Advancing Interprofessional Primary Health Care Services in Rural Settings for People with Chronic Low Back Disorders: Protocol of a Community-Based Randomized Controlled Trial

Brenna Bath, Stacey Lovo Grona, Stephan Milosavljevic, Nazmi Sari, Biaka Imeah, Megan E O'Connell, Brenna Bath, Stacey Lovo Grona, Stephan Milosavljevic, Nazmi Sari, Biaka Imeah, Megan E O'Connell

Abstract

Background: Chronic low back disorders (CLBDs) are a substantial burden on individuals and societies, and impact up to 20% of Canadians. Rural and remote residents are approximately 30% more likely to have CLBDs. Reduced access to appropriate team-based health services, including physical therapy, is a key factor that may magnify the impact of CLBD on pain, physical function, overall quality of life, health-related system costs, and individual costs.

Objective: The purpose of this project is to evaluate the validity, comparative effectiveness, costs, barriers, and facilitators of an interprofessional management approach for people with CLBDs, delivered via telehealth.

Methods: This project will examine 3 different health care delivery options: (1) in-person nurse practitioner (NP); (2) in-person physical therapist (PT); and (3) a team approach utilizing an NP (in-person) and a PT joining via telehealth. Validity of the telehealth team care model will be explored by comparing the diagnostic categorization and management recommendations arising from participants with CLBD who undergo a team telehealth, in-person NP, and in-person PT assessment. Comparative effectiveness and costs will be examined using a community-based randomized controlled trial in a rural Saskatchewan community with limited PT services. The 3 arms of the trial are: (1) usual care delivered by a local rural NP; (2) a local NP and an urban-based PT joining via telehealth; and (3) face-to-face services by a PT traveling to the community. Patient-reported outcomes of pain, physical function, quality of life, satisfaction, and CLBD care-related costs will be evaluated up to 6 months after the intervention. Patient and provider experiences with the team telehealth approach will be explored through qualitative interviews.

Results: The study was funded in July 2013 and the University of Saskatchewan Biomedical Research Ethics Board approved the study in November 2013. Participant recruitment began in September 2014 and data collection was completed in December 2015. Analysis is in progress and results are anticipated in 2017.

Conclusions: CLBD is a widespread public health problem, particularly in rural and remote areas, which requires new innovative approaches to deliver appropriate health care. The results of this project will inform the development of evidence-informed approaches and community-based implementation strategies to improve access to PT services in primary health care settings in other rural and remote underserved areas. Findings might also provide a framework for cost-effective and patient-centered models of service delivery for the management of other chronic conditions.

Clinicaltrial: ClinicalTrials.gov NCT02225535; https://ichgcp.net/clinical-trials-registry/NCT02225535 (Archived by WebCite at http://www.webcitation.org/6lqLTCNF7).

Keywords: low back pain; physical therapy; rural health; telehealth.

©Brenna Bath, Stacey Lovo Grona, Stephan Milosavljevic, Nazmi Sari, Biaka Imeah, Megan E O’Connell. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 09.11.2016.

Figures

Figure 1
Figure 1
Design of rural community-based trial part of the study. CLBD: chronic low back disorder; NP: nurse practitioner; PT: physical therapist.

References

    1. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez M, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabé E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, Birbeck G, Black JA, Blencowe H, Blore JD, Blyth F, Bolliger I, Bonaventure A, Boufous S, Bourne R, Boussinesq M, Braithwaite T, Brayne C, Bridgett L, Brooker S, Brooks P, Brugha TS, Bryan-Hancock C, Bucello C, Buchbinder R, Buckle G, Budke CM, Burch M, Burney P, Burstein R, Calabria B, Campbell B, Canter CE, Carabin H, Carapetis J, Carmona L, Cella C, Charlson F, Chen H, Cheng AT, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahiya M, Dahodwala N, Damsere-Derry J, Danaei G, Davis A, De Leo D, Degenhardt L, Dellavalle R, Delossantos A, Denenberg J, Derrett S, Des Jarlais DC, Dharmaratne SD, Dherani M, Diaz-Torne C, Dolk H, Dorsey ER, Driscoll T, Duber H, Ebel B, Edmond K, Elbaz A, Ali SE, Erskine H, Erwin PJ, Espindola P, Ewoigbokhan SE, Farzadfar F, Feigin V, Felson DT, Ferrari A, Ferri CP, Fèvre EM, Finucane MM, Flaxman S, Flood L, Foreman K, Forouzanfar MH, Fowkes FG, Franklin R, Fransen M, Freeman MK, Gabbe BJ, Gabriel SE, Gakidou E, Ganatra HA, Garcia B, Gaspari F, Gillum RF, Gmel G, Gosselin R, Grainger R, Groeger J, Guillemin F, Gunnell D, Gupta R, Haagsma J, Hagan H, Halasa YA, Hall W, Haring D, Haro JM, Harrison JE, Havmoeller R, Hay RJ, Higashi H, Hill C, Hoen B, Hoffman H, Hotez PJ, Hoy D, Huang JJ, Ibeanusi SE, Jacobsen KH, James SL, Jarvis D, Jasrasaria R, Jayaraman S, Johns N, Jonas JB, Karthikeyan G, Kassebaum N, Kawakami N, Keren A, Khoo J, King CH, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lalloo R, Laslett LL, Lathlean T, Leasher JL, Lee YY, Leigh J, Lim SS, Limb E, Lin JK, Lipnick M, Lipshultz SE, Liu W, Loane M, Ohno SL, Lyons R, Ma J, Mabweijano J, MacIntyre MF, Malekzadeh R, Mallinger L, Manivannan S, Marcenes W, March L, Margolis DJ, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGill N, McGrath J, Medina-Mora ME, Meltzer M, Mensah GA, Merriman TR, Meyer A, Miglioli V, Miller M, Miller TR, Mitchell PB, Mocumbi AO, Moffitt TE, Mokdad AA, Monasta L, Montico M, Moradi-Lakeh M, Moran A, Morawska L, Mori R, Murdoch ME, Mwaniki MK, Naidoo K, Nair MN, Naldi L, Narayan KM, Nelson PK, Nelson RG, Nevitt MC, Newton CR, Nolte S, Norman P, Norman R, O'Donnell M, O'Hanlon S, Olives C, Omer SB, Ortblad K, Osborne R, Ozgediz D, Page A, Pahari B, Pandian JD, Rivero AP, Patten SB, Pearce N, Padilla RP, Perez-Ruiz F, Perico N, Pesudovs K, Phillips D, Phillips MR, Pierce K, Pion S, Polanczyk GV, Polinder S, Pope CA, Popova S, Porrini E, Pourmalek F, Prince M, Pullan RL, Ramaiah KD, Ranganathan D, Razavi H, Regan M, Rehm JT, Rein DB, Remuzzi G, Richardson K, Rivara FP, Roberts T, Robinson C, De Leòn FR, Ronfani L, Room R, Rosenfeld LC, Rushton L, Sacco RL, Saha S, Sampson U, Sanchez-Riera L, Sanman E, Schwebel DC, Scott JG, Segui-Gomez M, Shahraz S, Shepard DS, Shin H, Shivakoti R, Singh D, Singh GM, Singh JA, Singleton J, Sleet DA, Sliwa K, Smith E, Smith JL, Stapelberg NJ, Steer A, Steiner T, Stolk WA, Stovner LJ, Sudfeld C, Syed S, Tamburlini G, Tavakkoli M, Taylor HR, Taylor JA, Taylor WJ, Thomas B, Thomson WM, Thurston GD, Tleyjeh IM, Tonelli M, Towbin JA, Truelsen T, Tsilimbaris MK, Ubeda C, Undurraga EA, van der Werf MJ, van Os J, Vavilala MS, Venketasubramanian N, Wang M, Wang W, Watt K, Weatherall DJ, Weinstock MA, Weintraub R, Weisskopf MG, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams SR, Witt E, Wolfe F, Woolf AD, Wulf S, Yeh P, Zaidi AK, Zheng Z, Zonies D, Lopez AD, Murray CJ, AlMazroa MA, Memish ZA. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2163–96. doi: 10.1016/S0140-6736(12)61729-2.
    1. Lim K, Jacobs P, Klarenbach S. A population-based analysis of healthcare utilization of persons with back disorders: results from the Canadian Community Health Survey 2000-2001. Spine (Phila Pa 1976) 2006 Jan 15;31(2):212–8.
    1. Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord. 2010;11:144. doi: 10.1186/1471-2474-11-144.
    1. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006 Apr;88 Suppl 2:21–4. doi: 10.2106/JBJS.E.01273.
    1. Gandjour A, Telzerow A, Lauterbach KW. European comparison of costs and quality in the treatment of acute back pain. Spine (Phila Pa 1976) 2005 Apr 15;30(8):969–75.
    1. Waddell G. Waddell G. The Back Pain Revolution. 2nd edition. Toronto, ON: Churchill Livingstone; 2004:1-480.
    1. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32. doi: 10.1186/1471-2474-6-32.
    1. Bath B, Trask C, McCrosky J, Lawson J. A biopsychosocial profile of adult Canadians with and without chronic back disorders: a population-based analysis of the 2009-2010 Canadian Community Health Surveys. Biomed Res Int. 2014;2014:919621. doi: 10.1155/2014/919621.
    1. Allen O. Anthill and other injuries: a case for mobile allied health teams to remote Australia. Aust J Rural Health. 1996 Feb;4(1):33–42.
    1. Grimmer K, Bowman P. Differences between metropolitan and country public hospital allied health services. Aust J Rural Health. 1998 Nov;6(4):181–8.
    1. Pitblado R. Geographical distribution of rural health human resources. In: Kulig JC, Williams AM, editors. Health in Rural Canada. Vancouver, BC: UBC Press; 2012. p. 83.
    1. Canadian Institute for Health Information . Physiotherapists in Canada, 2011 - National and Jurisdictional Highlights. Ottawa, ON: 2012. [2016-09-21]. .
    1. Statistics Canada . Quarterly population estimates, national perspective — Population. Ottawa, ON: Statistics Canada; 2012. [2016-09-21]. .
    1. Bath B, Gabrush J, Fritzler R, Dickson N, Bisaro D, Bryan K, Shah TI. Mapping the physiotherapy profession in Saskatchewan: examining rural versus urban practice patterns. Physiother Can. 2015 Aug;67(3):221–31. doi: 10.3138/ptc.2014-53.
    1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976) 2006 Nov 1;31(23):2724–7. doi: 10.1097/.
    1. Bath B, McCrosky J, Janzen B, Pahwa P. Healthcare utilization by people with chronic back disorders: a population-based analysis of the 2008 Canadian Community Health Survey. In: IFOMPT 2012: A Rendez-Vous of Hands and Minds. 2012 Oct 05. International Federation of Orthopaedic and Manipulative Physiotherapy; September 30, 2012-October 5, 2012; Quebec, QC, Canada. pp. a68–a69.
    1. Foster NE, Hartvigsen J, Croft PR. Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis. Arthritis Res Ther. 2012;14(1):205. doi: 10.1186/ar3743.
    1. Hartvigsen J, Foster NE, Croft PR. We need to rethink front line care for back pain. BMJ. 2011;342:d3260.
    1. Pinney SJ, Regan WD. Educating medical students about musculoskeletal problems: are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am. 2001 Sep;83-A(9):1317–20.
    1. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002 Apr;84-A(4):604–8.
    1. Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med. 2007 May;82(5):452–7. doi: 10.1097/ACM.0b013e31803ea860.
    1. Connolly JF, DeHaven KE, Mooney V. Primary care management of musculoskeletal disorders: managed care is redefining the physician's role. J Musculoskelet Med. 1998;15(8):28–44.
    1. Roberts C, Adebajo AO, Long S. Improving the quality of care of musculoskeletal conditions in primary care. Rheumatology (Oxford) 2002 May;41(5):503–8.
    1. Lin CC, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of general practice care for low back pain: a systematic review. Eur Spine J. 2011 Jul;20(7):1012–23. doi: 10.1007/s00586-010-1675-4.
    1. DiCenso A, Bourgeault I, Abelson J, Martin-Misener R, Kaasalainen S, Carter N, Harbman P, Donald F, Bryant-Lukosius D, Kilpatrick K. Utilization of nurse practitioners to increase patient access to primary healthcare in Canada — thinking outside the box. Nurs Leadersh (Tor Ont) 2010 Dec;23 Spec No 2010:239–59.
    1. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002 Apr 6;324(7341):819–23.
    1. Dierick-van Daele AT, Metsemakers JF, Derckx Emmy W C EW, Spreeuwenberg C, Vrijhoef HJ. Nurse practitioners substituting for general practitioners: randomized controlled trial. J Adv Nurs. 2009 Feb;65(2):391–401. doi: 10.1111/j.1365-2648.2008.04888.x.
    1. Barranco-Mendoza A, Persaud D. Virtual health-care communities: the use of web-based mobile intelligent technologies for risk assessment and health management in rural and remote communities. In: Kulig JC, Williams AM, editors. Health in Rural Canada. Vancouver, BC: UBC Press; 2012. pp. 178–196.
    1. Lemaire ED, Boudrias Y, Greene G. Low-bandwidth, Internet-based videoconferencing for physical rehabilitation consultations. J Telemed Telecare. 2001;7(2):82–9.
    1. Russell T, Truter P, Blumke R, Richardson B. The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders. Telemed J E Health. 2010 Jun;16(5):585–94. doi: 10.1089/tmj.2009.0163.
    1. Jarvis-Selinger S, Chan E, Payne R, Plohman K, Ho K. Clinical telehealth across the disciplines: lessons learned. Telemed J E Health. 2008 Sep;14(7):720–5. doi: 10.1089/tmj.2007.0108.
    1. Jennett P, Jackson A, Ho K, Healy T, Kazanjian A, Woollard R, Haydt S, Bates J. The essence of telehealth readiness in rural communities: an organizational perspective. Telemed J E Health. 2005 Apr;11(2):137–45. doi: 10.1089/tmj.2005.11.137.
    1. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ. 2003;81(9):646–56.
    1. Breivik H, Eisenberg E, O'Brien T, OPENMinds The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health. 2013;13:1229. doi: 10.1186/1471-2458-13-1229.
    1. Marras WS. The case for cumulative trauma in low back disorders. Spine J. 2003;3(3):177–9.
    1. Koehoorn M, Xu F, Village J, Trask C, Teschke K. Back injury trajectories in heavy industries: defining outcomes for epidemiological research. J Occup Environ Med. 2010 Sep;52(9):908–12. doi: 10.1097/JOM.0b013e3181f02806.
    1. Canadian Insitute for Health Information Physiotherapist workforce, 2012. 2012. [2016-09-21]. .
    1. Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, Wyatt M, Cassidy JD, Rossignol M, Leboeuf-Yde C, Hartvigsen J, Leino-Arjas P, Latza U, Reis S, Gil Del Real MT, Kovacs FM, Oberg B, Cedraschi C, Bouter LM, Koes BW, Picavet HS, van Tulder MW, Burton K, Foster NE, Macfarlane GJ, Thomas E, Underwood M, Waddell G, Shekelle P, Volinn E, Von Korff M. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976) 2008 Jan 1;33(1):95–103. doi: 10.1097/BRS.0b013e31815e7f94.
    1. Bath B. [2016-09-21]. Biopsychosocial Evaluation of a Spinal Triage Service Delivered by Physiotherapists in Collaboration With Orthopaedic Surgeons [dissertation]. Saskatoon, SK: University of Saskatchewan; 2012. .
    1. Hulley S, Cummings S, Browner WS, Grady D, Newman TB. Designing clinical research. 4th edition. Philadelphia, PA: Lippincot Williams & Wilkins; 2001. Designing an experiment: clinical trials 1; pp. 143–55.
    1. Dillman D, Smyth J, Christian L. Internet, mail and mixed-mode surveys: the tailored design method. 3rd edition. Hoboken, NJ: John Wiley & Sons Inc; 2009.
    1. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, Malmivaara A, Roland M, Von Korff M, Waddell G. Outcome measures for low back pain research: a proposal for standardized use. Spine (Phila Pa 1976) 1998 Sep 15;23(18):2003–13.
    1. Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine (Phila Pa 1976) 2000 Dec 15;25(24):3100–3.
    1. Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980 Aug;66(8):271–3.
    1. Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine (Phila Pa 1976) 2000 Dec 15;25(24):3115–24.
    1. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994 Sep;58(3):387–92.
    1. [2016-10-28]. EuroQol Research Foundation. EQ-5D 2012. 2016.
    1. Kennedy DM, Robarts S, Woodhouse L. Patients are satisfied with advanced practice physiotherapists in a role traditionally performed by orthopaedic surgeons. Physiother Can. 2010;62(4):298–305. doi: 10.3138/physio.62.4.298.
    1. Bath B, Janzen B. Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service. J Multidiscip Healthc. 2012;5:1–15. doi: 10.2147/JMDH.S26375.
    1. Sim J, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther. 2005 Mar;85(3):257–68.
    1. Salisbury C, Foster NE, Bishop A, Calnan M, Coast J, Hall J, Hay E, Hollinghurst S, Hopper C, Grove S, Kaur S, Montgomery A. 'PhysioDirect' telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial. BMC Health Serv Res. 2009;9:136. doi: 10.1186/1472-6963-9-136.
    1. Bansback N, Tsuchiya A, Brazier J, Anis A. Canadian valuation of EQ-5D health states: preliminary value set and considerations for future valuation studies. PLoS One. 2012;7(2):e31115. doi: 10.1371/journal.pone.0031115.
    1. Canadian Institutes of Health Research Guide to knowledge translation planning at CIHR: integrated and end-of-grant approaches. 2016. Sep 21, [2016-09-21]. .
    1. Eysenbach G, CONSORT-EHEALTH Group CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res. 2011;13(4):e126. doi: 10.2196/jmir.1923.

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