The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial

Daniel I Rhon, Rachel J Mayhew, Tina A Greenlee, Julie M Fritz, Daniel I Rhon, Rachel J Mayhew, Tina A Greenlee, Julie M Fritz

Abstract

Background: Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks.

Objective: Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups.

Methods: This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs.

Results: Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention.

Conclusion: Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process.

Trial registration: clinicaltrials.gov NCT02777983 .

Conflict of interest statement

None of the authors have any conflicts of interest to disclose.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
CONSORT Flow Diagram for Trial. Note: LBP = low back pain; MDR = Military Health System Data Repository; PROMIS = Patient-Reported Outcomes Measurement Information System; UC = usual care
Fig. 2
Fig. 2
Comparison of all initial treatment choices for LBP based on group assignment. Note: LBP = low back pain; MRI = magnetic resonance imaging; TENS = Transcutaneous Electrical Nerve Stimulation (home-use unit); x-ray = radiograph
Fig. 3
Fig. 3
Pharmacological treatments for LBP based on group assignment. Note: LBP = low back pain

References

    1. Mafi JN, Russell K, Bortz BA, Dachary M, Hazel WA, Jr, Fendrick AM. Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending. Health Aff. 2017;36:1701–1704. doi: 10.1377/hlthaff.2017.0385.
    1. Atlas SJ. Management of Low Back Pain: Getting From Evidence-Based Recommendations to High-Value Care. Ann Internal Med. 2017;166:533–534. doi: 10.7326/M17-0293.
    1. Dieleman JL, Cao J, Chapin A, Chen C, Li Z, Liu A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323:863–884. doi: 10.1001/jama.2020.0734.
    1. Buchbinder R, Underwood M, Hartvigsen J, Maher CG. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain. 2020;161:S57. doi: 10.1097/j.pain.0000000000001869.
    1. Main CJ, Foster N, Buchbinder R. How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Pract Res Clin Rheumatol. 2010;24:205–217. doi: 10.1016/j.berh.2009.12.012.
    1. Petersen L, Birkelund R, Ammentorp J, Schiøttz-Christensen B. “An MRI reveals the truth about my back”: a qualitative study about patients’ expectations and attitudes toward the value of MRI in the assessment of back pain. 2016.
    1. Hoffmann TC, Del Mar CB, Strong J, Mai J. Patients’ expectations of acute low back pain management: implications for evidence uptake. BMC Fam Pract. 2013;14:7. doi: 10.1186/1471-2296-14-7.
    1. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to Harm, Hard to Heal: Patient Views About the Back. Spine. 2015;40:842–850. doi: 10.1097/BRS.0000000000000901.
    1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018. 10.1016/S0140-6736(18)30480-X.
    1. Hruschak V, Cochran G. Psychosocial predictors in the transition from acute to chronic pain: a systematic review. Psychol Health Med. 2018;23:1151–1167. doi: 10.1080/13548506.2018.1446097.
    1. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181–189. doi: 10.7326/0003-4819-154-3-201102010-00008.
    1. Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine. 2013;38:1939–1946. doi: 10.1097/BRS.0b013e3182a42eb6.
    1. Adams J, Bledsoe GH, Armstrong JH. Are Pain Management Questions in Patient Satisfaction Surveys Driving the Opioid Epidemic? Am J Public Health. 2016;106:985–986. doi: 10.2105/AJPH.2016.303228.
    1. Carrico JA, Mahoney K, Raymond KM, Mims L, Smith PC, Sakai JT, et al. The Association of Patient Satisfaction-Based Incentives with Primary Care Physician Opioid Prescribing. J Am Board Fam Med. 2018;31:941–943. doi: 10.3122/jabfm.2018.06.180067.
    1. Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for general practice guidelines on low back pain a qualitative study. Spine. 2001;26:E348–E353. doi: 10.1097/00007632-200108010-00013.
    1. Lim YZ, Chou L, Au RT, Seneviwickrama KMD, Cicuttini FM, Briggs AM, et al. People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. J Physiother. 2019. 10.1016/j.jphys.2019.05.010.
    1. Verbeek J, Sengers M-J, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine. 2004;29:2309–2318. doi: 10.1097/01.brs.0000142007.38256.7f.
    1. Carman KL, Maurer M, Yegian JM, Dardess P, McGee J, Evers M, et al. Evidence that consumers are skeptical about evidence-based health care. Health Aff. 2010;29:1400–1406. doi: 10.1377/hlthaff.2009.0296.
    1. Lantz PM, Evans WD, Mead H, Alvarez C, Stewart L. Knowledge of and Attitudes Toward Evidence-Based Guidelines for and Against Clinical Preventive Services: Results from a National Survey. Milbank Q. 2016;94:51–76. doi: 10.1111/1468-0009.12181.
    1. Campbell EG, Regan S, Gruen RL, Ferris TG, Rao SR, Cleary PD, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795–802. doi: 10.7326/0003-4819-147-11-200712040-00012.
    1. Neprash HT, Barnett ML. Association of Primary Care Clinic Appointment Time With Opioid Prescribing. JAMA Netw Open. 2019;2:e1910373. doi: 10.1001/jamanetworkopen.2019.10373.
    1. Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord. 2017;18:466. doi: 10.1186/s12891-017-1831-7.
    1. O’Keeffe M, Maher CG, Stanton TR, O’Connell NE, Deshpande S, Gross DP, et al. Mass media campaigns are needed to counter misconceptions about back pain and promote higher value care. Br J Sports Med. 2018;:bjsports – 2018–099691.
    1. Suman A, Armijo-Olivo S, Deshpande S, Marietta-Vasquez J, Dennett L, Miciak M, et al. A systematic review of the effectiveness of mass media campaigns for the management of low back pain. Disabil Rehabil. 2020;:1–29.
    1. Chandra K, Atkinson PR, Chatur H, Fraser J, Adams CL. To Choose or Not To Choose: Evaluating the Effect of a Choosing Wisely Knowledge Translation Initiative for Imaging in Low Back Pain by Emergency Physicians. Cureus. 2019;11:e4002.
    1. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c869. doi: 10.1136/bmj.c869.
    1. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. doi: 10.1136/bmj.g1687.
    1. Clinically Relevant Technologies. The Truth About Low Back Pain. App Store. 2018. . Accessed 12 Mar 2020.
    1. Burton AK, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine. 1999;24:2484–2491. doi: 10.1097/00007632-199912010-00010.
    1. Hill JC, Whitehurst DGT, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560–1571. doi: 10.1016/S0140-6736(11)60937-9.
    1. Butera KA, George SZ, Lentz TA. Psychometric evaluation of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool: factor structure, reliability, and validity. J Pain. 2019. 10.1016/j.jpain.2019.09.003.
    1. Cherkin D, Deyo RA, Berg AO. Evaluation of a physician education intervention to improve primary care for low-back pain. II. Impact on patients. Spine. 1991;16:1173–1178. doi: 10.1097/00007632-199110000-00008.
    1. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–191. doi: 10.3758/BF03193146.
    1. Fitzmaurice GM, Ravichandran C. A primer in longitudinal data analysis. Circulation. 2008;118:2005–2010. doi: 10.1161/CIRCULATIONAHA.107.714618.
    1. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:514–530. doi: 10.7326/M16-2367.
    1. Pangarkar SS, Kang DG, Sandbrink F, Bevevino A, Tillisch K, Konitzer L, et al. VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain. J Gen Intern Med. 2019;34:2620–2629. doi: 10.1007/s11606-019-05086-4.
    1. George SZ, Childs JD, Teyhen DS, Wu SS, Wright AC, Dugan JL, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial. BMC Med. 2011;9:128. doi: 10.1186/1741-7015-9-128.
    1. Chou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Sullivan K, et al. Patients’ perceived needs of health care providers for low back pain management: a systematic scoping review. Spine J. 2018;18:691–711. doi: 10.1016/j.spinee.2018.01.006.
    1. Dwyer CP, MacNeela P, Durand H, O’Connor LL, Main CJ, McKenna-Plumley PE, et al. Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial. Pain Med. 2020;21:939–950. doi: 10.1093/pm/pnz284.
    1. Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, et al. Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial. BMJ Qual Saf. 2018;27:355–364. doi: 10.1136/bmjqs-2017-006699.
    1. Garcia AN, Cook C, Rhon D. Which patients do not seek additional medical care after a self-management class for low back pain? An observational cohort. Clin Rehabil. 2019;33:1831–1842. doi: 10.1177/0269215519865013.
    1. Rhon DI, Lentz TA, George SZ. Utility of catastrophizing, body symptom diagram score and history of opioid use to predict future health care utilization after a primary care visit for musculoskeletal pain. Fam Pract. 2020;37:81–90. doi: 10.1093/fampra/cmz046.
    1. Lentz TA, Rhon DI, George SZ. Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability? J Pain. 2020;21:135–145. doi: 10.1016/j.jpain.2019.06.004.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi