: 08/07/2024]
Affiliation(s)
- Haley Ponce
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Institute for Health Policy, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kevin Bozic
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Institute for Health Policy, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham NC, USA
| |
Collapse
|
2
|
Jayakumar P, Crijns TJ, Misciagna W, Manickas-Hill O, Malay M, Jiranek W, Mather RC, Lentz TA. What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis? Clin Orthop Relat Res 2024; 482:633-644. [PMID: 38393957 PMCID: PMC10937005 DOI: 10.1097/corr.0000000000003003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 01/11/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care. QUESTIONS/PURPOSES (1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors? METHODS We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores. RESULTS Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated. CONCLUSION This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions. LEVEL OF EVIDENCE Level III, prognostic study.
Collapse
Affiliation(s)
- Prakash Jayakumar
- The Musculoskeletal Institute, The University of Texas at Austin, Dell Medical School, Austin, TX, USA
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Tom J. Crijns
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Will Misciagna
- The Musculoskeletal Institute, The University of Texas at Austin, Dell Medical School, Austin, TX, USA
| | - Olivia Manickas-Hill
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Morven Malay
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Department of Physical Therapy and Occupational Therapy, Duke University, Durham, NC, USA
| | - William Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Richard C. Mather
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Trevor A. Lentz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| |
Collapse
|
3
|
Lentz TA, Coffman CJ, Cope T, Stearns Z, Simon CB, Choate A, Gladney M, France C, Hastings SN, George SZ. If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain. Phys Ther 2024; 104:pzad127. [PMID: 37756618 PMCID: PMC10851867 DOI: 10.1093/ptj/pzad127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/10/2023] [Accepted: 07/09/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. METHODS Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. RESULTS Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. CONCLUSION In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. IMPACT These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.
Collapse
Affiliation(s)
- Trevor A Lentz
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Tyler Cope
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Zachary Stearns
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Corey B Simon
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Micaela Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Courtni France
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven Z George
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
4
|
Sullivan MB, Hill K, Ballengee LA, Knoblach D, Fowler C, Haun J, Saenger M. Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231209751. [PMID: 37901847 PMCID: PMC10605678 DOI: 10.1177/27536130231209751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/17/2023] [Accepted: 10/04/2023] [Indexed: 10/31/2023]
Abstract
Background While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020. Objective This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program. Methods Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming. Discussion/Results Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement. Conclusion TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.
Collapse
Affiliation(s)
- Marlysa B. Sullivan
- TelePain-EVP National Program Coordinator EVP Mindful Movement, Atlanta VA Health Care System (AVAHCS), Atlanta, GA, USA
| | - Kelsea Hill
- TelePain-EVP Mindful Movement, Veterans Administration Maryland Health Care System (VAMHCS), Baltimore, MD, USA
| | - Lindsay A. Ballengee
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Daniel Knoblach
- Veterans Administration Maryland Health Care System (VAMHCS), Baltimore, MD, USA
| | - Christopher Fowler
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, USA
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Jolie Haun
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael Saenger
- Creator of Empower Veterans Program and National Director of TelePain-EVP, Atlanta VA Health Care System (AVAHCS), Atlanta, GA, USA
- School of Medicine, Emory University, Atlanta, GA, USA
| |
Collapse
|