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Hohenschurz-Schmidt D, Cherkin D, Rice ASC, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Evans SR, Farrar JT, Kerns RD, Rowbotham MC, Wasan AD, Cowan P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Methods for pragmatic randomized clinical trials of pain therapies: IMMPACT statement. Pain 2024; 165:2165-2183. [PMID: 38723171 PMCID: PMC11404339 DOI: 10.1097/j.pain.0000000000003249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 03/08/2024] [Indexed: 09/18/2024]
Abstract
ABSTRACT Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, United Kingdom
- Research Department, University College of Osteopathy, London, United Kingdom
| | - Dan Cherkin
- Osher Center for Integrative Health, Department of Family Medicine, University of Washington, Seattle, WA, United States
| | - Andrew S C Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, United Kingdom
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - Scott R Evans
- Biostatistics Center and the Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD, United States
| | - John T Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D Kerns
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Michael C Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo, NY, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | - Barbara I Karp
- National Institutes of Health, Bethesda, MD, United States
| | - Bethea A Kleykamp
- University of Maryland, School of Medicine, Baltimore, MD, United States
| | - John D Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States
| | - Kushang V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | | | - Jan Vollert
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
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Hyde AM, Johnson E, Luig T, Schroeder D, Carbonneau M, Campbell-Scherer D, Tandon P. Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation. BMC Health Serv Res 2023; 23:636. [PMID: 37316822 DOI: 10.1186/s12913-023-09632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Standardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers' perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada. METHODS We utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups. RESULTS Key findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation. CONCLUSIONS Implementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.
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Affiliation(s)
- A M Hyde
- Division of Gastroenterology (Liver Unit), Faculty of Medicine & Dentistry, University of Alberta, 8540 112 St NW, Edmonton, AB, T6G 2P8, Canada
| | - E Johnson
- Division of Gastroenterology (Liver Unit), Faculty of Medicine & Dentistry, University of Alberta, 8540 112 St NW, Edmonton, AB, T6G 2P8, Canada
| | - T Luig
- Physician Learning Program, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - D Schroeder
- Physician Learning Program, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | | | - D Campbell-Scherer
- Physician Learning Program, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada.
- Department of Family Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada.
- Office of Lifelong Learning and Physician Learning Program, Edmonton Clinic Health Academy (ECHA), 2-590, Edmonton, AB, T6G 1C9, Canada.
| | - P Tandon
- Division of Gastroenterology (Liver Unit), Faculty of Medicine & Dentistry, University of Alberta, 8540 112 St NW, Edmonton, AB, T6G 2P8, Canada.
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Espin-Garcia O, Baghel M, Brar N, Whittaker JL, Ali SA. Can genetics guide exercise prescriptions in osteoarthritis? FRONTIERS IN REHABILITATION SCIENCES 2022; 3:930421. [PMID: 36188938 PMCID: PMC9397982 DOI: 10.3389/fresc.2022.930421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022]
Abstract
Osteoarthritis (OA) is the most common form of arthritis and has a multifactorial etiology. Current management for OA focuses on minimizing pain and functional loss, typically involving pharmacological, physical, psychosocial, and mind-body interventions. However, there remain challenges in determining which patients will benefit most from which interventions. Although exercise-based interventions are recommended as first-line treatments and are known to be beneficial for managing both the disease and illness of OA, the optimal exercise “prescription” is unknown, due in part to our limited understanding of the precise mechanisms underlying its action. Here we present our perspective on the potential role of genetics in guiding exercise prescription for persons with OA. We describe key publications in the areas of exercise and OA, genetics and OA, and exercise and genetics, and point to a paucity of knowledge at the intersection of exercise, genetics, and OA. We suggest there is emerging evidence to support the use of genetics and epigenetics to explain the beneficial effects of exercise for OA. We identify missing links in the existing research relating to exercise, genetics, and OA, and highlight epigenetics as a promising mechanism through which environmental exposures such as exercise may impact OA outcomes. We anticipate future studies will improve our understanding of how genetic and epigenetic factors mediate exercise-based interventions to support implementation and ultimately improve OA patient care.
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Affiliation(s)
- Osvaldo Espin-Garcia
- Department of Biostatistics, Princess Margaret Cancer Centre and Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Division of Biostatistics, Dalla Lana School of Public Health and Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
- *Correspondence: Osvaldo Espin-Garcia
| | - Madhu Baghel
- Bone and Joint Center, Department of Orthopaedic Surgery, Henry Ford Health, Detroit, MI, United States
| | - Navraj Brar
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Jackie L. Whittaker
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
| | - Shabana Amanda Ali
- Bone and Joint Center, Department of Orthopaedic Surgery, Henry Ford Health, Detroit, MI, United States
- Center for Molecular Medicine and Genetics, School of Medicine, Wayne State University, Detroit, MI, United States
- Department of Physiology, College of Human Medicine, Michigan State University, East Lansing, MI, United States
- Shabana Amanda Ali
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Ali SA, Walsh KE, Kloseck M. Patient perspectives on improving osteoarthritis management in urban and rural communities. J Pain Res 2018; 11:417-425. [PMID: 29503578 PMCID: PMC5826243 DOI: 10.2147/jpr.s150578] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Although there is no cure for osteoarthritis (OA), there are lifestyle modifications that can mitigate symptoms such as pain, and improve management of the disease. This information is not always translated to community-dwelling seniors. Individuals in rural areas often face additional challenges due to geographic isolation and decreased access to community services. Methods We used qualitative research methodology (hermeneutic phenomenology) to better understand the lived experiences of urban and rural community-dwelling seniors diagnosed with OA. We explored their sources of information about OA, how they manage their OA pain, and how OA management could be improved in the community. Purposeful sampling was used to recruit 20 information-rich participants (11 urban, 9 rural) in Ontario, Canada. All participants were aged >65 and diagnosed with OA. Semi-structured interviews were conducted, audio recorded, and transcribed verbatim. NVivo 11 Pro qualitative software was used to code transcripts. Results Thematic analysis revealed 9 key themes where 8 were common to urban and rural participants, and 1 was unique to rural participants. Most significant among the common themes was the description of the social network as a source of OA information, the trial-and-error approach used for OA management, and the individual contextualization of OA management. Our results suggest that there are several common experiences among urban- and rural-dwelling seniors living with OA, including the desire for support over time, but also a unique experience to rural-dwelling seniors, namely lack of access to local care. Conclusion These findings can be used to improve translation of OA information in both urban and rural communities in Canada, highlighting that common strategies may be effective in different contexts for this disease.
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Affiliation(s)
| | | | - Marita Kloseck
- Faculty of Health Sciences, University of Western Ontario, London, ON
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