Effects of Two Guideline Implementation Strategies on Patient Outcomes in Primary Care

Becker, Annette; Leonhardt, Corinna; Kochen, Michael M.; Keller, Stefan; Wegscheider, Karl; Baum, Erika; Donner-Banzhoff, Norbert; Pfingsten, M.; Hildebrandt, J.; Basler, Heinz-Dieter; Chenot, Jean‐François

doi:10.1097/brs.0b013e3181657e0d

Cited by 78 publications

(107 citation statements)

References 30 publications

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“…Our findings do seem to concur with the findings of some of the earlier work in this area particularly in the moderating effects of age and employment, moderate disability and fear avoidance belief on treatment [27,28]. We identified one further trial which, prima facia, reported that intervention effects differed with gender; but the analysis did not include a formal test for interactions so we excluded it [29]. Our findings about treatment expectations also concur with earlier work [30][31][32].…”

Section: Discussionsupporting

confidence: 93%

Identifying potential moderators for response to treatment in low back pain: A systematic review

et al. 2015

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Section: Discussionsupporting

confidence: 93%

Identifying potential moderators for response to treatment in low back pain: A systematic review

et al. 2015

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“…It also increases the likelihood of following up with referrals to other providers, such as psychologists or physical therapists, who can instruct the patient on self-management strategies. Becker et al [59] showed that a low back pain intervention had stronger effects when provided in conjunction with a nurse-led motivational counseling component compared to the intervention alone or a control group that received information about pain. In addition, Habib and colleagues [60] examined the effect of an assessment and feedback intervention on attendance at pain self-management workshops.…”

Section: Improving Adherence By Increasing Patient Knowledge Motivatmentioning

confidence: 99%

Providers' roles in enhancing patients' adherence to pain self management

Dorflinger

Kerns

Auerbach

2012

Behav. Med. Pract. Policy Res.

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Practice guidelines and empirical research related to pain management encourage clinicians to take active roles in providing education about self management and promoting adoption of a self-management approach. The purpose of the study was to review the relevant literature, summarize aspects of the patientprovider interaction that influence patient engagement in self management for chronic pain, and outline practice recommendations in this area. Review of the literature on aspects of the patient-provider interaction that promote engagement in pain self-management was used. Findings are synthesized into recommendations for providers. Patients benefit from a biopsychosocial and patient-centered approach. Patients are more likely to fully disclose when providers respond empathically, which can improve conceptualization and treatment. Patient education and motivation play important roles in engaging patients in self management. Self management is influenced in part by the patient-provider communication process. Suggestions for communication strategies to facilitate patient engagement in self-management techniques, including empathic discussion of barriers and motivation enhancement, are provided. KEYWORDSChronic pain, Self management, Doctor-patient communication, Patient-centered care, Adherence Pain is one of the most common presenting problems in medical settings [1], and the majority of pain treatment tends to be carried out in the primary care context [2]. Pain that persists beyond 3 months and that does not remit with typical treatments for acute pain, such as rest, non-steroidal anti-inflammatory drugs, and heat or ice, is considered chronic pain. It is estimated that more than 100 million Americans have chronic pain [3], and prevalence in other countries varies from about 10-50 % of the general population [4]. Not only is chronic pain a prevalent health issue but it also significantly impacts quality of life [5][6][7][8] and the costs of care, and lost productivity are estimated to total almost $635 billion each year [3].Pain guidelines have recommended selfmanagement strategies in the treatment of chronic pain [9,10]. Self management differs from other treatments such as surgery and medication in that it emphasizes the patient's own control over his/her pain experience rather than relying on external factors to treat pain symptoms. At its most rudimentary level, self management consists of basic methods such as distraction, physical activity, and ice or heat to manage pain. Many patients use these practices on their own or are able to easily implement them after receiving reassurance and encouragement from their providers. Other patients may benefit from additional self-management techniques, such as those emphasized in cognitivebehavioral treatment for chronic pain, that aim to modify the thoughts and behaviors that contribute to the maintenance and exacerbation of pain. Such self-management skills include time-based pacing, relaxation, stress management, and identifying and modifying catastrophic ...

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“…49, 60, 62-65, 68, 70, 71  Four studies reported subgroup analyses within individual subgroups rather than between group interaction. 60,66,70,88 We examined the conduct and reporting of subgroups in terms of reporting of interpretation and discussion and found: …”

mentioning

confidence: 99%

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Patel

Hee

Mistry

et al. 2016

Programme Grants Appl Res

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Total word count including appendix: 93,499 ii ABSTRACT BackgroundThere is good evidence that therapist delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority. Aim and objectivesOverall aim was to improve the clinical and cost-effectiveness of LBP treatment by providing patients, their clinical advisors, and health service purchasers with better information about which participants are most likely to benefit from which treatment To achieve these objectives required substantial methodological work including the development and evaluation of some novel statistical approaches. This programme of work was not designed to analyse main effect of interventions and no such interpretations should be made.iii MethodsFirstly, we reviewed the literature on treatment moderators and subgroups. We initially invited investigators of trials of therapist-delivered interventions for LBP with >179 participants to share their data with us; some further smaller trials offered to us were also included. Using these trials we developed a repository of individual participant data of therapist delivered interventions for LBP. Using this dataset we sought to identify which participant characteristics, if any, predict response to different treatments (moderators) for clinical and cost effectiveness outcomes.We did an ANCOVA to identify potential moderators to apply in our main analyses.Subsequently we developed and applied three methods of subgroup identification; recursive partitioning (interaction trees and subgroup identification based on a differential effect search), adaptive risk group refinement, and an individual participant data indirect network meta-analysis to identify sub-groups defined by multiple parameters. ResultsWe included data from 19 randomised controlled trials with 9,328 participants (mean age 49 years, 57% females). Our prespecified analyses using recursive partitioning and adaptive risk group refinement performed well and allowed us to identify some subgroups. The differences in the effect size in the different subgroups were typically small, and unlikely to be clinically meaningful. Increasing baseline severity on the outcome of interest was the strongest driver of sub-group identification that we identified. Additionally we explored the application of Bayesian indirect network metaanalysis. This method produced varying probabilities that a particular treatment choice would be most likely to be effective for a specific patient profile. ConclusionThese data lack clinical or cost-effectiveness justification for the use of baseline characteristics in the development of subgroups for back pain. The methodological developments from this work have the potential to be applied in other clinical areas.iv The pooled repository database will serve as a valuable resource to the LBP research community. FundingFunding from the NIHR Programme Grants for Ap...

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Effects of Two Guideline Implementation Strategies on Patient Outcomes in Primary Care

Abstract: Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Cited by 78 publications

References 30 publications

Identifying potential moderators for response to treatment in low back pain: A systematic review

Identifying potential moderators for response to treatment in low back pain: A systematic review

Providers' roles in enhancing patients' adherence to pain self management

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

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