Perceptions of Provider Communication and Patient Satisfaction for Treatment of Acute Low Back Pain

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain

Background

Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.

Methods

This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.

Results

We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.

Conclusions

We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021.

Trial registration

ClinicalTrials.gov NCT03254719

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01008-0.

Comparing disability and return to work outcomes between alternative and traditional workers' compensation programs

BACKGROUND

The Union Construction Workers' Compensation Program (UCWCP) was developed in 1996 as an alternative workers' compensation arrangement. The program includes use of a preapproved medical and rehabilitation network and alternative dispute resolution (ADR), and prioritizes a quick and safe return-to-work. The aim of this study is to determine if differences in recovery-related outcomes exist between UCWCP and the statutory workers' compensation system (SWCS).

METHODS

Claims data from 2003 to 2016 were classified as processed through UCWCP or SWCS. Outcomes included: temporary total disability (TTD), vocational rehabilitation (VR), claim duration and costs, and permanent partial disability (PPD). The relative risk of incurring TTD, VR, and PPD in UCWCP vs SWCS was calculated using log-binomial regression. Linear regression examined the relationship between programs and continuous outcomes including costs and duration. Estimates were adjusted for age, sex, wage, and severity.

RESULTS

The UCWCP processed 15.8% of claims; higher percentages of UCWCP claimants were older and earned higher wages. Results point to positive findings of decreased TTD incidence and cost, lower risk of TTD extending over time, higher likelihood of VR participation, and less attorney involvement and stipulation agreements associated with UCWCP membership. Differences were more apparent in workers who suffered permanent physical impairment.

CONCLUSION

Findings suggest that the defining programmatic elements of the UCWCP, including its medical provider and rehabilitation network and access to ADR, have been successful in their aims. Claims with increased severity exhibited more pronounced differences vs SWCS, potentially due, in part, to greater use of programmatic elements.

People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review

QUESTION

What health information needs are perceived by people with low back pain?

DESIGN

Systematic review of publications examining perceived health information needs related to low back pain identified through Medline, EMBASE, CINAHL and PsycINFO (1990 to 2018).

PARTICIPANTS

Adults with low back pain of any duration.

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted descriptive data regarding study design and methodology, and assessed risk of bias. Aggregated findings of the perceived needs of people with low back pain regarding health information were meta-synthesised.

RESULTS

Forty-one studies (34 qualitative, four quantitative and three mixed-methods) were identified. Two major areas of perceived health information needs for low back pain emerged. The first major area was needs related to information content: general information related to low back pain, its cause and underlying pathology; strong desire for diagnosis and imaging; prognosis, future disability and effect on work capacity; precipitants and management of flares; general management approaches; self-management strategies; prevention; and support services. The second major area of needs related to how the information was delivered. People with low back pain wanted clear, consistent information delivered in suitable tone and understandable language.

CONCLUSION

Available data suggest that the information needs of people with low back pain are centred around their desire for a diagnosis, potentially contributing to expectations for and overuse of imaging. People with low back pain expressed a strong desire for clear, consistent and personalised information on prognosis, treatment options and self-management strategies, related to healthcare and occupational issues. To correct unhelpful beliefs and optimise delivery of evidence-based therapy, patient and healthcare professional education (potentially by an integrated public health approach) may be warranted.

Patient Satisfaction Measurement in Occupational and Environmental Medicine Practice

: High patient satisfaction is a desirable goal in medical care. Patient satisfaction measures are increasingly used to evaluate and improve quality in all types of medical practices. However, the unique aspects of occupational and environmental medicine (OEM) practice require development of OEM-specific measures and thoughtful interpretation of results. The American College of Occupational and Environmental Medicine has developed and recommends a set of specific questions to measure patient satisfaction in OEM, designed to meet anticipated regulatory requirements, facilitate quality improvement of participating OEM practices, facilitate case-management review, and offer fair and accurate assessment of OEM physicians.

Patients' perceived needs of health care providers for low back pain management: a systematic scoping review

BACKGROUND CONTEXT

Optimal management of low back pain (LBP) involves patients' active participation in care, facilitated by positive interactions with their health care provider(s) (HCP). An understanding of patients' perceived needs regarding their HCP is, therefore, necessary to achieve such outcomes. Therefore, the aim of the present study is to review the existing literature regarding patients' perceived needs of HCP managing LBP.

METHODS

A systematic scoping review of publications in MEDLINE, EMBASE, CINAHL, and PsycINFO (1990-2016) was performed. Descriptive data regarding study design and methodology were extracted, and risk of bias was assessed. Aggregates of patients' perceived needs of HCP for LBP were categorized.

RESULTS

Forty-three studies (30 qualitative, 12 quantitative, and 1 mixed methods) from 1,829 were relevant. Four areas of perceived need emerged: (1) there are several characteristics of HCP that patients desire, such as good communication and shared decision-making; (2) patients wanted HCP to provide information, including a cause of their LBP and legitimization of their symptoms; (3) patients' valued holistic, individualized care, and continuity of care; and (4) patients perceived long waiting times, difficulties with access to treatment, cost, and personal effort to be obstacles to care.

CONCLUSIONS

Patients with LBP want patient-centered care, to be actively involved, and they have identified characteristics of HCP that foster a good provider-patient relationship. They noted areas of dissatisfaction with HCP and perceived obstacles to care. Given limited health care resources, HCP and policy makers need to implement novel methods of health care delivery that address these issues to facilitate improved patient satisfaction and achieve better patient and health system outcomes.

Insurance workers' and physiotherapists' perceptions of their roles in the management of workers with injuries in the Western Australian workers' compensation system

BACKGROUND

Insurance workers and physiotherapists are important stakeholders in the rehabilitation of workers with an injury and subsequent musculoskeletal pain. Understanding perceptions of roles may facilitate communication between these stakeholders.

OBJECTIVE

Increase knowledge around, (i) the self-perception of and (ii) the external perception of the insurance workers and physiotherapists roles in the management of a worker with an injury in an Australian workers' compensation environment.

METHODS

A cross-sectional study assessed the perceptions of insurance workers and physiotherapists related to the roles of these two professions in managing a worker with an injury via questionnaire. Respondents were also asked about potential communication barriers.

RESULTS

Insurance workers (n = 48) and physiotherapists (n = 80) reported contrasting role perceptions, with their perception of the other profession leaning towards negative attributes. There was greater alignment of their beliefs of roles in the 'ideal' situation. The perception of barriers to communication also differed between the two professions. Effective and efficient communication was identified as a central component of mismatched role perceptions between stakeholders, but recognised as a critical attribute of 'ideal' stakeholder roles.

CONCLUSION

Insurance workers and physiotherapists self-perception of their roles differs from external perceptions. This information highlights the importance of a shared understanding of stakeholder roles in the management of a worker with an injury.

Beyond Race and Gender: Measuring Behavioral and Social Indicators of Pain Treatment Satisfaction in Older Black and White Cancer Patients

There are a number of factors that influence compliance with prescribed plans of care. However, there remains a need to identify the collective source health, behavioral, and social constructs have on treatment satisfaction. This study aimed to identify indicators of pain treatment satisfaction among older adults receiving outpatient treatment from a comprehensive cancer center in the southeast region of the United States. Data included a sample of 149 Black and White patients diagnosed with cancer, with the majority being White (85%) and female (57%). Patients were surveyed on questions assessing pain treatment satisfaction, pain severity, and additional social characteristics. A series of multivariate models were specified, whereby patients reporting multiple chronic conditions, poor communication, and perceived discrimination were less satisfied with treatment. Positive communication, higher self-efficacy, and fewer perceived discriminatory acts were significant among the female patients only. These findings suggest the need to develop clinical models that assess how these factors influence the degree of treatment satisfaction, while providing a comprehensive mechanism by which to service the long-term needs of older adults.

Effects of Therapy in Patients Suffering from Chronic Back Pain Treated with Spinal Cord Stimulation

Pain in the lumbosacral part of the spine in the course of degenerative disease is the most common cause of physical activity limitation in adults. Treatment includes pharmacotherapy, physiotherapy, psychotherapy, health promotion, and sometimes surgery. Surgical treatment is not always successful, and the various clinical and psychosomatic symptoms that result from surgical treatment failure are known as failed back surgery syndrome. For some patients with this condition, spinal cord stimulation can provide relief. The aim of the work was to define subjective and objective spinal cord stimulation effects by assessing chosen disability and physical activity limitation ratios. Pain intensity, level of disability, and presence of neurological symptoms were assessed. The examination was performed twice: before the stimulator implantation and at least 6 months postimplantation. The study was conducted at the Department of Neurosurgery and Paediatric Neurosurgery in Lublin. Thirty-six patients suffering from failed back surgery syndrome were recruited for this study. The Visual Analog Scale, modified Laitinen's pain questionnaire, and Oswestry Disability Index were used in this work. The study showed that spinal cord stimulation was effective in treating spinal and lower limb pain in 64% of patients, similar to results obtained in other departments. Although back pain and neuropathic pain radiating to the lower limbs decreased, moderate physical activity impairment was still observed according to the Oswestry Disability Index scale. The decrease in neuropathic pain radiating to the lower limbs had the most significant influence on reducing physical activity impairment.

Impact of a Script-based Communication Intervention on Patient Satisfaction with Pain Management

Pain is a common complaint among hospitalized patients no matter the diagnosis. Pain has a negative effect on many aspects of a patient's life, including quality of life, sleep, and activities of daily living as well as increased health care expenses. The aim of this study was to evaluate the effectiveness of an intervention (script-based communication, use of white boards, and hourly rounding) related to pain management on patient satisfaction with nurses' management of pain. A prospective, quasi-experimental pretest-posttest design was used. Data were collected from two units that provided care for patients with a variety of medical-surgical diagnoses in a hospital located in an academic health sciences center in the southern United States. When nurses used clear and consistent communication with patients in pain, a positive effect was seen in patient satisfaction with pain management over time. This intervention was simple and effective. It could be replicated in a variety of health care organizations.

Satisfaction with pain treatment in older cancer patients: Identifying variants of discrimination, trust, communication, and self-efficacy

How satisfied a patient is with their medical treatment may influence compliance and adherence to medical regimens. While a number of studies have examined patient satisfaction among younger populations, few have determined the impact social factors have on satisfaction with pain treatment among older adults. This study aimed to determine the influence discrimination, trust, communication, and other health characteristics have on satisfaction with pain treatment among older adults receiving outpatient services from a comprehensive cancer center. Participants were surveyed on questions assessing pain symptomatology, and identified social (discrimination, trust, and communication), physical (comorbidities, pain interference), behavioral (self-efficacy), and demographic characteristics. Analyses were calculated to determine the total and indirect effects of trust, communication, and self-efficacy as mediators on the perceived discrimination-patient satisfaction with pain treatment relationship. Data showed a significant relationship of communication and discrimination on patient satisfaction. However, none of the mediating effects were significant. It must be recognized that patient satisfaction is contingent upon a myriad of social factors that are not exclusive, but rather coexisting determinants of health. Particularly among the elderly, perceived discrimination and incidences of poor communication may be significant influences on health and the lived day-to-day experiences of this adult population.

What circumstances prompt a workplace discussion in medical evaluations for back pain?

PURPOSE

To determine how frequently workplace topics emerge in the interactions between patients and providers in an evaluation for low back pain (LBP) and to determine its association with patient and provider characteristics.

METHODS

Adults with work-related LBP (N = 97; 64 % male; median age = 38) completed a demographic questionnaire and a survey of disability risk factors, then agreed to audio-taping of their visits with a participating occupational healthcare provider (n = 14). Utterance-level verbal exchanges were categorized by trained coders using the Roter interaction analysis system. In addition, coders flagged any instance of workplace discussion between patients and providers.

RESULTS

Workplace discussions occurred in 51 % of visits, and the most frequent topic was physical job demands. Workplace discussions were more frequent among the oldest and youngest patients and when patients were seen by providers who were more patient-centered and made more efforts to establish patient rapport and engagement. However, patients reporting numerous disability risk factors and workplace concerns in the pre-visit questionnaire were no more likely to discuss workplace topics with their providers (p > 0.05). Only the patient-centered orientations of providers and patients remained statistically significant predictors in multivariate modeling (p < 0.05).

CONCLUSIONS

Workplace discussions are facilitated by a patient-centered orientation and by efforts to establish patient engagement and rapport, but workplace discussions are no more frequent among patients with the most significant workplace concerns. Screening questionnaires and other assessment tools may be helpful to foster workplace discussions to overcome possible barriers for returning to work.

Development and preliminary validation of the MedRisk instrument to measure patient satisfaction with chiropractic care

OBJECTIVE

The purpose of this study is to provide preliminary information regarding the factor-structure, group- and individual-level reliability, and criterion-referenced validity of measures obtained from the MedRisk Instrument for Measuring Patient Satisfaction with Chiropractic Care.

METHOD

Three hundred twenty-three subjects who had completed a course of chiropractic care responded to questionnaire in which they rated their degree of satisfaction from 1 to 5 (1 = very unsatisfied to 5 = very satisfied) for each of 20 items. Factor structure was assessed using item-correlation and exploratory factor analysis. Group-level reliability for single test administration was assessed by calculating Cronbach α, and individual-level reliability was determined using the standard error of measure. Criterion-referenced validity was investigated by comparing the item scores and mean scores of individual factors to global measures of satisfaction.

RESULTS

Individual item scores ranged from 3.98 for "Office location was convenient" to 4.77 for "My chiropractor treats me respectfully." The items that were most highly correlated with overall patient satisfaction were "My chiropractor thoroughly explained the treatment I received" (r = 0.77) and "My chiropractor answered all of my questions" (r = 0.71). Exploratory factor analysis suggested a 2-factor solution: a 5-item "internal" factor and a 6-item "external" factor. The mean scores from these factors were correlated with the 2 global measures ranging from r = 0.68 to r = 0.80. The standard error of measure was 0.20 for the internal factor and 0.17 for the external factor.

CONCLUSIONS

Preliminary assessment suggests that a 13-item version of the MedRisk instrument provides psychometrically sound measures to assess patient satisfaction with chiropractic care; however, additional confirmatory validation should be performed.

Returning back pain patients to work: how private musculoskeletal practitioners outside the national health service perceive their role (an interview study)

BACKGROUND

Private musculoskeletal practitioners treat a large section of people with back pain, and could play an important role in returning and maintaining patients to work.

METHOD

We conducted a qualitative study to explore the self-perceived role of such practitioners in the UK. We interviewed 44 practitioners, including chiropractors, osteopaths and physiotherapists.

RESULTS

Thematic analysis of the interview transcripts indicated that return to work is a high priority for patients, many of whom are self-employed. Although in general work was perceived as beneficial to health, practitioners perceived work as a threat for some of their back pain patients. They perceived their role as giving ergonomic, postural and exercise based advice, but were more reluctant to address psychosocial problems related to back pain. A common view was that patients' reluctance to take a break from work impacted badly on their condition, and many practitioners advocated a short time off work duties to focus on rehabilitation. Contact with employers was very limited, and determined by the patients' request.

CONCLUSION

In summary, the study identifies several areas in which further education could expand the role of musculoskeletal practitioners and benefit their back pain patients. However, further study is required to determine whether these results are generalisable beyond the limits of this qualitative study UK based study.

Communicating about the experience of pain and fatigue in disability

PURPOSE

To examine the experiences of people with chronic disabling conditions as they communicate with health care providers about pain and fatigue.

METHOD

Twenty-three adults with a variety of chronic disabling conditions participated in 5 focus groups. The following issues were raised: tell me about your pain/fatigue; what things go along with pain/fatigue? how do you talk about pain/fatigue with your health care provider (HCP)? What should your HCP know that they do not ask you about?

RESULTS

Results of qualitative analysis suggested two major themes. The first theme was labeled "Putting it in words" and suggests that both pain and fatigue are described in many ways, including the dimensions of type, intensity, level of interference and temporal aspects. Participants reported difficulty with responding to a single question that asked them to assign a number to their level of pain or fatigue. The second theme was labeled, "Let's talk about it" and suggested that participants wanted HCPs "to listen and believe me when I describe my experience". They wanted to be asked about how pain or fatigue interferes with life and about compensatory strategies rather than being asked to rate symptom intensity. Participants wished to be viewed as experts and to be actively involved in decisions about their health care.

CONCLUSIONS

Pain and fatigue were viewed as having many facets that are associated in complex ways with other aspects of the health/disability condition. From the participants' perspective, assignment of a pain intensity rating does not represent the complexity of their pain experience. Suggestions are provided for HCPs when communicating about pain and fatigue with people with chronic conditions.

Effect of self-triage on waiting times at a walk-in sexual health clinic

BACKGROUND AND METHODOLOGY

Lengthy waiting times can be a major problem in walk-in sexual health clinics. They are stressful for both patients and staff and may lead to clients with significant health issues leaving the department before being seen by a clinician. A self-triage system may help reduce waiting times and duplication of work, improve patient pathways and decrease wasted visits. This paper describes implementation of a self-triage system in two busy sexual and reproductive health clinics. Patients were asked to complete a self-assessment form on registration to determine the reason for attendance. This then enabled patients to be directed to the most appropriate specialist or clinical service. The benefits of this approach were determined by measuring patient waiting times, reduction in unnecessary specialist review together with patient acceptability as tested by a patient satisfaction survey. The ease of comprehension of the triage form was also assessed by an independent readers' panel.

RESULTS

A total of 193 patients were recruited over a 4-month period from November 2004 to February 2005. Patients from the November and December clinics were assigned to the 'traditional treatment' arm, with patients at subsequent clinics being assigned to the 'self-triage' system. Waiting times were collected by the receptionist and clinic staff. Ninety six patients followed the traditional route, 97 the new self-triage system. Sixty-nine (35.8%) patients completed the satisfaction survey. The self-triage system significantly reduced waiting time from 40 (22, 60) to 23 (10, 40) minutes [results expressed as median (interquartile range)]. There was a non-significant reduction in the proportion of patients seeing two clinicians from 21% to 13% (p = 0.17). Satisfaction levels were not significantly altered (95% compared to 97% satisfied, p = 0.64). The readers' panel found the triage form both easy to understand and to complete.

CONCLUSIONS

Self-triage can effectively reduce clinic waiting times and allow better organisation of resources. Urgent cases can be prioritised. This process appears to be acceptable to and understandable by patients.

Patient Satisfaction with Nurse Practitioner and Physician Services in the Occupational Health Setting

The purpose of this research was to determine if patient satisfaction differed when clinical services were provided by nurse practitioners versus physicians in the occupational health setting. This convenience sample included 129 patients visiting community-based occupational medicine clinics for evaluation of a new work-related injury. There was high satisfaction with both nurse practitioner and physician providers. There was no significant difference in overall patient satisfaction between provider types. Results of this study support a practice model using nurse practitioners as primary providers in the occupational health setting.

Patient Satisfaction with Nurse Practitioner and Physician Services in the Occupational Health Setting

The purpose of this research was to determine if patient satisfaction differed when clinical services were provided by nurse practitioners versus physicians in the occupational health setting. This convenience sample included 129 patients visiting community-based occupational medicine clinics for evaluation of a new work-related injury. There was high satisfaction with both nurse practitioner and physician providers. There was no significant difference in overall patient satisfaction between provider types. Results of this study support a practice model using nurse practitioners as primary providers in the occupational health setting.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

Examining correlates of treatment satisfaction for injectable insulin in type 2 diabetes: lessons learned from a clinical trial comparing biphasic and basal analogues

BACKGROUND

Successfully managing diabetes is a complex process that includes addressing issues of drug efficacy, safety and treatment satisfaction. Additionally, the combined impact of patient/disease characteristics and treatment outcomes on treatment satisfaction is not well understood. The purpose of this study was to examine the impact of age, weight, gender, co-morbid conditions, diabetes history, treatment burden, efficacy (HbA1c) and side effects (weight gain, hypoglycemic events) on patients' appraisal of treatment satisfaction using linear regression models.

METHODS

Data from a multi-center, randomized clinical trial comparing the efficacy/safety of biphasic insulin aspart 70/30 (BIAsp 70/30) vs. glargine (Glar) among insulin naïve type 2 patients were analyzed. Subjects were between ages 18-75, with baseline HbA1c > 8% and BMI < or = 40 kg/m2 (N = 233). Treatment satisfaction was assessed by the Insulin Treatment Satisfaction Questionnaire (ITSQ).

RESULTS

When factors were examined independently, multiple significant relationships (age, co-morbidity, hypoglycemic events, and weight gain) with overall and/or domains of treatment satisfaction were found. However, when all significant relationships were examined together, only neuropathy, treatment efficacy, and number of hypoglycemic events maintained their previous significance.

CONCLUSION

By examining predictors independently, significant relationships were identified. However, not all findings remained significant when examined in combination with each other. Thus, to more accurately characterize the impact of factors on treatment satisfaction, a more comprehensive approach may be necessary. By improving patient treatment satisfaction, the efficacy of treatments, as well as critical treatment outcomes such as compliance and cost of care should be improved.

Initial Patient and Clinician Expectations of Return to Work After Acute Onset of Work-Related Low Back Pain

OBJECTIVE

The objective of this study was to compare patient and provider expectations of return to work (RTW) after acute onset of low back pain (LBP).

METHODS

Workers sick-listed after onset of LBP (N = 300) completed a questionnaire about work, injury, and psychosocial disability risk factors and rated their likelihood of full RTW within 4 weeks. Clinicians provided an independent estimate of work absence, and patients were followed for 3 months.

RESULTS

Clinician and patient expectations were weakly correlated, and both were predictive of actual RTW outcomes. Patient expectations were associated with differences in pain, mood, prior back pain, job demands, functional limitation, and marital status. Factors associated with clinician prognosis were similar but with more emphasis on physical examination findings.

CONCLUSIONS

Even before treatment, patients may form a negative expectation for RTW that is associated with a longer duration of work absence.