Exploring the feasibility of a network of organizations for pain rehabilitation: What are the lessons learned?

BACKGROUND AND AIMS: Integration of care is lacking for chronic musculoskeletal pain patients. Network Pain Rehabilitation Limburg, a transmural health care network, has been designed to provide integrated rehabilitation care from a biopsychosocial perspective to improve patients' levels of functioning. This feasibility study aims to provide insight into barriers and facilitators for the development, implementation, and transferability. METHODS: This study was conducted with a three-phase iterative and incremental design from October 2017 to October 2018. The network comprises two rehabilitation practices, and three local primary care networks, with a general practitioner together with, a mental health practice nurse, and a physiotherapist or exercise therapist. These stakeholders with a random sample of participating patients took part in evaluations, consisting of interviews, focus groups, and observations. Field notes and observations were recorded during meetings. The Consolidated Framework for Implementation Research guided data collection and analysis. Results were used to refine the next phase. RESULTS: According to health care professionals, guidelines and treatment protocols facilitate consistency and transparency in collaboration, biopsychosocial language, and treatment. One mentioned barrier is the stigmatization of chronic pain by the general population. In regular care, approaches are often more biomedical than biopsychosocial, causing patients to resist participating. The current organization of health care acts as a barrier, complicating implementation between and within practices. Health care professionals were enthusiastic about the iterative, bottom-up development. A critical mass of participating organizations is needed for proper implementation. CONCLUSION: Network Pain Rehabilitation Limburg is feasible in daily practice if barriers are overcome and facilitators of development, implementation, and transferability are promoted. These findings will be used to refine Network Pain Rehabilitation Limburg. A large-scale process and effect evaluation will be performed. Our implementation strategies and results may assist other health care organizations aspiring to implement a transmural network using a similar model. TRAIL REGISTRATION: Registration number: NTR6654 or https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6654.

An eCoach-Pain for Patients with Chronic Musculoskeletal Pain in Interdisciplinary Primary Care: A Feasibility Study.

eHealth could support cost-effective interdisciplinary primary care for patients with chronic musculoskeletal pain. This study aims to explore the feasibility of the eCoach-Pain, comprising a tool measuring pain complexity, diaries, pain education sessions, monitoring options, and chat function. Feasibility was evaluated (June-December 2020) by assessing learnability, usability, desirability, adherence to the application, and experiences from patients and general practitioners, practice nurses mental health, and physiotherapists. Six primary healthcare professionals (PHCPs) from two settings participated in the study and recruited 29 patients (72% female, median age 50.0 years (IQR = 24.0)). PHCPs participated in a focus group. Patient data was collected by evaluation questionnaires, individual interviews, and eCoach-Pain-use registration. Patients used the eCoach during the entire treatment phase (on average 107.0 days (IQR = 46.0); 23 patients completed the pain complexity tool and used the educational sessions, and 12 patients the chat function. Patients were satisfied with the eCoach-Pain (median grade 7.0 (IQR = 2.8) on a 0-10 scale) and made some recommendations for better fit with patient-specific complaints. According to PHCPs, the eCoach-Pain is of added value to their treatment, and patients also see treatment benefits. However, the implementation strategy is important for successful use of the eCoach-Pain. It is recommended to improve this strategy and involve a case-manager per patient.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review.

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg.

BACKGROUND: Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied. METHODS: In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients. INCLUSION CRITERIA: age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy. EXCLUSION CRITERIA: pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods. DISCUSSION: NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Developing the Network Pain Rehabilitation Limburg: a feasibility study protocol.

INTRODUCTION: Patients having chronic musculoskeletal pain (CMP) face challenges as mismatches often exist between the complexity of patient's pain problem and the rehabilitation treatment offered. This can result in less efficient care for the patient and increased medical shopping. The Network Pain Rehabilitation Limburg (NPRL), a transmural integrated healthcare network, will be designed to improve daily care for patients with CMP. NPRL focusses on improving patient's level of functioning despite pain by stimulating a biopsychosocial approach given by all involved healthcare professionals. A feasibility study will be performed which will give insight into the barriers and facilitators, perceived value, acceptability and implementation strategies for NPRL. METHODS AND ANALYSIS: This study has a three-phase iterative and incremental design, based on key principles of a user-centred design. Mixed methods will be used in which healthcare professionals and patients involved in NPRL will participate. In phase 1, NPRL will be developed and healthcare professionals educated. Phase 2 focusses on the implementation and phase 3 on the transferability of NPRL. In addition, preliminary data on patient's work status, general health and participation level will be collected. The qualitative results of each phase will be analysed following the Consolidated Framework for Implementation Research (CFIR) and will be used to refine NPRL in daily practise. ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. The results of this feasibility study will form the basis for refinement of NPRL and planning of a large-scale process and effect evaluation of the Quadruple Aim outcomes. Dissemination will include publications and presentations at national and international conferences. Ethical approval for this study was granted by the Medical Ethics Committee Z, the Netherlands, METC 17 N-133.