System plasticity and integrated care: informed consumers guide clinical reorientation and system reorganization

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.

Prioritizing a sequence of short-duration groups as the standardized pathway for chronic noncancer pain at an Australian tertiary multidisciplinary pain service: preliminary outcomes

OBJECTIVE

To describe implementation and report preliminary outcomes of a resource-efficient, standardized group pathway for chronic noncancer pain.

DESIGN

Descriptive cross-sectional study of a group-based pain management pathway in comparison with an Australasian benchmarking data set.

SETTING

An Australian tertiary multidisciplinary pain service.

SUBJECTS

Patients with chronic noncancer pain actively participating in the group pathway in 2016.

METHODS

Referred patients were prioritized to a short-duration group-based standardized pain management pathway linking education, assessment, and treatment groups. Measures of pain, mood, self-efficacy, and catastrophizing and reduction in daily opioid use were collated from the Australasian data set.

RESULTS

In 2016, 928 patients were actively engaged with the pain service. More patients were prioritized to receive treatment in a group format in comparison with other Australasian services (68.4% vs 22%). A greater percentage of patients attended their first clinical contact within 3 months of referral (81.4%) compared with the Australasian average (68.6%). Comparable improvements in average pain intensity, pain interference, depression, anxiety, stress, pain catastrophizing, and self-efficacy were observed. There was significantly greater reduction in opioid use, including for those taking more than 40 mg of oral morphine equivalent daily dose.

CONCLUSION

Implementation of a sequence of short-duration groups as the default clinical pathway resulted in shorter waiting times and noninferior outcomes in key areas for patients completing the program, compared with Australasian averages. Given the resource efficiencies of the group process, this finding has implications for service design.

Implementing evidence-informed policy into practice for health care professionals managing people with low back pain in Australian rural settings: a preliminary prospective single-cohort study

OBJECTIVE

To provide access to professional development opportunities for health care professionals, especially in rural Australian regions, consistent with recommendations in the Australian National Pain Strategy and state government policy.

DESIGN AND SETTING

A preliminary prospective, single-cohort study design, which aligned health policy with evidence-informed clinical practice, evaluated the implementation and effectiveness of an interprofessional, health care provider pain education program (hPEP) for management of nonspecific low back pain (nsLBP) in rural Western Australia.

INTERVENTION

The 6.5-hour hPEP intervention was delivered to 60 care providers (caseload nsLBP 19.8% ± 22.5) at four rural WA regions.

OUTCOME MEASURES

Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale [HC-PAIRS]), Back Pain Beliefs Questionnaire [BBQ]), and self-reported evidence-based clinical practice (knowledge and skills regarding nsLBP, rated on a 5-point Likert scale with 1 = nil and 5 = excellent).

RESULTS

hPEP was feasible to implement. At 2 months post-hPEP, responders' (response rate 53%) improved evidence-based beliefs were indicated by HC-PAIRS scores: baseline mean (SD) [43.2 (9.3)]; mean difference (95% CI) [-5.9 (-8.6 to -3.1)]; and BBQ baseline [34.3 (6.8)]; mean difference [2.1 (0.5 to 3.6)]. Positive shifts were observed for all measures of clinical knowledge and skills (P < 0.001) and increased assistance with planning lifestyle changes (P < 0.001), advice on self-management (P = 0.010), and for decreased referrals for spinal imaging (P = 0.03).

CONCLUSIONS

This policy-into-practice educational program is feasible to implement in rural Western Australia (WA). While preliminary data are encouraging, a further randomized controlled trial is recommended.

Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice

Musculoskeletal health conditions such as arthritis, osteoporosis and pain syndromes impart a profound socioeconomic burden worldwide, particularly in developed nations such as Australia. Despite the identified burden, substantial evidence-practice and care disparity gaps remain in service delivery and access that limit the potential for improved consumer outcomes and system efficiencies. Addressing these gaps requires a whole-of-sector response, supported by evidence-informed health policy. Models of care (MoCs) serve as a policy vehicle to embed evidence into health policy and guide practice through changes in service delivery systems and clinician behaviour. In Australia, MoCs for musculoskeletal health have been developed by networks of multidisciplinary stakeholders and are incrementally being implemented across health services, facilitated by dedicated policy units and clinical champions. A web of evidence is now emerging to support this approach to driving evidence into health policy and practice. Understanding the vernacular of MoCs and the development and implementation of MoCs is important to embracing this approach to health policy. What is known about the topic? The impact of musculoskeletal health conditions is profound. As the awareness around the magnitude of the impact of these conditions increases, the importance of system-wide policy responses and platforms for health service improvements is now recognised. The term ‘models of care’ is not new. It has been used for many years, mainly at the hospital level, for planning and delivering clinical services. However, over the past 8 years an alternative approach using health networks has been adopted for the development and implementation of models of care to achieve broad engagement and a wider and more sustainable scope for implementation. What does this paper add? Here, we provide a rationale for the development of models of care for musculoskeletal health and draw on experience in their development and implementation using a health network model, referring to an emerging web of evidence to support this approach. We describe what models of care are, how they are developed and question whether they make a difference and what the future may hold. What are the implications for practitioners? All indications suggest that models of care are here to stay. Therefore, this paper provides practitioners with a contemporary overview of models of care in Australia, their relevance to musculoskeletal healthcare, particularly related to closing evidence-practice gaps, and opportunities for sector engagement.

Self-management in palliative medicine

PURPOSE OF REVIEW

Self-management in the palliative care domain means equipping patients and carers to manage medical aspects of illness, managing life roles and allowing adaptation to the changing dynamics brought on by illness and its progression. As well as dealing with the psychological consequences of living with a life-threatening illness in which the aim is to optimise living. This review will consider the rationale for developing and adopting self-management as a model of care.

RECENT FINDINGS

Health policy currently advocates de-investment in traditional approaches to patient management paralleled with a re-engineering of services towards approaches required to underpin self-management care. However, the literature suggests that patients lack a fundamental knowledge and more importantly an understanding of the progression of their illness or what palliative of hospice care is. As a first step, this issue must be addressed in any self-management intervention. In terms of outcomes evidence continues to emerge that when compared with care self-management imparts sustainable understanding in targeted areas and has the potential to create a preventive spend environment.

SUMMARY

The role of self-management in palliative care requires further elucidation yet based on the evidence which is predominately gleaned from long-term conditions it would seem sensible if not ethical to educate patients/carers to actively be involved in decision making.

Applying a Health Network approach to translate evidence-informed policy into practice: a review and case study on musculoskeletal health

BACKGROUND

While translation of evidence into health policy and practice is recognised as critical to optimising health system performance and health-related outcomes for consumers, mechanisms to effectively achieve these goals are neither well understood, nor widely communicated. Health Networks represent a framework which offers a possible solution to this dilemma, particularly in light of emerging evidence regarding the importance of establishing relationships between stakeholders and identifying clinical leaders to drive evidence integration and translation into policy. This is particularly important for service delivery related to chronic diseases. In Western Australia (WA), disease and population-specific Health Networks are comprised of cross-discipline stakeholders who work collaboratively to develop evidence-informed policies and drive their implementation. Since establishment of the Health Networks in WA, over 50 evidence-informed Models of Care (MoCs) have been produced across 18 condition or population-focused Networks. The aim of this paper is to provide an overview of the Health Network framework in facilitating the translation of evidence into policy and practice with a particular focus on musculoskeletal health.

CASE PRESENTATION

A review of activities of the WA Musculoskeletal Health Network was undertaken, focussing on outcomes and the processes used to achieve them in the context of: development of policy, procurement of funding, stakeholder engagement, publications, and projects undertaken by the Network which aligned to implementation of MoCs.The Musculoskeletal Health Network has developed four MoCs which reflect Australian National Health Priority Areas. Establishment of community-based services for consumers with musculoskeletal health conditions is a key recommendation from these MoCs. Through mapping barriers and enablers to policy implementation, working groups, led by local clinical leaders and supported by the broader Network and government officers, have undertaken a range of integrated projects, such as the establishment of a community-based, multidisciplinary rheumatology service. The success of these projects has been contingent on developing relationships between key stakeholders across the health system.

CONCLUSIONS

In WA, Networks have provided a sustainable mechanism to meaningfully engage consumers, carers, clinicians and other stakeholders; provided a forum to exchange ideas, information and evidence; and collaboratively plan and deliver evidence-based and contextually-appropriate health system improvements for consumers.

Consumers' experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours

Background

Coordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP.

Methods

Fourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes.

Results

Five key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.

Conclusions

Consumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

A policy-into-practice intervention to increase the uptake of evidence-based management of low back pain in primary care: a prospective cohort study

Background

Persistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs).

Methods

To encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1 =  nil and 5 =  excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale).

Results

Ninety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change  = −5.6±8.2, p<0.0001; 95% confidence interval: −7.6 to −3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention.

Conclusion

An interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice.

Engaging consumers living in remote areas of Western Australia in the self-management of back pain: a prospective cohort study

Background

In Western Australia (WA), health policy recommends encouraging the use of active self-management strategies as part of the co-care of consumers with persistent low back pain (LBP). As many areas in WA are geographically isolated and health services are limited, implementing this policy into practice is critical if health outcomes for consumers living in geographically-isolated areas are to be improved.

Methods

In this prospective cohort study, 51 consumers (mean (SD) age 62.3 (±15.1) years) participated in an evidence-based interdisciplinary pain education program (modified Self Training Educative Pain Sessions: mSTEPS) delivered at three geographically isolated WA sites. Self report measures included LBP beliefs and attitudes (Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)), use of active and passive self-management strategies, and health literacy, and global perceived impression of usefulness (GPIU) recorded immediately pre-intervention (n = 51), same day post-intervention (BBQ; GPIU, n = 49) and 3 months post-intervention (n = 25).

Results

At baseline, consumers demonstrated adequate health literacy and elements of positive health behaviours, reflected by the use of more active than passive strategies in self-managing their persistent LBP. Immediately post-intervention, there was strong evidence for improvement in consumers’ general beliefs about LBP as demonstrated by an increase in BBQ scores (baseline [mean (SD): 25.8 (7.6)] to same day post-intervention [28.8 (7.2); P < 0.005], however this improvement was not sustained at 3 months post-intervention. The majority of consumers (86.4%) reported the intervention as very useful [rated on NRS as 7–10].

Conclusions

To sustain improved consumer beliefs regarding LBP and encourage the adoption of more positive health behaviours, additional reinforcement strategies for consumers living in remote areas where service access and skilled workforce are limited are recommended. This study highlights the need for aligning health services and skilled workforce to improve the delivery of co-care for consumers living in geographically isolated areas.