An RCT of a clinician communication training intervention to improve - PowerPoint PPT Presentation

An RCT of a clinician communication training intervention to improve pain management in primary care Stephen Henry, MD MSc CHPR seminar February 5, 2020

Disclosures None

Objectives 1. Review “best practices” for communicating about pain and opioids in primary care 2. Describe benefits of using standardized patient instructors to change clinician behavior 3. Identify impacts of communication training on communication during visits and pain-related care outcomes

Background • Discussions about chronic pain are often frustrating for both patients and clinicians • Clinicians often struggle to manage patients taking opioids for chronic pain • Communication skills training may result in more satisfied patients, less frustrated physicians, and better pain management

Project overview Interviews with patients, residents, clinical experts Develop communication framework Design intervention to teach framework Conduct pilot RCT to test framework

Project overview Qualitative data collection : Interviews with patients, residents, clinical experts 1-on-1 interviews: 15 patients with chronic pain 10 UCD primary care residents Develop communication Conversations with clinical experts framework Focus group data from tapering project Design intervention to Video-recorded primary care visits involving teach framework patients with pain Conduct pilot RCT to test framework

Project overview Interviews with patients, residents, Step 1 : Mentally prepare for the visit clinical experts Step 2 : Show that you take the patient’s pain Develop seriously communication framework Step 3 : Assess the patients’ risk for opioid - related harm Design intervention to teach framework Step 4 : Set pain treatment goals Conduct pilot RCT to Step 5 : Develop a goal-directed treatment plan test framework

Project overview Interviews with patients, residents, Used “Standardized Patent Instructor” clinical experts approach to delivering this behavioral intervention. Develop communication JGIM 2009; 24:606-13 (SEE-IT residents) framework JGIM 2016;31:715-722 (SEE-IT PCPs) Design intervention to JAMA IM 2016;176:191-7 (PCORI - residents) teach framework JAMA Oncology 2017;3:92-100 (VOICE- oncologists) Conduct pilot RCT to test framework

Intervention components SP visit #1 ~ 9 minute instructional video Pamphlet with detailed examples Pocket card SP#1 role play and feedback SP#2 role play and feedback

Project overview Interviews with patients, residents, clinical experts Develop communication framework Design intervention to teach framework Conduct pilot RCT to test framework

RCT overview Clinician Post-visit Recruit intervention surveys patients (1-2 per MD) Recruit R 2-month physicians follow up Audio record Clinician phone call clinic visits control Code visit EHR data recordings

Recruitment - physicians • IM or FCM residents at UC Davis • PGY2 or greater • Have continuity clinic in ACC

Recruitment - patients INCLUSION • Established adult clinic patients • On long- term opioids (≥1 dose per day for >90 days) • Chronic MSK pain with severity ≥4 out of 10 • Scheduled to see an enrolled physician • Report either dissatisfaction with current pain meds or desire to discuss change in pain meds at visit

Recruitment - patients EXCLUSION • Doesn’t speak English during visits • Active cancer treatment • Palliative care / hospice • Opioids not managed by primary care clinic

Physician control CDC handout on opioid prescribing and pain management

Outcomes ClinicalTrials.gov ID: NCT03629197 Primary • # of targeted communication skills coded from recorded patient visits • Pain-related interference 2 months after study visit Secondary • Physician self-efficacy for communication and pain management • Physician reported visit difficulty • Patient experience • Pain intensity 2 months after study visit

Visit coding • Identified observable behaviors for each step in the 5 step framework

Visit coding Framework step Step 1 : Mentally prepare for the visit Step 2 : Show that you take the patient’s pain seriously Step 3 : Assess the patients’ risk for opioid-related harm Step 4 : Set pain treatment goals Step 5 : Develop a goal-directed treatment plan

Visit coding Framework step Observable behaviors (26 total) Step 1 : Mentally prepare for the visit None (0) Step 2 : Show that you take the patient’s Open-ended questions (5) pain seriously Supportive / empathetic statements (3) Elicit patient opinion (1) Step 3 : Assess the patients’ risk for Ask about opioid side effects (2) opioid-related harm Step 4 : Set pain treatment goals Setting function-based goals (4) Step 5 : Develop a goal-directed treatment Patient input into treatment (3) plan Responding to tapering resistance (2) Flexibility and follow up (4)

Visit coding • 3 coders trained to code from transcripts and audio • 3 coders independently coded each transcript • Disagreements resolved by discussion

Physician participants Total CDC guidelines Intervention (n=45) (n=21) (n=24) Age , mean (SD) 29.8 (2.7) 29.6 (2.5) 29.7 (2.5) Sex , n (%) Female 8 (38%) 21 (88%) 29 (64%) Male 13 (62%) 3 (13%) 16 (36%) Race/ethnicity , n (%) Black 1 (5%) 0 (0%) 1 (2%) Asian / Pac Island. 12 (57%) 9 (38%) 21 (47%) Non-Hispanic White 5 (24%) 7 (29%) 12 (27%) Hispanic White 2 (10%) 4 (17%) 6 (13%) Multi / other 1 (5%) 4 (17%) 5 (11%) Clinic *, n (%) Internal Medicine 14 (67%) 16 (67%) 30 (67%) Family Medicine 7 (33%) 8 (33%) 15 (33%) Self-efficacy for pain- related communication †, 3.05 (0.57) 2.83 (0.46) 2.94 (0.52) mean (SD) *Randomization was stratified by clinic † Mean of 8 different items; range 1 -5 (higher = greater self-efficacy).

Patient participants Saw Saw control MD intervention Total (n=21) MD (n=25) (n=46) Age , mean (SD) 59.9 (8.6) 61.2 (10.5) 60.6 (9.6) Female sex , n (%) 12 (57%) 20 (80%) 32 (70%) Race/ethnicity, n (%) Black 7 (33%) 9 (36%) 16 (35%) Non-Hispanic White 8 (38%) 9 (36%) 17 (37%) Native American 1 (5%) 0(0%) 1 (2%) Hispanic White 2 (10%) 4 (16%) 6 (13%) Multi / other 3 (14%) 3 (12%) 6 (13%) Household income , n (%) <$10,000 4 (19%) 8 (32%) 12 (26%) $10,001 – $20,000 8 (38%) 5 (20%) 13 (28%) $20,001 – $40,000 5 (24%) 6 (24%) 11 (24%) $40,001 – $80,000 3 (14%) 3 (12%) 6 (13%) >$80,000 1 (5%) 3 (12%) 4 (9%) Employment status* , n (%) Working full time 2 (10%) 2 (8%) 4 (9%) Disabled / unable to work 10 (48%) 15 (60%) 25 (54%) Retired 5 (24%) 6 (24%) 11 (24%) * 2 small categories not shown

Patient participants Saw Saw control MD intervention Total (n=21) MD (n=25) (n=46) Clinic , n (%) Internal Medicine 11 (52%) 15 (60%) 26 (57%) Family Medicine 10 (48%) 10 (40%) 20 (43%) Saw usual MD , n (%) 14 (67%) 21 (84%) 35 (76%) Brief Pain Index Pain-related interference (0-10) 6.2 (2.5) 7.4 (1.9) 6.9 (2.2) Pain-related intensity (0-10) 6.4 (1.8) 7.3 (1.8) 6.9 (1.8) PHQ-8 (0-24) 10.6 (6.1) 10.0 (6.8) 10.3 (6.4) GAD-7 (0-21) 8.0 (5.0) 9.6 (6.4) 8.9 (5.8) Opioid dose, median MME/day, (IQR) 22 (15, 40) 30 (15, 45) 30 (15, 45) No. of pain locations , median (IQR) 2 (2,3) 2 (1-2) 2 (1, 3)

Results Saw control MD Saw intervention MD Outcome (n=21) (n=25) Physician communication Total communication behaviors coded per visit, mean (SD) Post-visit measures Patient experience* MD-reported visit difficulty (10-60) MD self-efficacy for pain-related communication (1-5)** 2-month follow up measures Pain interference (0-10) Pain intensity (0-10) *standardized variable (mean 0, SD 1); higher values = more positive **mean of 8 items (each scored 1-5)

Results Saw control MD Saw intervention MD Outcome (n=21) (n=25) Physician communication Total communication behaviors 2.8 (2.4) 3.5 (2.8) coded per visit, mean (SD) Post-visit measures Patient experience* MD-reported visit difficulty (10-60) MD self-efficacy for pain-related communication (1-5)** 2-month follow up measures Pain interference (0-10) Pain intensity (0-10) *standardized variable (mean 0, SD 1); higher values = more positive **mean of 8 items (each scored 1-5)

Results Saw control MD Saw intervention MD Outcome (n=21) (n=25) Physician communication Total communication behaviors 2.8 (2.4) 3.5 (2.8) coded per visit, mean (SD) Post-visit measures Patient experience* 0.13 (0.6) -0.12 (1.1) MD-reported visit difficulty (10-60) 22.8 (7.0) 25.8 (12.3) MD self-efficacy for pain-related 3.4 (0.6) 3.8 (0.6) communication (1-5)** 2-month follow up measures Pain interference (0-10) Pain intensity (0-10) *standardized variable (mean 0, SD 1); higher values = more positive **mean of 8 items (each scored 1-5)

Results Saw control MD Saw intervention MD Outcome (n=21) (n=25) Physician communication Total communication behaviors 2.8 (2.4) 3.5 (2.8) coded per visit, mean (SD) Post-visit measures Patient experience* 0.13 (0.6) -0.12 (1.1) MD-reported visit difficulty (10-60) 22.8 (7.0) 25.8 (12.3) MD self-efficacy for pain-related 3.4 (0.6) 3.8 (0.6) communication (1-5)** 2-month follow up measures Pain interference (0-10) 5.8 (2.9) 6.3 (2.8) Pain intensity (0-10) 6.0 (1.8) 6.5 (2.3) *standardized variable (mean 0, SD 1); higher values = more positive **mean of 8 items (each scored 1-5)