Systematic Review of Costs and Effects of Self-Management Interventions for Chronic Musculoskeletal Pain: Spotlight on Analytic Perspective and Outcomes Assessment.

Background: Evidence for the cost-effectiveness of self-management interventions for chronic musculoskeletal pain (CMP) lacks consensus, which may be due to variability in the costing methods employed. Purpose: The purposes of the study were to identify how costs and effects have been assessed in economic analysis of self-management interventions for CMP and to identify the effect of the chosen analytical perspective on cost-effectiveness conclusions. Data Sources: Five databases were searched for all study designs using relevant terms. Study Selection: Two independent researchers reviewed all titles for predefined inclusion criteria: adults (≥18 years of age) with CMP, interventions with a primary aim of promoting self-management, and conducted a cost analysis. Data Extraction: Descriptive data including population, self-management intervention, analytical perspective, and costs and effects measured were collected by one reviewer and checked for accuracy by a second reviewer. Data Synthesis: Fifty-seven studies were identified: 65% (n = 37) chose the societal perspective, of which 89% (n = 33) captured health care utilization, 92% (n = 34) reported labor productivity, 65% (n = 24) included intervention delivery, and 59% (n = 22) captured patient/family costs. Types of costs varied in all studies. Eight studies conducted analyses from both health service and societal perspectives; cost-effectiveness estimates varied with perspective chosen, but in no case was the difference sufficient to change overall policy recommendations. Limitations: Chronic musculoskeletal pain conditions where self-management is recommended, but not as a primary treatment, were excluded. Gray literature was excluded. Conclusion: Substantial heterogeneity in the cost components captured in the assessment of self-management for CMP was found; this was independent of the analytic perspective used. Greater efforts to ensure complete and consistent costings are required if reliable cost-effectiveness evidence of self-management interventions is to be generated and to inform the most appropriate perspective for economic analyses in this field.

A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation.

BACKGROUND: Clinical practice guidelines for the treatment of low back pain suggest the inclusion of a biopsychosocial approach in which patient self-management is prioritized. While many physiotherapists recognise the importance of evidence-based practice, there is an evidence practice gap that may in part be due to the fact that promoting self-management necessitates change in clinical behaviours. Evidence suggests that a patient's motivation and maintenance of self-management behaviours can be positively influenced by the clinician's use of an autonomy supportive communication style. Therefore, the aim of this study was to develop and pilot-test the feasibility of a theoretically derived implementation intervention to support physiotherapists in using an evidence-based autonomy supportive communication style in practice for promoting patient self-management in clinical practice. METHODS: A systematic process was used to develop the intervention and pilot-test its feasibility in primary care physiotherapy. The development steps included focus groups to identify barriers and enablers for implementation, the theoretical domains framework to classify determinants of change, a behaviour change technique taxonomy to select appropriate intervention components, and forming a testable theoretical model. Face validity and acceptability of the intervention was pilot-tested with two physiotherapists and monitoring their communication with patients over a three-month timeframe. RESULTS: Using the process described above, eight barriers and enablers for implementation were identified. To address these barriers and enablers, a number of intervention components were selected ranging from behaviour change techniques such as, goal-setting, self-monitoring and feedback to appropriate modes of intervention delivery (i.e. continued education meetings and audit and feedback focused coaching). Initial pilot-testing revealed the acceptability of the intervention to recipients and highlighted key areas for refinement prior to scaling up for a definitive trial. CONCLUSION: The development process utilised in this study ensured the intervention was theory-informed and evidence-based, with recipients signalling its relevance and benefit to their clinical practice. Future research should consider additional intervention strategies to address barriers of social support and those beyond the clinician level.

Measurement tools for adherence to non-pharmacologic self-management treatment for chronic musculoskeletal conditions: a systematic review.

OBJECTIVES: To identify measures of adherence to nonpharmacologic self-management treatments for chronic musculoskeletal (MSK) populations; and to report on the measurement properties of identified measures. DATA SOURCES: Five databases were searched for all study types that included a chronic MSK population, unsupervised intervention, and measure of adherence. STUDY SELECTION: Two independent researchers reviewed all titles for inclusion using the following criteria: adult (>18y) participants with a chronic MSK condition; intervention, including an unsupervised self-management component; and measure of adherence to the unsupervised self-management component. DATA EXTRACTION: Descriptive data regarding populations, unsupervised components, and measures of unsupervised adherence (items, response options) were collected from each study by 1 researcher and checked by a second for accuracy. DATA SYNTHESIS: No named or referenced adherence measurement tools were found, but a total of 47 self-invented measures were identified. No measure was used in more than a single study. Methods could be grouped into the following: home diaries (n=31), multi-item questionnaires (n=11), and single-item questionnaires (n=7). All measures varied in type of information requested and scoring method. The lack of established tools precluded quality assessment of the measurement properties using COnsensus-based Standards for the selection of health Measurement INstruments methodology. CONCLUSIONS: Despite the importance of adherence to self-management interventions, measurement appears to be conducted on an ad hoc basis. It is clear that there is no consistency among adherence measurement tools and that the construct is ill-defined. This study alerts the research community to the gap in measuring adherence to self-care in a rigorous and reproducible manner. Therefore, we need to address this gap by using credible methods (eg, COnsensus-based Standards for the selection of health Measurement INstruments guidelines) to develop and evaluate an appropriate measure of adherence for self-management.