Development and Testing of a Communication Intervention to Improve Chronic Pain Management in Primary Care: A Pilot Randomized Clinical Trial.

OBJECTIVES: Effective communication skills are essential for optimally managing chronic pain and opioids. This exploratory, sequential mixed methods study tested the effect of a novel framework designed to improve pain-related communication and outcomes. METHODS: Study 1 developed a novel 5-step framework for helping primary care clinicians discuss chronic pain and opioids with patients. Study 2 pilot tested an intervention for teaching this framework using standardized patient instructors-actors trained to portray patients and provide immediate clinician feedback-deployed during regular clinic hours. Primary care physicians were randomized to receive either the intervention or pain management recommendations from the Centers for Disease Control and Prevention. Primary outcomes were pain-related interference at 2 months and clinician use of targeted communication skills (coded from transcripts of audio-recorded visits); secondary outcomes were pain intensity at 2 months, clinician self-efficacy for communicating about chronic pain, patient experience, and clinician-reported visit difficulty. RESULTS: We enrolled 47 primary care physicians from 2 academic teaching clinics and recorded visits with 48 patients taking opioids for chronic pain who had an appointment scheduled with an enrolled physician. The intervention was not associated with significant changes in primary or secondary outcomes other than clinician self-efficacy, which was significantly greater in the intervention group. DISCUSSION: This study developed a novel framework and intervention for teaching clinician pain-related communications skills. Although the intervention showed promise, more intensive or multicomponent interventions may be needed to have a significant impact on clinicians' pain-related communication and pain outcomes.

The transition from in-person to virtual museum programing for individuals living with chronic pain - A formative evaluation.

Museum engagement may be an effective approach for decreasing social disconnection and pain among individuals living with chronic pain. In October 2019, we launched a randomized controlled trial to assess the feasibility of museum engagement for individuals living with chronic pain; the study was halted in March, 2020 due to Covid-19-related safety concerns. This paper describes the process of transitioning from in-person to virtual museum programing in order to continue the study. Virtual museum programing is a feasible option for individuals living with chronic pain that is amenable to research and which may improve accessibility, inclusivity, and scalability relative to in-person programing.

Watchful waiting as a strategy to reduce low-value spinal imaging: study protocol for a randomized trial.

BACKGROUND: Patients with acute low back pain frequently request diagnostic imaging, and clinicians feel pressure to acquiesce to such requests to sustain patient trust and satisfaction. Spinal imaging in patients with acute low back pain poses risks from diagnostic evaluation of false-positive findings, patient labeling and anxiety, and unnecessary treatment (including spinal surgery). Watchful waiting advice has been an effective strategy to reduce some low-value treatments, and some evidence suggests a watchful waiting approach would be acceptable to many patients requesting diagnostic tests. METHODS: We will use key informant interviews of clinicians and focus groups with primary care patients to refine a theory-informed standardized patient-based intervention designed to teach clinicians how to advise watchful waiting when patients request low-value spinal imaging for low back pain. We will test the effectiveness of the intervention in a randomized clinical trial. We will recruit 8-10 primary care and urgent care clinics (~ 55 clinicians) in Sacramento, CA; clinicians will be randomized 1:1 to intervention and control groups. Over a 3- to 6-month period, clinicians in the intervention group will receive 3 visits with standardized patient instructors (SPIs) portraying patients with acute back pain; SPIs will instruct clinicians in a three-step model emphasizing establishing trust, empathic communication, and negotiation of a watchful waiting approach. Control physicians will receive no intervention. The primary outcome is the post-intervention rate of spinal imaging among actual patients with acute back pain seen by the clinicians adjusted for rate of imaging during a baseline period. Secondary outcomes are use of targeted communication techniques during a follow-up visit with an SP, clinician self-reported use of watchful waiting with actual low back pain patients, post-intervention rates of diagnostic imaging for other musculoskeletal pain syndromes (to test for generalization of intervention effects beyond back pain), and patient trust and satisfaction with physicians. DISCUSSION: This trial will determine whether standardized patient instructors can help clinicians develop skill in negotiating a watchful waiting approach with patients with acute low back pain, thereby reducing rates of low-value spinal imaging. The trial will also examine the possibility that intervention effects generalize to other diagnostic tests. TRIAL REGISTRATION: ClinicalTrials.gov NCT04255199 . Registered on January 20, 2020.

Acceptability, Usability, and Effectiveness: A Qualitative Study Evaluating a Pediatric Telemedicine Program.

BACKGROUND: Pediatric emergency telemedicine consultations have been shown to provide support to community emergency departments treating critically ill pediatric patients. However, despite the recognized value of telemedicine, adoption has been slow. To determine why clinicians frequently do not use telemedicine when it is available for pediatric patients, as well as to learn how to improve telemedicine programs, we conducted a qualitative study using stakeholder interviews. METHODS: We conducted a qualitative study using grounded theory methodology, with in-depth interviews of referring and accepting physicians and referring, transport, and transfer center nurses. We analyzed data iteratively and adapted the interview guide based on early interviews. We solicited feedback from the participants on the conceptual model. RESULTS: Sixteen interviews were conducted; all respondents had been involved in a telemedicine consultation at least five times, with some having used telemedicine more than 30 times. Analysis resulted in three themes: 1) recognizing and addressing telemedicine biases are central to gaining buy-in; 2) as technology advances, telemedicine processes need to adapt accordingly; and 3) telemedicine increases collaboration among health care providers and patients/families in the patient care process. CONCLUSIONS: To improve patient care through increased use of telemedicine for pediatric emergency consultations, processes need to be modified to address provider biases and end-user concerns. Processes should be adapted to allow users to utilize a variety of technologies (including smartphones) and to enable more users, such as nurses, to participate. Finally, telemedicine can be used to improve the patient and family experience by including them in consultations.

Patients' Experience With Opioid Tapering: A Conceptual Model With Recommendations for Clinicians.

Clinical guidelines discourage prescribing opioids for chronic pain, but give minimal advice about how to discuss opioid tapering with patients. We conducted focus groups and interviews involving 21 adults with chronic back or neck pain in different stages of opioid tapering. Transcripts were qualitatively analyzed to characterize patients' tapering experiences, build a conceptual model of these experiences, and identify strategies for promoting productive discussions of opioid tapering. Analyses revealed 3 major themes. First, owing to dynamic changes in patients' social relationships, emotional state, and health status, patients' pain and their perceived need for opioids fluctuate daily; this finding may conflict with recommendations to taper by a certain amount each month. Second, tapering requires substantial patient effort across multiple domains of patients' everyday lives; patients discuss this effort superficially, if at all, with clinicians. Third, patients use a variety of strategies to manage the tapering process (eg, keeping an opioid stash, timing opioid consumption based on planned activities). Recommendations for promoting productive tapering discussions include understanding the social and emotional dynamics likely to impact patients' tapering, addressing patient fears, focusing on patients' best interests, providing anticipatory guidance about tapering, and developing an individualized tapering plan that can be adjusted based on patient response. Perspective: This study used interview and focus group data to characterize patients' experiences with opioid tapering and identify communication strategies that are likely to foster productive, patient-centered discussions of opioid tapering. Findings will inform further research on tapering and help primary care clinicians to address this important, often challenging topic.